,text
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,"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**]



"
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 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**]"
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**]



"
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**]"
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**]"
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**]"
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**]"
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**]"
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**]"
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) **].



"
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



"
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**]
"
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.
"
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
"
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 ------
"
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:
"
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:
"
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:
"
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:
"
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 ------
"
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**]
"
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



"
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**]



"
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**]"
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**]

"
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.



"
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**]"
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**]"
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**]
"
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.



"
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



"
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**]

"
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**]"
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**]
"
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**]



"
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**]

"
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**]
"
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**]

"
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**]"
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**]"
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.


"
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**]



"
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**]"
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**]"
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**]"
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**]"
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**]

"
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**]
"
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



"
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**]
"
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



"
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**]

"
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**]"
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**]

"
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**]"
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.



"
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



"
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**]"
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**]
"
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**]"
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**]"
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**]
"
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**]
"
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**]
"
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**]"
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**]"
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**]"
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



"
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 **]
"
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**]

"
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**]"
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**]
"
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**]"
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**]

"
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**]"
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**]"
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**]"
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**]"
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**]"
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.



"
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**]

"
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**]"
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.



"
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**]"
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.



"
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**]"
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.



"
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 **]
"
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.



"
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).



"
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**]"
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**]"
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**]
"
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**]
"
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



"
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**].



"
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**]"
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**]"
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**]

"
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



"
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**]
"
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**]



"
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**]"
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**]

"
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 **].



"
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**]"
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**].



"
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**]"
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**]

"
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**]



"
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**]"
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



"
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**]

"
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**]"
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**]"
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



"
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**]"
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 **]
"
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.



"
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**]"
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**]



"
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**]
"
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) **]"
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

"
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**]"
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**]"
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



"
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**]
"
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**]"
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**]"
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



"
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**]"
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**]
"
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**]
"
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:
.


"
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.


"
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) **].



"
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



"
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**]"
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



"
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) **].



"
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.


"
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**]"
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



"
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



"
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**]
"
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**]
"
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**]

"
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**]"
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 **]
"
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**]
"
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



"
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**]
"
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**]"
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**]"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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:
"
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
"
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:
"
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
"
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.
"
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.
"
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.
"
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 ------
"
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 adverse reactions.
   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.
"
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.
"
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.
"
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.
"
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.
"
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:
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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.
"
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
"
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:
"
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**]
"
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 ------
"
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.
"
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.
"
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.
"
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.
"
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
"
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 ------
"
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:
"
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:
"
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:
"
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:
"
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
"
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 ------
"
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:
"
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
"
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
"
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
"
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 ------
"
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
"
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 ------
"
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.
"
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:
"
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:
"
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:
"
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:
"
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
"
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
"
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
"
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.
"
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.
"
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.
"
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.
"
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
"
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
"
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.
"
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.
"
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:
"
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
"
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.
"
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
"
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:
"
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
"
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 ------
"
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:
"
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 ------
"
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:
"
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:
"
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:
"
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:
"
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 ------
"
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:
"
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 ------
"
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:
"
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.
"
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:
"
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:
"
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.
"
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 ------
"
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:
"
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
"
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:
"
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
"
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 ------
"
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.
"
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 ------
"
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:
"
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:
"
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.
"
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
"
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
"
268,"title:
   respiratory care: atrovent nebs administered  @ 4:00 . bs are clear
   bilaterally in apecies with diminished bases. no adverse reactions
   following tx.
"
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:
"
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 ------
"
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:
"
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 ------
"
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:
"
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:
"
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:
"
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 ------
"
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 ------
"
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.
"
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
"
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.
"
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.
"
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
"
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
"
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
"
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 ------
"
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 ------
"
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.
"
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.
"
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.
"
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.
"
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
"
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:
"
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
"
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
"
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.
"
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.
"
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.
"
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.
"
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 ------
"
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.
"
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
"
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
"
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
"
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
"
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:
"
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
"
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
"
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.
"
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.
"
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.
"
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:
"
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.
"
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:
"
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
"
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
"
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
"
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
"
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.
"
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
"
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
"
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.
"
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.
"
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.
"
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:
"
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
"
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
"
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.
"
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.
"
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
"
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 ------
"
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 ------
"
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:
"
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.
"
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
"
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
"
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
"
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
"
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
"
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.
"
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
"
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
"
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
"
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
"
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:
"
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
"
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:
"
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
"
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
"
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
"
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 ------
"
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:
"
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:
"
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.
"
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:
"
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:
"
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
"
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.
"
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.
"
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
"
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
"
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.
"
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.
"
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
"
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
"
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
"
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
"
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
"
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.
"
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.
"
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.
"
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.
"
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:
"
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:
"
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:
"
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
"
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.
"
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.
"
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
"
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:
"
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 ------
"
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:
"
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:
"
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:
"
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
"
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
"
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:
"
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 ------
"
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 ------
"
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 ------
"
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
"
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:
"
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
"
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
"
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
"
397,"title:
   respiratory care: alb/atr nebs administered as ordered q 6hrs with no
   adverse reactions. bs are coarse bilaterally.
"
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
"
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
"
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 ------
"
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 ------
"
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.
"
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
"
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
"
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.
"
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 ------
"
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:
"
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
"
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
"
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
"
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.
"
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.
"
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.
"
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:
"
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:
"
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:
"
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.
"
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.
"
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.
"
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:
"
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.

"
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.


"
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.

"
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.

"
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.




"
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.

"
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.



"
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.

"
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.



"
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)

"
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.




"
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)

"
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)

"
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)

"
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.



"
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.


"
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.


"
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)

"
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.

"
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)

"
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.



"
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.



"
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.


"
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)

"
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)

"
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)

"
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.

"
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)

"
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.

"
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.


"
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.

"
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.






"
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)

"
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.

"
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.

"
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.


"
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.


"
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)

"
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.









"
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.

"
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.

"
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)

"
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.


"
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.

"
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.

"
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)

"
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.

"
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)


"
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.


"
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.


"
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.

"
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.

"
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.



"
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.



"
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.


"
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.


"
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.


"
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.



"
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)

"
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.

"
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**].


"
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.



"
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)

"
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**].


"
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)


"
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.


"
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**].


"
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.



"
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.



"
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.



"
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)

"
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.



"
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


"
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.


"
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.

"
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.


"
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)

"
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.



"
500,"[**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  21 year old man with
 reason for this examination:
  r/o inj
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: eez sat [**2185-1-29**] 12:58 am
  aorta ok. tiny, non-linear focus of decreased attenuation in posterior spleen,
  less than 1cm deep, too small to characterize by ct, but cannot exclude a
  small laceration. no perisplenic hematoma is present. no free fluid in abdomen
  or pelvis. no free air.
 ______________________________________________________________________________
                                 final report *abnormal!
 indication:    motor vehicle accident.

 technique: helically acquired axial images were obtained of the abdomen and
 pelvis from the lung bases to the pubic symphysis with 150 cc of optiray
 contrast.  there were no adverse reactions to contrast administration.
 multiplanar reformations were made.

 ct chest with contrast: the aorta is well opacified demonstrating no
 extravasation or contour abnormality. there is no aortic dissection or para
 aortic hematoma. age appropriate thymus tissue and a small pretracheal lymph
 node are present. evaluation of the lung parenchyma is limited due to
 respiratory motion but there are no gross consolidations or pulmonary
 contusions.  there is no pneumothorax. no rib fractures are seen.  there are
 no pleural or pericardial effusions.

 ct abdomen with contrast:  no hepatic lacerations or parahepatic hematoma is
 present.  there is no hematoma adjacent to the spleen but there is a tiny
 focal area of decreased attenuation along the posterior splenic border. no rib
 fractures are seen in this region.  there is no perisplenic hematoma. the area
 of decreased attenuation is too small to accurately characterize by ct, but
 overall depth is less than 1 cm.  the kidneys enhance symmetrically without
 evidence of obstruction or injury.  the adrenal glands, duodenum, pancreas and
 gallbladder are unremarkable.  intra abdominal loops are normal. there is no
 free air or free fluid within the abdomen or pelvis.

 ct pelvis with contrast: distal ureters are unremarkable. the bladder contains
 a foley catheter but is otherwise unremarkable. there is no free fluid in the
 pelvis or pelvic or inguinal lymphadenopathy.

 no fractures are seen.

 multiplanar reconstructions: coronal and sagittal reformats show no evidence
 of traumatic aortic injury.

                                                             (over)

 [**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report *abnormal!
 (cont)
 impression:
 1) no evidence of aortic injury.
 2) tiny focus of decreased attenuation in the posterior spleen, too small to
 characterize on ct.  there is no adjacent hematoma. overall depth of the area
 of decreased attenuation is less than 1 cm. a tiny laceration cannot be
 excluded.


"
501,"[**2198-2-14**] 8:31 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8085**]
 ct 150cc nonionic contrast
 reason: s/p fall, trauma, r/o internal injuries, abdominal distension
 field of view: 36 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with s/p fall
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  status post 20 foot fall.

 ct abdomen and pelvis with contrast:

 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 abdomen with iv contrast: there is no basilar pneumothorax. there is a
 small left lower lobe contusion vs atelectasis. no pleural or pericardial
 effusions are present. no hepatic or splenic lacerations are seen. the
 kidneys, pancreas, gallbladder, and stomach are unremarkable. there  is motion
 throughout portions of the scan, limiting evaluation somewhat. there is no
 free fluid in the abdomen or evidence of free intra- abdoimnal air. the bowel
 is unremarkable.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable. there is no free fluid in the pelvis.subcutaneous contusion
 is see in the right buttock region

 osseous structures:  bilateral nonunionized apophyses are present adjacent to
 the posterior acetabular rim. no acute fractures are seen.

 impression:   no evidence of acute intra-abdominal injury.  no fractures seen.


"
502,"[**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  59 year old man with
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications: trauma.

 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.  there were no adverse reactions to contrast administration.
 additional delay sequences of the superior mediastium and liver/spleen were
 acquired.

 ct of the chest with iv contrast: on the initial sequence, there is fluid
 density anterior to the distal ascending aorta.  on the delayed scan with a
 breath hold, this is not seen.  there is a small retrosternal hematoma, but
 the fat adjacent to the aorta is unremarkable. there is no evidence of
 extravasation of iv contrast from the aorta. on the reconstructed images, the
 aortic contours are smooth. there is no evidence of disssection.  there are
 areas of calcification in the aortic arch, and in the left subclavian artery.
 no pneumothorax is seen.  no focal pulmonary consolidations or contusions are
 seen.  there are no pleural or pericardial effusions.  no pathologically
 enlarged axillary, hilar, or mediastinal lymph nodes are seen.  no rib
 fractures are seen.  visualized portions of the clavicles and scapula appear
 intact.

 ct of the abdomen with iv contrast:  the liver and spleen are intact without
 focal laceration or adjacent hematoma.  the adrenal glands, pancreas, and
 kidneys show no evidence of acute traumatic injury.  there is no free
 intraabdominal air.  there is no free fluid within the abdomen or in the
 mesentery.  bowel loops are all normal in course and caliber.  the abdominal
 aorta is unremarkable.

 ct of the pelvis with iv contrast: the bladder contains a foley catheter with
 internal air.  there is no free fluid in the pelvis.  distal bowel is normal.

 bone windows: there is a comminuted fracture of the proximal right femur.
 within the proximal femoral diaphysis, there are three major fragments, one of
 which is anterior, the other lateral, and the final one is medial.  the
 lateral fragment is contiguous with the greater trochanter, femoral neck, and
 head. the anterior fragment is small and extends superiorly to the level of
 the femoral neck, where there is a small anterior cortical defect within the
 femoral neck, but no full thickness femoral neck fracture.  the smallest
 fragment is the medial fragment, which is highly comminuted, and it consists
 mostly of an avulsed lesser trochanter.  the left proximal femur is intact.
                                                             (over)

 [**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 osseous structures of the pelvis appear intact.  no spinal fractures are seen.
 note is made of a likely healed left 11th rib fracture laterally. there is
 extensive costal cartilage calcinosis.

 ct reconstructions:  coronal and sagittal reformations show a normal aortic
 contour.

 impression:
 1.  no aortic extravasation, periaortic hematoma, or dissection.
 2.  no evidence of acute traumatic intraabdominal injury.
 3.  comminuted fracture of the proximal right femur as described above.


"
503,"[**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  68 year old man pod#3 s/p r colectomy now with increasing o2 requirement,
  hypoxia, and tachycardia
 reason for this examination:
  evaluate for pulmonary embolism
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: oxygen requirement.  evaluate for pulmonary embolism.

 technique: axial images of the chest were aquired helically from the lung
 bases through 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 angiography of the pulmonary vessels.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:

 ct chest with iv contrast:  the pulmonary vasculature is well opacified and
 demonstrates no intraluminal filling defects suggestive of pulmonary emboli.
 there is extensive collapse/consolidation in both lower lobes. small bilateral
 pleural effusions are present. portions of the right lower lobe consolidation
 are more patchy, raising suspicion for pneumonia.  there is an additional
 dense consolidation in the dependent portion of the right upper lobe which is
 suspicious for aspiration or pneumonia.  there is fluid within the esophagus.
 numerous small mediastinal lymph nodes are seen which do not meet size
 criteria for pathological enlargement by ct scan. no pathologically enlarged
 axillar or hilar nodes are seen.  osseous structures are unremarkable. limited
 evaluation of upper abdominal structures shows possible fluid adjacent to the
 liver and a cystic structure immediately under the left hemidiaphragm which is
 not fully evaluated.

 ct reconstructions: multiplanar reformations show no evidence of pulmonary
 embolism.

 impression:
 1) no evidence of pulmonary embolism.

 2) bilateral pleural effusions with extensive consolidation in both lower
 lobes and the right upper lobe from aspiration or pneumonia.

 3) fluid filled esophagus. further evaluation with barium esophagram may be
 performed to evaluate for achalasia, stricture, or possible reflux.

 results were discussed with the surgical team at the time of interpretation.

                                                             (over)

 [**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)










"
504,"[**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
     66 year old man with persistent fevers, increasing abdominal pain, s/p
  ex-lap. also decreasing hematocrit.
 reason for this examination:
  evaluate for abscess/intra-abdominal infection, as well as source of bleeding.
  with po and iv contrast.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  fevers, increasing abdominal pain after exploratory laparotomy,
 decreasing hematocrit.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 findings:  comparison is made to the prior torso ct from [**12-28**] and the
 gallbladder ultrasound from [**2119-1-6**].

 ct of the abdomen with iv contrast:  there are moderate-sized bilateral
 pleural effusions with associated bibasilar atelectasis.  again identified is
 a likely cyst within the right posterior hepatic lobe inferiorly (segment vi).
 there is stable intrahepatic biliary ductal dilatation.  the gallbladder
 contains calcified stones and asymmetrical areas of wall thickening consistent
 with the previously seen adenomyomatosis.  the common bile duct remains
 prominent extending into the duodenum.  there is no stranding around the
 gallbladder.  the pancreas is unremarkable.  the adrenal glands and kidneys
 are unchanged.  within the posterior aspect of the spleen is a wedge-shaped
 focal area of decreased attenuation, which likely reprents an infarct.  the
 spleen has progressively enlarged over the past two ct scans, now measuring
 over 13 cm. the appearance of the stomach is unchanged. there is no evidence
 of bowel obstruction.

 ct of the pelvis with iv contrast:  again, there is a small amount of fluid in
 the pelvis, but no loculated pockets with enhancing rims or internal air to
 indicate an abscess.  multiple cecal diverticula are seen.  the appendix is
 visualized, and is filled with oral contrast, and normal.  again, there is a
 suggestion of cecal, and transverse colonic wall thickening.  again, these
 segments are not fully distended, limiting evaluation.  there is some ascites
 in the right inguinal fat-containing hernia.

 osseous structures:  no suspicious lytic or sclerotic lesions are present.

 impression:
                                                             (over)

 [**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 1) no definite intraabdominal abscess.  moderate bilateral pleural effusions
 with associated bibasilar atelectasis.
 2) progressive splenic enlargment compared to [**2118-12-28**] and [**2118-12-16**]. the spleen
 now measures over 13cm. findings are suspicous for possible lymphoma in the
 absence of other etiologies for splenic enlargement.

 results were discussed with dr. [**last name (stitle) 4478**] at 9:55 pm on [**2119-1-8**].

"
505,"[**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old woman with s/p intramural hemmorage in sigmoid
 reason for this examination:
  s/p intramural hemmorage in sigmoid-?resolved
 ______________________________________________________________________________
                                 final report
 indications:  status post intramural hemorrhage in sigmoid colon.  evaluate
 for resolution.

 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.  non-ionic contrast was used secondary to the patient's
 asthma history.  there were no adverse reactions to contrast administration.

 findings:  comparison is made with the study from [**2158-12-7**].

 ct of the abdomen with iv contrast:  no focal lung lesions are identified.
 there are no pleural or pericardial effusions.  no focal liver lesions are
 identified.  the spleen contains several punctate calcifications, likely
 calcified granulomas.  the adrenal glands, pancreas, stomach, and
 intraabdominal loops of small bowel are unremarkable.  there is a single focus
 of decreased attenuation in the lower pole of the left kidney which likely
 represents a simple cyst, and is unchanged in appearance since the prior
 study.  the kidneys otherwise enhance symmetrically without evidence of focal
 mass or obstruction.  there is no ascites or pathological mesenteric or
 retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast:  there has been marked reduction in the
 previously seen sigmoidal wall thickening.  extensive diverticular disease and
 likely muscular hypertrophy in the sigmoid colon, but there is no evidence of
 surrounding stranding to indicate acute diverticulitis.  the previously seen
 small amount of free fluid in the pelvis has also resolved. distal ureters and
 bladder are unremarkable.  there is no pathological pelvic lymphadenopathy.

 a small sclerotic focus is seen in the superior pubic ramus, which is likely a
 bone island.  additional sclerotic foci are seen in lower-thoracic vertebral
 bodies, which are also likely bone islands.  no suspicious lytic lesions are
 identified.

 impression:
 1) marked improvement in the previously seen sigmoidal wall thickening, and
 resolution of free fluid in the pelvis.  extensive diverticular disease is
 present, but there is no evidence of acute diverticulitis.

 2) tiny left renal cyst.

 3) multiple splenic granulomas.
                                                             (over)

 [**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)



"
506,"[**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  66 year old man with h/o gallstone/necrotizing pancreatitis and multiple
  drainage procedures
 reason for this examination:
  pancreatic protocol - renewed pancreatitis?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  history of necrotizing/gallstone pancreatitis.  evaluate for
 acute pancreatitis.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 comparison:  [**2107-2-10**] abdominal ct scan.

 findings:

 ct of the abdomen with iv contrast:  there are small bilateral pleural
 effusions, left greater than right, with associated compressive atelectasis of
 both lower lobes.  no focal liver lesions are identified.  the spleen, adrenal
 glands, kidneys, and stomach are unremarkable.  again seen are two drainage
 catheters in the region of the pancreas and a jejunostomy tube.  located
 immediately below the catheters are fluid pockets with internal air.  these
 appear slightly smaller than on the previous study.  only the head of the
 pancreas enhances. the degree of inflammatory change surrounding the pancreas
 has not changed appreciably. the fluid pocket adjacent to the tip of the
 pancreas extending inferiorly is unchanged.  the degree of abdominal
 stranding/fluid is unchanged.

 ct of the pelvis with iv contrast:  the distal ureters and bladder are
 unremarkable.  the bladder contains a foley catheter and internal air.  no
 sigmoid bowel wall thickening.  no pathologically enlarged inguinal or pelvic
 lymph nodes are seen.

 osseous structures are unchanged, again showing diffuse degenerative changes.

 impression:
 peripancreatic fluid collections with internal air slightly smaller adjacent
 to the two drainage catheters.  the degree of inflammatory stranding around
 the pancreas and in the abdomen has not changed significantly. only the
 pancreatic head enhances.

                                                             (over)

 [**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)


"
507,"[**2146-12-28**] 7:12 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8484**]
 ct 100cc non ionic contrast
 reason: trauma
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with mva
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  trauma.

 technique:  axial images of the abdomen and pelvis were acquired helically
 from the lung bases through the pubic symphysis with 150 cc optiray contrast.
 there were no adverse reactions to contrast administration.

 findings:

 ct of the abdomen w/iv contrast:  there is a small focal area of consolidation
 in the right lower lobe, medial basal segment.  no pleural or pericardial
 effusions are seen.  there is periportal edema, consistent with vigorous fluid
 resuscitation.  the liver is intact without evidence of laceration.  the
 spleen appears intact.  the adrenal glands, kidneys, pancreas, and duodenum
 are all unremarkable.  the gallbladder is normal.  there is a general lack of
 intra-abdominal fat, limiting sensitivity for mesenteric injury.  there is no
 free fluid in the abdomen.  no free air is seen.

 ct of the pelvis w/iv contrast:  the bladder contains a foley catheter and
 air.  sigmoid colon and rectum are unremarkable.  there is no free fluid in
 the pelvis.

 no pelvic fractures are seen.  note is made of a densely sclerotic area in the
 left femoral neck, which likely represents a bone island.  there is a
 diminutive first right lumbar rib.  no rib fractures are seen.

 impression:

 1. no evidence of acute traumatic intra-abdominal injury.
 2. likely diminutive right first lumbar rib. no acute fracture.


"
508,"[**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  62 year old woman with hx of bladder cancer with resection of tumor and
  retroperitoneal disection as well as chemotherapy.
 reason for this examination:
  pt with hx of bladder cancer with resection of right kidney and ureter as well
  as retroperitoneal dissection and has received chemotherapy now needs  ct of
  torso for staging.
 ______________________________________________________________________________
                                 final report
 indication:  renal cancer, status post resection of right kidney, ureter, and
 retroperitoneal dissection.

 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.

 comparison:  comparison is only able to be made to the study from [**2171-10-28**].  the more recent torso ct from [**2171-12-9**] is not available
 secondary to pacs malfunction.

 ct of the chest with iv contrast:  there are no pathologically enlarged
 axillary, hilar, or mediastinal lymph nodes.  there are no pleural or
 pericardial effusions.  again identified are multiple bilateral pulmonary
 nodules.  one previously seen nodule in the right lung base laterally is not
 visualized on the current study, but the largest nodule, in the left lung
 base, has increased in size.  the bronchi remain patent to the subsegmental
 levels.  the heart and great vessels is unremarkable.

 ct of the abdomen with iv contrast:  there has been marked progression of the
 patient's multiple hepatic masses.  there is some local biliary ductal
 dilatation adjacent to one of the masses in the right lobe.  surgical clips
 are seen in the right renal fossa from prior nephrectomy.  no soft tissue
 density suggestive of disease recurrence is present in this area.  there is a
 slight prominence of the first and second portion of the duodenum, but the
 bowel is not fully opacified, limiting evaluation.  the pancreas and adrenal
 glands, along with the spleen, and stomach are unremarkable.  the left kidney
 enhances uniformly.  there is no filling defect in the left renal pelvis or
 ureter.  no pathologically enlarged mesenteric or retroperitoneal lymph nodes
 are seen.  the descending aorta is calcified.  there is no ascites.

 ct of the pelvis with iv contrast:  the appearance of the cystic structure in
 the right adnexa is unchanged.  again seen is stranding in the presacral fat,
 likely post operative in nature, which is unchanged since [**2171-10-28**].
 the distal left ureter is unremarkable, with a normal appearing left ureteral
 jet.  the bladder is within normal limits.  there is no free fluid in the
 pelvis or pathological inguinal or pelvic lymphadenopathy, although multiple
                                                             (over)

 [**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 small pelvic nodes are seen which do not meet size criteria for pathological
 enlargement by ct scan.  the sigmoid colon and rectum are unremarkable.

 no new suspicious lytic or sclerotic osseous lesions are identified.

 impression:  progression of multiple intrahepatic masses, some of which are
 associated with localized biliary ductal dilatation.  no ascites.  enlargement
 of pulmonary nodule in left lung base.  findings all consistent with
 progression of disease.

"
509,"[**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   42 year old man with pod#10 s/p ex-lap, small bowel resection x4, found to
  have celiac sprue, t-cell lymphoma on path, now w/ temps post-op, and new pus
  draining from ex-lap wound.
 reason for this examination:
  evaluate for perforations, fluid collections, wound infection.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: celiac  sprue, multiple small bowel resections, now with post
 operative fevers, pus draining from exploratory laparotomy wound.  evaluate
 for intraabdominal abscess or perforation.

 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 contrast.  there were no adverse reactions to contrast
 administration.

 findings:  comparison is made to the study from [**2150-3-2**].

 ct abdomen with iv contrast: again seen is a rounded 4 mm nodule in the right
 lower lobe which is unchanged in appearance.  there is bibasilar atelectasis.
 no focal consolidations suggestive of pneumonia are present.  no focal hepatic
 lesions or splenic lesions are seen.  the pancreas and gallbladder are normal
 in appearance.  both adrenal glands and kidneys are unremarkable.  multiple
 surgical suture lines are seen throughout the small bowel.  there are multiple
 dilated small bowel loops, and enlarged mesenteric lymph nodes.  the
 appearance is unchanged since [**2150-3-2**]. there is no free intraperitoneal
 air. again seen is a heterogeneous area of attenuation in the anterior
 abdominal wall in between the rectus muscles, which measures 13 x 22 mm on
 today's study.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable.  again seen is a small amount of fluid adjacent to the
 sigmoid mesocolon which is slightly smaller than on the previous study.  no
 new intrapelvic abscess is present.  there is no pathologic inguinal or pelvic
 lymphadenopathy.

 impression: no new focal intraabdominal abscess.  stable appearance of
 multiple small bowel resections, with dilated small bowel loops and mesenteric
 lymphadenopathy.

                                                             (over)

 [**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

"
510,"[**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  32 year old woman with ard and pancreatitis s/p multiple medication overdose
 reason for this examination:
  please check pancreas for necorsis by pancreatitis protocol and evaluate lungs
  for ards
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  multiple medication overdose, with pancreatitis and acute
 respiratory distress.

 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 patient's debility.  there were no adverse reactions to
 contrast administration.

 findings:  reference is made to the portable ap chest x-ray from [**2167-2-16**].

 ct of the chest with iv contrast:  again seen are sternal wires.  the
 orogastric and post-pyloric feeding tubes in appropriate positions.  the
 endotracheal tube is present in satisfactory position.  there are extensive
 bilateral areas of ground-glass opacity and consolidation consistent with
 ards.  there are small bilateral pleural effusions.  no pericardial effusion
 is seen.  oral contrast is seen within the thoracic esophagus, suggestive of
 possible aspiration. there are multiple prominent mediastinal lymph nodes,
 which are likely reactive.

 ct of the abdomen with iv contrast:  no focal hepatic lesions are identified.
 the spleen, adrenal glands, kidneys, stomach, and intra-abdominal loops of
 small and large bowel are unremarkable.  the gallbladder is mildly distended,
 but there is no adjacent stranding to suggest acute cholecystitis.  the
 pancreas enhances symmetrically without adjacent fluid collection.  there is
 minimal stranding adjacent to the pancreatic tail, consistent with the
 patient's known pancreatitis.  there is no ascites or pathological mesenteric
 or retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast: the appendix, distal ureters, sigmoid
 colon, and rectum are within normal limits.  there is a small amount of free
 fluid within the pouch of [**location (un) **].  the bladder contains a foley catheter.
 there is no pathological inguinal or pelvic lymphadenopathy.

 no suspicious lytic or sclerotic osseous lesions are identified.

 impression:
                                                             (over)

 [**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 1)  stranding adjacent to the tail of the pancreas consistent with patient's
 known pancreatitis.  no peripancreatic fluid collection or hematoma or
 abnormal pancreatic perfusion.

 2)  ards.


"
511,"[**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  44 year old man with all s/p allo-bmt with likely cmv colitis here with new,
  diffuse abdominal tenderness.
 reason for this examination:
  eval for evidence of perforation, other pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 history:  all s/p bone marrow transplant. diffuse abdominal tenderness, likely
 cmv colitis.

 comparison:  no prior ct studies.

 technique:  helically acquired contiguous axial images of the abdomen and
 pelvis were obtained with intravenous optiray per cte  protocol.  however,
 oral contrast was not administered secondary to the patient's inability to
 tolerate po intake or an ng tube, due to esophageal ulcers.  coronal
 reconstructions were performed.

 contrast: 122 cc  of intravenous optray were administered through a right
 antecubital iv catheter. during the initial injection, a few cc's of optiray
 squirted out between the external portion of the iv catheter and the power
 injector tubing. there was no subcutaneous infiltration of optiray. the
 intravenous line remained patent, allowing for normal drawing back of blood
 and flushing with saline.  the power injector was reconnected to the iv
 catheter, and injection of optiray was continued without further
 complications. the intravenous line was removed immediately after the study to
 reduce the risk of infection.  there was no adverse reaction to optiray during
 or immediately following the study.

 abdomen ct with intravenous contrast:  several subcentimeter nodular opacities
 are present at the visualized lung bases.  the largest opacity in the right
 lower lobe measures 8 mm, and the largest opacity in the left lower lobe
 measures  5 mm.  there are no pleural effusions.

 there is diffuse wall thickening in the proximal small bowel, with associated
 stranding and small lymph nodes in the proximal mesentery.  both the proximal
 and distal small bowel is distended with fluid.  however, there is no wall
 thickening in the distal small bowel, including the terminal ileum.  this
 appearance is consistent with enteritis, which may be due to graft-vs-host
 disease or infection.

 there is a 2 mm appendicolith within the appendix.  the appendix does not
 contain any air.  it measures 8 mm in cross-section diameter at the level of
 the appendicolith, but appears smaller distal to the stone. the cecal tip
 appears mildly thickened. there is some periappendiceal stranding, which is
                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)
 less advanced than the stranding in the proximal small bowel mesentery. there
 is no periappendiceal free air or fluid collection. these findings are
 equivocal regarding the presence of appendicitis. there may be mild typhlitis
 at the cecal tip , consistent with graft-vs-host disease. serial clinical
 exams are suggested. if clinically indicated, repeat imaging of the appendix
 may be helpful.

 the remainder of the ascending colon and the transverse colon are distended
 with fluid, without wall thickening.  the descending and sigmoid colon are
 collapsed. there is no free air or free fluid. in addition to the previously
 described proximal mesenteric stranding and small mesenteric lymph nodes,
 there is stranding and small lymph nodes in the para-aortic retroperitoneum.
 the liver, gallbladder, spleen, pancreas, kidneys, adrenal glands and ureters
 are unremarkable.

 pelvis ct with intravenous contrast:  calcifications are seen within the
 prostate gland.  the bladder, seminal vesicles and rectum are unremarkable.
 there is no pelvic or inguinal lymphadenopathy. there is no free fluid.

 bone windows:  there are no suspicious lytic or sclerotic lesions within the
 visualized osseous structures.

 ct reconstructions:  coronal reconstructions confirm the presence of wall
 thickening in the proximal small  bowel, with adjacent mesenteric stranding.

 the findings were discussed with dr. [**last name (stitle) 104418**] at 11:40 pm on [**2140-4-5**].

 impression:

 1)  proximal enteritis, which may represent graft-vs-host disease or
 infection.

 2)  appendicolith.  the appearance of the appendix is equivocal for
 appendicitis.  there may be mild typhlitis. serial abdominal exams are
 suggested. if clinically indicated, repeated imaging of the appendix may be
 helpful.

 3) subcentimeter peripheral nodular opacities at both lung bases, which are
 nonspecific. follow-up is suggested.





                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)




"
512,"[**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  60 year old man with
 reason for this examination:
  fu aortic dissection and last week 4 d sx sob, chest pain radiating to back
 ______________________________________________________________________________
                                 final report
 indications: followup of aortic dissection. chest pain radiating to back.

 technique: contiguous axial images of the chest and abdomen were acquired
 helically from the lung apices through the proximal common iliac vessels,
 before and after administration of 150 cc of optiray contrast, secondary to
 the rapid bolus injection rate required for ct angiography of the aorta. there
 were no adverse reactions to contrast administration. coronal reformations
 were made.

 findings: comparison is made to the chest cta from [**2178-11-3**].

 ct chest with iv contrast:  again seen are changes from repair of a prior
 aortic dissection, with graft material extending from the aortic root to the
 proximal aortic arch. no extravasation is seen.  previously seen small amount
 of contrast in the false lumen and aortic arch is no longer present. the
 origins of the brachiocephalic, left common carotid, and subclavian arteries
 are all patent. no contrast is seen in the false lumen, until the dome of the
 right hemidiaphragm. there is a tiny circular area of contrast present which
 is not continuous with either the true lumen or the more inferiorly mixing
 contrast within the false lumen. there is symmetrical opacification of the
 true and false lumens by the level of the aortic hiatus in the diaphragm. the
 true lumen perfuses the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left renal artery is fed by both
 the true and false lumens.  the dissection flap extends into both common iliac
 vessels for a longer extent into the left than into the right. there is no
 peri-aortic hematoma or evidence of active extravasation. there are no pleural
 or pericardial effusions. emphysematous changes are seen in the lungs. again
 identified is a small, ill defined right middle lobe nodule which is unchanged
 in appearance. bibasilar atelectasis is seen.  no pathologically enlarged,
 axillary, hilar, or mediastinal lymph nodes are seen.

 ct abdomen with iv contrast: limited evaluation with only one phase of
 contrast shows no focal hepatic or splenic lesions. multiple bilateral renal
 cysts are present which are unchanged in appearance. visualized portions of
 intra-abdominal bowel loops are unremarkable.  the adrenal glands are normal.
 ct reconstructions: coronal reformats show a stable appearance of the aortic
 disection, without definite evidence of leak.

 impression:

 1. status post surgical repair of prior type a dissection. overall, appearance
                                                             (over)

 [**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 is unchanged compared to [**2178-11-3**].  the previously seen small amount of
 contrast in the false lumen in the aortic arch is no longer present.  the true
 lumen supplies the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left kidney is supplied from
 both the false and true lumen. there is a small rounded contrast pocket within
 the false lumen located slightly above the site of mixing, but this is not
 definitely connectable to either the true lumen, or to the mixing contrast.



"
513,"[**2129-10-30**] 1:23 pm
 cta head w&w/o c & recons; ct 150cc nonionic contrast           clip # [**clip number (radiology) 85922**]
 reason: ? bleed and emboli
 admitting diagnosis: pulmonary edema,dm
  contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   74 year old man with history of somnolence, now w/ acute delta ma, lethargy

 reason for this examination:
  ? bleed and emboli
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 indication:  acute mental status changes.  history of endocarditis.  evaluate
 for embolus or stroke.

 technique:  axial images of the brain were acquired before and after
 administration of 150 cc of optiray contrast.  nonionic contrast was used
 secondary to the rapid bolus infusion rate required for ct angiography.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:  comparison is made to the study from [**2129-10-16**].  again
 identified is an old left frontal lobe infarct.  there is no acute intra- or
 extra-axial hemorrhage, hydrocephalus, or shift of normally midline
 structures.  no areas of abnormal enhancement are present to suggest septic
 emboli.  there is no evidence of impending herniation.

 both internal carotid arteries are visualized.  there is moderate stenosis of
 the distal cervical portion of the right internal carotid artery, likely due
 to atherosclerotic disease, albeit this is a somewhat unusual locale.
 atherosclerosis seems more likely than dissection, as the vessel shows mural
 calcifications, and there is a history of diabetes as well. note is made of
 moderately stenotic left cavernous carotid artery.  the middle cerebral
 arteries to the level of the bifurcation, anterior communicating artery, and
 anterior cerebral arteries are unremarkable.  both vertebral arteries are
 patent.  the basilar artery is slightly small, but demonstrates good flow, and
 fills both posterior cerebral arteries, the proximal portions of which are
 normal.

 impression:  remote infarct of left frontal lobe.  atherosclerotic stenoses
 as noted above.


"
514,"[**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  55 year old woman with
 reason for this examination:
  55 yo female.  change in bowel habits.  unable to do colonoscopy secondary to
  adverse reactions to sedations.  request ct colonography to screen for colon
  ca.
 ______________________________________________________________________________
                                 final report
 indication:  recent change in bowel habits, unable to tolerate conventional
 colonoscopy secondary to adverse reaction to conscious sedation.  assess for
 colon cancer.

 technique:  contiguous axial images were obtained from the lung bases to the
 pubic symphysis after insufflation of intrarectal air in the prone and supine
 positions.  iv contrast was not administered.

 comparison:  ct abdomen/pelvis of [**2180-9-28**].

 ct colonography:  no suspicious lesions are seen.  there is no evidence of
 polyps, masses, strictures, or inflammatory disease.  there is a small amount
 of fluid within the cecum, descending colon and sigmoid which displaces with
 repositioning.  there is minimal retained fecal matter.

 ct of abdomen w/o iv contrast:  the imaged portions of the lung bases again
 show a 1-2 mm noncalcified nodule of the peripheral right lower lobe.  the
 liver, spleen, pancreas, adrenal glands, kidneys, and unopacified loops of
 small bowel are unremarkable.  there is no free air, free fluid, or
 lymphadenopathy.  the patient has had a previous cholecystectomy.

 ct of pelvis w/o iv contrast:  the rectum, urinary bladder and adnexal regions
 are unremarkable.  there is no free air, free fluid, or lymphadenopathy.

 bone windows:  there are no suspicious osseous lesions.

 multiplanar reformatted images and full endoluminal navigation performed in
 the antegrade and retrograde direction confirm and aid in the above findings.

 conclusion:
 1)  no significant polyp or mass identified (greater than 1 cm).  please note
 that the sensitivity of ct colonography for polyps greater than 1 cm is
 85-90%.  the sensitivity for polyps 6-9 mm is about 60-70%.  flat lesions may
 be missed with ct colonography.

 2)  stable 1-2 mm noncalcified nodule within the right lower lobe, likely
 representing a benign granuloma.  in the absence of any known primary
 malignancies, no further follow up is needed.

                                                             (over)

 [**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
                                 final report
 (cont)

"
515,"[**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  36 year old man with cerebral palsy, epilepsy and history of recurrent
  aspiration pneumonias now with fever, rll cavitation
 reason for this examination:
  please assess for lung abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  cerebral palsy, epilepsy, and history of recurrent aspiration
 pneumonia.  now with fever, and right lower lobe cavitation on chest x-ray.
 please assess for lung abscess.

 comparison:  no prior chest ct.  chest radiograph of [**2191-11-7**] is
 available for comparison.

 technique:  axial multidetector ct images were obtained from the thoracic
 inlet through the adrenal glands without intravenous contrast.

 chest ct without contrast:  there is extensive consolidation in the right
 middle and lower lobes.  evaluation of these areas is somewhat limited by the
 patient's body habitus, lack of intravenous contrast enhancement, and streak
 artifact from surgical hardware in the spine.  there is a large rounded cavity
 with irregular margins and a fluid level in the right lower lobe, which
 appears most consistent with an abscess.  there are necrotizing areas in the
 adjacent lung in the right lower and middle lobes.  no definite pleural
 disease is seen in this area or in the remainder of the thorax.  there are
 patchy peribronchiolar ground-glass opacities in the dependent portions of the
 left lung, suggestive of aspiration.  paraseptal emphysema is noted in the
 medial left lower lobe.

 the airways appear patent to the level of segmental bronchi.  there is no
 mediastinal or axillary lymphadenopathy.  the heart and great vessels appear
 unremarkable.

 there is high-density material layering within the gallbladder, suggestive of
 previously administered intravenous contrast.  the patient did not have any
 radiology studies with intravenous contrast at our institution. alternatively,
 this finding may represent unusually dense sludge or stones. clinical
 correlation is suggested. there is a hiatal hernia.  there are gas-distended
 bowel loops in the upper abdomen.  clinical correlation is suggested.
 evaluation of the visualized portions of the liver, spleen, pancreas, adrenal
 glands, and kidneys is limited by streak artifact from the [**location (un) 1354**] rod in
 the spine. no abnormalities are detected.  marked scoliosis is noted.

 the findings were discussed with dr. [**last name (stitle) 25949**] at 10:50 a.m. on [**2191-11-8**].

 impression:
                                                             (over)

 [**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
                                 final report
 (cont)

 1.  necrotizing right middle and lower lobe pneumonia with a large abscess in
 the right lower lobe.

 2.  patchy ground-glass opacities in the left lung, with appearance suggestive
 of aspiration.

 3.  dense material in the gallbladder, which may represent intravenous
 contrast or unusually dense sludge or stones.  contrast in the gallbladder
 could represent an adverse reaction to intravenous contrast, or it may be seen
 in renal failure.

 4.  gas-distented bowel loops, incompletely assessed. consider dedicated
 abdominal radiograph series.

 5.  hiatal hernia.


"
516,"[**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  72 year old woman pod4 from r. colectomy for cecal mass, now with fevers,
  tachycardia, incr abd distention, tenderness
 reason for this examination:
  assess for leak, collections
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  72-year-old female with abdominal distention.

 comparisons:  comparison is made to ct of the abdomen from [**2126-11-19**] and ct
 of the abdomen from [**2126-11-14**].

 technique:  ct of the abdomen and pelvis with oral and iv contrast.  150 cc of
 optiray 350 were administered without adverse reaction.

 coronal reconstructions were performed.

 ct of the abdomen with oral and iv contrast:  there are mild atelectatic
 changes in the right base.  there are no pleural effusions.  there is a small
 hiatal hernia.  there is no pericardial effusion.  the liver is slightly
 fatty.  however, there are no focal lesions.  there are two gallstones within
 the gallbladder.  there is no evidence of cholecystitis.  the spleen, adrenal
 glands are unremarkable.  there is a small hypodense area in the mid pole of
 the right kidney that was not completely evaluated in this study.  although
 statistically, it most likely represents a simple cyst, ultrasound could be
 performed to further evaluate this.

 there is a large transverse incision in the right aspect of the abdomen. there
 is fluid and air in the subcutaneous tissues, which could be postoperative.
 however, infection cannot be excluded on the basis of the ct scan.

 the proximal small bowel loops contain contrast and are dilated.  the distal
 small bowel loops are slightly decompressed.  however, there is contrast in
 the distal small bowel loops and the appearance most likely represents an
 ileus.  there are staples in the splenic flexure of the colon from prior right
 colectomy.  there are several slightly thickened small bowel loops, however,
 this appearance could be postoperative.  there is no evidence of free air or
 fluid collections within the abdomen.

 ct of the pelvis with oral and iv contrast:  there are multiple diverticula
 within the colon without evidence of diverticulitis.  as described above, the
 same postoperative changes are present in the pelvis.  there are also multiple
 mesenteric lymph nodes that are small and do not meet ct criteria for
 pathology.  there is no significant free fluid in the pelvis.  there is a
 foley catheter within the urinary bladder, which contains air.  the rectum is
                                                             (over)

 [**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
                                 final report
 (cont)
 unremarkable.

 bone windows:  there are no suspicious lytic or blastic lesions.

 impression:

 1.  postoperative changes as described above.  fluid and air in subcutaneous
 tissues could be postoperative, but infection cannot be excluded by ct scan.

 2.  mildly dilated loops of small bowel likely representing ileus.

 3.  multiple small mesenteric lymph nodes as described above.  they do not
 meet ct criteria for pathology and attention at followup is recommended.

 4.  multiple gallstones.

 5.  fatty liver without focal lesions in the liver.

 6.  diverticular disease without evidence of diverticulitis.

 7.  small hypodense area in the mid pole of the right kidney was not
 completely evaluated in this study.  although statistically, it most likely
 represents a simple cyst, ultrasound could be performed to further evaluate
 this.

"
517,"[**2113-7-18**] 7:48 am
 lumbar puncture                                                 clip # [**clip number (radiology) 42757**]
 reason: please do lumbar puncture, not cervical - ? cns infection
 admitting diagnosis: weakness
 ********************************* cpt codes ********************************
 * [**numeric identifier 2678**] lumbar spinal puncture          [**numeric identifier 2679**] fluoro guid for spine diag/the   *
 ****************************************************************************
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  78 year old man with waxing/[**doctor last name 561**] mental status - ? cns infection, unable to
  obtain lp.
 reason for this examination:
  please do lumbar puncture, not cervical - ? cns infection; please also note the
  patient should receive no benzos for sedation given prior adverse reactions.
 ______________________________________________________________________________
                                 final report
 indication:  78-year-old male patient with waxing and [**doctor last name 561**] mental status
 changes.  evaluate for cns infection.  referring service unable to obtain
 bedside lumbar puncture.

 radiologist:  drs. [**first name8 (namepattern2) 4228**] [**last name (namepattern1) 33771**] and [**first name8 (namepattern2) **] [**last name (namepattern1) 722**], the attending
 neuroradiologist, was present and supervising throughout the procedure.

 procedure and findings:  the risks and benefits of the procedure were
 discussed with the patient through a portuguese interpreter.  written informed
 consent was obtained.  a preprocedure timeout was performed using two patient
 identifiers.

 the patient was brought to the fluoroscopy suite and placed on the
 angiographic table in prone position.  the lower back was prepped and draped
 in the usual sterile fashion.  using fluoroscopic guidance in ap and lateral
 planes, a suitable location for lumbar puncture was identified at the l2-3
 level.  approximately 10 cc of 1% lidocaine was used for local anesthesia.
 using fluoroscopic guidance, a 22 gauge spinal needle was used to access the
 lumbar subarachnoid space at the l2-3 level.  approximately 12 cc (four tubes,
 2 cc, 3 cc, 3 cc and 4 cc) of clear cerebrospinal fluid was removed and
 submitted to the laboratory for requested diagnostic test.  the patient
 tolerated the procedure well without immediate complications.

 impression:  technically successful fluoroscopic guided lumbar puncture.  csf
 samples sent for laboratory analysis.

"
518,"[**2137-6-1**] 10:51 am
 mr hip w&w/o contrast left; mr 3d rendering w/post processing on independent wsclip # [**telephone/fax (1) 89222**]
 reason: preop planning - eval neurovascular structures, response to
  contrast: magnevist amt: 13
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  42 year old man with left posterior hip chondrosarcoma soft tissue recurrence
  s/p xrt/chemo
 reason for this examination:
  preop planning - eval neurovascular structures, response to tx
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  left posterior hip chondrosarcoma with soft tissue recurrence status
 post radiation therapy and chemotherapy.  preoperative evaluation.

 comparison:  mr thigh, [**2136-1-30**], and ct pelvis [**2137-4-29**].

 technique:  the following sequences of the pelvis and superior thighs were
 obtained on a 1.5 tesla magnet:  axial t1, axial t2, axial stir, coronal t1,
 axial 3d spgr pre- and post-contrast, coronal 3d spgr post-contrast, axial t1
 post-contrast with fat suppression.  gadolinium-dtpa was administered without
 adverse reaction.

 findings:

 the patient is status post left hip bipolar arthroplasty, and susceptibility
 artifact from the hardware slightly limits evaluation of the adjacent
 structures.

 again demonstrated centered within the gluteus muscles, especially the gluteus
 maximus, is a lobulated, multiseptated lesion which measures 14.0 x 7.2 x 18.2
 cm.  this lesion is predominantly hypointense on t1-weighted imaging with
 respect to the surrounding musculature and hyperintense on t2- weighted
 imaging.  post-contrast administration, there is predominantly peripheral rim
 enhancement with minimal internal enhancement of the septations.  given the
 lack of internal enhancement and predominantly fluid signal of the lesion, a
 large amount of necrosis is likely present in this mass.  no nodular
 enhancement is seen within the lesion.  this lesion drapes around the
 posterior aspect of the left ischial tuberosity, and extends along the course
 of the left sciatic nerve, which appears expanded and demonstrates
 heterogeneous high signal on t2-weighted imaging.  additionally, it appears
 that there is perineural extension of the tumor to involve the left s1, s2,
 and s3 nerve roots as they exit the neural foramina, as these nerve roots
 appear enlarged.  the extent of this mass overall appears grossly unchanged
 from the previous ct.

 subcutaneous edema is demonstrated within the scar in the left lateral
 proximal thigh.  edema is also seen along the superior fascial planes of the
 left hamstring muscles.  presacral edema is also present which crosses the
 midline and involves the right pelvis.

 there also appears to be abnormal signal involving the left piriformis and
                                                             (over)

 [**2137-6-1**] 10:51 am
 mr hip w&w/o contrast left; mr 3d rendering w/post processing on independent wsclip # [**telephone/fax (1) 89222**]
 reason: preop planning - eval neurovascular structures, response to
  contrast: magnevist amt: 13
 ______________________________________________________________________________
                                 final report
 (cont)
 obturator internus muscles, similar to the prior ct.

 visualized intrapelvic parenchymal structures appear grossly unchanged.  no
 pelvic or inguinal lymphadenopathy is demonstrated.

 the remaining bone marrow signal appears within normal limits.

 impression:

 1.  soft tissue recurrence involving the left pelvis and hip which appears
 predominantly necrotic in nature.  there is extension of tumor into the pelvis
 along the left s1 through s3 nerve roots to the left neural foramina, as well
 as along the entire course of the left sciatic nerve.

 2.  presacral edema extends to the right of midline.

"
519,"[**2104-8-26**] 12:26 am
 mr head w & w/o contrast                                        clip # [**clip number (radiology) 45621**]
 reason: 41 year old man with left thalamic brain mass
 admitting diagnosis: brain mass
  contrast: magnevist amt: 12
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  41 year old man with left thalamic brain mass
 reason for this examination:
  41 year old man with left thalamic brain mass
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jrci [**name2 (ni) 2384**] [**2104-8-26**] 5:44 pm
  mass centered within the left thalamus with extension into the brainstem most
  consistent with a glioblastoma multiforme.  metastasis, lymphoma and pnet also
  in the differential.
 ______________________________________________________________________________
                                 final report
 study:  mri head with and without contrast.

 indication:  41-year-old male with left thalamic brain mass.

 comparison:  ct head without contrast, [**2104-8-25**].

 technique:  sagittal short tr, a short te spin echo images were obtained
 through the brain.  axial imaging was performed with long tr, long te, fast
 spin echo, flair, gradient echo, and diffusion technique.

 contrast: 12 ml magnevist gallium base contrast material was administered
 without adverse reaction.

 findings:  a lesion centered within the left thalamus demonstrates thick-
 walled nodular enhancement with patchy enhancement centrally with predominant
 non- enhancement centrally.  the lesion measures 3.6 (cc) x 3.3 (ap) x 3 cm
 (tr). there is approximately 8 mm of rightward shift of midline of the massa
 intermedia at this level.  superior and rightward mass effect is demonstrated
 upon the ipsilateral lateral ventricle.  a relatively large region of high
 signal flair abnormality is detected associated with this lesion extending
 throughout the entire ipsilateral basal ganglia and into the surrounding
 corona radiata.  there is inferior extension of a predominantly nonenhancing
 portion of the lesion inferiorly into the mid brain and pons.  flair high
 signal abnormality is seen extending into the ipsilateral middle cerebellar
 peduncle.

 diffusion-weighted imaging demonstrates slow diffusion within the enhancing
 portion of the lesion which may suggest a component of high cellularity.
 within the nonenhancing portion, there is a predominant component of fast
 diffusion which is suggestive of necrosis.

 impression:
 1.  irregular rim-enhancing mass centered within the left thalamus with
 inferior extension into the brainstem.  the imaging characteristics including
 inferior extension favor a glioblastoma multiforme.  less likely in the
                                                             (over)

 [**2104-8-26**] 12:26 am
 mr head w & w/o contrast                                        clip # [**clip number (radiology) 45621**]
 reason: 41 year old man with left thalamic brain mass
 admitting diagnosis: brain mass
  contrast: magnevist amt: 12
 ______________________________________________________________________________
                                 final report
 (cont)
 differential are metastasis, lymphoma and pnet.

 of note, it has been shown that slow diffusion within the enhancing portion of
 a glioblastoma multiforme, as in this case, is associated with an aggressive
 behavior.




"
520,"[**2117-10-26**] 8:54 pm
 mr head w & w/o contrast; mr orbit w &w/o contrast              clip # [**clip number (radiology) 45362**]
 reason: evaluate for stroke, stenosis
 admitting diagnosis: stroke;telemetry;transient ischemic attack
  contrast: magnevist amt: 12
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  76 year old woman with sudden onset of right eye pain and visual blurring
 reason for this examination:
  evaluate for stroke, stenosis
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jrci wed [**2117-10-27**] 7:22 pm
  no evidence of infarction or orbital abnormality.
 ______________________________________________________________________________
                                 final report
 study:  mri brain and orbit.

 indication:  76-year-old female with sudden onset of right eye pain and visual
 blurring.

 comparison:  concurrent cta of the head and neck.

 technique:  sagittal short tr, short te spin echo images were obtained through
 the brain.  axial imaging was performed with long tr, long te, fast spin echo,
 flair, gradient echo, and diffusion technique.  short tr, short te spin echo
 imaging was repeated after intravenous administration of gadolinium-based
 contrast.  mri of the orbits was performed with coronal stir, axial and
 coronal precontrast t1w, and postcontrast fat-suppressed axial and coronal t1w
 images.

 contrast:  12 ml magnevist gadolinium based contrast material was administered
 without adverse reaction.

 mri head:  there is no evidence of hemorrhage, edema, masses, mass effect or
 infarction.  no diffusion abnormalities are detected. mild prominence of the
 sulci and ventricles is consistent with cerebral atrophy.  there is no flow
 void in the right internal carotid artery, corresponding to the occlusion
 demonstrated on the concurrent cta. a right frontal developmental venous
 anomaly is noted.  foci of high t2 signal in the subcortical, deep and
 periventricular white matter of the cerebral hemispheres, and in the right
 pons, likely correspond to chronic microvascular ischemic disease in a patient
 of this age.

 fluid and aerosolized secretions are present in the left maxillary sinus.

 mri orbits: coronal postcontrast images are limited by motion, but axial
 postcontrast images are diagnostic in quality. no abnormalities are detected
 in the orbits or cavernous sinuses. the optic nerves are normal in morphology
 and signal intensity.

 impression:

                                                             (over)

 [**2117-10-26**] 8:54 pm
 mr head w & w/o contrast; mr orbit w &w/o contrast              clip # [**clip number (radiology) 45362**]
 reason: evaluate for stroke, stenosis
 admitting diagnosis: stroke;telemetry;transient ischemic attack
  contrast: magnevist amt: 12
 ______________________________________________________________________________
                                 final report
 (cont)
 1.  occlusion of the right internal carotid artery, better demonstrated on the
 concurrent cta. no evidence of acute infarction.

 2.  chronic small vessel ischemic disease.

 3.  right frontal lobe developmental venous anomaly.

 4.  fluid and aerosolized secretions in the left maxillary sinus, which may
 indicate acute sinusitis.

 5.  normal appearance of the orbits.

"
521,"[**2100-8-24**] 11:19 am
 ct t-spine w/ contrast                                          clip # [**clip number (radiology) 31907**]
 reason: pls perform with and without contrast to r/o infection/abces
 admitting diagnosis: pancoast tumor/sda
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  60 year old man with t1-3 lami and removal of pancoast tumor w/ chest wall
  reconstruction.
 reason for this examination:
  pls perform with and without contrast to r/o infection/abcess include cervical
  spine c6 thru t6 s/p t1-3 lami pod#8
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 study:  ct c-spine with contrast and reconstructions.

 indication:  60-year-old male with t1 through t3 laminectomy and removal of
 pancoast tumor with chest wall reconstruction.  please evaluate for infectious
 process, fever.

 comparison:  ct thoracic spine without contrast [**2100-8-17**], mri
 thoracic spine [**2100-8-4**].

 technique:  multidetector ct axially acquired images were obtained of the
 thoracic spine after the uneventful intravenous administration of contrast
 material.  multiplanar reformatted images were obtained.

 contrast:  100 cc optiray 350 is administered without adverse reaction.

 findings:  soft tissue with minimal enhancement is present within the
 postoperative bed status post right partial laminectomies from t1 through t3.
 the soft tissue findings obliterate the right paraspinal musculature, however,
 not appreciably changed since comparison study from [**8-17**].

 two new right apically oriented chest tubes are present.  an endotracheal tube
 is present in standard position approximately 5 cm from the [**month (only) 5381**].  ng tube
 courses through the mediastinum into the stomach and out of the field of view.
 a surgical drain is noted in the right mediastinum in between the azygos vein
 and right pulmonary artery.  the medial aspect of the right pleural effusion
 demonstrates a new loculated appearance (2a:51).  overall, the right
 pleural effusion is slightly larger with little change to a tiny effusion on
 the left. there is a mild increase in the degree of atelectasis on the left.

 impression:

 1.  no appreciable change in soft tissue appearance within the post-surgical
 bed. findings are difficult to distinguish between purely postoperative change
 versus superimposed infection; however, no findings specific to infection are
 detected. mri with gadolinium versus labled white blood cell nuclear medicine
 scan may be of use as necessary.

 2.  right pleural effusion is slightly larger with appearance of new medial
                                                             (over)

 [**2100-8-24**] 11:19 am
 ct t-spine w/ contrast                                          clip # [**clip number (radiology) 31907**]
 reason: pls perform with and without contrast to r/o infection/abces
 admitting diagnosis: pancoast tumor/sda
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 loculated component.



"
522,"[**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  81 year old man with s/p mvc, ct without contrast showing ? hemothorax osh
 reason for this examination:
  please eval r/o intra thoracic injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: ipf [**doctor first name 137**] [**2161-10-15**] 8:48 pm
  right hemothorax with active extravasation from a branch of interal mammary
  artery.
  stranding in the mediastinum.
 ______________________________________________________________________________
                                 final report
 ct of the chest with contrast, ct of the abdomen with contrast, ct of the
 pelvis with contrast, [**2161-10-15**] at [**2086**] hours

 history:  post-trauma from motor vehicle collision with outside hospital
 non-contrast ct demonstrating a large hemothorax.  assess for thoracic
 vascular injury.  the patient is now hypotensive with hematocrit drop.

 technique:  serial transverse images were acquired sequentially during the
 arterial phase administration of 80 ml of optiray 350.  no adverse reaction
 was encountered.  multiplanar reformatted images were generated.

 comparison:  non-contrast torso ct obtained earlier same day from outside
 hospital and uploaded to local pacs.

 findings:  similar to the prior study performed without contrast, there is a
 large anterior extrapleural collection in the right hemithorax.  with the
 benefit of contrast, it is markedly heterogeneous with large areas of fluid
 attenuation, a high-attenuation fluid-fluid level, surrounding rim
 enhancement, and multiple foci of active extravasation of vessels.  one of the
 larger foci of active extravasation is seen on series 2 image #74.  this is at
 the level of a non-displaced transverse fracture of the distal sternal body.
 foci of active extravasation are also seen at slightly more cephalad levels
 including at the inferior margin of the second sternocostal junction and at
 the inferior margin of the first sternocostal margin all along the course of
 the right internal mammary artery.  these are presumed extravasations off
 direct branches from that vessel, likely the proximal aspects of the
 corresponding intercostal vessels.  a component of this large extrapleural
 hematoma extends along the retrosternal space anterior to the mediastinum and
 heart.  a corresponding anterior mediastinal hematoma is also present.  no
 aortic injury is identified.  there is mass effect on the heart, specifically
 the anterior aspect of the heart, principally the right ventricle.

 in addition to the large extrapleural anterior hematoma, there is a relative
 large free-flowing dependent hemothorax with a hematocrit level layering
 posteriorly in the right hemithorax.  the combination of both of these
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)
 hematomas, results in significant mass effect on the underlying lobes of the
 right lung with compressive atelectasis seen both in the right upper, right
 middle and right lower lobes.  a small effusion is identified on the left.
 there is calcification over the apex of the right lung, presumably along the
 visceral pleura.  no pneumothorax is present.  there are no focal
 consolidations or areas of pulmonary contusion identified.

 the study was acquired predominantly in expiratory phase with inward bowing of
 the posterior membrane of the trachea and the major bronchi.  however,
 otherwise the major airways are widely patent.  incidental note is made of an
 aortic origin of the left vertebral artery, an anatomic variant.  the aorta
 otherwise is intact with normal contour, caliber and course.  there is
 scattered calcified plaque seen at multiple levels.  there is no apparent
 aortic injury.  there is fullness in the supraclavicular space on the right.
 this is incompletely evaluated on this chest ct protocol.

 timing was not optimized for solid organ evaluation given the concern for
 vascular injury.  however, grossly there are no discrete traumatic lesions of
 the solid abdominal organs of the upper abdomen.  a focal curvilinear
 calcification in the right hepatic lobe likely is reflective of prior
 granulomatous insult.  there is a high-attenuation focus in the most inferior
 tip of the right hepatic lobe.  this is most reminiscent of a flash-filling
 hemangioma although focal nodular hyperplasia or adenoma may also be
 considered.  gallbladder is present but otherwise unremarkable.  bilateral
 kidneys enhance symmetrically.  there are small cortical scars on both kidneys
 presumably due to prior infection.  conceivably, these may reflect prior small
 infarcts as well.  a 10 mm x 30 mm hypoattenuated lesion is identified
 anteriorly in the pancreatic body.  this is incidental and not related to
 trauma.  no pancreatic ductal dilatation is evident.

 the stomach and small bowel are largely collapsed.  no wall thickening or
 dilatation is evident.  a normal appendix is identified.  there is scattered
 stool throughout the colon.

 similar to the chest, there is scattered calcified and non-calcified plaque of
 the abdominal aorta and major branch vessels.  eccentric irregular plaque is
 identified at the bifurcation of the right common iliac artery.  no pathologic
 lymphadenopathy is seen within the abdomen or pelvis.  there is no free
 intraperitoneal fluid or air.

 the urinary bladder is markedly distended.  there is an enlarged prostate.
 the enlargement of the prostate is relatively non-uniform with an irregular
 focus of enlargement centered at left of midline causing mass effect on the
 base of the bladder.  there is no apparent invasion.  however, given the
 relative morphology of the enlarged prostate, an underlying mass lesion such
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)
 as prostate cancer cannot be excluded.  seminal vesicles image normally.

 osseous structures:  aside from the non-displaced horizontal fracture through
 the distal sternal body described above, no further fracture of the chest,
 abdomen, or pelvis is identified.  there are no suspicious osseous lesions.
 multilevel degenerative disease is seen principally in the upper lumbar spine
 and in the mid lower thoracic spine.

 impression:

 1.  there is active extravasation of the medial branches of the right internal
 mammary artery into a large presumed extrapleural anterior right hemithorax
 hematoma.  there is some element of tamponade of this hematoma and a portion
 of it does extend along the retrosternal space.  there is minimal at this
 point mass effect on the underlying heart.

 2.  no apparent aortic injury.  no obvious cardiac injury; however, the
 evaluation for such is limited on ct.

 3.  large layering hemothorax posteriorly in the right chest as well.  small
 pleural effusion on the left.

 4.  as above, a non-displaced transverse distal sternal body fracture.  this
 coincidentally occurs at the site of the largest focus of extravasation
 detailed above.

 5.  no evidence of acute solid organ injury in the abdomen or pelvis.  there
 may have been prior infections or infarcts of the kidneys as detailed above.

 6.  enlarged and irregularly shaped prostate.  underlying prostate cancer
 cannot be excluded.  appropriate workup after acute presentation is resolved,
 may be pursued.

 7.  hypoattenuated lesion of the pancreas, nontraumatic in etiology.  further
 evaluation after emergent conditon is addressed should be pursued with
 referral to pancreas center and likely abdominal mri (without
 contraindication).

 the emergent results of the study were immediately placed on the ed dashboard
 as a wet read.  the study was also reviewed in person with surgical consult,
 dr. [**first name4 (namepattern1) 1688**] [**last name (namepattern1) 2723**], of the trauma surgery team at approximately 9 p.m.
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)

"
523,"[**2165-10-27**] 2:52 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 50239**]
 reason: pe?
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  83 year old man with pleuritic chest pain and dyspnea, positive d-dimer.
  creatinine 1.6, baseline. hydrating.
 reason for this examination:
  pe?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sun [**2165-10-27**] 3:42 pm
  1. no pe or acute aortic syndrome.
  2. small (7-8 mm thick) pericardial effusion; may represent pericarditis in
  the setting of pleuritic chest pain; no compression of heart [**doctor last name 4473**] to
  suggest tamponade at this time.
  3. trace r and small l pleural effusions w/ associated atelectasis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with pleuritic chest pain and dyspnea.

 study:  chest cta.

 mdct images were generated through the chest without iv contrast.  subsequent
 mdct images were generated through the chest after administration of 100 cc of
 optiray intravenous contrast in the pulmonary arterial phase.  there is no
 adverse reaction or complication.  coronal, sagittal, and right and left
 oblique reformatted images were also generated.

 comparison:  v/q scan from [**2165-10-3**].

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.

 the aorta is of a normal caliber along its course without evidence of
 intramural hematoma or dissection.  minimal calcified atherosclerotic disease
 is seen in the aortic arch.  the pulmonary artery is of a normal caliber at
 its origin and there are no filling defects to the subsegmental level.
 coronary artery calcifications are seen bilaterally.  a small pericardial
 effusion is present, measuring up to 7 mm in thickness in the axial plane.
 subtle stranding is seen in the adjacent mediastinal fat.  the heart [**doctor last name 4473**]
 do not yet show evidence of compression.  bilateral pleural effusions are
 seen, trace on the right and small on the left, with associated atelectasis.
 otherwise, the lungs are clear.

 visualized portion of the upper abdomen shows no gross abnormality.  the
 previously described opacity in the posterior base of the lung still may
 represent an eventration versus a diaphragmatic hernia.

 the visualized bones demonstrate moderate degenerative changes of the thoracic
 spine, but there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2165-10-27**] 2:52 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 50239**]
 reason: pe?
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 1.  no pe or acute aortic syndrome.
 2.  pericardial effusion with surrounding inflammation, compatible with
 pericarditis.
 3.  small left and trace right pleural effusions with associated atelectasis.

"
524,"[**2144-9-7**] 10:05 am
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 25226**]
 reason: r/o pe
 admitting diagnosis: pancreatitis
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  60 year old man with asthma, factor v leiden p/w etoh vs stone pancreatitis,
  transferred from osh with hypoxia, tachycardia
 reason for this examination:
  r/o pe
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2144-9-7**] 12:55 pm
  1.  pe involving the right lower lobe branch of the pulmonary artery without
  evidence right heart strain.  this finding was communicated to [**first name8 (namepattern2) 490**] [**last name (namepattern1) 1021**]
  at 12:27 p.m. on [**2144-9-7**] but [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
  2.  bilateral moderate pleural effusions with compressive atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with asthma, factor v leiden deficiency, now with
 pancreatitis; now with hypoxia and tachycardia.

 study:  chest cta; mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after the
 administration of 100 ml of intravenous contrast without complication or
 adverse reaction.  coronal, sagittal as well as right and left oblique
 reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.

 the pulmonary arterial trunk is of a normal caliber at its origin.  the
 pulmonary artery is of a normal caliber at its origin.  filling defect is
 noted at the right lower lobe branch of the pulmonary artery, which extends
 into the posterior basal, lateral basal, and anterior basal segments.

 the aorta is of a normal caliber along its course and shows no evidence of
 dissection or intramural hematoma.  there is no pericardial effusion. there is
 no inward bowing of the intraventricular septum into the left ventricle to
 suggest right heart strain.

 the visualized portion of the right lower lobe lung parenchyma shows no
 evidence of infarct.  a small area of ground-glass opacity is seen in the
 right upper lobe.  moderate bilateral simple pleural effusions are seen with
 associated compressive atelectasis.

 the visualized portion of the upper abdomen shows no overt abnormality.

 the visualized portion of the bones show no aggressive-appearing lytic or
 sclerotic lesions.
                                                             (over)

 [**2144-9-7**] 10:05 am
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 25226**]
 reason: r/o pe
 admitting diagnosis: pancreatitis
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 1.  pe involving the right lower lobe branch of the pulmonary artery without
 evidence right heart strain.  this finding was communicated to [**first name8 (namepattern2) 490**] [**last name (namepattern1) 1021**]
 at 12:27 p.m. on [**2144-9-7**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
 2.  bilateral moderate pleural effusions with compressive atelectasis.
 3.  small right upper lobe opacity - inflammatory versus infectious etiologies
 may be considered.

"
525,"[**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old man with group g strep sepsis and unknown source
 reason for this examination:
  abscess?  gi pathology which might cause bacteremia?
 contraindications for iv contrast:
  esrd, gets hd on mondays, needs to have hd after scan;esrd, hd on mondays
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2186-7-31**] 11:56 pm
  1. no acute intra-abdominal process.
  2. ragged appearance of l4-l5 intervertebral disc endplates - this can be seen
  in discitis - correlate with patient's clinical condition.
 pfi version #1 jekh mon [**2186-7-31**] 12:59 pm
  no acute intra-abdominal process; specifically no evidence of a bacteremic
  source.
 ______________________________________________________________________________
                                 final report
 history:  45-year-old male with group g strep sepsis, an unknown source.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was given without complication or adverse reaction.
 coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  visualized portion of the lung bases appears unremarkable.

 the liver shows no focal lesion or biliary duct dilation.  the gallbladder is
 decompressed.  the spleen is normal in size and appearance.  pancreas shows no
 surrounding fluid collection.  the adrenal glands are normal appearing
 bilaterally.

 the kidneys enhance with and excrete contrast symmetrically without evidence
 of hydronephrosis or perinephric fluid collection.  in the inferior pole of
 the right kidney is a hypodensity that is too small to characterize but likely
 represents a simple cyst.

 the small and large intestine show no evidence of obstruction or wall edema.
 the appendix is visualized and is normal.  there is no free air, free fluid,
 or lymphadenopathy.

 pelvis:  the bladder, prostate, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.

 bones:  there are no aggressive appearing lytic or sclerotic lesions.
 moderate degenerative changes are seen throughout the lumbar spine.  anterior
                                                             (over)

 [**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 osteophytes are also noted throughout the lumbar spine.  at the l4-l5 level,
 there is enplate sclerosis, likely degenerative, however there is ragged or an
 erosive/destructive appearance to the adjacent endplates with mild soft tissue
 prominence anteriorly.

 impression:
 1. no acute intra-abdominal or intra-pelvic process.
 2. abnormal appearance of l4-l5 level, as described above, concerning for
 discitis/ostemyelitis - correlate with patient's clinical condition.

 findings discussed with [**first name8 (namepattern2) **] [**last name (un) 29352**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone at 8:49 am
 on [**2186-8-1**].

"
526,"[**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old man with fall from roof, unequal bps
 reason for this examination:
  pls evaluate aortic arch
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2189-8-17**] 4:50 pm
  chest:
  1. 50% r anterior ptx w/ mediastinal shift and compressive effects on both
  lungs; r chest tube enters low and is oriented in posterior pleural space
  (away from ptx).
  2. no l ptx.
  3. no aortic or injury.
  4. extensive r chest wall emphysema.
  5. r posterolateral rib fx [**3-24**]; l posterolateral rib fx [**8-24**]; r clavicle fx.

  abdomen/pelvis:
  1. worsening hepatic and splenic lacerations w/ growing perihepatic and
  perisplenic hematomas - active extrav around spleen; small amt blood tracking
  along b paracolic gutters.
  2. prominent r adrenal gland - ? hematoma.
  3. no free intraabdominal air.
  4. extensive r abd/flank wall emphysema extending into r groin; early r flank
  hematoma.
  5. no spine or pelvic fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  75-year-old male with fall off roof of rv.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was given without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  torso ct from [**2189-8-17**], from an outside hospital at
 1304.

 findings:

 chest:  the patient is intubated with the tube terminating in the mid trachea.
 there is a pneumothorax involving 50% of the right hemithorax and is situated
 mostly anteriorly.  a chest tube placed on the right exists in the posterior
 pleural space, but does not come in contact with this pneumothorax.  there is
 severe mass effect on the right lung, mediastinum and left lung, consistent
 with tension pneumothorax.  additionally, extensive pneumomediastinum and
 pneumopericardium is noted.  both lungs demonstrate extensive atelectasis
 primarily in their lower lobes.  the heart shows no pericardial effusion.
 there is no mediastinal hematoma.  the aorta demonstrates no evidence of
                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 dissection.  there is no contrast extravasation.  extensive chest wall
 emphysema is demonstrated.

 abdomen:  multiple liver lacerations are demonstrated in segments v, vi, vii
 and viii with surrounding dense fluid around the liver and tracking along the
 right paracolic gutter.  a single focus of peripheral contrast blush is
 demonstrated in segment viii (2; 41), concerning for active extravasation.
 this appearance appears worse and has progressed from prior ct.

 multiple splenic lacerations are demonstrated with a growing surrounding
 splenic hematoma.  additionally, multiple areas of contrast blush are noted,
 concerning for active extravasation.  this fluid tracks along the left
 paracolic gutter.  this too represents an increase from prior study.

 thickening of the head of the right adrenal gland is compatible with hematoma.

 the kidneys enhance with and excrete contrast symmetrically.  there are no
 perinephric fluid collections.  pancreas appears unremarkable.  the small and
 large intestine show no evidence of obstruction or wall thickening.  there is
 no free air.  the abdominal aorta is intact.

 continued subcutaneous emphysema and a developing right flank hematoma are
 demonstrated along the right abdominal wall.

 pelvis:  the bladder contains locules of gas and a foley balloon.  the
 prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.  gas tracking along the right abdominal wall tracks down into
 the right groin.

 bones:  multiple segmental fractures are demonstrated in the right
 posterolateral ribs from the third rib through the twelfth rib; there is
 additionally a fracture of the right clavicle.  multiple posterolateral rib
 fracture is also noted in the left ribs 9 through 12 although they appear to
 be older in age.  no acute left rib fracture is seen.  no spinal fracture is
 demonstrated.  the sternum is intact.  the pelvis is intact.  a total hip
 arthroplasty on the left is in place without evidence of periprosthetic
 fracture or loosening.

 impression:
 1.  right tension pneumothorax; right chest tube and posterior pleural space,
 not evacuating this pneumothorax; mediastinal deviation and compression of the
 right and left lungs are concerning for tension pneumothorax.
 pneumomediastinum and pneumopericardium is also present along with extensive
 right chest and abdominal wall subcutaneous emphysema extending into the
 groin.

                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  extensive hepatic and splenic lacerations with growing perihepatic and
 perisplenic hematomas with areas concerning for active extravasation.

 points 1 and 2 were called to or 15 at the time of dictation to make the
 operating team aware.

 3.  multiple segmental rib fractures on the right; the potential for flail
 chest exists.  right clavicular fracture.

 4.  right adrenal hematoma.

"
527,"[**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  36 year old woman with hemorrhagic pancreatitis s/p ercp for choledochal cyst
  s/p ex-laps/washouts, perc drain drain removed on [**2129-10-10**].
 reason for this examination:
  please do a ct scan of the abdomen and pelvis w/ oral and iv contrast to assess
  for recurrent collection. patientis having ongoing pain. please page dr. [**first name8 (namepattern2) **]
  [**last name (namepattern1) 1350**] w/ a wet read, thanks.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  36-year-old female with choledochal cyst status post ercp,
 complicated by hemorrhage pancreatitis and persistent fluid collection, now
 with percutaneous drain removed with recurrent abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; optiray 350 intravenous
 contrast was administered without complication or adverse reaction.  coronal
 and sagittal reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis with contrast from [**2129-8-26**].

 findings:

 abdomen:  the visualized portion of the lungs appears unremarkable.

 the liver demonstrates no defined hypodensity measuring 15 x 9 mm in the axial
 plane (4; 15), which is incompletely characterized but similar appearance to
 prior study.  again is seen fusiform aneurysmal dilatation of the cbd
 measuring 39 x 20 mm in the axial plane, compatible with a type 1 choledochal
 cyst.  the gallbladder is decompressed.  the spleen, pancreas and adrenal
 glands appear unremarkable.

 multiple fluid collections are seen in the abdomen.  two fluid collections
 just beneath the hepatic flexure of the colon are seen measuring 22 x 15 and
 44 x 11 mm in the axial plane (4; 33).  these are slightly decreased in size
 when compared to prior study.  further down in the right mid to lower abdomen
 is a larger fluid collection measuring 44 x 25 mm in the axial plane; two
 smaller fluid collections are seen lateral to it measuring 16 x 14 mm (4; 43)
 and 18 x 13 mm (4; 45).  these fluid collections are thick rimmed and
 peripherally enhancing.  there is extensive inflammatory fat stranding around
 them.  there is extensive right colonic wall thickening and pericolonic
 stranding, compatible with reactive change.  additionally, reactive fluid
 stranding around the right kidney represents reactive change.  there is no
 free air.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  no free fluid
 or lymphadenopathy is seen.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 multiple abdominal fluid collections as described above, concerning for
 abscesses, the largest of which measures 4.4 x 2.5 cm in the axial plane and
 is amenable to percutaneous drainage from an anterior approach.  these
 findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 1350**] at 16:40 on [**2129-10-18**] by [**first name8 (namepattern2) 405**]
 [**last name (namepattern1) 406**] over the phone.

"
528,"[**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  51f s/p polytrauma, mult bilateral rib fx, bilateral ptx, now with bilateral
  chest tubes
 reason for this examination:
  pls assess residual ptx
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh tue [**2116-10-27**] 3:46 pm
  pfi:
  1.  worsening bilateral pneumothoraces; chest tubes within the major fissures
  bilaterally, but the right one has a side hole outside of the chest cavity.
  significant collapse of portions of the right upper and right lower lobes.
  extensive chest wall emphysema.
  2.  unchanged bilateral rib and lumbar transverse process fractures; complex
  pelvic fracture better evaluated on pelvic ct performed on same day.
  minimally displaced sternal fracture.
  3.  retroperitoneal and right paracolic fluid; thickening of the cecal wall
  likely represents an injury to the bowel, such as bowel wall hematoma.
  4.  no evidence of left renal injury.
 pfi version #1 jekh tue [**2116-10-27**] 2:51 pm
  pfi:
  1.  worsening bilateral pneumothoraces; current chest tubes still within the
  major fissures bilaterally.  significant collapse of portions of the right
  upper and right lower lobes.
  2.  unchanged bilateral rib and lumbar transverse process fractures; complex
  pelvic fracture better evaluated on pelvic ct performed on same day.
  minimally displaced sternal fracture.
  3.  retroperitoneal and right pericolic fluid extending from the pancreatic
  head, likely representing an injury in that location; thickening of the cecal
  and internal ileal walls either represents reactive changes from the
  aforementioned fluid versus an injury to the bowel:
  4.  no evidence of left renal injury.
 ______________________________________________________________________________
                                 final report
 history:  a 51-year-old female with multiple traumatic injuries including
 bilateral pneumothoraces with chest tubes.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  trauma torso ct from [**2116-10-25**].

 findings:

 chest:  the patient is still intubated with the endotracheal tube in
 appropriate position.  an endogastric tube courses inferiorly to the distal
                                                             (over)

 [**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 esophagus (2; 48).

 bilateral chest tubes are seen, both entering the major fissures; the right
 one has a side hole outside of the chest cavity (2;23).  bilateral
 pneumothoraces have increased significantly from prior study, now encompassing
 40% of the right hemithorax and about 20% of the left hemithorax. neither
 chest tube sits within the pneumothoraces which are both positioned
 anteriorly, extensive subcutaneous gas has progressed tracking along the
 anterolateral chest wall.  there is no mediastinal shift or diaphragmatic
 flattening.  there is significant atelectasis of the right upper and right
 lower lung lobes.

 there is no pleural or pericardial effusion.  the aorta appears intact.
 minimal mediastinal hematoma persists in the region of a minimally displaced
 sternal fracture (2; 31).

 abdomen:  there is no perihepatic or perisplenic fluid.  the gallbladder
 demonstrates vicarious contrast excretion, indicating a degree of renal
 failure.  the adrenal glands are normal bilaterally.  the previously described
 suspected left lower pole renal contusion has resolved.

 the pancreas appears intact.  there continues to be retroperitoneal fluid
 extending from the head down to the right flank/paracolic gutter.  this fluid
 is not increased from prior study.  there is thickening of the cecal wall,
 possibly represent an injury to the bowel in that locale.  there is no free
 air.

 the previously described subcutaneous emphysema in the chest extends down into
 the left flank.

 pelvis:  streak artifact from external pelvic fixation hardware limits
 assessment of fine detail of the pelvis.  within that limitation, the bladder
 is somewhat decompressed around a foley balloon.  there continues to be a
 fibroid uterus and the rectum is unremarkable.  there is still a small amount
 of free fluid in the pelvis.  additionally, there is subcutaneous gas in the
 right inguinal region as well as anterior to the pubic symphysis, likely the
 sequelae of hardware placement.

 bones:  again multiple rib fractures are seen affecting the anterolateral
 portions of the right first through seventh ribs and the left first through
 eighth ribs.  the previously described fracture of the right clavicle is not
 well visualized on the current study.  again seen are left transverse process
 fractures of the left lumbar vertebrae, first through fifth.  again seen is a
 severe pelvic fracture with significant displacement about the pubic symphysis
 and right sacroiliac joint and comminuted fracture fragments at the right
                                                             (over)

 [**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 iliac crest.  this structure is better evaluated on the pelvic ct performed on
 the same day in which specific bone algorithms were used.

 impression:
 1.  worsening bilateral pneumothoraces.  this finding was discussed with
 [**first name8 (namepattern2) 2763**] [**last name (namepattern1) 2764**] at 11:42 am on [**2116-10-27**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
 2.  chest tubes within the major fissures bilaterally, but the right one has a
 side hole outside of the chest cavity.  significant collapse of portions of
 the right upper and right lower lobes.  extensive chest wall emphysema.
 3.  unchanged bilateral rib and lumbar transverse process fractures; complex
 pelvic fracture better evaluated on pelvic ct performed on same day. minimally
 displaced sternal fracture.
 4.  retroperitoneal and right paracolic fluid and thickening of the cecal
 wall is compatible with contusion. there is no free air to suggest perforation
 5. no evidence of left renal or pancreatic injury.

 findings 2, 4, and 5 were discussed with [**first name4 (namepattern1) 1789**] [**last name (namepattern1) 4749**] at 15:53 on [**2116-10-27**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


"
529,"[**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old woman with ho diverticulitis with abd pain ttp llq
 reason for this examination:
  pls eval ro acute proc
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**hospital 5197**] fri [**2163-8-19**] 12:03 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 wet read version #1
 wet read version #2 [**first name9 (namepattern2) 5197**] [**doctor first name 73**] [**2163-8-18**] 8:16 pm
  s/p partial colectomy; no diverticulitis or abscess.

 ______________________________________________________________________________
 provisional findings impression (pfi): [**year (4 digits) 5197**] fri [**2163-8-19**] 12:02 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 ______________________________________________________________________________
                                 final report
 history:  75-year-old female with a history of diverticulitis, now with left
 lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with iv contrast; 130 cc of optiray
 intravenous contrast was given.  there was no adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases demonstrate a 6 mm pulmonary nodule.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder is distended but shows no stones or wall edema.  the spleen is
 normal in size.  the pancreas shows no masses.  bilateral adrenal nodules,
 each about 1 cm, are incompletely characterized.  the kidneys enhance with and
 excrete contrast symmetrically.  at the superior pole of the left kidney is a
 well-circumscribed hypodensity measuring 3 cm in diameter, most compatible
                                                             (over)

 [**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 with a simple cyst.

 the small and large intestines show no evidence of obstruction.  the appendix
 is normal.  anastomosis is seen in the distal colon, most compatible with
 prior sigmoid resection.  there is no free air or free fluid.  scattered tiny
 fat-containing midline hernias are noted.

 pelvis:  the bladder and rectum appear unremarkable.  the patient is status
 post hysterectomy.  there is no free fluid or lymphadenopathy.  bilateral
 fat-containing inguinal hernias are noted.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  status post sigmoid colectomy without evidence of complication.  no
 evidence of diverticulitis.
 2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
 factors (non-smoker and no cancer history), follow-up ct in one year is
 recommended to document stability.
 3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
 for further evaluation.

 findings discussed with [**first name5 (namepattern1) 5296**] [**last name (namepattern1) 5297**] 12:05 am on [**2163-8-19**] by [**first name8 (namepattern2) 873**]
 [**last name (namepattern1) 5298**] over the phone.

"
530,"[**2150-5-16**] 1:47 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 58728**]
 reason: evaluate for lymphadenopathy, abscess
  contrast: omnipaque amt: 70
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  60 year old man with aml s/p allo-transplant presenting with nasal congestion
  and severe sore throat
 reason for this examination:
  evaluate for lymphadenopathy, abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with aml status post allotransplant, now with
 severe sore throat.

 study:  ct of the neck with contrast; coronal and sagittal reformatted images
 were also generated.  75 cc of omnipaque intravenous contrast was administered
 without adverse reaction or complication.

 comparison:  [**2150-2-20**], [**2150-2-4**].

 findings:  the visualized portion of the brain is unremarkable.  the orbits
 and globes are intact.  the visualized paranasal sinuses demonstrate minimal
 mucosal thickening in the right maxillary sinus floor.

 no retropharyngeal or peritonsillar fluid collection is present, although
 streak artifact from dental amalgam somewhat limits assessment of finer detail
 in this area.

 the parotid glands are within normal limits.  no lymphadenopathy is present.
 the thyroid is normal in appearance.  a right-sided central venous catheter is
 in place.  the visualized lung apices are clear; the 6-mm right lower lobe
 pulmonary nodule described on the [**2150-2-4**] scan is not imaged on the
 current exam.  incidental note is made of a common origin of the
 brachiocephalic and left common carotid arterial branches off the aortic arch.

 impression:  no evidence of retropharyngeal or peritonsillar abscess; no
 lymphadenopathy.


"
531,"[**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 46m with abd pain, n/v
 reason for this examination:
  r/o appy, other acute intraabdominal process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2200-3-29**] 7:08 pm
  inflammed duodenum w/ surrounding fluid and focal area of wall discontinuity,
  concerning for contained duodenal perforation; no free air; normal appendix

 wet read version #1
 wet read version #2 jekh sat [**2200-3-29**] 6:23 pm
  duodenitis; no free air; normal appendix

 ______________________________________________________________________________
                                 final report
 history:  46-year-old male with abdominal pain, nausea and vomiting.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the lung bases are clear.

 the liver contour is nodular with caudate and left lateral lobe hypertrophy
 and atrophy of the right posterior lobe of the liver, compatible with
 cirrhosis.  there is no intrahepatic biliary dilatation or definite focal
 hepatic lesion. portal vein is patent. calcified stones within the gallbladder
 fundus and neck are present.  there is no wall edema or pericholecystic
 stranding.  the spleen is normal in size and appearance.  the adrenal glands
 show no nodules.  the kidneys enhance with and excrete contrast symmetrically;
 subcentimeter hypodensities in both kidneys are too small to characterize,
 likely representing cysts; focal cortical scarring in the left kidney is
 compatible with prior infection or infarction.

 there is marked wall thickening and extensive surrounding fat stranding and
 mural edema involving the distal stomach and proximal duodenum, centered about
 the duodenal bulb.  a focal outpouching of the duodenal bulb is present,
 concerning for an ulcer, less likely a diverticulum.  no free air is seen,
 though a fluid collection is noted posterior to the distal stomach in the
 lesser sac measuring 19 x 19 mm.  the pancreatic head is adjacent to this
 inflammatory process and appears indistinct, although the pancreatic body and
 tail are also mildly atrophic.

 the remainder of the small and large bowel show no evidence of wall edema or
 obstruction.  the appendix is normal.  there is no lymphadenopathy or free
                                                             (over)

 [**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 air.

 pelvis:  gas is seen in the bladder and correlation with recent
 catheterization is recommended.  the prostate and rectum appear unremarkable.
 there is no free fluid or lymphadenopathy. small bilateral fat containing
 inguinal hernias are present.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. findings concerning for a contained perforation of a duodenal bulb ulcer
 with adjacent surrounding inflammation and associated duodenitis.  small focal
 fluid collection is present in the lesser sac. findings discussed with [**first name8 (namepattern2) **]
 [**known firstname **] at 19:00 [**2200-3-29**] by [**first name8 (namepattern2) 510**] [**last name (namepattern1) 5773**] over the phone.

 2. cirrhosis.

 3. cholelithiasis.

 4. gas within the bladder lumen. correlate with any history of recent
 instrumentation; otherwise, findings are concerning for an infectious process.

"
532,"[**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  50 year old woman with pedestrain struck by tow truck. no obvious injury other
  than head lac
 reason for this examination:
  trauma?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2133-3-19**] 7:55 pm
  1. no intrathoracic injury.
  2. distended stomach but no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old female pedestrian struck by a tow truck.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of thyroid demonstrates a 5-mm hypodensity in
 the left lobe of the thyroid (2; 6).  there is no axillary, hilar, or
 mediastinal lymphadenopathy.  the aorta is of normal caliber along its course
 without evidence of dissection or injury.  no mediastinal hematoma is present.
 the pulmonary arterial tree shows no central filling defect.  there is no
 pleural or pericardial effusion.  the lungs show a subtle ground-glass opacity
 in the right lower lobe which may represent an area of contusion or
 aspiration.  there is no pneumothorax.

 abdomen:  an area of enhancement in the left lobe of the liver likely
 represents a hemangioma or perfusion anomaly (2;50).  the gallbladder, spleen,
 pancreas, and adrenal glands appear unremarkable.  there is no perihepatic,
 perisplenic, or pericolic fluid.  there is no free fluid or free air.  the
 kidneys enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; bilateral subcentimeter hypodensities are too small to
 characterize but likely represent cysts.  the aorta is of a normal caliber
 along its course without evidence of injury.  small and large bowels show no
 evidence of wall edema or obstruction; the stomach, however, is notably
 distended with gas.

 pelvis:  the bladder is decompressed.  the uterus and rectum appear
 unremarkable.

 bones:  there is no acute fracture; old left rib fractures are present.  there
                                                             (over)

 [**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  small nonspecific area of ground glass in the right lung.  otherwise
 essentially unremarkable exam without acute intra-abdominal or intrathoracic
 injury; no acute fracture.
 2.  distended stomach may benefit from ng tube.

"
533,"[**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 65f with clinical question:
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2142-3-17**] 11:09 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; surrounding hematoma but no pelvic free fluid; hematoma along l medial
  thigh as well; hairline fx through l iliac w/ probable involvement of l si
  joint, but no sacral fx.
 wet read version #1
 wet read version #2 jekh sat [**2142-3-17**] 10:25 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; hairline fx through l iliac w/ probable involvement of l si joint, but
  no sacral fx.
 ______________________________________________________________________________
                                 final report
 history:  65-year-old female pedestrian status post struck by suv.

 study:  ct of the torso with contrast; coronal and sagittal reformatted images
 were also generated.  130 cc of omnipaque 350 intravenous contrast was
 administered without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  the aorta is of normal caliber along its course without evidence of
 injury; incidental note is made of a common origin of the brachiocephalic and
 left common carotid arteries, a normal variant (2a; 14).  the pulmonary artery
 shows no central filling defects.  there is no pleural or pericardial
 effusion.  the lungs are clear without evidence of contusion.  there is no
 pneumothorax.

 abdomen:  a subcentimeter hypodensity in the dome of the liver is too small to
 characterize but likely represents a cyst rather than a contusion/laceration
 as there is no perihepatic fluid.  a subcentimeter hypodensity in the
 periphery of the spleen also likely represents a cyst or hemangioma rather
 than a contusion or laceration as there is no perisplenic fluid.  the pancreas
 and adrenal glands appear unremarkable.  the kidneys enhance with and excrete
 contrast symmetrically; a well-circumscribed 1-cm hypodensity in the mid pole
                                                             (over)

 [**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 of right kidney is most compatible with a simple cyst.  there is no
 retroperitoneal fluid collection.  the small and large bowel show no evidence
 of obstruction or injury.  there is no free air or free fluid.  the abdominal
 aorta is of normal caliber along its course without evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.  the left obturator musculature is thickened,
 likely representing intramuscular or contained hematoma.  additional
 incompletely image hematoma of the medial left thigh is present.

 bones:  there is a burst fracture of the l1 vertebral body with 8-mm
 retropulsed fragments into the central canal.  additionally, a minimally
 displaced fracture is present along the right aspect of the lamina of l1.  a
 small amount of adjacent hematoma is seen around the anterolateral aspects of
 the vertebral body.  loss of height is approximately 50%.

 additionally, minimally displaced fractures of the left superior and inferior
 pubic rami are present; the lateral aspect of the superior pubic rami is
 fractured while the medial aspect of the inferior pubic rami is fractured.
 additionally, a hairline fracture is present along the left iliac bone just
 adjacent to the si joint and extending into the si joint on the left.  the
 sacrum itself appears intact.

 impression:
 1.  no acute intra-abdominal or intrathoracic injury.
 2.  l1 burst fracture with retropulsed fragments and minimally displaced
 fracture of the right l1 lamina; these findings suggest an unstable fracture
 and if clinical concern for cord injury exists, mr would be recommended.
 3.  fracture of the left pelvis as described above.

 these findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 7304**] in person at 10:00 a.m. and
 again at 11:05 a.m. by phone on [**2142-3-17**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
534,"[**2183-2-8**] 9:50 am
 ct l-spine w/ contrast                                          clip # [**clip number (radiology) 85002**]
 reason: ? l-spine fluid/disciitis
 admitting diagnosis: pneumonia;nstemi;sepsis
  contrast: optiray amt: 90
 ______________________________________________________________________________
                                 final addendum
 addendum:  the complex, unstable fracture involving the l2 vertebral body, its
 superior and inferior endplates, and pedicles is present.  the previously seen
 gas in the disc and vertebral body are likely the result of vacuum phenomenon
 in the setting of degenerative and post-traumatic change.  given that it has
 not increased, a worsening gas-producing infectious process is unlikely.
 surrounding fluid-stranding in the retroperitoneum may actually represent
 post-traumatic hematoma, especially given that the superior endplate of l2
 (except for the fracture) and inferior endplate of l1 are preserved, making a
 primary process of discitis/osteomyelitis less likely.  additionally, the
 fluid-stranding around the aorta is more likely hematoma than aortitis.  in
 the setting of fever, superinfection of the hematoma cannot be excluded.
 however, the hematoma is not organized/drainable, and its proximity to the
 aorta, left renal vasculature, and exiting nerve roots makes biopsy/drainage
 challenging.

 this revision was discussed with [**first name8 (namepattern2) 21839**] [**last name (namepattern1) 7355**] at 12:06 pm on [**2183-2-11**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


 [**2183-2-8**] 9:50 am
 ct l-spine w/ contrast                                          clip # [**clip number (radiology) 85002**]
 reason: ? l-spine fluid/disciitis
 admitting diagnosis: pneumonia;nstemi;sepsis
  contrast: optiray amt: 90
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  86 year old man with back pain, fevers and possible disciitis on osh scan
 reason for this examination:
  ? l-spine fluid/disciitis
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2183-2-8**] 11:50 am
  1.  findings concerning for discitis of the l1-l2 vertebral body as well as
  osteomyelitis of the l2 vertebral body.
  2.  concern for compression fracture of the l2 vertebral body with involvement
  of the inferior endplate and bilateral pedicle fractures.
  3.  extensive retroperitoneal inflammation in the region of the aforementioned
  discitis/osteomyelitis, and may involve the adjacent abdominal aorta.


 ______________________________________________________________________________
                                 final report
 history:  86-year-old male with back pain, fevers and concern for discitis on
 outside hospital scan.

 study:  ct of the l-spine with contrast; 90 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  mdct
 images through the lumbar spine were performed in the standard and bone
 algorithms; coronal and sagittal reformatted images were also generated.

 comparison:  outside hospital ct of the abdomen and pelvis from [**2183-2-6**].

 findings:  in the left [**year (4 digits) 85003**] gland, there is a 16 mm in diameter nodule of
 indeterminate characterization (3; 1).

 severe degenerative changes are noted throughout all levels of the lumbar
 spine, primarily in the form of large anterior bridging osteophytes and facet
 joint hypertrophy.  of greater concern are numerous locules of gas within a
 narrowed l1-l2 intervertebral disc with surrounding inflammation.  this
 inflammation also abuts and may even involve the adjacent abdominal aorta and
 left renal artery (3; 25).  additionally, a few locules of gas are seen within
 the l2 vertebral body as well as some mild loss of height; subtle
 non-displaced fracture lines are seen extending in the horizontal plane, but
 also extending to the inferior endplate.  more subtle hairline fractures are
 seen also in the bilateral pedicles (401b; 29 and 42) and (2; 26).  there are
 no locules of gas within the l1 vertebral body nor does there appear to be
 appreciable destruction or fracture of the l1 vertebral body.

 impression:
 1.  findings concerning for discitis of the l1-l2 vertebral body as well as
 osteomyelitis of the l2 vertebral body.
                                                             (over)

 [**2183-2-8**] 9:50 am
 ct l-spine w/ contrast                                          clip # [**clip number (radiology) 85002**]
 reason: ? l-spine fluid/disciitis
 admitting diagnosis: pneumonia;nstemi;sepsis
  contrast: optiray amt: 90
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  compression fracture of the l2 vertebral body with involvement of the
 inferior endplate and bilateral pedicle fractures; concerning for instability.
 3.  extensive retroperitoneal inflammation in the region of the aforementioned
 discitis/osteomyelitis, involving the adjacent abdominal aorta and left renal
 artery.
 4.  indeterminate left [**clip number (radiology) 85003**] nodule - mr [**first name (titles) **] [**last name (titles) **] ct may be considered
 if/when clinically indicated.

 findings [**12-24**] were discussed with [**first name8 (namepattern2) 416**] [**last name (namepattern1) 28438**] at 11:30 a.m. on [**2183-2-8**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.

"
535,"[**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  52m, h/o longstanding crohn's, started on [**first name9 (namepattern2) 22562**] [**2187-2-3**], has had better but
  incomplete control (all to remicaid).  has had a couple flares in the interum.
  returns today with s/s c/w flare.  c/o increased abd pain, esp in lrlq to deep
  palpation.  denies f/c/v, does c/o n/d which is normal for pt.  does report
  lrlq pain immidiately after eating or drinking nearly every time.  pt states
  otherwise, he feels well.  with dirty uaiv/po contrast pleaseplease eval
  kidneys and bowel,
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2188-3-22**] 6:43 pm
  1. s/p cholecystectomy, splenectomy, and total colectomy.
  2. l-sided loop of bowel w/ thickened wall and surrounding inflammation, c/w
  crohn's flare; no abscess.
  3. mild perinephric stranding but no e/o pyelonephritis or perinephric fluid
  collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with a history of crohn's disease, now with
 abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  oral contrast was also administered.

 coronal and sagittal reformatted images were also generated.

 comparison:  [**2186-11-29**].

 findings:

 abdomen:  the visualized portion of the lung bases are clear.  the liver shows
 no focal lesion or intrahepatic biliary dilatation.  clips in the gallbladder
 fossa compatible with prior cholecystectomy.  the spleen is surgically absent.
 pancreas shows no masses.  the adrenal glands show no nodules.  the kidneys
 enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; minimal perinephric stranding is present without an organized
 fluid collection or striated nephrogram.  patient is status post total
 colectomy without evidence of obstruction.  loops of bowel in the left abdomen
 demonstrate thickened wall with subtle surrounding fat stranding.  possible
 early phlegmon may be present in the left lower abdomen (2:54,601:38) without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude.  nearby scattered mesenteric lymph nodes are seen.  equivocal
 tethering of bowel loops in this area is also noted.  trace amount of reactive
 fluid is also seen in the mesentery.  there is no free air.  incidental note
                                                             (over)

 [**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is made of ventral abdominal wall mesh.

 pelvis:  the bladder and prostate appear unremarkable.  there is a transition
 in the diameter of the lumen from the small bowel to the rectosigmoid colon
 region through which contrast is passing (2; 62).  there is no free fluid or
 lymphadenopathy in the pelvis.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 intervertebral discs
 primarily in the form of vacuum phenomenon and endplate sclerosis.

 impression:
 1. status post cholecystectomy, splenectomy, and total colectomy.
 2. left-sided bowel with wall thickening and surrounding inflammation; given
 patient history compatible with an inflammatory process such as the patient's
 known crohn's disease.  infection might have a similar appearance .
 possible early phlegmon may be present in the left lower abdomen without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude. mre is more sensitive and may be helpful for further evaluation.

"
536,"[**2118-10-23**] 7:07 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 16327**]
 reason: r/o pe
 admitting diagnosis: pneumonia
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  53 year old man with acute hypoxia
 reason for this examination:
  r/o pe
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh sun [**2118-10-23**] 8:59 pm
  1.  no pe or acute aortic syndrome.
  2.  bibasilar opacities, likely reflecting components of early pneumonia and
  atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  53-year-old male with acute hypoxia.

 study:  chest cta.  mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after the
 administration of 100 cc of optiray intravenous contrast without complication
 or adverse reaction.  this is dominant in the pulmonary arterial phase.
 coronal, sagittal, and right and left oblique reformatted images were also
 generated.

 comparison:  none.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar or mediastinal lymphadenopathy.

 the aorta is of a normal caliber along its course without evidence of
 dissection or intramural hematoma.  incidental note is made of a direct
 takeoff of the left vertebral artery between the origins of the left common
 carotid and left subclavian arteries, a normal variant (4; 10).

 the pulmonary arterial trunk is of a normal caliber and there are no filling
 defects down to the subsegmental level.

 trace pericardial fluid is noted anteriorly (4; 52).

 bibasilar opacities, as well as focal opacity in the posterior rul adjacent to
 the minor fissure (image 4:22) are seen within the lungs, likely representing
 more than just dependent atelectasis, but rather an additional superimposed
 infectious process.as part of the opacities have a nodular appearance,[e.g.
 rll (4:34), lll (4:55)] follow-up ct when symptoms resolve is recommended.

 the visualized portion of the upper abdomen shows no gross abnormality.

 the visualized bones demonstrated incidentally fusion of the right lateral
 fifth and sixth ribs.  additionally, there is a bony bridge between the
 posterior aspect of the left sixth and seventh ribs (501b; 36).  there are no
                                                             (over)

 [**2118-10-23**] 7:07 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 16327**]
 reason: r/o pe
 admitting diagnosis: pneumonia
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  no pe or acute aortic syndrome.
 2.  bibasilar opacities, likely reflecting components of early pneumonia and
 atelectasis.however, due to several nodular areas, follow-up chest ct when
 symptoms resolve is recommended.

"
537,"[**2166-2-11**] 9:14 am
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 8970**]
 reason: melanoma
 ______________________________________________________________________________
                                 final report
 history:  49-year-old female with melanoma in need of assessment for
 metastatic disease.

 study:  ct of the neck with contrast; 50 ml of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  pet-ct from [**2165-11-12**] and ct of the torso from [**2-11**], [**2165**].

 findings:  the visualized portion of the brain shows no evidence of mass or
 abnormal enhancement; the circle of [**location (un) 501**] appears grossly intact.  the
 visualized portion of the globes and oribts appears within normal limits.

 the visualized paranasal sinuses and mastoid air cells are clear.  streak
 artifact is present, mildly limiting assessment of the mandible but it too
 appears intact.  cervical spine shows no evidence of malalignment or more
 aggressive-appearing lytic/sclerotic lesion.

 the parotid and submandibular glands appear normal.  no lymphadenopathy is
 present.  the jugular and carotid vasculature are patent.  a linear
 hypodensity in the right lobe of the thyroid measures 6 x 2 mm (2; 62).

 the visualized portion of the lung apices and upper mediastinum appears
 unremarkable.

 impression:  no evidence of lymphadenopathy or metastatic disease.

"
538,"[**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  [**age over 90 **] year old woman with mcv, positive fast
 reason for this examination:
  bleeding?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2102-1-26**] 4:38 pm
  1. r [**5-21**] lateral rib fx and l [**3-22**] lateral rib fx (segmental fx in l 9 and
  10).
  2. splenic lac and contusion; possible small liver lac; hemoperitoneum.
  3. dense fluid near r colon may represent contusion; no active extrav seen to
  suggest vascular injury.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  [**age over 90 **]-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  outside hospital ct of the torso without contrast from [**1-26**], [**2101**] at 13:43.

 findings:

 chest:  the visualized portion of the thyroid gland shows bilateral
 hypodensities in each lobe for which ultrasound may be considered if
 clinically indicated.  there is no axillary, mediastinal, or hilar
 lymphadenopathy.  the aorta is of normal caliber along its course without
 evidence of dissection or mediastinal hematoma.  the pulmonary arterial trunk
 shows no central filling defect.  the heart size is within normal limits
 without pericardial effusion.  there is no significant pleural effusion.  the
 lungs demonstrate bibasilar atelectasis but no consolidation or contusion.  a
 small hiatal hernia is present.

 abdomen:  a hypodense streak along the dome of the liver is equivocal for
 laceration versus a lobulation (2; 32-39).  extensive dense fluid is seen
 around the liver and spleen.  the uppermost portion of the spleen demonstrates
 a vertically oriented hypodensity that may represent a laceration (601b; 32).
 more inferiorly in the spleen is a hypodensity oriented in the ap dimension
 that may represent either laceration or lobulation (2; 45 and 601b; 38).  at
 the very least, there is a splenic contusion (602b; 54).  a calcified splenic
 artery aneurysm is noted measuring 9 mm in diameter (2; 46 and 601b; 28).

 a duodenal diverticulum is present.  the pancreatic duct appears contiguous
 and there is no peripancreatic fluid; the pancreas is atrophic.  the right
 adrenal gland appears normal; the left adrenal gland demonstrates a rounded
                                                             (over)

 [**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 soft tissue density measuring 13 mm in diameter that is incompletely
 characterized (2; 48) - ct or mr may be considered as clinically indicated.
 the kidneys enhance with contrast symmetrically without evidence of
 perinephric fluid.  incidental note is made of a calcified aneurysm of the
 left renal artery (2; 52) which measures 7 mm in diameter.

 the small bowel shows no areas of wall edema.  no free air is seen.  the large
 bowel demonstrates diverticulosis, but no evidence of bowel wall edema.
 complex fluid is seen sitting adjacent to the right colon (2; 61) within the
 mesentery (2; 62 and 601b; 26) and along a loop of jejunum.  a
 small-to-moderate amount of dense fluid is seen coursing throughout the
 mesentery and along the paracolic gutters.

 the aorta is of a normal caliber along its course without evidence of injury
 or active extravasation.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  dense free
 fluid seen in the pelvis, contiguous with that seen in the abdomen.  a
 left-sided [**doctor last name 13736**] hernia is present (2; 91).

 bones:  multiple minimally displaced fractures are present in the lateral
 aspects of the right ribs 6, 7, 8, 9, and 10 and in the left ribs 4 through
 11; of note, the fractures in left ribs 9 and 10 are segmental in nature.
 there does not appear to be an acute injury to the spine, although multilevel
 degenerative changes are present.  the clavicles are intact bilaterally.  the
 sternum is intact.  the pelvis and proximal femurs are intact.

 impression:  multiple rib fractures as described above with possible splenic
 (and less likely hepatic) lacerations with hemoperitoneum tracking along the
 right colon and jejunum concerning for bowel injury.  findings were discussed
 with [**first name4 (namepattern1) 9505**] [**last name (namepattern1) 612**] at 4 p.m. on [**2102-1-26**] in person by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
539,"[**2123-1-3**] 9:35 am
 ct chest w/contrast                                             clip # [**clip number (radiology) 1645**]
 reason: placement of pigtail catheter [**1-2**], evaluation for improveme
 admitting diagnosis: pleural effusion;elev inr
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old man with lung adenoca and pleural effusion s/p pigtail catheter
  placement
 reason for this examination:
  placement of pigtail catheter [**1-2**], evaluation for improvement in lung volumes
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with lung cancer and pleural effusion status post
 pigtail catheter placement.

 study:  ct of the chest with contrast; 75 cc of omnipaque 350 intravenous
 contrast was administered without adverse reaction or complication.  images
 were generated using standard and lung algorithms.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2122-12-29**].

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 continues to be a large mass lesion occupying most of the region of the left
 upper lobe of the lung.  the left upper lobe bronchus and left upper lobe
 pulmonary vasculature continue to be occluded.  the left lower lobe superior
 segment pulmonary artery is narrowed but patent.  the left lower lobe bronchus
 is narrowed and even occluded over a short segment, but it is unclear if this
 is the result of mass effect or mucus plugging.  while the left upper lobe
 remains completely collapsed, there is minimally improved aeration of the left
 lower lobe.  the pigtail catheter is in place and there has been a decrease in
 the inferior portion of the left pleural effusion, the components of which are
 minimally complex fluid.  the upper portion of the left pleural effusion is
 also improved and the previously described pleural implants are unchanged.
 continued mediastinal lymphadenopathy is seen, most prominently in the
 subcarinal region where a 3 x 5 cm lymph node persists.  the aorta is of a
 normal caliber along its course and its arch branches are patent.  the heart
 and mediastinal have shifted into a more anatomically appropriate position
 compared to prior exam.  there is no pericardial effusion.  a small right
 simple pleural effusion persists on the right with small amount of dependent
 atelectasis.  additionally, a new focus of consolidation is present in the
 right upper lobe (4:45), which either represents a persistent area of
 atelectasis from the previous mediastinal shift versus an additional focus of
 consolidation/pneumonia.

 the visualized portion of the abdomen demonstrates widespread ascites, a
 nodular liver compatible with cirrhosis, a distended gallbladder, and an
 incompletely characterized hypodensity in the superior pole of right kidney.

 there are continued lytic lesions in the t10 through t12 vertebral bodies as
 well as in the t6 vertebral body.  the previously described pathologic
                                                             (over)

 [**2123-1-3**] 9:35 am
 ct chest w/contrast                                             clip # [**clip number (radiology) 1645**]
 reason: placement of pigtail catheter [**1-2**], evaluation for improveme
 admitting diagnosis: pleural effusion;elev inr
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture of the posterior right eighth rib persists.

 impression:
 1.  status post left pleural pigtail catheter placement with improvement in
 the volume of left pleural effusion and minimally improved aeration of the
 left lower lobe.  left lower lobe bronchus shows short segment occlusion,
 likely reflective of a mucus plug.
 2.  continued large left upper lobe mass with mass effect on the adjacent
 bronchus and artery; mediastinal lymphadenopathy, most prominent in the
 subcarinal stations.
 3.  new small consolidation in the anterior portion of the right lung apex may
 represent residual atelectasis versus a new focus of pneumonia; small right
 simple pleural effusion with minimal associated atelectasis.
 4.  ascites.
 5.  bone metastases as described above.

 findings were discussed with bracken [**last name (un) 1646**] at 10:48 a.m. on [**2123-1-3**]
 by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


"
540,"[**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 43f with mvc, supobtimal fast,abrasion to abdomen, unrestrained
  driverclinical question: ? intrabdominal injury
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2150-3-5**] 5:33 pm
  1. bilateral dependent pulmonary edema.
  2. no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  42-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of normal caliber along its course without evidence of injury or
 mediastinal hematoma.  the pulmonary arterial tree shows no central filling
 defect.  the heart size is within normal limits and there may be trace
 pericardial fluid.  the lungs are clear of consolidation.  bibasilar
 ground-glass opacities, likely representing dependent edema. less likely
 contusions.  there is no pleural effusion or pneumothorax.

 abdomen:  the liver, spleen, adrenal glands, and pancreas appear normal.
 gallstones are present.  there is no perihepatic, perisplenic or pericolic
 gutter fluid.  there is no fluid in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically.  there is no free air or lymphadenopathy.
 the aorta is of normal caliber along its course of the abdomen without
 evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  foley catherter
 in place.  there is no free fluid or lymphadenopathy.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.  a wedge
 deformity in the t11 vertebral body is of indeterminate age but shows no
 retropulsed fragments or adjacent hematoma.

 impression:
 1.  dependent regions of ground glass in the lungs may represent edema, less
 likely contusion.  otherwise no evidence of intrathoracic or intra-abdominal
 injury.
                                                             (over)

 [**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  t11 wedge deformity of indeterminate age - correlate clinically.
 3.  cholelithiasis.

"
541,"[**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  24 year old man with s/p mvc and was ejected from vehicle +etoh
 reason for this examination:
  ?intrathoracic or intraabdominal injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2186-1-28**] 6:33 am
  1. no intrathoracic injury.
  2. small subcapsular hematoma of liver (2:43 and 301b:25); no free fluid in
  abdomen or pelvis.
  3. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 wet read version #1
 wet read version #2 jekh sat [**2186-1-28**] 6:27 am
  1. no intrathoracic or intraabdominal injury.
  2. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 ______________________________________________________________________________
                                 final report
 history:  24-year-old male status post mvc and ejected from vehicle.
 left-sided upper extremity weakness.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.

 comparison:  none.

 findings:

 the visualized portion of the thyroid appears normal.  there is no axillary,
 hilar, or mediastinal lymphadenopathy.  the aorta is of a normal caliber along
 its course without evidence of mediastinal hematoma.  the pulmonary arterial
 trunk is of a normal caliber with no central filling defect.  the heart shows
 no pericardial effusion.  there is no pleural effusion or pneumothorax.  the
 lungs are clear.

 abdomen:  there is no free fluid around the liver or spleen or tracking along
 the paracolic gutters.  the spleen, pancreas, adrenal glands, and kidneys
 appear normal.  the bowel wall is not edematous.  there is no free air.

 pelvis:  a foley is in the bladder with excreted contrast within the bladder.
 the prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.

 bones:  horizontally oriented fractures are seen through the posterior
 elements of the t9 vertebra.  the vertebral body does not definitively show
                                                             (over)

 [**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture, but a small right anterior hematoma is present in the soft tissue
 surrounding the vertebral body at that level.

 impression:
 1.  no intrathoracic injury.
 2.  horizontally oriented fracture of the posterior elements of t9 with right
 anterior surrounding soft tissue hematoma; mr is recommended to [**clip number (radiology) 4247**] for
 ligamentous, disc, and cord injury.

"
542,"[**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 50m with h/o cirrhosis, fever and ams of unclear [**name2 (ni) 97919**]
  question: intraabd infection?
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2186-1-11**] 8:28 pm
  1. cirrhotic liver w/ small amt of perihepatic ascites, splenomegaly, and
  recannulized umbilical vein (a portion of which sits in a small umbilical
  hernia).
  2. small pericardial effusion.
  3. no organized intraabdominal fluid collection; normal appendix; no bowel
  wall edema; no hydronephrosis; no peripancreatic stranding/fluid collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old male with cirrhosis, now with fever and altered mental
 status.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases are clear.  small pericardial effusion is
 present.

 the liver is shrunken and nodular compatible with cirrhosis.  small amount of
 perihepatic ascites is present.  the gallbladder is distended with a mildly
 thickened wall (likely secondary to hepatic disease).  small amount of
 pericholecystic fluid is also seen.  the spleen is enlarged measuring 14.8 cm
 in length.  the portal vein appears patent. there is a dilated recanalized
 umbilical vein, a portion of which has herniated through a small umbilical
 hernia (2; 60). the pancreas appears normal. the adrenal glands appear normal.
 the kidneys enhance and excrete contrast symmetrically without hydronephrosis.


 the small and large bowel show no evidence of ileus or obstruction.  there is
 no free air or lymphadenopathy.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  there is no pelvic free fluid or lymphadenopathy.  a
 small left buttock hematoma is present.

                                                             (over)

 [**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive appearing lytic or sclerotic lesions.

 impression:
 1.  cirrhotic liver with a small amount of ascites.
 2.  small pericardial effusion.
 3.  umbilical hernia containing a loop of the dilated, recannalized umbilical
 vein.

"
543,"[**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old woman with paralysis of lower extremities
 reason for this examination:
  please eval for acute process - s/p fall, unable to move her lower extremities
  and no sensation
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2101-10-21**] 10:31 pm
  1. splaying of l1 and l2 spinous process w/ subtle malalignment of l2 and l3,
  concerning for ligametous injury, and in the setting of paralysis, consequent
  central canal injury - mr is recommended.
  2. herniation of stomach into thorax.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old female with lower extremity paralysis after fall.

 study:  ct of the torso with contrast; 130 cc of optiray intravenous contrast
 was given without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of a normal caliber along its course with a few scattered areas of
 calcified atherosclerotic disease in the aortic arch and descending aorta;
 there is no evidence of intramural hematoma or dissection.  there is no
 central pulmonary arterial filling defect.  there is no pericardial or pleural
 effusion.  a small amount of fluid is seen in the pericardial recess adjacent
 to the ascending aorta.  the lungs are clear with bibasilar atelectasis.  the
 stomach has herniated into the thorax.

 abdomen:  there is no perihepatic fluid.  a non-specific hypodensity is seen
 in hepatic segment iv, too small to characterize but most likely a cyst.  the
 gallbladder is decompressed.  there is no perisplenic fluid.  the pancreas and
 adrenal glands are normal.  the kidneys enhance with and excrete contrast
 symmetrically.  small and large bowel show no obstruction or wall edema.
 there is no free fluid or free air.

 pelvis:  the bladder is decompressed around a foley.  the uterus and rectum
 appear unremarkable.  there is no free fluid or lymphadenopathy.

 bones:  there is splaying of the posterior elements at the level of l1-l2 with
 more subtle malalignment of l2 and l3 (602b; 36).  [**year (4 digits) **] material is seen
 within the spinal canal at this level and above.  otherwise, the pelvis and
 proximal femurs are intact.  no rib fractures are noted.

                                                             (over)

 [**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 impression:
 1.  splaying of the l1-l2 spinous processes is concerning for ligamentous
 injury and given the patient's history of paraplegia, mr should be performed.
 relatively [**name2 (ni) 3409**] material within the spinal canal is concerning for epidural
 hematoma.  findings were discussed with dr. [**last name (stitle) 3382**] in person at 22:00 on
 [**2101-10-21**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] and [**first name8 (namepattern2) **] [**doctor last name 853**].
 2.  no intrathoracic or intra-abdominal injury.

"
544,"[**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  31 year old woman with sudden onset abdominal pain, h/o cirrhosis
 reason for this examination:
  eval surgical pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2180-9-8**] 3:18 am
  1. cirrhotic liver w/ tips; patent portal vessels.
  2. decompressed gb w/ wall edema, unchanged from [**2180-7-21**] ct; likely reflective
  of hepatic dysfunction.
  3. small amt of ascites, increased since [**2180-7-21**] ct; if clincial concern for
  pancreatitis, correlate w/ lipase.
  4. normal appendix.
  5. no obstruction or free air.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  31-year-old female with sudden onset of abdominal pain and history
 of cirrhosis.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was used without adverse reaction and complication.
 coronal and sagittal reformatted images were also generated.

 comparison:  [**2180-7-21**].

 findings:

 abdomen:  the visualized lung bases are clear.  the liver demonstrates a
 portosystemic shunt.  the portal vein appears patent; assessment of the shunt
 is limited by the phase of the contrast although it also appears patent.  the
 liver demonstrates a nodular contour compatible with cirrhosis.  the
 gallbladder is decompressed although it shows small amount of wall edema.  the
 spleen is enlarged measuring 15.7 cm in its long axis (601b; 36).  coil
 material is seen in the region of the duodenum, likely to occlude varices.
 the splenic vein and sma are patent.

 the adrenal glands and pancreas show no masses.  subtle fluid-stranding is
 seen near the pancreatic tail and in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis.  the
 small and large bowel show no evidence of obstruction or wall edema.  there is
 no free air.  small amount of ascites is seen.  incidental note is made of a
 small fat-containing umbilical hernia.  the appendix is normal.

 pelvis:  the bladder, uterus and rectum appear unremarkable.  a small amount
 of fluid contiguous with the aforementioned ascites is seen.  there is no
 lymphadenopathy.

                                                             (over)

 [**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. cirrhotic liver with portosystemic shunt in place.  splenomegaly and small
 amount of ascites.  gallbladder wall edema most likely reflects sequela of
 hepatic dysfunction.
 2. if there is clinical concern for pancreatitis, correlate with lipase.

"
545,"[**2191-9-29**] 3:17 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 1246**]
 reason: please eval for colitis, diverticulitis, intrabdominal infec
  contrast: visapaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  88 year old woman with altered mental status, increased diarrhea x10 bm
  yesterday, and llq abdominal pain.
 reason for this examination:
  please eval for colitis, diverticulitis, intrabdominal infection
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh fri [**2191-9-30**] 1:06 am
  1.  biatrial enlargement and edematous liver, compatible with right heart
  failure.
  2.  cholelithiasis without evidence of cholecystitis.
  3.  ascites and bilateral pleural effusions with associated left lower lobe
  atelectasis.
  4.  t11 compression deformity, new from [**2191-6-20**].
 pfi version #1 jekh fri [**2191-9-30**] 1:05 am
  1.  biatrial enlargement and edematous liver, compatible with right heart
  failure.
  2.  cholelithiasis without evidence of cholecystitis.
  3.  ascites and bilateral pleural effusions with associated left lower lobe
  atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  88-year-old female with altered mental status and increase in
 diarrhea; left lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 100 cc of visipaque was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  abdomen/pelvis cts from [**2191-6-20**] and [**2187-6-26**].

 findings:

 lumg bases:  there has been interval development of bilateral pleural
 effusions, simple and layering and small no right and moderate on left.
 bilateral lower lobe compressive atelectasis is more notable on the left.
 calcified atherosclerotic disease is seen in the coronary arteries.  marked
 biatrial cardiac chamber enlargement is noted.

 abdomen:  heterogeneous mottled enhancement of the hepatic parenchyma likely
 reflects passive congestion secondary to right heart failure. there is a
 stable  hypodensity in segment [**doctor first name **] that is too small to characterize, but
 likely represents a simple cyst.  there is no intrahepatic biliary dilatation.
 mild periportal edema is noted.  the gallbladder contains gallstones.  both
 the liver and spleen contain a few punctate calcifications, compatible with
 prior granulomatous disease.

 the pancreas is atrophic.  the adrenal glands appear normal.  the kidneys
                                                             (over)

 [**2191-9-29**] 3:17 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 1246**]
 reason: please eval for colitis, diverticulitis, intrabdominal infec
  contrast: visapaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 enhance symmetrically, although excretion appears delayed on the left with
 slight fullness of the left upper renal collecting system. there is no sign of
 distal obstruction and overall configuration is stable.   well-circumscribed
 hypodensities in both kidneys are most compatible with simple cysts, the
 largest of which is seen in the mid pole of the left kidney and measures 16 mm
 in diameter.

 the small and large intestine show no sign of obstruction.  a significant
 fecal and gas burden is demonstrated throughout the colon.

 there is an unchanged appearance to a calcified retroperitoneal mass anterior
 to the aorto-iliac bifurcation measuring 28 x 20 mm in axial plane (2; 47) and
 has been stable since [**2187**].

 a small amount of ascites is seen, simple in nature.  there is no free air.

 pelvis:  the bladder is distended.  the clips posterior to the bladder are
 compatible with prior hysterectomy. clips along the pelvic sidewall likely
 reflect prior lymph node dissection.  stool is seen in the rectum.  at the
 rectosigmoid junction, there is underdistension though no frank bowel wall
 thickening.  scattered diverticula are seen in the sigmoid colon, although
 there is no evidence of an inflamed diverticulum.

 bones:  again, compression deformities are seen at l4, l2, and l1 as well as
 t11.  the t11 compression deformity is new from [**2191-6-20**].  sclerotic
 changes are seen about the si joints. body wall edema noted.

 impression:
 1.  biatrial enlargement with bilateral pleural effusions, body wall edema,
 ascites and congested liver, likely secondary to right heart failure.
 2.  cholelithiasis without evidence of cholecystitis.
 3.  t11 compression deformity, new from [**2191-6-20**].
 4.  stable size and appearance of calcified mass in the lower abdomen anterior
 to the aorto-iliac bifurcation. given stability since [**2187**], a benign etiology
 is suggested.

"
546,"[**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with new onset rlq abdominal pain, nausea, and vomiting
  starting last night. hx of percutaneous gallbladder tube that was removed
  earlier this year. pt is on coumadin
 reason for this examination:
  please eval for intrabdominal infection, sbo, nephrolithiasis, intraperiotneal
  or retroperiotneal bleed.
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2167-9-3**] 3:31 pm
  no acute intraabdominal process - specifically, normal appendix, no
  obstruction, no stones, no retroperitoneal collection, no abscess.

 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  a 57-year-old male with new-onset right lower quadrant pain, nausea,
 and vomiting.  on coumadin, and history of percutaneous gallbladder tube
 removed earlier this year.

 study:  ct of the abdomen and pelvis with and without contrast; mdct images
 were generated through the abdomen without iv contrast; coronal and sagittal
 reformatted images were generated.  subsequent mdct images were generated
 through the abdomen and pelvis after the administration of 130 ml of optiray
 intravenous contrast without adverse reaction or complication.  coronal and
 sagittal reformatted images were again generated.

 comparison:  [**2167-7-6**].

 findings:

 abdomen:  the visualized portions of the lung bases are clear.  calcified
 atherosclerotic disease is seen in both coronary arteries.

 diffuse fatty infiltration of the liver is noted. the liver otherwise shows no
 focal lesion or intrahepatic biliary dilatation.  the gallbladder is normal
 without stones, wall edema, or pericholecystic fluid.  the spleen is normal in
 size.  the pancreas and adrenal glands show no masses.  the kidneys enhance
 and excrete contrast symmetrically.  there is no hydronephrosis,
 hydroureteral, renal or ureteral calculi, or perinephric inflammation.  the
 small and large bowel shows no evidence of obstruction or wall edema.  there
 is no free air, free fluid, or lymphadenopathy.  no retroperitoneal fluid
 collections are seen. small fat-containing umbilical hernia is present.

 pelvis:  the bladder, prostate, and rectum are unremarkable.  the appendix is
 normal.  there is no free fluid or lymphadenopathy in the pelvis.
 calcification of the vas deferens suggests diabetes.

                                                             (over)

 [**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:  no acute intraabdominal process. fatty liver.
                                                                       dfddp

"
547,"[**2171-10-23**] 7:35 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 15768**]
 reason: evidence of pe, mets, or other acute cp process?
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  63 year old man with active ca, acute hypoxia, tachycardia, rle edema.
 reason for this examination:
  evidence of pe, mets, or other acute cp process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2171-10-23**] 9:06 pm
  1. technically limited study - basal lungs excluded; no pe in visualized
  pulmonary arteries; no acute aortic syndrome.
  2. clear lungs; no pleural/pericardial effusion.
  3. r apical mass 30 x 24 mm; l 7th lateral rib lesion, 43 x 25 mm.
  4. r hilar and mediastinal lymphadenopathy.
  5. bony mets in t3 and t4 vertebral bodies.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  63-year-old male with hypoxia, tachycardia and right lower extremity
 edema.

 study:  chest cta; mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after
 administration of 100 cc of optiray intravenous contrast in the pulmonary
 arterial phase without adverse reaction or complication.  coronal, sagittal as
 well as right and left oblique reformatted images were generated.

 please note due to technical difficulties, the lower portion of the chest was
 not been completely imaged on the contrast-enhanced phase.

 comparison:  pet-ct from [**2171-8-16**].

 findings: the aorta is of a normal caliber along its course without evidence
 of dissection or intramural hematoma.  the pulmonary arterial trunk is normal
 in size and there are no filling defects in the visualized pulmonary arteries,
 though, the basal segments bilaterally are incompletely visualized on the
 contrast enhanced portions.  there is no pleural or pericardial effusion. the
 heart and remaining great vessels are unremarkable.

 there is no axillary lymphadenopathy.  extensive mediastinal lymphadenopathy
 is seen, including a pretracheal lymph node measuring 13 mm (3; 42) and a
 subcarinal lymph node conglomerate measuring 28 x 48 mm (3; 58).
 additionally, two right hilar lymph nodes are seen measuring 16 and 10 mm in
 their short axes (3; 49). prominent left hilar lymph nodes are also noted.
 these are similar compared to prior study.

 diffuse pulmonary nodules are visualized in both lungs, though comparison with
 the prior pet-ct is difficult given differences in technique. redemonstrated
 is nodularity along the right major and minor fissures, unchanged from prior
 study.  mucus plugging is seen in the left lower love bronchi.
                                                             (over)

 [**2171-10-23**] 7:35 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 15768**]
 reason: evidence of pe, mets, or other acute cp process?
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

 within the visualized upper abdomen, no gross abnormality is seen.

 an expansile lytic lesion arising from the second rib measures 30 x 24 mm (3;
 11) and extends into the posterior elements at that level including the lamina
 on the left; this represent progression compared to prior study.  a soft
 tissue mass expanding the left seventh lateral rib is seen measuring 43 x 25
 mm (3; 58), which has increased in size.  lytic lesions in t5 and t6 vertebral
 bodies have increased from the prior study.  lesions in t12 and l1 are not
 signficantly changed.  two new lytic lesions in the left scapula are noted.
 the lytic lesion in the sternum has not changed.

 impression:
 1.  limited assessment of the basal segmental pulmonary arteries. otherwise,
 no pulmonary embolism or acute aortic pathology seen.
 2.  multiple bony metastases, many of which have progressed as described
 above.
 3.  innumerable bilateral pulmonary nodules with persistent mediastinal and
 hilar lymphadenopathy.
 3.  left lower lobe bronchial mucus plugging.

"
548,"[**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  84 yf presents from nursing home w/ dyspnea, tachypnea, tachycardia, otherwsie
  also complaining of abdominal pain, recently discharge from hospital with
  sepsis/bacteremia
 reason for this examination:
  ?pe, ?abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2180-9-20**] 5:39 am
  1. no pe or acute aortic syndrome.
  2. moderate r and small l pleural effusions w/ compressive atlectasis.
  3. reflux of contrast from r heart into hepatic veins, indicative of heart
  failure.
  4. continued rectal inflammation - proctitis.
  5. no abscess.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  84-year-old female with dyspnea, tachycardia, tachypnea and
 abdominal pain.

 study:  chest cta and ct of the abdomen and pelvis with contrast.  mdct images
 were generated through the chest without iv contrast.  subsequent mdct images
 were generated through the chest after the administration of 130 ml of optiray
 intravenous contrast in the pulmonary arterial phase without adverse reaction
 or complication.  coronal, sagittal, and right and left oblique reformatted
 images were also generated.

 subsequent mdct images were generated through the abdomen and pelvis in the
 venous phase of the same contrast administration.  coronal and sagittal
 reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis without contrast from [**2180-9-12**] and ct of the abdomen and pelvis without contrast from [**2180-9-5**].

 findings:

 chest cta:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course without evidence of intramural hematoma or
 dissection.  the pulmonary arterial trunk is of normal caliber, and there are
 no filling defects down to the subsegmental level.  there is no pericardial
 effusion.  bilateral simple pleural effusions are seen, moderate on the right
 and small on the left, with associated atelectasis; fluid is also tracking
 into the left major fissure.  fine assessment of the lung parenchyma is
 somewhat limited due to motion artifact.

 abdomen:  the liver shows minimal biliary prominence, an expected finding in a
                                                             (over)

 [**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 post-cholecystectomy patient of this age.  the spleen is normal in size, and a
 hypodensity in its anterior [**doctor last name 39**] is too small to characterize but is unchanged
 from prior studies.  the pancreas demonstrates no masses or fluid collections.
 the adrenal glands are normal appearing bilaterally.  the kidneys enhance with
 and excrete contrast symmetrically; hypodensity in the right lower pole is too
 small to characterize, likely represents a cyst.  the small and large
 intestine show no evidence of obstruction or wall thickening.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta.  there is no
 lymphadenopathy, free air, or free fluid.

 pelvis:  the bladder is decompressed around a foley and a single locule of gas
 within the bladder is likely from that catheterization.  the uterus appears
 unremarkable.  the rectum demonstrates hyperenhancing mucosa with thickening
 of the wall and a small amount of stranding in the perirectal fat, all
 compatible with proctitis and similar in appearance to the prior two ct scans.

 bones:  severe degenerative changes are seen throughout the thoracolumbar
 spine; compression deformity of the t10 vertebral body is similar in
 appearance compared to the ct of the torso from [**2177-11-7**].

 impression:
 1.  no pe or acute aortic syndrome.
 2.  moderate right and small left pleural effusions with compressive
 atelectasis.
 3.  rectal wall inflammation compatible with proctitis.
 4.  no evidence of abscess.

"
549,"[**name (ni) 257**] pt on [**last name (un) 33**] a/c 12/550/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small amount of white thick secretions. mdi's administered q4 atr with no adverse reactions. 02 sats @ 99%. cuff pressure @ 21 cm h20.  rsbi performed but no spont resp.  plan is to wean to psv then possibly extubate. no further changes noted.
"
550,"ccu (sicu border) nursing transfer accept note 7p-7a

64 yo male with pmh af, imi, ptca, cva x2(no residuals observed), asthma, lung ca, cabg x2 [**6-1**], chf, htn, bladder ca, mild copd, tia's, and mvr admditted to [**hospital1 2**] [**10-10**] with abd angina, diagnosed with mesenteric ischemia. pt underwent [**name (ni) 3549**] [**10-11**] of sma, developed sbo and later had ileocecectomy [**10-14**]. post-op course c/b chf/pneumonia. pt with difficulty breathing, low sats and pao2 44 last [**hospital 3550**] transferred to sicu service for closer resp monitoring/ ?cpap.

all: ativan, librium---adverse reactions

neuro: arrived alert, oriented x3, cooperative and pleasant. following commands appropriately. moving all extremities.

cv: hr 80-90's afib/vpaced. occ pvc's noted. bp 97-120/60's. denies chest pain/palpitations. ck neg x2 thus far. inr 2.7 yest. given 1mg coumadin x1, to be dosed per day.

pulm: ls bilateral crackles [**2-2**] way up. rr 20-30's. o2 sats 88-100% on 100% nrb. unable to speak full sentences but able to speak several words at a time. pt [**name (ni) 865**] rapidly to low 80's without o2 and takes a while to return to 90's. received lasix on floor prior to transfer, no further lasix given.

gi/gu: abd soft, +bs x4. abd incision with staples c/d/i. no drainage noted. pt with sips h20 and crackers only r/t desat without o2. no stool this shift. foley draining 20-30cc/hr clear amber/yellow urine. ho notified of low u/o, no intervention at this time.

id: afebrile. wbc yest 16.4. started on cipro and clinda for pneumonia.

endo: 11p fs 11. no coverage per ss.

social: wife called and updated by resident. other family members called also.

access: left dl picc. one port not flushing.

plan: observe resp status, cpap if needed. con't abx for pneumonia. diet as tolerated. full code. communication with family.
"
551,"resp care
pt has allergic reaction to antibiotics and became tachynepic, diaphertic, and broncospastic. bs diffuse wheezes, greater on the right side. resp rr 40s - 50s, hr 110-123 and spo2 > 97%. abgs drawn and results came up within normal limits. albuterol ud neb x 3 given back to back, with good effect. bs: increase in aeration, rr decreased to 30s, hr 105 and spo2 100%. no adverse reaction noted. will continue to monitor.
"
552,"condition update:
d/a:  t max 99.9 most of day, spike to 102.6 in ct.

neuro:  pt lethargic, [**name (ni) 759**] to voice, perl, at times will attempt to answer questions, at times no verbal response.  will locate painful stimuli, and mae's minimally on bed, not to command.  denies pain.  oriented x1 only.  pt with rigors at times, tremulous however no s+s of seizure activity.

cv:  hr 70's when afebrile to 120's when febrile.  neo titrated for [**name (ni) **] map > 60, [**name (ni) **] >90.  cvp 3-17.  fluid balance mn-1630 + 1111 cc's.  scant generalized edema, + ascitic abdomen.

resp:  ls clear, diminished.  when stimulated, pt rr increases and becomes wheezy at times.  ? if administration of meropenum contributes to overall worsening picture so benadryl now given before meropenum administration and it is given over 1 hour.  no s+s of adverse reaction noted today with x2 doses of meropenum.  pt on [**name (ni) 3674**] cool mist with am abg:  7.42, 46, 134, 31, 5.

gi:  abdomen distended, ascitic.  + bs.  no bm. tube feeds @ [**name (ni) **] via post-pyloric tube stopped this morning in preparation for procedure.  ivf started.  pt to angio and then to ct scan for ct guided placement of catheter.  pt remains in ct at this time intubated, with anesthesia, radiologist, and nursing in room.

gu:  foley-bsd with clear amber urine/icteric.

sx:  [**name (ni) **] [**name (ni) 731**] was [**name (ni) **] for consents.

r:  septic, dependent on pressors, currently in ct scan for drain placement.

p:  continue to titrate neo for [**name (ni) **] > 90, map > 60.  tobramycin levels due with next dose.  continue current close monitoring and management.




"
553,"resp: [**name (ni) 257**] pt on simv 14/500/+5/50%.  ett 7.5 retaped and secured  20@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of bloody, clots secretions. mdi's administered q4 with no adverse reactions. am abg 7.39/42/69/26. fio2 increased to 60%. plan trip today to or for debridment.
"
554,"resp:  pt continues to be mechanically ventilated on psv 15/+5/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve following suctioning. suctioned for small amount of thick white secretions. mdi's administed q 4hrs atr with no adverse reactions.  rsbi=117, plan to keep pt on psv and wean as tolerated.  no further changes
"
555,"continuation of previous note.
cv:  patient originally with low grade temp,  now afebrile.  patient on multiple cardiac medications thoughout the day with various adverse and not adverse reactions.  patient currently on esmolol for rate control, norepi for bp management, heparin, insulin and currently versed.  patient with poor [** **] pt on right foot and no dp on right foot.  [**name (ni) **] pt and dp on left foot.

resp: no vent changes made this shift, patient overbreathing on vent, with adequate oxygenation and good gases.  patient with minimal amounts of ett secreations.

gi:  patient started on insulin gtt for elevated blood sugars with multiple foul smelling bloody stools.

gu:  patient with patent foley voiding minimal amounts of urine.  please see flowsheets for all other information.  thank you
"
556,"7p-7a
neuro: pt opens eyes, does not follow commands, does not [**name8 (md) 506**] rn in room, does not move any extremeties. perrla. morphine 2mg ivp given for pain shown by increase in bp.

cv: hr 80-90s in and out of afib. at present 80s sr no ectopy, lytes repleted prn. sbp labile, see carevue, on and off neo. at present time sbp 102, on 0.5mcg/kg/min. picc to right arm patent and [**name8 (md) 235**]. left radial arm [**name8 (md) 235**] reddened. dopplerable pedal pulses. generalized anasarca. bilat upper extremties oozy moderate amts of serous fluid. sternal sutures cdi, covered w/ gauze and abd. binder [**name8 (md) 235**] to sternal area. received 1 unit of prbcs, no adverse reactions, repeat hct 28.

resp: ls clear- coarse, diminished bases. sats >98%. rr 25-35. trial of cpap rr increased to 40's. on cmv rate 10, fio2 40% peep 5, see carevue for abgs. suctioned for small amts of thick yellow secretions via ett.

gi/gu: abd soft, round, hypoactive bs. tf residual at 0030 250cc, given back to pt, tf on hold, pa [**doctor last name **] aware. dophoff +placement. foley [**doctor last name 3447**] adequate amts of clear yellow urine.

skin: stg 2 2cm round to coccyx area, duoderm on and [**doctor last name 235**]. see carevue for further details.

endo: riss.

plan: monitor hemodynamcis. monitor pulmonary status. follow labs and treat as appropriate. pain control. monitor neuro status.
"
557,"resp: [**name (ni) 257**] pt on psv 10/5/50%. bs are clear bilaterally with diminished bases. suctioned for scant to small amounts of thick tan secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's or changes this shift. rsbi=54. plan to wean to extubate today.
"
558,"npn shift 1900-0700:

neuro: a&ox3, periods of restlessness, anxiety. non-compliant w/ activity restriction. perrla. mae, equal strength.

resp: b/l bs coarse w/ rales mid to lower bases bilaterally. upper airway congestion, wet, unprod cough. resp tachypneic, labored, discoordinate. chest x-ray revealed fluid volume overload. lasix 20mg iv at 0000 w/ good response.  tol 4l nc for most of night. resp distress at 0500, desat to 80's, audible expiratory wheezing, verbalized feeling sob. 100% nrb on w/ good effect. alb/atro neb given. pt refused o2 humi face mask, ho aware. place on high flow nasal cannula, able to wean to 6l at 0600 w/ good effect. pt more comfortable.

cv: st, rare pvc's, pac's. sbp 130-170's. no s/s of cardaic distress. on metoprolol at home. lopressor 5mg iv ordered as tsanding w/ good  effect. no edema. +pp, feet pale, cool, dusky toes. ho aware. pt hypernatremic, 151, ho aware. other electrolytes wnl.

hem: tx prbc x3 for hct of 20 from 26. tol tx well, no s/s of an adverse reaction. post hct x2 stable at 29.0. no s/s of active bleed. inr=1.2.

id: wbc up from 12 to 17. afebrile.

gi: abdomin distended, rounded, firm. +bs x4. pt coughing w/ small sips of h20. made npo until am, will further eval. no bm.

gu: good amts of yellow urine, w/ sediment. pt w/ chronic renal failure, bun/cr=52/3.6.

plan: wife and family to come in for meeting w/ ho to discuss course of care, adviced to fill out health care proxy forms. possible mri? pt declines surgey so far for aaa, 6x6cm. full code. resusitation status must be addressed w/ family.
"
559,"resp: [**name (ni) 257**] pt on psv 18/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. continued periods of extreme aggitation with rr into 60's. ativan given to calm with results. peep ^ to 8 abg's 7.43/35/104/24. rsbi=164. will continue to wean appropriately.
"
560,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 20/5/50%. alarms on and functioning. ambu/syringe @ hob. portex #7 with spare inner cannula in room. cp @ 23 cmh20. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.39/36/133/23. rsbi=127. terminated with ^ rr to 40's. will continue to wean appropriately.
"
561,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c14/550/+5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellowish secretions. mdi's administered q4 combivent with no adverse reactions. vent changes: psv 12/5/35%, abg's drawn (careview)ps ^ 15, fio2^40% abg 7.39/42/99/26. rsbi=40, ps decreasd to 10. will continue to wean for possible extubation.  ett retaped and secured @ 22 lip. no further changes noted.
"
562,"npn 2300-0700:

pt tansfered from oncology floor, 7 [**hospital ward name 320**] at 2300 for gi bleed. +melanous stool, hct 21 down from 29.4. tx 2u at 7 [**hospital ward name 320**], 1 pack of platelets. after 1u prbc, hct remained at 21. neuro stable. a&ox3. oob supervised, gait slow, steady. equal strength, no weakness. perrla. no pain. ra, satting 95-100%. no distress. lungs clear. nsr-st, no ectopy. hypotensive, sbp 80's-90's, baseline as [**name6 (md) 20**] oncology rn. asymthomatic. pt w/ fuo, on prn tylenol 650mg given atc. pt spiked to 101.5. pt w/ chills at 0200. tylenol 650mg, benadryl 25mg po w/ good relief. ho aware, pan cx'd on floor. pt urinate in toilet, unable to get sample. npo, tolerated h2o with pills. no n/v/t. stool brown, small amt of blood clots evident, not bright red.  ordered for prbc x 4u, platelets 1 pack. tx'd 3u of prbc, 1pack of platelets via r subclavian hickman (triple port) w/ no adverse reaction. cortisol level test done and sent at 0700 w/ am labs.
"
563,"[**2125-3-25**] 1:29 pm
 ct chest w/contrast                                             clip # [**0-0-**]
 reason: evaluate for abscess around surgery site. please extend to l
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 55m with recent rib r fractures, now with increasing pain around
  fracture site as well as pain
 reason for this examination:
  evaluate for abscess around surgery site. please extend to liver as he feels
  the liver is swollen and tender (murpy's sign negative)
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sun [**2125-3-25**] 5:18 pm
  1. s/p fixation of r lateral [**6-25**] rib fx; adjacent pleural thickening raises
  question of repetitive irritation by hardware/screws.
  2. persisting fx of posterior r 8 & 9 rib fx.
  3. healing posterolateral r 10 rib fx.
  4. no chest wall/pleural fluid collection.
  5. no fluid around the visualized portion of the liver.
 wet read version #1
 wet read version #2 jekh sun [**2125-3-25**] 2:32 pm
  1. s/p fixation of r lateral [**6-25**] rib fx.
  2. persisting fx of posterior r 8 & 9 rib fx.
  3. healing posterolateral r 10 rib fx.
  4. no chest wall/pleural fluid collection.
  5. no fluid around the visualized portion of the liver.
 ______________________________________________________________________________
                                 final report
 history:  55-year-old male with recent right-sided rib fractures, now with
 pain around the fracture site.

 study:  ct of the chest with contrast; 70 cc of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  [**2125-2-4**] chest cta.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course.  the pulmonary arterial trunk is also of a normal
 caliber.  there is no mediastinal hematoma.  there is no pleural or
 pericardial effusion.  a small locule of fluid just anterior to the superior
 aspect of the heart measures approximately 2 cm in diameter and is most
 compatible with a pericardial cyst (2; 41).

 the lungs are clear of masses or consolidation.  small amount of
 atelectasis/scarring is present in the right lower lobe in the region of the
 rib fracture repair.

 the visualized portion of the upper abdomen shows no abnormality; specifically
 there is no fluid around the liver or in the superior portion of the
 retroperitoneum.
                                                             (over)

 [**2125-3-25**] 1:29 pm
 ct chest w/contrast                                             clip # [**0-0-**]
 reason: evaluate for abscess around surgery site. please extend to l
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)

 examination of the bones again demonstrates lateral fixation plates of the
 right seventh, eighth, and ninth ribs with the screw tips extending just
 beyond the inner cortical rib margins, of uncertain clinical significance.
 adjacent mild pleural thickening is also present.  non-united fracture of the
 posterior aspect of the right seventh and eight ribs are also present.  the
 posterolateral aspect of the right ninth rib demonstrates a non-displaced
 fracture with callus surrounding it (2; 61).  otherwise, the spine and sternum
 appear unremarkable.  no fluid collections are present in the soft tissues
 adjacent to the fracture fixation.

 impression:
 1. status post fixation of the right seventh through ninth lateral ribs with
 non-united posterior fractures of right ribs eight and nine.  adjacent pleural
 thickening raises the question of irriation from hardware/screws.  this
 finding was discussed with [**first name8 (namepattern2) 305**] [**last name (namepattern1) 1509**] at 17:17 on [**2125-3-25**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**]
 over the phone.
 2. healing posterolateral right 10th rib fracture.
 3. no evidence of chest wall or pleural fluid collection.
 4. limited views of the upper liver show no perihepatic fluid.

"
564,"[**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 52m with new r pleural effusion
 reason for this examination:
  charac of fluiid?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with new right pleural effusion and abdominal pain.

 study:  ct of the torso with contrast; 150 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest radiograph from [**2164-8-17**] at 9:59 a.m.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  scattered
 axillary and mediastinal lymph nodes are present, although none meet
 pathologic size criteria.  multiple prominent bilateral hilar lymph nodes are
 present measuring 14 mm in their short axis on the right and 12 and 6 mm in
 their short axis on the left (601:45).  the aorta is of a normal caliber along
 its course with incidental note made of a common origin of the brachiocephalic
 and left common carotid arteries, a normal variant.  the pulmonary arterial
 trunk caliber is at the upper limits of normal, and there are no central
 filling defects.

 again is noted a large loculated effusion with minimally complex to simple
 fluid, unlikely to be hemorrhagic.  there is associated consolidation of
 nearly all the right lower and right middle lobes as well as compressive
 atelectatic effect on the right upper lobe.  portions of these collapsed lobes
 show variable enhancement, and multiple rounded hypodensities may in fact
 represent saccular bronchiectasis versus multiple foci of necrotizing
 pneumonia.  the left lung shows a clear upper lobe and saccular bronchiectasis
 of the lower lobe with diffuse bronchial wall thickenking in addition to some
 dependent atelectasis.  there is no pleural effusion on the left, and there is
 no pericardial effusion.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 subtle dense material in the neck of the gallbladder may represent small
 stones or sludge, but there is no pericholecystic fluid, wall edema or
 gallbladder distention.  the pancreas shows no masses or peripancreatic fluid
 collections.  the spleen is normal in size and appearance with a small 1-cm
 splenule noted anteroinferiorly.  the adrenal glands show no nodules.  the
 kidneys enhance with and excrete contrast symmetrically.  multiple
 well-circumscribed hypodensities are present in both kidneys, too small to
 characterize but likely representing simple cysts.  the small and large bowel
                                                             (over)

 [**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 show no evidence of obstruction or wall edema.  the aorta, ivc and portal vein
 appear normal.  there is no free fluid, free air or lymphadenopathy.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  there is no
 pelvic lymphadenopathy or free fluid.

 bones:  a schmorl's node is present at the inferior endplate of l4 and t12.
 otherwise, there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  large loculated right pleural effusion; saccular bronchiectasis of the
 bilateral lower lobes and consolidation of the right middle and right lower
 lobes with heterogeneous hypoenhancement and rounded hypodensities that may
 represent either the underlying saccular bronchiectasis versus multifocal
 necrotizing pneumonia.
 2.  cholelithiasis without cholecystitis.
 3.  hilar lymphadenopathy may be reactive; follow up imaging after treatment
 is recommended to ensure resolution.

"
565,"[**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  71 year old woman with pancreatic cancer s/p ex-lap with bx of periduodenal
  nodule, chole, [**last name (un) **], choledochojejunostomy, and gastrojejunostomy
 reason for this examination:
  for oncology staging
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 ct chest with contrast

 comparison:  none.  correlation is made with cta abdomen of [**2143-8-14**].

 technique:  multiple axial ct images were obtained through the chest following
 the administration of 75 cc of omnipaque iv contrast.  sagittal and coronal
 reconstructions were obtained.  no adverse reactions were reported.

 indication:  71-year-old female with pancreatic cancer, status post
 exploratory laparotomy with biopsy of peri-duodenal nodule, cholecystectomy,
 roux-en-y procedure, choledochojejunostomy, and gastrojejunostomy.  exam is
 done for oncology staging.

 findings:  right picc terminates at the superior atriocaval junction.  no
 supraclavicular, mediastinal, hilar, or retrocrural lymphadenopathy.  small
 right hilar lymph node measures 8 mm on short axis and does not meet criteria
 for pathologic enlargement by size.  scattered left hilar pulmonary calcified
 granulomas.  heart size is within normal limits without pericardial effusion.
 the thoracic aorta is normal in caliber without dissection or aneurysmal
 dilatation.  branches of the aortic arch are normal.  pulmonary trunk is
 within normal limits by size.  no central pulmonary thromboembolic disease is
 identified.  thyroid gland demonstrates homogeneous attenuation without focal
 lesions.

 there is a 4-mm nodule in the middle lobe and a 3-mm nodule in the subpleural
 right lower lobe (2:36).  no pulmonary mass is identified.  bilateral basilar
 subsegmental atelectasis.  small bilateral pleural effusions.  no
 pneumothorax.

 abdomen:  pneumobilia is likely related to recent changes of reported
 choledochojejunostomy. hypodensity in the gallbladder fossa with intrinsic air
 is compatible with surgicel packing although an abscess would have a similar
 appearance.  stable 0.9 x 1.3 cm hypodensity in the right hepatic lobe
 (segment vii).  small perihepatic and perisplenic ascites.  colonic
 diverticulosis without diverticulitis involving the visible splenic flexure.
 there is patchy fluid surrounding the splenic flexure, which may be due to
 post-surgical change.

 bones and soft tissues:  no acute fracture or destructive osseous process.
                                                             (over)

 [**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 multilevel degenerative disc disease.  advanced degenerative changes of the
 right and moderate degenerative changes of the left acromioclavicular joint.
 degenerative arthrosis of both humeral heads.  there is a calcific structure
 along the greater tuberosity of the left humerus which may relate to calcific
 tendinosis.  no acute fracture or destructive osseous process.

 impression:
 1.  indeterminate right middle lobe and lower lobe pulmonary nodules.  in a
 patient with history of prior malignancy, unenhanced ct chest is recommended
 in three months to monitor growth pattern and malignant potential.
 2.  no intrathoracic lymphadenopathy.
 3.  pneumobilia, abdominal ascites and pericolonic fluid involving the splenic
 flexure are likely related to recent surgery. hypoattenuation in gallbladder
 fossa with intrinsic air is compatible with surgicel packing, however an
 abscess would have a similar appearance and cannot be excluded.
 4.  scattered colonic diverticulosis.

"
566,"[**2123-9-16**] 9:25 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 20502**]
 reason: please evlauate for occult malignancy
 admitting diagnosis: nausea;vomiting;liver tx
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with recent weight loss and dysphagia
 reason for this examination:
  please evlauate for occult malignancy
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  57-year-old male with recent weight loss and dysphagia concerning
 for occult malignancy.

 study:  ct of the neck with contrast; 70 cc of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the brain is unremarkable.  please refer
 to the head ct report performed from the same day.

 the orbits and globes are intact.

 the paranasal sinuses are clear.  the mastoid air cells are clear.

 the nasopharynx and oropharynx demonstrate no evidence of masses; streak
 artifact from dental amalgam limits assessment of the tongue and adjacent soft
 tissues.  the parotid glands are normal appearing bilaterally.  the
 submandibular glands are normal appearing, although slight asymmetry is
 present with the left gland larger than the right.

 the carotid arteries and jugular veins are patent; a small amount of calcified
 atherosclerotic disease is present at both carotid artery bifurcations.  no
 lymphadenopathy is present.

 the thyroid appears unremarkable.

 the lung apices demonstrate scattered areas of ground-glass opacity,
 compatible with sites of infection or inflammation.  a moderate right pleural
 effusion is present, non-hemorrhagic in nature.

 the bones demonstrate mild to moderate multilevel degenerative changes in the
 spine, but no aggressive appearing lesion is present.

 impression:  no evidence of occult malignancy.
                                                             (over)

 [**2123-9-16**] 9:25 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 20502**]
 reason: please evlauate for occult malignancy
 admitting diagnosis: nausea;vomiting;liver tx
 ______________________________________________________________________________
                                 final report
 (cont)

"
567,"[**2130-8-3**] 2:15 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 100592**]
 reason: hx cough, pulmonary nodules and smoking, rule out mass or pn
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  67 year old woman with cough, copd, pulmonary nodules
 reason for this examination:
  hx cough, pulmonary nodules and smoking, rule out mass or pneumonia
 contraindications for iv contrast:
  possible adverse reaction
 ______________________________________________________________________________
                                 final report
 [**last name (un) **] ct without contrast

 indication:  history of cough, pulmonary nodules and smoking.  rule out mass
 or pneumonia.

 comparison:  multiple chest ct from [**2119**] to [**2124**].

 technique:  axial helical mdct images were obtained from the suprasternal
 notch to the upper abdomen without administration of iv contrast and 1.25 mm
 slice collimation.  multiplanar reformatted images in coronal and sagittal
 axis were generated.

 findings:

 airways and lungs:

 panlobular and centrilobular severe emphysema is predominant in upper lobes.
 the airways are patent to subsegmental level.
 there is no pneumonia.

 new 4 mm apical left lung nodule (4; 35) is probably bronchiolar.  all the
 other nodules are stable since [**2122**], series 4, image 37, 67, 162, 209).  the
 dominant one measures up to 6 mm in right lower lobe.  there is no lung nodule
 concerning for malignancy.

 mediastinum:  the thyroid is unremarkable.  there is no lymph node enlargement
 by ct size criteria.  patient had prior sternotomy for cabg with extensive
 calcification of her venous graft from the aorta to lad with probably a stent
 inside of it.  aorta is not dilated and is moderately calcified.  there is no
 pericardial or pleural effusion.  epicardial wires are still in the
 mediastinum.

 osseous structures:  there is no bony lesion concerning for malignancy.

 upper abdomen:  this unenhanced study is not tailored for assessment of
 intra-abdominal organs.  gallstone is measuring 1.2 cm.  abdominal aorta is
 slightly ectatic measuring 26 x 23 mm.

 conclusion:

 1.  there is no pneumonia.
                                                             (over)

 [**2130-8-3**] 2:15 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 100592**]
 reason: hx cough, pulmonary nodules and smoking, rule out mass or pn
 ______________________________________________________________________________
                                 final report
 (cont)

 2.  4 mm left apical new ground-glass nodule is probably bronchiolar.  a chest
 ct followup is suggested in a year.

 3.  all the other nodules are stable since [**2122**].

"
568,"[**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 81m with sudden onset rlq pain at mcburney's point since yesterday.
  +rebound at pcp office
 reason for this examination:
  eval for appy, intra-abd process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh tue [**2194-9-23**] 11:02 pm
  1. no appendix seen, but no secondary signs of appendicitis.
  2. sigmoid diverticulosis w/o diverticulitis.
  3. l iliac vein [**year (4 digits) **]; early contrast phase limits evaluation of patency.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  81-year-old male with sudden-onset right lower quadrant pain
 yesterday.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2191-3-23**] ct of the torso with contrast.

 findings:

 abdomen:  visualized portion of the lung bases show minimal dependent
 atelectasis.  a moderate hiatal hernia is also present.  pacer leads are also
 present in the right ventricle.  the liver shows no focal lesion or
 intrahepatic biliary dilatation.  clips in gallbladder fossa are compatible
 with prior cholecystectomy.  the spleen is normal in size and appearance.  the
 adrenal glands show no nodules.  the pancreas shows no masses or fluid
 collections.  multiple hypodensities are present in both kidneys, too small to
 characterize, likely represents simple cysts.  the kidneys enhance with and
 excrete contrast symmetrically without evidence of hydronephrosis.  small and
 large bowel show no evidence of wall edema or obstruction.  diverticulosis is
 noted in the descending and sigmoid colon without diverticulitis.  there is no
 free air, free fluid or lymphadenopathy.  the appendix is not visualized.

 pelvis:  the bladder is unremarkable.  a left external iliac vein [**year (4 digits) **] is
 present, but due to early phase of contrast administration, its patency is not
 well evaluated on the current study.

 bones:  no aggressive-appearing lytic or sclerotic lesion is present.
 degenerative changes are present in the lower lumber spine, primarily in the
 form of facet joint hypertrophy and osteophytes.

 impression:
 1.  appendix not visualized, but no secondary signs of appendicitis.
                                                             (over)

 [**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  descending and sigmoid diverticulosis without diverticulitis.
 3.  status post cholecystectomy.
 4.  left external iliac vein [**clip number (radiology) **], incompletely evaluated for patency.

"
569,"[**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 80f with nausea/vomiting, diffuse abd pain
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2188-10-10**] 5:17 am
  1. no acute intraabdominal process.
  2. cirrhosis, ascites, splenomegaly, and smv thrombosis w/ downstream
  reconstitution (similar to [**2188-6-8**] ct).
  3. stable panc tail ipmn.
  4. cholelithiasis w/o cholecystitis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  80-year-old female with nausea, vomiting and diffuse abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; omnipaque iv contrast was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2188-6-8**].

 findings:

 abdomen:  the lower portion of the chest demonstrates calcified
 atherosclerotic disease of the coronary arteries as well as mitral and aortic
 valve calcifications.  the central line tip sits in the upper part of the
 right atrium.

 again the liver demonstrates a shrunken nodular contour compatible with
 cirrhosis.  the portal vein is patent and thrombosis of the smv persists with
 downstream reconstitution, similar to prior exam.  the gallbladder is
 decompressed with dense layering material within it.  the spleen is large
 measuring 15.6 cm in its long axis (2:26).  the adrenal glands are normal
 appearing bilaterally.  again the pancreas demonstrates a 13 mm hypodensity in
 the tail that is circumscribed and stable from prior exam, likely an ipmn.
 kidneys enhance with contrast symmetrically but are noted to be atrophic in
 this patient with known end-stage renal disease.  incidental note is made of a
 circumaortic left renal vein.  the small and large bowel show no evidence of
 obstruction.  a thickened appearance of the wall is likely secondary to the
 large amount of ascites that is present.  there is no free air.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta and into its
 major branches.

 pelvis:  streak artifact from bilateral hip hardware limits assessment of fine
 detail.  within that limitation, the bladder and rectum appear unremarkable.
 calcified uterine fibroids are present.
                                                             (over)

 [**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 level in the form of vacuum
 phenomenon as well as at the l3-l4 level in the form of narrowing, endplate
 sclerosis, and anterior osteophytes.  a hip arthroplasty is present on the
 right and repair of a proximal femoral fracture is evident on the left in the
 form of screw and plate fixation hardware.  old healed pubic rami and
 bilateral rib fractures are unchanged from prior exam.

 impression:
 1.  no acute intra-abdominal process.
 2.  cirrhosis, ascites, splenomegaly, and stable smv thrombosis with
 downstream reconstitution.
 3.  stable pancreatic tail ipmn.
 4.  cholelithiasis without cholecystitis.

"
570,"[**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 79f with fever, leukocytosis, elevated lactate, abd ttp.pt is on
  dialysis; renal aware of contrast and plan for dialysis.
 reason for this examination:
  acute abd process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2136-10-3**] 3:31 am
  1. no pe or aortic dissection.
  2. small b pleural effusions w/ mild pulmonary edema.
  3. cardiomegaly.
  4. nonspecific periportal edema in the liver.
  5. decompressed gb w/ mild wall edema - nonspecific but can be seen in chf,
  hypoproteinemia, or liver dysfunction.
  6. atrophic kidneys w/ multiple indeterminate lesions, some of which are
  cysts.
  7. sigmoid diverticulosis w/o diverticulitis.
  8. small amt of free fluid of unclear etiology, possibly reactive.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  79-year-old female with fever, leukocytosis, elevated lactate, and
 tenderness to palpation.

 study:  ct of the torso with contrast.  although the patient's creatinine was
 6.2, the patient is on dialysis and renal team is aware and plans for dialysis
 after the scan.  100 ml of omnipaque intravenous contrast was administered
 without adverse reaction or complication.  images were acquired in the
 arterial phase.

 images were then acquired in the chest, abdomen, and pelvis.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of the thyroid demonstrates a heterogeneous 1.8
 x 1.3 cm nodule in the left lobe of thyroid (2:7).  no axillary, hilar, or
 mediastinal lymphadenopathy is noted.  the aorta is of a normal caliber along
 its course without evidence of dissection or intramural hematoma; incidental
 note is made of a common origin of the brachiocephalic and left common carotid
 arteries, a normal variant.  the pulmonary arterial trunk is of a normal
 caliber and there are no filling defects to the subsegmental level.  the heart
 size is large, but there is no pericardial effusion.  small bilateral pleural
 effusions are present, but they are nonhemorrhagic in nature and minimal
 associated atelectasis is present.  scattered areas of ground-glass opacity
 are most compatible with pulmonary edema.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 abdomen:  within the limits of early phase scan, the liver shows no focal
 lesion and mild-to-moderate periportal edema.  contrast is seen refluxing into
 the hepatic veins, raising the possibility of hepatic congestion.  the
 gallbladder is decompressed, but shows moderate wall edema/pericholecystic
 fluid.  no calcified stones are noted.  the spleen is normal in size.  the
 pancreas and adrenal glands show no masses or nodules.

 the kidneys enhance symmetrically but are atrophic.  both kidneys demonstrate
 multiple hypodense exophytic indeterminate lesions, some of which are cysts,
 but some of which have more mass-like or have more soft tissue-like densities.
 neither kidney demonstrates hydronephrosis.

 the small and large bowel shows no evidence of obstruction or wall edema.
 there is no pneumatosis or portal venous gas.  scattered diverticula are
 present along the descending and sigmoid colon.  there is no free air or
 lymphadenopathy.

 the abdominal aorta is of normal caliber along its course.  the celiac and sma
 are widely patent.  the renal arteries and [**female first name (un) 85**] are not narrowed.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  small amount of
 free fluid is present in the pelvis.  sigmoid diverticulosis is present
 without evidence of diverticulitis.  no lymphadenopathy is seen.

 bones:  a lucent lesion with a sclerotic rim is present in the right iliac
 bone measuring 15 x 13 mm in the coronal plane (601b:49), and is
 benign-appearing.  mild-to-moderate multilevel degenerative changes are
 present throughout the thoracolumbar spine.

 impression:
 1.  no pe or aortic dissection.
 2.  cardiomegaly and pulmonary edema.
 3.  heterogeneous nodule of the left lobe of the thyroid as described above.
 ultrasound may be considered as clinically indicated.
 4.  atrophic kidneys with multiple indeterminate lesions, some of which are
 cysts, but many of which are incompletely characterized, so rcc cannot be
 excluded; mr may be considered for further characterization.
 5.  descending and sigmoid colonic diverticulosis without diverticulitis.
 6.  periportal edema and decompressed gallbladder with wall edema, which is a
 nonspecific finding and may reflect chf, hyperproteinemia, or hepatic
 dysfunction.
 7.  small amount of free fluid in the pelvis, possibly reactive.
 8.  benign-appearing but indeterminate lytic lesion in the right iliac bone
 without evidence of cortical disruption.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

"
571,"[**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 83m with vomiting, fever, lethargy
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2191-7-28**] 3:33 am
  1. hiatal hernia.
  2. cholelithiasis w/o cholecystitis.
  3. nonspecific perinephric stranding.
  4. enlarged prostate.
  5. l fat-containing inguinal hernia, also containing a small portion of
  bladder, similar to prior ct in [**2188**].
  6. mild-to-moderate colonic fecal burden.
  7. no acute findings.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with vomiting, fever, and lethargy.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  abdomen ct from [**2189-10-7**], and abdomen and pelvis ct from
 [**2188-10-2**].

 findings:

 abdomen:  bibasilar atelectasis is present as well as a small hiatal hernia.
 calcified atherosclerotic disease is present in the coronary arteries, and
 mitral valve calcifications are also present.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder shows a single calcified layering stone, but no wall edema or
 pericholecystic fluid.  spleen is normal in size.  the pancreas is markedly
 atrophic with a punctate calcification, possibly representing a degree of
 chronic pancreatitis.  the adrenal glands are normal appearing bilaterally.

 the kidneys enhance with and excrete contrast symmetrically.  small
 subcentimeter hypodensities in each kidney are too small to characterize, but
 likely represents cysts.  mild urothelial thickening is present in the left
 renal pelvis.  non-specific perinephric stranding is present bilaterally.

 the small and large bowel show no evidence of wall edema or obstruction.  the
 colon demonstrates a moderate fecal burden.  the aorta is of a normal caliber
 along its course with areas of calcified and non-calcified atherosclerotic
 disease present.  scattered subcentimeter retroperitoneal lymph nodes are seen
                                                             (over)

 [**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in the periaortic stations, but none meet pathologic size criteria.  there is
 no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley balloon with herniation of
 the left aspect of the bladder into the primarily fat-containing left inguinal
 hernia.  the prostate continues to be enlarged.  there is no pelvic
 lymphadenopathy or free fluid, and the rectum appears unremarkable.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 mild-to-moderate degenerative changes are seen throughout the thoracolumbar
 spine.

 impression:
 1.  no acute intra-abdominal process; moderate colonic fecal burden.
 2.  hiatal hernia.
 3.  enlarged prostate and left fat- and bladder-containing inguinal hernia.
 4.  mildly thickened left renal pelvis urothelium of unclear significance; no
 evidence of hydronephrosis or pyelonephritis.

"
572,"[**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  85 year old woman s/p colectomy for bowel ischemia, now with rigid abdomen,
  fever
 reason for this examination:
  s/p colectomy, now with rigid abdomen, fever. please do ct abd/pelvis with po
  contrast
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2194-9-1**] 7:13 pm
  1. sbo w/ transition pt at ileostomy exit site; cause appears to be mass
  effect from herniated mesenteric fat adjacent to the ileostomy.
  2. s/p r colectomy w/ tiny locules of gas adjacent to colonic staple line -
  may be post-operative although leak cannot be excluded.
  3. small amt of complex free fluid in abdomen/pelvis - ddx includes blood or
  bowel leak contents - correlate w/ exam and hct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  85-year-old female status post right partial colectomy, now with
 rigid abdomen, and fevers.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2194-8-18**].

 findings:

 abdomen:  the visualized lung bases demonstrate a moderate right and small
 left pleural effusion with associated atelectasis.

 the previously described hemangioma in the left lobe of the liver is not well
 visualized on the current exam given difference in the phase of the contrast
 administration.  the gallbladder is distended, but shows no hyperdense stones
 or wall edema.  the spleen is normal in size.  no peripancreatic fluid
 collections are present.  the cbd again is still prominent with minimal
 central intrahepatic biliary dilatation as well as a prominent pancreatic
 duct.  the adrenal glands are normal appearing bilaterally.  multiple
 hypodensities within both kidneys are too small to characterize but compatible
 with simple cysts.  the kidneys enhance and excrete contrast symmetrically.
 the aorta is of a normal caliber along its course with scattered areas of
 calcified atherosclerotic disease.  there is no lymphadenopathy.

 the stomach and small bowel are distended with multiple air-fluid levels all
 the way to the ileostomy exiting from the right lower quadrant of ventral
 abdominal wall.  a locule of mesenteric fat has herniated through the ventral
 abdominal wall narrowing the lumen of the ileostomy, resulting in relative
                                                             (over)

 [**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 transition point.

 the patient is status post right colectomy; a small amount of right paracolic
 gutter fluid is present with adjacent peritoneal enhancement, potentially
 reflecting post-surgical changes in the resection bed (2:38).  a blind-ending
 left/transverse colon is present with gaseous distention of the transverse
 portion and apparent wall discontinuity/hypoenhancement at its posterior wall
 (2:38) and potentially involving the aterior wall as well.  near the staple
 line and at the anterior wall of the transverse colon are few small locules of
 intraperitoneal gas (2:39).  additionally, there is a small amount of gas
 within a ventral wall subcutaneous fat.  small amount of intra-abdominal free
 fluid is present and is of borderline complexity.

 pelvis:  the bladder is decompressed around a foley balloon.  uterus
 demonstrates multiple calcified fibroids.  the distal colon shows sigmoid
 diverticulosis with no evidence for diverticulitis.  minimally complex free
 fluid is present in the pelvis.  multiple inguinal lymph nodes are present,
 prominent in size but not meeting pathologic size criteria and are likely
 reactive in nature.  the right sided intramuscular hematoma is unchanged.

 bones:  no aggressive-appearing lytic or sclerotic lesions are present.
 degenerative disc disease is present at the l4-l5 level with endplate
 sclerosis and small anterior osteophytes.

 impression:
 1.  post operative changes of recent right hemicolectomy.  distended remaining
 transverse colonic pouch with apparent area of wall
 discontinuity/hypoenhancement; given the small locules of adjacent gas and
 minimal complex free fluid, colonic perforation potentially from ischemia is a
 possibility.
 2.  status post right colectomy with end ileostomy.  small bowel distnsion
 with relative transition point and mesenteric fat herniation through the
 ventral abdominal wall resulting in possible small-bowel obstruction vs ileus.
 3.  new bilateral effusions and adjacent atelectasis.

 findings raising possibility of ischemia/postoperative leak of the transverse
 colon were were discussed with [**first name8 (namepattern2) 4486**] [**last name (namepattern1) 30172**] at 19:52 by [**first name4 (namepattern1) 30173**] [**last name (namepattern1) 30174**] by
 phone.

"
573,"[**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 60m with hcc, abd pain and fever recently d/ced
 reason for this examination:
  1: eval for pe 2. ct abd for eval for fluid collection in ruq, possible
  hepatobilary etiology for ruq pain and fever
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2119-8-7**] 11:38 pm
  1. large porta hepatis mass invading the r portal vein w/ 2 crossing biliary
  stents, and multiple hepatic mets.
  2. 2 new (from [**2119-8-2**] ct) large dilated intrahepatic ducts (2: 16 and 22)
  that are more rounded and rim enhancing, appearing more abscess-like.
  3. stable collection near the pancreatic tail compared to [**2119-8-2**] ct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with hepatocellular carcinoma, now with abdominal
 pain and fever after recent discharge.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2119-8-2**] abdominal ct.

 findings:

 abdomen:  the visualized portions of the lung bases demonstrate streaky
 atelectasis. right gynecomastia is incompletely imaged. no pleural effusion.
 prominent 9-mm right diaphragmatic lymph node is unchanged.

 the spleen is normal in size and appearance.  the adrenal glands show no
 nodules.  the kidneys enhance with and excrete contrast symmetrically without
 focal lesion or hydronephrosis. the small and large bowel show no evidence of
 obstruction or wall edema.  a lobulated low-attenuation peripancreatic
 collection adjacent to the tail, is redemonstrated and currently measures 4.6
 x 3.0 cm in greatest conglomerate axial dimensions, which is similar to the
 prior study where it measured approximately 4.3 x 2.8 cm at similar level. the
 pancreas is otherwise unremarkable.

 a dominant ill-defined enhancing hypodense mass involving segments [**last name (lf) 70637**], [**first name3 (lf) 751**],
 and ivb measuring 6.1 x 5.4 cm in the axial plane (2:20) is similar in size
 and appearance from the prior study and results in biliary obstruction in both
 hepatic lobes.  it has invaded the bifurcation of the main portal vein as well
 as the left and right portal veins, and has occluded the anterior right portal
 venous branch, unchanged. multiple stable-appearing ill-defined, peripherally
 enhancing satellite lesions are present primarily involving the right hepatic
 lobe, concerning for metastases.  incidental note is made of a fiducial seed
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in segment [**clip number (radiology) 70637**] of the liver (2:22).  enlarged porta hepatis and
 paraesophageal lymph nodes are present, similar to the prior exam.

 since the prior study, there has been marked interval increase in size of
 lobulated tubular hypodensities with rim enhancement within segments vii and
 [**clip number (radiology) 70637**] compatible with marked worsening of biliary obstruction and cholangitis
 (2:16, 2:22). new rounded rim-enhancing hypodensities are noted adjacent to
 these dilated bile ducts compatible with abscesses (2:14), the largest
 discrete abscess measuring 12-mm which is located at the junctions of segments
 vii and [**clip number (radiology) 70637**] (2:14). additionally, the more inferiorly located blown-out
 intrahepatic bile duct in segment [**clip number (radiology) 70637**] demonstrates extension into the
 subcapsular space with a focal subcapsular abscess noted measuring 2.1 x 0.9
 cm (2:20).

 moderate intrahepatic biliary dilatation elsewhere in the right lobe as well
 as in the left lobe of the liver is not significantly changed. two metal
 biliary stents are seen coursing from the main left and right hepatic ducts
 through the common bile duct and terminate within the duodenum. as before, the
 left stent traverses the mass; the right stent terminates within the mass
 (2:23). a small amount of pneumobilia is present within the gallbladder and
 cystic duct, an expected finding in a patient with stents.

 there is no free air or free fluid.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  the appendix
 is normal.  there is no pelvic lymphadenopathy or free fluid.

 bones:  there is degenerative disc disease at l5-s1 intervertebral disc.
 additionally, there is subtle grade i anterolisthesis of l4 on l5.  otherwise,
 there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  worsening biliary obstruction in segments vii and [**clip number (radiology) 70637**] with peribiliary
 enhancement and multiple new adjacent rim enhancing round hypodensities
 compatible with cholangitis and abscess formation. the blown-out intrahepatic
 bile duct within the inferior aspect of segment [**clip number (radiology) 70637**] extends into the
 subcapsular space with a focal subcapsular abscess identified.

 2.  relatively unchanged appearance of dominant mass compatible with
 hepatocellular carcinoma within segments [**doctor first name 751**], ivb and [**doctor first name 70637**] with invasion into
 the portal venous system and biliary obstruction. numerous ill-defined lesions
 primarily within the right lobe of the liver which appear similar compared to
 the prior exam likely reflect metastases, although developing abscess
 formation cannot be completely excluded.

 3.  moderate left intrahepatic biliary dilatation is similar.
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)

 4.  no significant change in peripancreatic tail lobulated fluid collection.

"
574,"resp: [**name (ni) 257**] pt on psv 15/8/40%. bs reveal noted aeration with sub q bilaterally. suctioned for moderate amounts of thick yellow secretions, copious thick clear from oral cavity. mdi's administered alb/atr with no adverse reactions. pt 02 sats to 80's with ^ wob then placed on simv (see carview). attempted rsbi but no resps. sedation lightened and plan is to change settings to psv.
"
575,"resp: pt rec'd on simv 20/450/10/+5/40%. ett #7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration and sub q noted on ls and up front of chest. suctioned for small amounts of thick yellow/whitish secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions. am abg 7.44/47/95/33. rsbi=no spont resps. plan to attempt wean to psv today as tolerated.
"
576,"resp: pt rec'd on simv 20/400/20/+5/50%. bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions with a few plugs. mdi's administered q4 hrs alb/atr with no adverse reactions. attempted to wean to psv this am and pt ^ wob,^rr to 38+ with vt's @ 200, so returned to simv. abg's 7.37/56/116/34. vent changes to  decrease fio2 to 40%, increase vt to 450. no further changes noted.
"
577,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] 10/8/40%. alarms on and functioning. ambu/syringe @ hob.  cp @ 20, trach #8 portex. bs auscultated reveal bilateral clear sounds. suction for small amount of thick yellow. mdi's administered q4 hrs combivent with no adverse reactions. plan to continue t/c trials as pt tolerates.  am abg's 7.36/42/100/25. rsbi=56.  will continue to wean appropriately.
"
578,"resp: [**name (ni) 257**] pt on psv 12/8/50%. #8 portex with positional [**name (ni) **] at times. bs are coarse bilaterally. suctioned small amounts of thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt still very anxious with rr 6 to 40's.  no abg's or vent changes this shift. vt's 300's
"
579,"resp: rec'd on psv 8/5/40%. portex #8, ^ cuff pressures md aware. bs reveal bilateral aeration, chest tubes sealed. suctioned for moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. pt had episodes of ^ wob/rr. increased psv to 10, peep to 8 with vt's 300's, 02 sats 98%. no abg's.
"
580,"resp: pt remains on pcv dp20/r20/+5/40%. bs are coarse with small amounts of thick yellow secretions suctioned. no changes or abg's noc. 02 sats @100%. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. will continue full vent support
"
581,"ccu nursing progress/proceedure note 2:15pm-5;30pm
s:  i feel like i'm drunk!

o:  pt pre medicated on [**hospital ward name **] 3 with 5mg po benedryl prior to asa desensitization.  alert and cooperative throughout, but sleepy and does doze at times.

desensitization started at 2:30pm per protocol with doses administered every 15min.  pt tolerated without itching, sob, hives or other adverse reaction.

cv - hr 58-70 nsr/sb with rare pvc's.  bp 138-148/80's.  4pm lopressor held d/t hr parameters, but administered at 5:20pm.   heparin maintained at 400u/hr.

resp - ls are clear on ra with sats 96-100%.

gu - voiding in urinal q1-2hrs approx 400cc per void.   1 liter infusing upon admission, absorbed and dc/d.

gi- abd is soft with +bs.  tolerating clear liq with asa

a:  successful asa desensitization

p:  cath planned for [**7-11**], cont asa and heparin and monitor for s/s intolerance.  keep pt informed of poc per multidisiciplinary rounds.
"
582,"resp: [**name (ni) 257**] pt on simv 20/450/+5/40%. alarms on and functioning. ett 7.5, 23 @ lip. bs are diminished bilaterally. ls chest tube in place. mdi's administered q4 hrs with no adverse reactions. abg's 7.39/49/98/29. rsbi=126. placed pt on psv 15/8/40%. vt's 400/ve's 6/rr 18/02 sats @99% with am abg to follow. no further change noted.
"
583,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/+8/60%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal ls coarse, rs diminished with some aeration noted in apecies. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.40/44/144/28. decreased fio2 to 50%. rsbi=16. plans to wean to possible extubate this am.
"
584,"resp:  [**name (ni) 257**] pt on [**last name (un) **] a/c 20/500/40%/+8.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal rs clear apecies with ls coarse, diminished bases. 02 sats ^ 90's, 98%.  suctioned for small to moderate amounts of thick yellowish secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=153. no further changes noted
"
585,"resp: [**name (ni) 257**] pt on a/c 12/500/+5/40%. bs are slightly coarse. suctioned for moderate amounts of tan-yellow thick secretions. mdi's administered as ordered of atr with adverse reactions. am abg 7.41/39/104/26. plan is for possible extubation today.
"
586,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 15/5/40%. bs are clean bilaterally with diminished bases. mdi's administered q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions. spare trach, ambu in room. no abg's. t/c trials to continue today as tolerated.
"
587,"resp care
pt seen for prn nebulizer tx.  given 2.5 mg albuterol + 2 ml of normal saline.  breath sounds are wheezy bilat with increased aeration post-tx.  no adverse reaction.  spo2: 96 on 4l nc.  pt states that breathing feels fine.  will continue to monitor for bronchodilator tx.
"
588,"resp: [**name (ni) 257**] pt on psv 22/10/50%. bs are coarse bilaterally. suctioned for small amounts of thick secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.43/47/148/32. vent changes; decreased ps to 20/fio2 to 40%. will continue to wean appropriately.
"
589,"resp: [**name (ni) 257**] pt on a/c 26/350/12+/40%. pt is trached #8 [**last name (un) 3338**]. alarms on and functioniong. ambu/syringe @ hob. bs are coarse with noted improvement following suctioning. suctioned for moderate amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=no sponts. am abg 7.33/38/80/21. no changes noc.
"
590,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  a+ox3.  speech clear.  mae ad lib.  med per [**month (only) **] with morphine for face/head/neck pain while double lumen balloon in place--pain tolerable with morphine however pt has not been pain free with balloon in place.

cv/pulm:  mp=vpaced with freq pvc's noted.  bp 140's-160's/40's-60's.  heparin titrated according to sliding scale/ptt's.  transtracheal 02 catheter in place at 1liter cont.  breath sounds clear upper lobes, crackles lower lobes.  bumex 1mg iv given with brisk diuresis, breath sounds clear/coarse after bumex.  at 1630 return of bibasilar crackles noted--team aware, no intervention at this time.  doe noted; no sob at rest.  [**first name8 (namepattern2) 3568**] [**last name (namepattern1) 3569**] in to see pt from outpatient pt; attempted to remove transtracheal catheter over wire for stripping; unable to remove.  several attempts following humidified air over next 4 hours unsuccessful.  dr. [**last name (stitle) 3570**] in to see pt, catheter removed over wire, cleaned and reapplied by dr. [**last name (stitle) 3570**]. sm amts mucous and old blood noted on catheter prior to cleaning.  o2 sats mid 90's throughout day, airway intact throughout day.  pt remains with double lumen balloon in r nares, scheduled for embolicectomy [**2131-5-18**] ? time.  vit k given both po and iv in addition to one unit ffp to correct inr in preparation for procedure in am.  one unie prbc's given for hct 27.3 with increase in hct to 32.0.  no adverse reactions noted with prbc, ffp or vit k iv.

gi/gu:  tol po's--does have some difficulty swallowing.  abd soft, non-tender, bowel sounds present.  no flatus, no bm.  voiding clear yel urine; [**name8 (md) 20**] md foley inserted following void--25ml residual obtained.  foley left in place, draining clear yel urine at this time.

id/integ:  tmax 99.1 po.  remains on cefazolin.  skin intact.  old scarring noted from r mastectomy.

psychosocial/plan:  husband in to visit.  emotional support given to pt and fam.  plan is to cont to titrate heparin according to sliding scale/ptt, npo after midnight for embolectomy in am, cont to follow labs, monitor i+o, assess for signs of bleeding, monitor airway/cont 02 sat monitoring.  cont with current nursing/medical regime.
"
591,"resp: [**name (ni) 257**] pt on a/c 26/350/+12/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. abg' 7.31/46/78/24. vent changes to increase rr to 28, fio2 to 50%. am xray and additonal abg's pending. no further changes noted.
"
592,"respiratory care note
pt received on ac as noted with no changes this shift. bs are slightly decreased, but clear bilaterally. pt suctioned for no secretions. mdi's given q4 - pt tolerated well with no adverse reactions. plan to continue on current settings at this time.
"
593,"resp: [**name (ni) 257**] pt on nrb. hhn administered of xopenex 0.63 as ordered with no adverse reactions. pt placed back on niv @ 4:00 psv 15/5/60%. fio2 ^ to 60% due to 02 sats in low 80's. abg pending. will continue to monitor progress to wean.
"
594,"resp: pt rec'd on a/c 14/400/+5/50%.bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q 4 hrs [** **] with no adverse reactions. no abg's. rsbi=>200. plan is to attempt wean today as tolerated.
"
595,"resp: pt remains on a/c. bs are coarse with occasional wheezing. mdi's administered q4hrs [** 892**] with no adverse reactions. suctioned for moderate amounts of thick tan secretions.  will continue full vent support.
"
596,"resp: pt remains vented on a/c 18/400/+10/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4h [** 892**] with no adverse reactions. plan to wean to psv as tolerated.
"
597,"[**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  43 year old man with new diagnosis of [**hospital 21613**] transferred from outside hospital
  with possible septic arthritis and pneumonia, still spiking fevers despite
  treatment with vanc/meropenem/azithro, and with worsening abdominal pain and
  distension
 reason for this examination:
  ? acute intra-abdominal infection, ? degree of pneumonia, ? other acute process
  to explain abdominal pain and fevers
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  43-year-old male with new diagnosis of aml, now with fevers despite
 treatment with broad-spectrum antibiotics as well as worsening abdominal pain
 and distention.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest cta from [**2123-5-8**] from an outside hospital.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  a
 prominent lymph node in the right axilla measures 9 mm in its short axis (2;
 12).  scattered small mediastinal lymph nodes are present, the largest of
 which is in the precarinal station measuring 11 mm in its short axis (2; 25).
 additionally, a right hilar lymph node measures 10 mm in its short axis (2;
 34).  the aorta is of a normal caliber along its course.  an incidental note
 is made of the left vertebral artery filling directly off the aortic arch, a
 normal variant (2; 20).  the pulmonary arterial trunk shows no central filling
 defect.  the heart demonstrates a simple pericardial effusion measuring a
 maximum thickness of 11 mm in the axial plane (2; 38).  additionally, small
 amount of bilateral pleural effusions are present, simple in nature, with
 associated atelectasis.  additionally, scattered areas of airspace opacity in
 the right upper and superior segment of the right lower lobes are compatible
 with pneumonia.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 the gallbladder shows no stones or wall edema.  the spleen measures 14.8 cm in
 its long axis.  the adrenal glands show no nodules.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis or
 masses.  the aorta is of a normal caliber along its course; the celiac axis is
 mildly narrowed as it ducks beneath the diaphragmatic crus.  the small and
 large bowel show no evidence of obstruction or wall edema.  scattered
 retroperitoneal and mesenteric lymph nodes are noted although do not meet
 pathologic size criteria.  portions of the lower retroperitoneum have a
                                                             (over)

 [**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 ""[**doctor first name 2778**]"" appearance, of unknown clinical significance.  the appendix is
 visualized and is fluid filled but not dilated, nor is there adjacent
 inflammation (2; 106 and 301b; 33).  there is no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  bilateral inguinal lymph nodes are present measuring 9
 mm in their short axes (2; 124).  there is no free fluid.

 bones:  there is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  airspace opacity at the right upper lobe and superior segment of the right
 lower lobe compatible with pneumonia; small-to-moderate bilateral pleural
 effusions and small-to-moderate pericardial effusion, all of which fluid is
 simple in nature.
 2.  scattered areas of prominent lymph nodes and splenomegaly compatible with
 patient's known diagnosis of leukemia.

"
598,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration in apecies with diminished lll noted.  mdi's administered q4 hrs combivent with no adverse reactions. episodes of desaturation during the noc, fio2 increased to 60%. 02 sats 95-97%.  rsbi=69. pt scheduled for trache today [**3-31**]. no further changes noted.
"
599,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex. bs are clear in apecies with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. no abg's and rsbi=72. will continue with t/c trials.
"
600,"resp: [**name (ni) 257**] pt on psv 12/8/50%. ett #7, 26 @ lip. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. suctioned for small amounts of yellow to white thick secretions. mdi's administered alb/atr with no adverse reactions. vt's 500-600, ve's [**11-22**], 02 sats @ 98%. [**month/year (2) **]=80. plan to wean to extubate this am.
"
601,"respiratory care note:
     received patient on ac as noted in carevue.  ett is secured and patent.  no changes have been made this shift.  for specific settings please refer to carevue.  bs are coarse throughout with occasional wheezes noted on the left side.  sx for small amounts of tan thick secretions, blood tinged at the beginning of the shift.  no rsbi this am due to increased fio2 and peep settings (.60 fio2 and 10 peep).  patient remained afebrile this shift.  mdi's administered as ordered with no adverse reactions noted.  spo2 remains 94-95%.  plan is to maintain current therapy and wean fio2 and peep as tolerated.
"
602,"resp: [**name (ni) 257**] pt on psv 12/8/40%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioning scant amounts. mdi's administered as ordered alb/atr with no adverse reactions. vt's 500-700, rr 20's to 30's when aggitated.  no changes this shift.
"
603,"resp: [**name (ni) 257**] pt on 50% t/c. pt removed t/c and 02 sats to 60's with ^ rr. place on [**last name (un) 33**] psv 5/5/40% to rest noc. suctioned for moderate amounts of thick yellow secretions. mdi's administerd q4 hrs alb/atr with no adverse reactions.am abg 7.38/57/132/35. will place on 50% t/c in am.
"
604,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/5/50%. alarms on and functioning.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  rsbi=168. 02 sats remain in ^ 90's @ 97%.  no further changes noted.
"
605,"resp: pt rec'd on psv 5/5/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. pt had some episodes of anxiety. 02 sats @ 99% with rr 18. vt 400. rsbi=37. plan to continue with t/c trials.  will continue to wean.
"
606,"resp:  [**name (ni) 257**] pt on psv 15/5/35%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned for small to moderate amounts of thick tannish secretions.  mdi's administered q4 alb/atr with no adverse reactions. pt rested noc on a/c 12/350/+5/35% where he remains. will return to psv this am.  no further changes noted.
"
607,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 24/380/+8/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of greenish thick secretions. mdi's administered q4 alb/atr with no adverse reactions. no further changes noted.
"
608,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate-copious amounts of yellow and some bloody tinged secretions.  mdi's administered q4 hrs with no adverse reactions. no further changes noted.
"
609,"resp: [**name (ni) 257**] pt on a/c 14/700/+8/50%. ett 7.5, 26@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse with diminished bases. suctioned for small amounts of thick secretions.  mdi's administered as ordered with no adverse reactions.  no changes or abg's noc. md ask to hold off on [**name (ni) 817**] and to attempt around 10:00am due to pt's past hemodynamic instability.  plan to lighten sedation, attempt [**name (ni) **] then wean as tolerated.
"
610,"resp: rec'd on psv 15/5/40%. bs are coarse bilaterally. suctioned for copious amounts of thick bloody secretions with large clot under tongue. pt has open cuts on tongue and md aware. mdi's administered q 4 hrs alb/atr with no adverse reactions. rsbi=101. will continue with present support.
"
611,"resp:  [**name (ni) 257**] pt on 16/400/5/40%. bs auscultated reveal ls clear with diminished rll. suctioned for small amounts of yellow thick secretions, sample sent. mdi's administered alb/atr with no adverse reactions. vent changes to decrease r to 14, fio2 to 30%. am abg 7.47/43/109/32.  rsbi attempted with no resps results. will attempt again on day shift.
"
612,"ccu npn
please see admit note for pmh, allergies and events leading to ccu admit.

pt arrived to ccu ~1500, awake, alert, oriented.
hr 75 sr no vea, 139/60.
lungs cta
sats 98% on ra
appitite fine
vdg qs
pt given benadryl 25mg po at 1830, prior to 1st dose of asa. benadryl iv, epinepherine at bedside, methyl prednisone will be tubed from pharmacy if needed.
a: pt admitted to ccu for asa desensitization, premedicated
p: administer metered asa per protocol, monitor for adverse reaction.
"
613,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 15/+12/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick bloody tinged secretions due to new trach.  mdi's given q4 hrs alb with no adverse reactions. vt's 600/ve 16-19, rr 28. pt has tachy periods with ^ rr in ^ 30's at times.   no rsbi due to ^ peep. no a-line for abg's presently, but expect new a-line started today. 02 sats @ 97%. no further changes noted.
"
614,"respiratory: pt remains intubated on psv 8/8/50%. ett retaped and secured @ 21 lip. bs are diminished with some crackles noted in bases. suctioned for copious amounts of thick yellow secretions and oral secretions. mdi's administered q4 hrs alb with no adverse reactions. vt's 500-600/ve 9/rr 17. rsbi=29. around 5:00 pt self extubated even though pt was restrained. pt was placed on nrb with sats @ 99%. wife was called and informed. will continue to monitor and will re-intubate if necessary.
"
615,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 20/5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal diminished rll with aeration noted on ls/slightly coarss/occasional wheeze.  suctioned for moderate amounts of thick yellow/bloody secretions, as well as out of oral cavity.  mdi's administered q4 alb/atr with no adverse reactions. pt became ^ sob, vent settings changed to a/c 20/400/+5/35%. abg's this am 7.37/51/99/31.  maintain settings with no further changes noted.
"
616,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv8/5/50%.alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal clear apecies with diminished bases. suctioned for small amounts of white thick secretions. mdi's administered q6 combivent with no adverse reactions. trip to mri without incident, results negative. am abg's 7.36/48/107/28. vent changes to decrease ps to 5 and fio2 to 40%. will continue to wean appropriately.
"
617,"npn
n: pt agitated when light attempting to sit up/self extubate. reoriented->fc's inconsistently/mae's with equal strength. sedated overnight on diprivan gtt with no adverse reaction noted.
cv: nsr 60-80's. no ectopy. cks sent and flat. hct 31.8 and stable. coags nl. hypotensive to 80's-->given total 3l fld with improvement though following lr boluses worsening met acidosis-->lactate 4. given 1l bolus 1/2ns with improvement now be -1 (-7). currently sbp 95-110 with maps >65. lt ct to 20cm sxn with sang drainage. +fluctuate/-leak. -crepitus.
r: lungs course throughout. sxn'd for mod amt thick yellow sec. simv 20->16 x 600/peep 5/50%. improving lactic acidosis.
gi: npo. ogt to lcs with mod amt bilious drainage. abd soft/distended with hypo bs.
gu: urine clear yellow 30-70cc/hr.
id: afebrile.
soc: no contact with any family. when pt awake, rn asked if there was anyone to be notified and pt shook head no. sw to get involved this am.
a/p: clinically clear neck/spine. extubate. transfer to flr.

"
618,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 28/500/12+/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 alb with no adverse reactions. vent changes reflect abg's. am abg's 7.45/45/109/29. no further changes noted.
"
619,"7a-7p
neuro: pt alert, disoriented to time and place. perrla. mae. medicated w/ one darvocet po for c/o incisional pain.

cv: hr 60-70s sr no ectopy noted. epicardial wires secured and attached, see carevue for details, no paced beats noted. sbp >100. a- line [**name6 (md) **] [**name8 (md) 20**] md [**last name (titles) 132**]. pressure dsg applied. 2 units of prbcs given as ordered for low hct. no adverse reactions w/ blood transfusions. extra dose of lasix 20mg given iv secondary to extra volume today. hct after prbcs 31.

resp: ls clear/ rales at bases. sats greater than 97% on 4l nc. breathing regular, not labored. chest tubes [**name6 (md) **] by md [**last name (titles) 132**]. pressure dsg intact.  cxr done.

gi/gu: abd round distended. +bs. no bm. groin area swollen w/ ecchymosis. md [**doctor last name 132**] aware. no new orders. foley draining yellow -> [**location (un) 138**], decreased u/o in afternoon- extra dose of lasix given increasing u/o. see carevue for details.

endo: fs 176-198, covered by csru protocol. md [**doctor last name 132**] changed protocol to pt's own scale to cover fs.

plan: monitor resp. status. pulmonary toilet. replete electrolyes as needed. ? transfer to floor.


"
620,"nursing (0700-1900)
todays events- right ij line dc'd by resident

a&ox3. dilaudid for abd. surgical pain with no adverse reactions, previous night experienced hallucinations. oob to chair tolerated well, no futher complaints of pain.

periods of sinus tachycardia otherwise cv signs wnl.  afebrile.

abdominal incision tender upon palpation, open to air, no drainage, jt.

nasal cannula 2l, independent incentive spirometery (1250ml) and cough deep breathe.

abdomen soft and distended. ngt dc'd by surgery, previously clws with moderate amounts bilious drainage. tolerating jt trophic feeds.  bg treated with 2units riss.

diuresing, urine potassium level-wnl; p.m. level pending.

pt. tolerated 6 hrs. in chair today.  stood and walked back to bed with max assist, but tolerated well.

patient and family met with surgery to discuss results of tumor debulking.

plan of [**hospital 5826**] transfer to floor (bed), continue diuresing goal is -3l, continue activity oob to chair as tolerated, pain management, skin care, keep family informed of plan of care.

[**first name8 (namepattern2) 5827**] [**last name (namepattern1) 5828**] bc student nurse

"
621,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex trach. bs are diminished bilaterally. suctioned for small to moderate amounts of thick white/yellow secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. pt having ^ wob and ps ^ to 12. vt's 500's ve's [**6-4**]. am abg 7.48/45/141/34 and ps decreased back to 10. rsbi=90. plan to continue to wean ps as tolerated.
"
622,"resp: [**name (ni) 257**] pt on psv 10/5/40%. bs are coarse bilaterally. suctioned for large amounts of thick white secretions. mdi's administered as ordered (see careview) with no adverse reactions. pt ^ rr to 30's and bp to 190, placed on a/c to rest. abg 7.47/40/146/30. rsbi=126. plan to wean to psv as tolerated.
"
623,"resp;  [**name (ni) 257**] pt on [**last name (un) 33**] psv 5/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned for moderate-copious thick yellow secretions. mdi's administered q4 with no adverse reactions.  pt awake, not following commands. pt returned to a/c noc for ^ in rr, bp, hr. rsbi=65.  returne o psv this am. plan to possible extubate today.
"
624,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+10/50%.  ambu/[**last name (un) 1299**] @ hob.  bs auscultated reveal bilater coarse sounds which clear with suctioning.  suctioned x3 small to moderate amounts of thick tan secretions.  also, had a substantial amount in oral cavity.  mdi's administered in line q4hrs (6 p) combivent with no adverse reactions.  rsbi performed = 19.4, then placed back on current settings.  no further changes are noted.

"
625,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 14/600/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. re-taped and secured ett. mdi's administered q4 hrs alb/atr with no adverse reactions. pt is waking up. rsbi=68.  still not following commands.  will proceed to wean to psv trial in am.  no further changes noted.
"
626,"resp: [**name (ni) 257**] pt on psv 10/10/50%.  ett # 7.5 taped @ 21 lip.bs are clear in apecies and diminished in bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. pt had periods of apnea, then placed on simv 14/500/10+/50% until 4:00 and returned to psv 10/10/50%. am abg 7.42/58/100/39. no further changes noted.
"
627,"resp: pt placed back on mmv due to periods of apnea. psv 10/5/40% (see careview for mmv settings) bs are coarse to clear and suctioning for small to moderate amounts of thick white secretins. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=50. no abg's this shift. 02 sats @ 99%. adequate tv's/ve's.
"
628,"resp: pt rec;d on a/c 20/500/+10/60%. ett #8.0 retaped and secured @ 26 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear apecies with diminished bases. mdi's administered q4 hrs alb/atr with no adverse reactions. no rsbi=^ peep. no abg's or changes this shift. will continue full vent support.
"
629,"npn shift 1900-0700:

[**2107**]: pt extubated at [**2107**] by rt w/ anesthesia at bedside. pt lifting head, following commands prior to extubation. tol extubation. post abg wnl. weaned o2 to 2l nc. sat 100%. no s/s of resp distress. b/l bs clear, prod cough, clear sputum.

2200: prbc ordered for hct of 21.0. complete at 0100. at 1245 pt noted to have macular, red, generalized rash to hair line, bue, and ble. no s/s of resp distress. temp up from 97.7 to 99.4. vss. ho called and at bedside. tylenol 1000mg, benadryl 50mg iv given as per ho. blood done, not suspected to be cause of rash. prbc#2 tx 0200-0400. tol tx well, disaplaying no s/s of an adverse reaction. no recurrence of rash.

0600: pt a&ox3 at start of shift, approp. towards morning, pt w/ poor st memory, a&ox2, inapprop. abg sent, wnl. 7.35/29/181/17. pt in compensated metabolic alkolosis. hco3=16. am hct stable at 34.7. plt=66 wbc=1.4. pt in neutrapenic precautions. repleted last night of ca+,k+,mg+,kphos. am k+=4.4, mg+=2.6, phos 2.2, ionized ca+=1.19. no repletion ordered as of yet. tol clears. +bmx2, brown, loose, guiac neg.
"
630,"resp: [**name (ni) 257**] pt on mmv (psv 10/5/40%). ett 7.5, rotated, taped and secured @ 21 lip. bs are coarse to clear and suctioning for white to yellow thick secretions. mdi's administered as ordered alb/atr without adverse reactions. no abg's this shift. pt weaned back to psv 10/5/40% this am. results from abdominal ct unchanged. rsbi=95. plan: trach/peg? continue on present settings.
"
631,"resp: pt remains intubated on a/c 16/500/+5/50%. bs are coarse bilaterally. suctioning for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs. combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. no vent changes this shift. am abg's 7.52/36/95/30. will continue full vent support.
"
632,"[**name (ni) 5986**] note
 pt arrived to sicu from ed with c/o n/v/d x3 days. pt a&ox3 upon arrival in ed, became agitated, recieved haldolx1, adverse reaction, intubated for airway protection. pt tachycardic and hypotensive, recieved a total of 6l ns in ed and 3 units of prbc's for hct of 23. placed on pressors and brought to ct for abd scan, showing ischemic bowel. pressors weaned off, maintaining sbp>100.

 upon arrival to unit, pt recieved 1 unit prbc's and 2 units ffp. pressors remain off. metabolic acidosis, recieving bicarb 150meq and 1 amp with some improvement. lactate increasing. lytes repleted. 40k in ns after bicarb finishes, 1l bolus ns inbetween.

neuro: pt remains sedated on prop gtt. sedation not shut off due to hemodynamic issues. pt able to mae, does not follow commands, withdraws to nailbed pressure, pupils equal and reactive. becomes agitated with increased activity.

resp: no vent changes made. ls clear bilat. suctioned prn for scant amount of thin white secretions.  svo2 in the 80's.

cv: remains in nsr, no ectopy. sbp wnl. fem aline placed at bedside upon arrival to unit. pressors remains off.

gi: abd firmly distended upon arrival. fib placed for lg amounts of melena stool, abd softer. ogt to lcs, scant output, flushed multiple times, placement checked.

gu: oliguric, clear yellow urine.

endo: blood sugars remain elevated. insulin gtt titrated per csru s/s.

plan:
 check abg, bs, and k q 1 hr. monitor lactate, monitor output. glucose control. provide pt and family with emotional support.
"
633,"resp: pt rec'd on psv 15.+5/50% bs are coarse to clear. suctioned for small amounts of white thick secretions. mdi's administered q4 hrs combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt had ^ wob with rr to ^ 30's, bp >200, increased ps to 20 with no affect. place pt on a/c 18/500/+5/50%. abg' 7.50/40/87/32. pt comfortable noc. attempted to wean to psv this am and pt bp went over 220 immediately, then placed back on a/c.will attempt wean to psv in am.
"
634,"resp: [**name (ni) 257**] pt on psv 10/5/40%. ett 7.5 secured @ 21 lip. bs reveal slightly coarse to clear and suctioned for small amounts of secretions. mdi's administered alb/atr with no adverse reactions. pt having periods of apnea and placed on mmv for noc. rsbi=48. pt opening eyes to name. plan: wean to psv in am. no abg's this shift.
"
635,"71 y/o female with cirrhosis,esrd,l leg fracture due to fall at home now in hypotension currently on dopamine gtt 2 mcg/kg/mt attempted to wean and d/c but drpopped to sbp 60-80 with map < 40.

events;crit stable today but low to 23,transfused 1 unit prbc without any adverse reactions.

cvs;hr 73-80 nsr no ectopy,abp 94-126/40-60 on dopamine gtt unable to wean off.cvp 10-12.post transfusion crit send please see carevue for lab results.pedal pulses are doppled.

access;rij and rt r a-line remains patent.lt av fistula positive for bruit and thrill.

neuro;looks more alert today answers all question appropriately but remains confused at times and trying to pull out invasive lines ,rt hand restrained for few hrs and released with reorientation.lt leg spilnted and able to move lower extrimities on bed and upper extrimites are able to move off the bed,no tremors or flaps noted today.

resp;ls are clear to dim at bases o2 sats are maintained 100% on room air,breathing efforts are normal.

gi;abdomen soft,positive bowel sounds tolerating diet,no n/v pantoprasole increased to bd,gi followed up not planning for any invasive procedures at this time. draining brown colored liquid stool via mushroom catheter which is positive for guaic.on bowel regimen.

gu;not dialysed since 5 days due to hypotension.please see carevue for lab values.

skin;multiple areas of bruises all over teh body due to fall rt upper extrimities has weeping areas and bleeding.lt leg is spilnted.positioned as needed for comfort.

id;afebrile,wbc 7.5 on zosyn and daptomycin(recieved only one dose/on hd days)on contact precautions for mrsa/vre.

endo;blood sugar > 200 sliding scale renewed and started on fixed dopse today.

social;daughter called and updated and will be coming later to visit her.

plan;follow crit bd,transfuse prn
maintain  map>60
reorientation and restraints as needed
fs q6h,calorie count till monday.
 pt for left leg.
"
636,"[**2170-8-10**] ""b"" admission note:

80 yr old pt came to ed with diarrhea&vomiting for 4 days, 1 day of burning on urination. fever up to 105.0. u/a+ and 3 bld cults+,still has some nausea.

pmh:  htn,cva with no residual effect,anemia,niddm.quit smoking 40yrs ago.

allergy:  codeine-makes her ""crazy""

cvs:  afebrile. hr=58-75 nsr no ectopy since arrival, reportedly in afib in ed.  sbp=110-135 in left arm and 70-80 in right arm.  given 6l of fluid in ed and 1500cc lr iv bolus upon arrival when bp low.  hct=23.4 down from 30.2, given 2 units prbc's with no adverse reactions noted.  mg=1.6 given 2gm iv mgso4.

resp:  o2 3l nc, lung sounds clear, diminished at bases.  sats=98-100%.  no sob noted.

gu:  sent u/a this am.  given 3 antibiotics in ed. u/o=30-55cc/h

gi:  +bs, ate small amt supper that family brought in, she says she doesn't eat much because she doesn't like the diet restrictions. no stools.  rectal guaiac was - in ed.

neuro:  a&ox3, mae. speech clear and appropriate.  follows all commands.  screaming and crying whenever aline or iv lines were attempted to be inserted.

skin:  no open areas noted.  old brown bruises noted on both knees, shins, upper back, legs.

plan:  continue antibiotics, monitor vss and labs. [**hospital **] transfer to floor when bed available.

"
637,"micu nursing note 1900-0700
events:  hemodynamically stable overnight.  remains alert but confused.  ? of visual hallucinations at times.  continues on iv insulin gtt at 2 units/hr.  continues to require bear hugger for hypothermia.  remains on continuous infusion of iv anti-thymocyte globulin (atg) gtt at 10mg/hr for desensitization....no evidence of adverse reaction during the night.  stable hct at 9pm= 26----am labs still pending.

neuro:  alert to person and place and disoriented to time however requires freq. reminders on what is happening to her and requires freq. reminders regarding all care and explanations.  mumbles at times.  asking questions about things that aren't present ie:  what are all those pants hanging on the windows?""/ "" why is my room full of all those boxes?""  freq. reorientation.  pleasant and cooperative with care, follows all commands, moves all extremities, pearl.  freq. safety checks.

cardiac:  hr= 50-70's sr with occas pvc's.  occasional brief and self-limiting episodes of bradycardia to 40's---ekg obtained and no change from previous and no evidence of block noted.  bp= 98-130/40-60.  bp and hr slightly decrease when pt is lying on left side.  episode of bp to 80/40 while asleep---bp back to baseline with stimulation and no further hypotension during the night.  diuresed with 20 mg. lasix during evening.

resp:  lungs clear but diminished at bilat. bases.  room air sats= 96-99%.  dry nonprod. cough noted.  rr= 18-22

gi:  abd soft with + bowel sounds.   c/o abd cramps while moving bowels.  npo maintained.  continues on iv tpn at 63 ml/hr.  incontinent large amts brown liquid stool x 3---pt pulled fecal incontinence bag off and smeared stool with hands x 2---now with mushroom catheter in place.  stool brown in color but tested guiac +.

gu:  foley to cd draining clear dark yellow urine >40ml/hr.  diuresed with 20 mg. iv lasix during evening but remains 8 liters + for los

skin:  perineum pink with slight rash---miconazole applied.  buttocks reddened--barrier cream applied.  remains on air bed.

id:  continues on neutropenic precautions with wbc < 0.1.  remains hypothermic with temps 95-97 on bear hugger.   continues on multiple antibx. as ordered.  pt's temps drop when she takes off blanket and requiring freq. reapplication of blanket.  temp up to 97 and bear hugger off x2 hours but restarted for temp=95.

endo:  continues on iv insulin gtt at 2 units/hr with fingersticks 105-143 all night.

social:  no contact from family or friends during night.

plan:  possible tee today.  continue freq reorientation and safety checks, continue neutropenic and vre precautions, monitor closely for reaction to atg infusion, transfuse prn, support pt and family prn.
"
638,"resp: [**name (ni) 257**] pt on a/c 22/500/+8/40%. bs are clear with diminished bases. suctioned for small amounts of white thicksecretions. mdi's administered alb/atr with no adverse reactions. no changes [**name (ni) **] or abg's pt remains on [**name (ni) 1858**].
"
639,"7a-7p
neuro: pt alert and oriented following commands. mae. perrla. percocet for pain w/ good relief.

cv: hr 70-80s sr w/ occasional pacs, lopressor increased to 25mg [**hospital1 **], np [**doctor last name **] aware of pacs. sbp >90 , map >60, see carevue for details. +palpable pulses. introducer patent in rij, #20 rw patent and intact. epicardial wires intact, shut off secondary to inappropriate spiking, team aware on rounds. 1 unit of prbcs given in am, no adverse reactions.

resp: ls clear- diminished at bases, wheezy w/ activity, later in shift rales at bilat bases, np [**doctor last name **] aware. inhalers given. sats on 3lnc >94%. breathing unlabored. pt denies trouble breathing. no resp. distress noted. ct dc'd at bedside dsgs intact, cxr taken results pending. much encouragement needed for oob,coughing and deep breathing, and the use of is.

gi/gu: abd softly distended +bs, no bm. foley draining yellow urine, around 2pm u/[**name initial (md) **] decreasing, np [**doctor last name **] aware, labs sent to eval if pt needs increased dose of lasix, labs pending at present see carevue for details.

endo: insulin gtt weaned to off, po glyburide started and continuing riss.

social: family updated w/poc.

plan: monitor hemodynamics. monitor resp. status. aggressive pulmonary toilet. follow labs, including creatinine and glucose. increase activity and po intake as pt tolerates. ? transfer in am.
"
640,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] simv 14/800/5/+5/40%.  alarms on and funtioning. ambu/syringe @ hob. cuff pressure @ 21.  bs auscultated reveal bilateral coarse sounds. suctioned x3 small to moderate amounts of thick pale yellow secretions.  mdi's administered q4 hrs with no adverse reactions.  vent changes to decrease rr to 12 vt to 650 to obtain improvement in abg.  rsbi=86, although no sbt initiated due to ^ in rr to 40's.  placed on psv [**2110-11-1**] where pt remains with 02 sats @ 100, rr 20-22 and not distress noted.  no further changes at this time.
"
641,"resp: pt rec'd on 70% cam f/t. bs are coarse bilaterally with strong cough although pt unable to expectorate. nebs administered q6  hrs alb/atr with no adverse reactions. no nts this shift. will continue to follow.
"
642,"resp: [**name (ni) 257**] pt on psv 5/5/50%. pt has #9 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs of atrovent with no adverse reactions. vent changes to decrease fio2 to 40%. am  abg 7.43/45/85/31. vt's 500, ve's 13, rr 22. rsbi=49. no further changes noted.
"
643,"7a-7a
neuro: pt extubated at 11am, alert and oriented, following all commands. perrla. mae. morphine ivp and percocet prn for pain w/ fair relief.

cv: hr 80-100s sr/st, hr 100s st at beginning of shift, lopressor 12.5mg po started and digoxin 0.25mg started po bringing hr 80-90s sr. frequent pacs noted around 11am, mg 2 gm iv given, no ectopy noted since 12pm. sbp labile, as high as 120-130 while intubated and w/ activity, nipride as high as 1.2mcg, md [**doctor first name **] aware, at present 0.2mcg w/ bp 100/50. see carevue for details. ci [**3-20**], see carevue for filling pressures. cvp 10s. 1 unit of prbcs, no adverse reactions noted. +palpable pulses.

resp: ls clear, diminished bases- coarse. inhalers restarted. pt extubated at 11am, acidotic prior to extubation 7.29, 1 unit of prbcs given and 1 amp of bicarb as [**name8 (md) 20**] md [**last name (titles) **]. repeat ph 7.32. post abg 7.32/44/113/-3/24/98%, md [**doctor first name **] aware, no new orders. instructed how to use cough pillow and is. using is as high as 500-750cc. oob to chair.

gi/gu: abd softly distended, obese. +bs, no bm. ogt dc'd w/ extubation. tolerating clears. u/o low at beginning of shift, md [**doctor first name **] aware, blood given, lasix 20mg ivp started. foley draining adequate amt of yellow clear urine.

endo: insulin gtt restarted, as high as 9units/hr, at present at 2units/hr. see carevue for details of gtt.

social: many family members into see pt throughout day. spouse updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. follow labs including blood glucose. wean nipride as pt tolerates.


"
644,"nursing update
   temp dropped 100-96.1.  hr stable nsr, no ectopy or arrythmias.  co/ci stable 6.45/3.52 @ 0400. pap's and cvp stable.
   plts 20 @ [**2141**], heparin stopped @ 2230 and 10-pack platelets tx @ 2300.  rec'd cmvig 3.2g @ 2330 - no adverse reactions.  hct 24.7 @ 2400, ho notified, recheck @ 0300 25.3. no new orders @ this time. continues to bleed from nasal to oral cavity.
   not retaining ca+, ica repleted with ca gluc 4g x4.  glucose rx per s/s, tolerating post-pyloric tf's well, green bile only draining per ngt.   stooling large amount loose green bile colored stool.
   abg's stable, weaned off nitrous oxide.

"
645,"resp: rec;d pt on cam @ 100%. pt desating to 80's change to hi-flow with f/t. (see careview for changes in fio2) nasal trumpet inserted in l nare. suctioned for moderate amounts of bloody secretions. nebs ordered alb/atr and adminisered q6 hrs with no adverse reactions. will continue to follow.
"
646,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 18/+5/30%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions.  pt gets anxious at times resulting in ^ rr, then settles down.  no resp distress noted. rsbi=200, no further changes noted.
"
647,"7a-7p
neuro: pt [**last name (lf) **], [**first name3 (lf) **], follows all commands. right pupil 5mm sluggish, left 3mm briskly reactive to light. daughter [**name (ni) **] called re: eye gtts. np [**doctor last name **] aware. [**name8 (md) **] md following pt, opthamology called today so pt can be re-evaluated per daughter's request to review eye gtts and assess right eye. pt medicated w/ 1mg morphine sc for incisional pain, w/ relief.

cv: hr 60-70s sr. no ectopy qt 0.43. amio gtt dc'd and po amio started via ogt. sbp 100-130s. see carevue for filling pressures. ci>2. pa dc'd w/o incident. + palpable pulses. received 1 unit of prbcs, no adverse reactions. repeat hct 32. k+ repleted prn.

resp: ls scattered rhonchi-> clear diminished bases. sats 98-100%. orally intubuted. weaned vent to [**3-21**] 40% fio2, 7.50/36/80/4/29/95%, np [**doctor last name **] aware. plan to extubate in am, resumed 5/10ps fio2 50% at present, see carevue for abgs and vent settings. suctioned for small to moderate amts thin yellowish white via ett.

gi/gu: abd softly distended. +ogt placement. dophoff in stomach (clamped) [**name8 (md) 20**] np [**doctor last name **]. foley draining clear yellow urine lasix frequency decreased from tid to [**hospital1 **].np [**doctor last name **] aware of alkalotic abgs.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. awaiting eye re-consult. plan to extubate tomorrow am.


"
648,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  pt remains alert but ? level of orientation.  moving r arm, r leg ad lib; no movement l arm or l leg noted.  mouthing words around trach, occasionally speaking in single word sentances, nodding ""yes"" and ""no"" appropiately.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  one unit platelets given without evidence of adverse reactions.  repeat plt count done.  remains on trach collar at 50% cont with sats mid to high 90's.  bs coarse, diminished bil.  expectorating lg amts thick white sec; did suction this am for blood tinged mucous plug.

gi/gu:  remains on tf fs probalance at goal of 60ml/hr via peg.  peg dsg d+i.  one lg formed soft bm this am.  u/o qs q1-2h via foley.  abd round, soft, bowel sounds positive.

id/endo/integ:  afebrile.  pipercillin dc'd as platelet count dropping. remains on contact precautions for +mrsa, +vre.  sliding insulin coverage for fingerstick glucose [**name8 (md) 20**] md orders.  buttocks raw, pink--barrier cream applied, duoderms reapplied prn.  l heel black area x2 unchanged.  multiple ecchymotic areas noted on arms (not new).

labs:  k repleted with 40meq via peg.  one unit platelets given; rpt plat count 96.

psychosocial/plan:  fam in to visit.  emotional support given to pt and family.  plan is to return to rehab in am.  family aware and agrees to plan.  cont to monitor loc, mp, vs, 02 sats, maintain o2, tf, monitor i+o.  administer meds as ordered/continue to follow medical/nursing regime.   cont to provide emotional support to pt and family.  replete labs as ordered.  repeat labs in am.
"
649,"resp: pt rec'd on [**last name (un) 33**] simv 18/750/+10/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished sounds with noted aeration in apecies.  mdi's administered q4 hrs combivent with no adverse reactions. rsbi=49, am abg's 7.39/35/160/22.  vent changes to simv 10/750/+5/5/50%.  no further change noted.
"
650,"nursing update
cv:
   tmax 100.2, remains in chronic afib.  receiving ntg gtts @ 1mcg/kg/min. bp stable, dipping into upper 90's @ tmies but generally ranging 100-116. lopressor increased to 10mg q6 for rate control with good effect, irregular ventricular response ranging from 84-116 most of noc.  co/ci 4.55/2.30 @ 0400 with pcwp 23.
   hct @ 2400 24.6, recheck 24.9,  ho notified and pt transfused with 1u prbc's over 3h. no adverse reaction.  huo 80-130cc.
   plan: ekg this am, continue cyclic ck/isos.


respiratory:
   finger sats 97% on o2 4l n/prongs.  breath sounds persistantly coarse, crackles @ bilateral bases persist but finer and substantially diminished.  continues to collect secretions in hypopharynx, but unable to suction due to resulting exacerbation of anxiety.  haldol 1mg x1 for anxiety state with good effect.  encouraged to cough but weak.  abdominal pain also on cough or activity, prn mso4 2mg given regularly q2h.
   latest abg's @ 0500  7.38/113/43/26/97% be 0.
"
651,"resp: [**name (ni) 257**] pt on a/c 22/400/80%/10+. bs are clear with diminished bases. mdi's ordered and administered alb/atr with no adverse reactions. multiple abg's and vent changes (see carview) pt presently on psv 5/5/40%. plan to wean to extubate this am. am abg pending.
"
652,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 32/450/12+/50%.  alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral clear apecies with diminished bases. suction for  scant amounts of white secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.31/45/126/24.  no further changes noted.
"
653,"resp: pt is [** **] with #6 cuffless trach on 35% t/c. bs are coarse bilaterally with diminished bases. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. no distresss noted. will continue to follow.
"
654,"social work note:

new trauma pt on t-sicu.  pt is a 23 year old man who is s/p fall/jump from 5 stories.  he has some head bleeds and an l2 burst fx.  pt was intubated this morning when this sw visited initially but has been extubated this afternoon.

[**name (ni) 25**] girlfriend, [**name (ni) 6199**] (misidentified as his sister initially) and pt's [**last name (lf) 344**], [**first name3 (lf) **] and les, are visiting this afternoon.  this sw met with pt and then his [**first name3 (lf) 344**], and then his girlfriend.  girlfriend's cell # is [**telephone/fax (1) 6200**] and work # is [**telephone/fax (1) 6201**].  she will likely return to work on thursday.

pt is a student at [**university/college 6202**].  he lives in [**hospital1 **] with his girlfriend, [**name (ni) 6199**].  [**name2 (ni) **] has one more semester of college.  family reports that only recent stressor is that their cat is quite ill and will likely be put down.

when this sw met with pt, he was alert and oriented to self and knew that he was in a hospital.  he was polite and engaged easily.  he was talking ""ragtime"" at various points and seemed concerned about getting in trouble legally.  he encouraged this sw to talk with his girlfriend for further information.  pt reports remembering being on a roof and that the people he was with were not strong enough to keep him from doing something that he wanted to do.  he referred to what happened as a ""dream"" and made reference to ""external reality"" and the involvement of his ""ego"" and the effect that had on his ""short term memory"".  pt denies wanting to hurt himself.  he feels comforted by his [**name2 (ni) 344**] and girlfriend's presence.

pt's [**name2 (ni) 344**] seem mutually supportive and expressed relief that pt is not more injured.  they report that they have been told that pt took some mushrooms last night and that his girlfriend has more information.  they said that one of pt's grandmothers had schizophrenia but that pt has no psychiatric hx himself.  he was evaluated during grade school and was found to have above-average intelligence and borderline add.  [**name2 (ni) **] said that pt does not use drugs and treats his body like ""a temple"".

[**name (ni) 25**] girlfriend reports that to her knowledge pt has never been suicidal and is generally quite ""happy"".  she said that pt tried mushrooms yesterday for the first time and had an ""adverse reaction"".  the friends that pt was with did not seek assistance for him (seemingly because they feared getting in trouble) and pt got away from them and got up to rooftop prior to fall/jump.  he left her a voicemail prior to fall/jump begging for help.  [**name (ni) 25**] girlfriend said that he does not otherwise use drugs.  the police have been involved and pt's [**name (ni) 344**] will be in contact with them.  [**name (ni) 25**] girlfriend does not think that there will be legal implication for pt from this incident following her conversation with police.

[**name (ni) **] and girlfriend given contact information for this sw for support as needed.  family given written information for themselves about emotional reactions to traumatic experiences.  pt is being evaluated by psychiatry and this sw met with them briefly to share above
"
655,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] simv 20/300/10/10+/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amounts of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions. sensitivity decreased to 8, pt tolerated well. no further changes noted.
"
656,"resp: [**name (ni) 257**] pt on 35% t/c with #6 cuffless trach. ambu/syringe @ hob. bs are coarse bilaterally which clear with suctioning. suctioned for small to moderate amounts of thick white secretions. mdi's atrovent  administered via trach with no adverse reactions. water bottle filled/trap emptied. will continue to follow.
"
657,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 10/320/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats @ 100%.  rsbi performed without adequate results.  no further changes noted.
"
658,"resp: rec'd pt on psv 10/5/40%. pt has #8 portex trach. inner cannula clean. bs are coarse bilaterally. suctioned for small amount of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions. no aline, or abg's 02 sats @ 99%. rsbi=78. plan to wean as tolerated and continue planning for d/c to rehab.
"
659,"resp: [**name (ni) 257**] pt on psv 10/5/50%. ett #8.0, 25 @ lip. bs are coarse to clear. suctioned for x1 bloody thick secretions, subsided in am. no changes noc. vt 400's ve's [**8-27**]. mdi's administered alb/atr with no adverse reactions. rsbi=41. plan to wean to sbt this am with possible extubation.
"
660,"resp care
attempted for a blood gas stick, could not obtain. md will attempt. no adverse reaction.
"
661,"respiratory care
pt remains trached (#7.0 portex) with cuff inflated (3.5-4cc's of air) and positional [** **]. pt remains on a fio2 of 0.40 via trach mask. lung sounds were course t/o. suctioned for mod thk white. mdi's given with no adverse reactions. 1 prn dose of albuterol was given. last abg showed chronic resp acidosis with metabolic alk. care plan is to continue current therapy and to have pt remain off vent as long as tol. continue with trach care and suction as needed. will continue to follow pt.
"
662,"7pm-7am([**2154-5-4**])

on full code

[**age over 90 148**]y/o female got admitted on [**2154-4-23**] in micu from ccu with c/o fatigue weaknes,increased abd girth,pedal edema and was found down at home.has pmh of cad,copd,htn,mi remains intubated since the day of admission.


cvs;hr-78-100 nsr,no ectopy.nibp-122-101/41-50 cvp-[**6-7**]. pedal pulses by doppler.

access: rij is patent.

resp;on vent,cmv-30/400/14/5,ls are dim at right side and coarse at left side.spo2-95-97,no vent changes are done at this shift.requires frequent oral sxn and et sxn were done minimally  and obtained small amt of thick white sxn.


neuro;not on any sedation, remains sleepy throughout but follows verbal commands by making facial expressions,no limb movements are noted.
received ivig last evening beginning at 1830,no adverse reactions noted on completion of infusion.

gi;abd soft and mildly distened with positive bs,tf@ goal with very minimal residual.small amt semi-formed stool passed at this shift.

gu;u/o-20-40 and nil  at 22hr informed ho,advised not to give fluid bolus since pt remains on + balance.urine is concentrated with sediment.

skin;temp-98.5,noted echymosis on right hand,has abrations on b/l elbows,duoderm in situ.

social: family visited last evening and were updated by this rn.

plan:monitor resp status,watch spo2,frequent oral sxn,observe muscle strength.watch u/o.


"
663,"resp: pt rec'd on psv 15/10/40%. ett #8, 25 @ lip. bs are coarse to clear and suctioning for small to moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt continues to have periods of apnea, then placed on a/c 12/600/10+40%. am abg 7.41/59/69/39. no rsbi=^peep.  plan to wean to psv as tolerated.
"
664,"resp: [**name (ni) 257**] pt on psv 15/5/40%. pt has #8 portex trach. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administed q 4 hrs with no adverse reactions. vt's 300-400, ve's [**7-7**], with periods of low ve's. ps decreased to 10. rsbi=100. plan to continue with t/c trials. rehab planning continues.
"
665,"resp:  [**name (ni) 257**] pt on psv 8/+10/40%. alarms on and functioning. ambu/syringe @ hob. ett 7.0, retaped and secured @ 20 lip. ett tube has been cut back.  bs are coarse bilaterally and suctioned for small amount of white thick secretions. mdi's administered atr q4 hrs with no adverse reactions. abg 7.34/55/105/31. vent changes to ^ peep to 10.  no rsbi due to ^ peep. will continue to moniter to wean as tolerated.
"
666,"resp: [**name (ni) 257**] pt on pcv 30/pinsp 35/10+/40%/dp25. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. rr at times to 40, no changes this shift. am abg 7.40/29/89/19. will continue full [**name (ni) **] support.
"
667,"resp: [**name (ni) 257**] pt on n/c @ 4lpm. bs auscultated reveal bilateral wheezing throughout lung fields. discussed continous tx with md and agreed. set up 3.0mg albuterol for 4 hrs continous neb. no adverse reactions and notable improvement. proceeded to administer alb/atr as ordered. pt feels better this am with no distress noted.  will continue to follow aggressively.

"
668,"resp: [**name (ni) 257**] pt on psv 5/15+/40%. ett#7.5 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse with diminished bases. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb with no adverse reactions. abg's (see carview). pt rr in mid 30's with ^ wob noted. bicarb drip initiated. placed on pcv pinsp 35/10+/dp 25/r30/40% with abg 7.28/35/89/17. will continue present settings.
"
669,"resp: [**name (ni) 257**] pt on psv 12/10/40%. ett #8, retaped, rotated and secured @ 22 lip. bs are coarse to clear. suctioned for moderate amounts of thick white/yellow thick secretions. mdi's alb/atr administered with no adverse reactions. ps weaned to 7 due to periods of apnea, abg 7.29/77/94/39. ps ^ to 12. additional abg pending. will continue to wean as tolerated.
"
670,"resp: pt rec'd on a/c 16/350/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions, although it does initiate a cough reflex. abg 7.47/32/87/24, rsbi >200. will continue full vent support.
"
671,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminished l base.  suctioned moderate amounts of thick white secretions. re-taped and secured ett @22 lip. mdi's administered q4 alb/atr with no adverse reactions. pt placed on a/c 12/600/+5/50% noc to rest,then placed back on psv setting this am.  no abg's. rsbi=47
"
672,"resp: pt rec'd on psv 10/8/50%. bs are coarse bilaterally. suctioned for small-moderate thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg's 7.41/50/95/33, removed vd with abg pending. will continue to wean appropriately.
"
673,"continued npn 7 am 7 pm

continued see above...

pt receiving two units of blood, family came by at 5 pm and consented to tranfusion, unit up at 1730, temp 99.0 then 99.8, no adverse reaction noted. cvvhdf system clotted at 1800, syatem lasted 3.5 hours, team updated heparin dose increased.

respiratory- o2 sats 98-100 on 2l drops to 91-94 on room air, pt denies sob, no crackles.

[**name (ni) **] pt ox2-3, moves all extrem, strong, taking po fluids
without problems, awakens forgetful and slightly confused but reorients well.

gi- as above taking some regular diet, fruit, pudding , shakes,
eggs. loose stool with increase in afternoon team aware.

a: pt with arf, creat still high, on cvvhdf, however ? how well dialysis is going as it is contantly interupted with system clotting, team and renal are aware and are increasing the heparin. now pt with increased watery stools, ? c diff.

p: continue to follow lytes, ionised ca, ph, glucose, hct post blood transfusion, creat bun, continue cvvhdf with new clotting plan, continue monitor cv resp renal status, follow i/o goal is to keep pt even.
"
674,"resp: pt rec'd on mmv 10/500/15/+5/40%. bs are clear with diminished bases. vt's 800-900, ve [**9-12**], rr 14, 02 sats @ 99%. suctioned for small amounts of thick yellow secretions. mdi's administered q4 alb with no adverse reactions. rsbi=60. will continue t/c trials.
"
675,"resp: [**name (ni) 257**] pt on mmv 10/500/15/+5/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. vt's 700-900, ve 8-13l, rr 12-18.  rsbi=42. plan to continue with t/c trials as tolerated.
"
676,"resp: [**name (ni) 257**] pt on psv 12/+5/40% (mmv) bs auscultated reveal bilateral clear sounds with slight coarse bases. suctioned for moderate amounts of white thick secretions. mdi's administered q4 hrs alb with no adverse reactions. no a-line. 02 sats @ 99%. vt's 400-500, ve's [**10-11**], rr 12-18. rsbi=21. plan to wean on t/c trials as tolerated.
"
677,"resp: [**name (ni) 158**] pt on a/c 26/600/10+/40%. ett #8, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease tv to 550 and rate to 22. abg 7.46/34/79/25 with no further changes noted. will continue full vent support.
"
678,"resp: [**name (ni) 158**] pt on a/c 32/500/12+/50%. ett #8, taped @ 22 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse and suctioned small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt is on rotating bed and pip's fluctuate with rs ^ tend to higher. no abg's or changes noc. will continue full vent support.
"
679,"resp: [**name (ni) 158**] pt a/c 32/500/+10/40%. ett#8, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with occasional exp. wheeze. suctioned for copious amounts of thick tan secretions as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg' (see carview) and multiple vent changes. present settings a/c 22/600/10+/40%. no rsbi=^ peep. possible bronch today? will continue full vent support.
"
680,"resp: pt rec'd on psv 15/+5/50%. bs auscultated reveal bilateral aeration. suctioned for moderate amounts of white thin secretions. pt has frequent episodes of coughing spells.  no mdi's administered due to adverse reactions of bronchospasms. no abg's a-line not working. pt schedule for or this am for trach insertion.  vt's 500, ve7-8l, o2 sats @ 99%.
"
681,"s/p cabg
pt is a 71 year old male arrived from or s/p cabgx2. arrived on propofol, ntg, epi at 0.02mcg/kg/min. see carevue for details. continues to be cold. 1 unit of blood given, no adverse reactions noted. plan assess neuro status, monitor for bleeding, wean to extubate.
"
682,"resp: pt rec'd on [**last name (un) 647**] psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds and suctioned for small amounts of tan/yellowish thick secretions. mdi's administered q4 [**last name (un) 741**] with adverse reactions. pt bronchospasms and complains of chest pain, rn aware as well as md. [**first name (titles) 742**] [**last name (titles) 741**], suggest try flovent to help with inflammation.  will continue full vent support. possible trip to ctscan today. no abg's. vt 500's ve 9-13l, rr 20, o2 sats 96-98%
"
683,"resp: [**name (ni) 257**] pt on simv 20/600/10+/50%.  ett #7.5, 24 @ lip. bs are slightly coarse with diminished bases. suctioned for moderate to small amounts of bloody tinged secretions.  mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. vent changes to decrease peep to 5, am abg 7.40/40/125/26. rsbi greater than 200. plan to wean to psv as tolerated.
"
684,"resp:  [**name (ni) **] pt on [**name (ni) **] pcv 35/peep +12/ 80% r 42 i/e 1:1. alarms on and functioning. ambu/syringe @ hob.  auscultated bs reveal bilateral clear apecies with diminished bases.  mdi's administered q4 hrs alb with no adverse reactions.  suctioned x4 copious amounts of bloody secretions/clots from oral cavity.  vent changes to accomodate improvement in abg's with ^ peep resulting in decrease in bp.  fi02 ^ 90%, driving pressure @35.  no further changes noted
"
685,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 20/550/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies.  mdi's administered q4 alb with no adverse reactions. vent changes reflect am abg's (see careview). rsbi=67. plan to wean to extubate this am.
"
686,"resp:  [**name (ni) **] pt on [**name (ni) **] pcv 35/rr 34/ 20+ itime .6 i:e 1:1.9 /90%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal ls clear apecies with diminished bases. rs coarse sounds.  suctioned x3 moderate amounts of thick bloody secretions/clots from oral cavity with improvement noted.  mdi's administered q4h alb with no adverse reactions. ett moved to ls taped and secured.  pt remains on present vents settings.  no changes.
"
687,"ccu npn 1900-0700
s: "" i'm feeling antsy now ""
o:  at [**2048**], pt. appearing very awake but slightly anxious....c/o feeling restless.  pt. smokes 1 [**11-27**] ppd.  no etoh hx.  gave 1mg po ativan at [**2118**].  fell asleep and stable until 2200 (last check was 2110) when pt. was found standing at bedside.  iabp was disconected at the aline site.  pt. was disoriented....assisted back to bed.  vss at the time.  new aline tubing was reconnected and good iabp waveform was obtained.  cxr was obtained.  placement appears intact...did not detatch from sutures and marks on leg.

pt. appearing very lethargic and responding only with one word answers...skin warm, dry...pupils equal and reactive.  gradual increase in attentivness throughout night....a/o x3 by 0500.  pt. awake but does not remember getting oob.

cv:  hr 78-83 nsr.  one 11bt. run vt asymptomatic.  map 75-90.  slightly dampened waveform..unchanged from cath.  poor augmentation.  1-12pts. syst. unloading.
heparin gtt at 850u/hr.  ptt 67.2   post cath ivf completed.
plts 209.  cpk #2 329(416).  no cp/sob.  pulses 3+ bilat.
iabp site d/i.

resp:  ls clear.  2lnc sats 99%.
gu:  foley placed 400cc in bladder.  100-300cc qhr u/o.  neg. 300cc since 12am.
gi:  no c/o.  abd flat.  no stool.  eating ice chips.
access:  piv x3.  right fem. iabp.

neuro:  as above....currently pt. a/o x3 at 0500.  instructed to lay on back. leg immobilizer placed on right leg in eve.   pt. prefers to sleep on side and will move on own....needs freq. reminders and watching.  bed alarm on and all siderails up.

a:  adverse reaction to ativan.  d/c'd.
r/i for mi.  stable on iabp.  on asa. no plavix.  or fri.  ? d/c pump today....safety risk.
follow lytes, hct.  monitor pulses.
"
688,"resp: pt rec'd on psv 10/8/50%. bs auscultated reveal bilateral clear with diminished bases.ett 7.5, 22 @ lip. mdi's administered q 4 hrs combivent with no adverse reactions. suctioned for small amounts of thick yellow secretions. no vent changes noc. rsbi=46. plan to wean to extubate this am.
"
689,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] pcv 31/+12/80%/r 42 i/e 1:1 ambu/syringe @ hob.  alarms on and functioning.  bs auscultated reveal bilateral clean apecies with some fine scattered crackles.  suctioned x2 small to moderate amount of thick bloody tinged secretions.  mdi's administered q4hr with no adverse reactions.  vent changes as follows: peep^ 15, bp dropped, decreased peep to 12 where it remains.  abg's still acidoic with poor pao2.  no further changes noted. no rsbi performed pt is paralized.
"
690,"resp: pt trached #8 portex rec'd on [**last name (un) 33**] a/c 20/400/10+/40%, bs are clear bilaterally. suctioned for small amount of tan secretions. mdi's administered q4 combivent, no adverse reactions. vent changes to decrease peep to 8, then 5 with 02 sats @ 98% and tolerating well. rsbi=61. plan to wean to psv this am.
"
691,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**2165-5-2**] to er wtih fever, decreased u.o., received 1x dose of gent and iv hydration at [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levofloxacin and flagyl. pt refused presep cath in er. lactate 1.8. pt treated for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy but was ordered to try meropenem per [**hospital unit name **] and id team. overnight pt had an adverse reaction within minutes to the meropenem developing audible wheezing with sob and +n/v- see care vue for details. ivabx changed to iv aztreonam with no adverse reaction. cvp remained low ranging [**3-6**] with bicarb ranging 18-20. pt was given a liter of d5w with 150 meq na bicarb. k of 3.1 was repleted with 40 meq kcl total. will draw repeat labs at 6am.

neuro: a&ox3, mae, pt with l aka with some stump discomfort this am which pt reports is tolerable and he doesn't take any medicine for it at home. he was given tylenol shortly prior to the complaint for fever. t max 102.6 po. pt given total of 650mg tylenol x2 with t current 101.6po. bld cx x2 and urine cx sent. central line was pulled back 2cm as was in too far via cxr per team. repeat cxr confirmed proper line placement. pt following commands appropriately. requires max assist with adls.

cv: hr ranging 80s-100s sr/st with no ectopy noted. bp ranging 100s-150s/60s-90s. +pp via doppler in r leg. l stump warm to touch.

resp: lungs cta except developed wheezing shortly after receiving iv meropenem. then after meropenem stopped, pt with no further wheezing. sp02 ranging 97-98% on rm air. pt had been placed on 2lnc during time when pt had a reaction to the meropenem with sob but within a few minutes after the meropenem was stopped, pt was weaned back to rm air with sats in high 90s.

gi/gu: abd soft, nt, +bs, had small loose brown bm x2 smeared on his pad unable to send for cdiff. +n/v with meropenem reaction but no further incident afterward. foley patent draining adequate amts yellow urine with sediment in it. u/a c&s sent along with urine tox screen.

skin: warm, dry, and intact.

comfort: c/o stump discomfort this am shortly after tylenol given for fever. states pain level acceptable.

lines: r ij tlcl patent and was pulled back by 2cm and reconfirmed via cxr per team. r piv was found pulled out by pt d/t discomfort at insertion site. some small amt swelling at insertion site but subsided with pressure and elevation. l piv intact.

social: has been living at the [**hospital3 **] recently but prior to that had lived in own home.

plan: monitor temp, tylenol prn, monitor micro data, ivabx, make note of new meropenem allergy (also allergic to pcn). f/u with am labs and need for more k and bicarb repletion. monitor cvp and need for more ivf.


"
692,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**5-2**] to er with fever, decreased, u.o., received 1x dose of gent and iv hydration and [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levoflox and flagyl. pt refused presep cath in er. lactate 1.8. pt tx'd for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy and developed a meropenem [**last name (un) **] noc of [**5-2**]-5 with audible wheezing with sob and n/v. pt was switched to iv aztreonam with no adverse reaction. pt continues to spike temps with 3 sets bld cx sent since adm.

neuro: a&ox3 with cueing. mae, l aka with some stump discomfort that is his baseline ""phantom"" pain relieved without intervention. t max 103.9. given tylenol 650mg with temp down to 98.9.

cv: hr ranging 90s-110s sr with no ectopy. bp ranging 120s-160s/40s-90s. +pp via doppler in r leg. laka. no edema noted.

resp: lungs cta, sp02 ranging 97-99% on rm air.

gi/gu: abd soft, nt, +bs, small bm x2 brown loose. drinking water with meds with no difficulty swallowing. foley patent draining adequate amt clear yellow urine 40cc+/hr. pt approx .5 liters negative since mn and 4.2 l + los.

skin: raw areas on coccyx and testicle area. aloe vesta cream applied to areas.

lines: r ij tlcl patent.

social: no contact from family. pt a dnr.

plan: continue to monitor temp and provide tylenol prn. iv abx, monitor micro data. ? call out to floor later today.
"
693,"3p-7p
see carevue for vital signs and for full assessment. received 2 units of prbcs, no adverse reactions. temp 94-95.9 orally, np [**doctor last name **] aware. right groin [**doctor last name 2169**] culture sent. dophoff placed by np [**doctor last name **], awaiting cxr. see carevue for vent changes and abgs, np [**doctor last name **] aware of abgs, pco2 28-30, bicarb 19. plan: to go to ct tonight at 8pm. if needed, restarted neo gtt.
"
694,"1100-2300 npn
see carevue for subjective/objective data.
neuro:  pt unresponsive to verbal stimuli; does withdraw to painful stimuli.  no movement of arms, legs noted.  no attempts to speak or communicate, does not track.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  daughter agrees to prbc;  first of two units prbc started without evidence of adverse reaction noted thus far.  kphos started, to infuse over 6hrs as [**name8 (md) 20**] md orders.  np at 1liter cont with clear breath sounds bil.

gi/gu:  one episode melena thus far this shift.  abd firm, no tenderness to palpation noted, bowel sounds present.  u/o borderline qs via foley.

id/endo/integ:  tmax 99.2 r.  sliding scale insulin coverage for fingersticks.  hands, feet edematous, elevated on pillows.  one .5x.5 pink area noted on coccyx--pt turned q2h with skin care given.  no other open areas noted.

psychosocial/plan:  fam in to visit.  emotional support given to pt and fam.  plan is to infuse two units prbc (first unit up), rpt labs, monitor for signs of active bleeding.  cont with current nursing/medical regime.
"
695,"resp care
pt extubated tonight, present air leak. no adverse reactions. pt currently on nc 3lpm and sating 99. will continue to follow.
"
696,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions.  mdi's administered q4 hrs alb with no adverse reactions.  02 sats remain in ^ 90's (96-99%).  attempted to lower the peep to 16, although pt did not tolerate.  increased rr to 35.  returned peep to 18 where it remains.  no further changes noted.
"
697,"7a-7p
neuro: pt [** **] and oriented x2, knows pt is at [**hospital1 **] and knows self. [**hospital1 **]. follows commands. mae,weakly. denies pain when asked.

cv: hr 90s-100s. sr rare pvcs. sbp >100. map>60. +[**hospital1 **] pedal pulses.

resp: ls coarse. sats >93% on 5lnc. nebs x2. productive cough, not bringing up sputum. talc to ct by thoracic resident.

gi/gu: abd obese, hypoactive bs. dophoff placed, cxr done + in stomach [**name8 (md) 20**] md [**last name (titles) **]. tf started at 1600 as ordered, continue tpn [**name8 (md) 20**] md [**last name (titles) **]. foley draining greenish yellow urine (intensivist aware on rounds)- from dye. draining adequate amts.

endo: per own's scale.

id: afebrile. antibiotics changed- meropenem started, no adverse reactions noted. bc sent from central line, need peripheral.

plan: monitor hemodynamics. monitor resp. status. skin care.




"
698,"condition update
d: please see carevue flowsheet for specifics
 pt running [**name (ni) 10073**] temps all day with tmax 100.4. hr 60-80 in nsr with occassional pac's noted this afternoon. nmed goal is to maintain sbp 100-150 this am pt required neo which was weaned to off for a couple of hours and then pt required labetolol gtt to be started. all solutions are mixed in ns per request of nsurg. mannitol was restarted with no adverse reactions after dosing, and glycerin po was d/c'd.
 pt's neuro status has waxed and waned throughout the day. at most alert moments will open eyes on command-at other times won't even open to sternal rub. perrla but does not track/attend. pt consistently has purposeful movement and normal strength in left extremeties. rue has no movement to withdraws slightly and moves on bed to pain.
 no vent changes made today. pt remains on simv 600x16 with 5peep and 5ips and 50%. thick tan to blood frothy secretions-sputum spec sent for culture. patient is not breathing over the vent rr 16 except when stimulated.
 wife in and spoke to dr. [**last name (stitle) 10074**] who had been updated by nmed and nsurg service. wife's nephew was present during visit and due to wife's expressive aphasia it was agreed with wife and nephew that he would be the contact person-phone # in chart. social worker also met with wife/nephew.
plan:
 neuro checks
 sbp 110-150
 dose mannitol according to serum osmolality
 notify h.o. with any change
"
699,"7a-7p
neuro: pt alert and orientedx3. mae equally. perrla. intermittent twitching of left arm noted, pa [**doctor last name 372**] aware, no new orders. right eye droopy pt states ""has been like that for years"". perrla,smile symmetrical, mae equally.  morphine and percocets po for incisional pain, percocets po work better per pt. pt states is anxious at times,team aware.

cv: hr 70-110s. 110s at start of shift, lopressor started, received total of 10mgx2 ivp during shift. lopressor 50mg po started. sbp 110-140s. goal sbp<140 per pa [**doctor last name 372**]. ntg as high as 3mcg, pa [**doctor last name **] aware, captopril and hydralazine started, see med orders, captopril increased during day as per pa [**doctor last name 372**]. pt received 1 unit of prbcs no adverse reactions, repeat hct 27.2, pa [**name6 (md) 372**] and md [**doctor last name **] aware, no new orders. ci>2. svo2 57 when received pt pa [**name (ni) 372**] aware, recal'd, svo2 improved >60, see carevue. pa dc'd w/o incident. cordis flushes well though unable to draw blood from, pa [**doctor last name 372**] aware, ok to use per pa [**doctor last name 372**]. plavix started today 300mg loading dose today as ordered. epicardial wires intact, a side sense appropriately, do not capture appropriately. on vdemand 50, v wires sense and capture appropriately. lytes repleted prn. dopplerable pedal pulses.

resp: ls clear diminished bases. sats decreased on 6lnc to 91-93%, pa [**doctor last name 372**] aware, inhalers ordered. face tent and nc applied, see carevue for settings and sats. present sat 95% on face tent 50%, 4lnc. pt using is appropriately, 750cc. encouraged coughing and deep breathing. ct no air leak, draining 10-40cc/hr serosang drainage.

gi/gu: abd soft hypoactive bs. no bm. tolerating sips of clears. foley draining clear yellow urine, lasix 20mg ivp given this am, w/ minimal (1st hour only 140cc after lasix then tapered to 30cc/hr) results, pa [**doctor last name 372**] aware, additional lasix 40mg ivp given at approx. 1400 as ordered w/ improved results. see carevue for i+o's.

endo: insulin gtt as per protocol. fs 100-170s.

plan: monitor hemodynamcis. monitor resp. status. pulmonary hygeine. follow labs and treat as appropriate. wean ntg to keep sbp<140. pain control. increase diet and activity as pt tolerates.
"
700,"resp: pt remains intubated on psv 10/+5/40% with no changes this shift. bs are coarse to clear. suctioned small amounts of tan/yellow thick secretions/moderate amounts of oral secretions. some seizure activity noted without incident. mdi's administered alb/[**last name (un) **] with no adverse reactions. abg 7.41/38/188/25. vt's 300-400, rr 20-24, ve7-8l. rsbi=93.
"
701,"resp: [**name (ni) 257**] pt on psv 5/5/40%. ett 7.5 retaped, rotated and secured @ 25 lip. abg 7.46/45/126/33. placed back on a/c 12/500/5/40% to rest noc. bs are coarse bilaterally and suctioning frequently for copious yellow thick secretions. mdi's administered q4 atr with no adverse reactions. rsbi=68. plan to wean to psv in am.
"
702,"resp: pt rec'd on a/c 12/500/+5/40%. bs are coarse bilaterally and suctioned frequently for copious thick yellow to tan secretions. mdi""s administered atr with no adverse reactions. rsbi =62. plan to wean to psv as tolerated. talk of possible trach? will continue to follow.
"
703,"npn
n: unchanged neuro exam. remains unresponsive to painful stim. perrl ~3mm/bsk. ativan gtt d/c'd per team and currently on ativan 1mg/q6hr in attempts to wake pt. mso4 remains at 2mg/hr. icp teens until pt dropping sats and then became elevated to mid 20's. returned to teens as hypoxia corrected. ventric draining sm amts serous fld.
cv: neo titrated and currently 2.25mcg/kg/min to maintain cpp 65-70. k repleted with diuresis. nsr 60-70's- no ectopy. cvp high teens-20.
r: lungs course throughout and [** **]'d frequently this am for mod to lg amts thick tan secretions. after pt acutely [**name (ni) 2141**] to 85%, and pao2 61-->bronched for sm amt thick clear/white sec and peep inc 15 with much improvement pao2 130/sats >97%. remains on ac 600x15, 50%.
gi: abd firm/distended with absent bs. reglan in tpn. restarted vivonex at 10cc/hr. no stool.
gu: urine clear yellow. diuresed with lasix 20mg this am and currently ~1l neg. due for add'l dose this evening--?hold this eve if remains neg with inc need for pressor.
id: tmax 102.8-rec'd tylenol and current 100.3 levoquin/flagyl d/c'd. bld cx's x2 sent. sputum cx grew staph areaus. initiated oxacillin desensitization and so far no adverse reaction to drug.(noted pcn allergy.)
endo: gluc 86-114. insulin gtt titrated 2u/hr. 100u reg insulin in tpn today.
skin: back/buttocks intact. chin healed. lt forearm with adaptic/dsd. rt ankle with dime sized black decub. lt post ankle with red blister intact.
soc: [**name (ni) **] wife and daughter in visiting. approp concerned and updated on progress.
a/ trauma now with staph pneumonia s/p bronch today.
p/ monitor neuro/resp status closely. or when stable.
"
704,"resp: pt rec'd on a/c 12/500/5+/40%. ett 7.5, 25 @ lip. bs are coarse bilaterally and suctioned for copious amounts of thick white secretions. mdi's administered atr as ordered with no adverse reactions. ps trials to continue as tolerated today. see careview for rsbi. no abgs this shift.
"
705,"resp: rec'd on 50% t/c. bs are coarse bilaterally. suctioned for small amounts of [** **] yellow secretions. mdi's administered alb/atr via trach with spacer with no adverse reactions. pt remains on t/c. vent pulled.
"
706,"npn shift 1900-0700:

neuro: a&o x3, no deficits. perrla. some generalized weakness. no c/o pain.

resp: b/l bs present, clear. dry cough. no resp distress. weaned o2 2l to off. tol well, sats 94-100%.

cv: nsr, occasional multifocal pvc's. [**2112**] lytes sent, wnk; k=5.2, mg=2.1. no c/o chest pain. bp wnl. am lytes pending. skin cool. no edema.

hem: [**2112**] cbc: h&h:22.5/8.1, plt:56, wbc:17.6. 0200 cbc: h&h: 21.2/8.1. plt:56. wbc: 17.6. 1st dose ivg given at start of shift per protocol, no s/s of an adverse reaction. prbcx 2 given w/ no s/s of an adverse reaction. plt x1pack  given. second dose ivg started at 0500.

id: afebrile. wbc=12.5 at 0200.

gi: abd distended, firm, baseline. +bs x4. golytley started. rectal bag applied. frequent liquid maroon stool, 1l tol for shift. npo except golytly since mn.

gu: foley patent, draining 60-150cc/hr hematuria, brown, sediments, rare clots. no c/o bladder fullness.

plan: colonscopy if plt wnl. ho will discuss further treatments plans w/ pt.


"
707,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs ascultated reveal bilateral coarse sound which improve with suctioning.  suctioned x3 small to moderate thick yellow secretions.  mdi's admininstered q4 hr alb with adverse reactions.  pt vomited early this morning.  02 sats remain in ^90's @ 96%.  rsbi=130. no further changes noted
"
708,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 12/600/40%/+[**6-16**].  alarms on and functioning. ambu/syringe @ hob.  cuff pressure @ 21 cmh20. bs auscultated reveal bilateral diminished sounds.  092 sats @ 99%.  mdi's administered q4 hrs alb with no adverse reactions.  no rsbi performed, pt had no spontaneous breathing rate.  rsbi to be performed on day shift as rn to lighten up on sedation.  no further changes noted.
"
709,"resp: [**name (ni) 158**] pt on pcv 38/r27/50%/0+. pt has #8 shiley trach with audible leak. bs are coarse bilaterally. suctioned for small amount of tan thick secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions. am abg 7.26/74/127/35. pt following commands this shift. remains on cvvhd. no rsbi, pt is vent dependent. no changes noted this shift. will continue with present therapy.
"
710,"resp: pt rec'd on simv 10/500/+5/40%. bs are clear bilaterally. suctioned for small amounts of bloody tinged secretions due to new trach. mdi's administered q4 combivent with no adverse reactions. abg 7.49/44/171/34. vent changes to psv 18/5/40% with abg pending. rsbi=85. will continue to wean appropriately.
"
711,"resp: [**name (ni) 158**] pt on a/c 22/340/60%/0+. pt has #8 shiley. audible leak noted. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white/tannish secretions. mdi's administered alb/atr as ordered with no adverse reactions. abg's (see careview) ph consistant 7.1. bicarb drip initiated for ^ in bicarb to 30's. pt placed on pcv (see careview for settings) no change. am abg pending. will continue with present mode of ventilation.
"
712,"resp: pt rec'd on pcv 44/32/+0/55%. pt has #8 shiley trach with audible consistant leak. vt's 300-400. bs are coarse  to diminished at bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no [** 353**] due to vent dependency. no changes or abg noc. will continue with present settings.
"
713,"resp: pt rec'd on pcv 38/27/50%. pt has #8 trach. bs are coarse bilaterally. suctioned for small rusty secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg's 7.27/72/120/35. no changes noc. pt is vent dependent so no rsbi.
"
714,"7p-7a
neuro: pt sedated on propofol as high as 50mcg/kg/min. increased propofol secondary to pt awoken during am care, nodding appropriately, mae. perrla. fentanyl 50-100mcg iv as needed for pain control.

cv: hr 90s-110s vvi permanemt pacer. epicardial wires attached and in place. noted occasional pvcs. repleted electrolytes as needed. sbp 90-110s. nitro gtt off. milrinone gtt at 0.5mcg/kg/min as ordered. epinepherine gtt infusing at 0.02mcg/kg/min as ordered. ci >2. md [**doctor last name 840**] aware of hr and hct 26.5, 1 unit of prbcs ordered and given. no adverse reactions noted. cvp 7-11. received 500cc ns fluid bolus for cvp 7 and sbp 90s w/ maps 55-60 as [**name8 (md) 52**] md [**last name (titles) 840**], see carevue for details. pap 40s/20s. doppler pedal pulses. hands and feet cool to touch. pt w/ hx of raynauds.

resp: pt orally intubated. simv rate decreased to 8, and fio2 decreased to 40% secondary to po2 170s, and pco2 low 30s. see carevue for details. ls clear but diminished at the bases. sats 99-100%. suctioned for small amt of thick white.ct intact draining serosang drainage.

gi/gu: abd soft, absent bs. ogt +placement. foley draining clear yellow 45-100/hr. see carevue for details.

endo: on insulin gtt as high as 9units/hr, fs checked per protocol and insulin gtt maintained as per protocol.

plan: monitor hemodynamics. monitor respiratory status. monitor blood sugars.
"
715,"resp: rec'd on pcv pinsp 44/32/0+/55%. pt has #8 shiley traach. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. audible trach leak noted. vt's 200's ve-[**8-9**]. 02 sats @ 98%. plan to have family meeting today to discuss cmo status. will continue with present settings.
"
716,"resp: [**name (ni) 158**] pt on pcv pinsp 44/32/+0/55%. pt has #8 shiley trach with notable audible leak. bs are coarse bilaterally. suctioned for scant to small amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no changes noc. no abgs. plan to continue with present settings.
"
717,"resp: pt presently on 4 lpm n/c. bs reveal bilateral wheezing, mostly due to fluid.  hhn given alb/atr x2  ud with no adverse reactions. no other changes noted.
"
718,"resp: pt remains intubated on simv 14/500/+5/40%. bs reveal bilateral diminished sounds. suctioned for small-moderate amounts of secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.50/51/123/41. no changes noc. plan to trach/peg. will continue full vent support.
"
719,"resp: pt rec'd on a/c 20/500/+8/50%. ett 7.5, 26 lip.bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. abg with pa02 75, ^ fio2 to 60%. am abg 7.47/36/153/27. no changes noc. will continue full vent support.
"
720,"resp: pt rec'd on pcv pinsp 44/r32/+5/60%.  pt has #8 shiley trach with persistant positional leak. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tannish secretions. mdi's administered as ordered alb/atr with no adverse reactions. abgs with decrease in pao2, fio2 ^ to 70%. am abg 7.13/146/87/13. family meeting expected tomrrow. will continue present settings.
"
721,"resp: pt rec'd on psv 16/5/40% (mmv 500/10) bs auscultated reveal bilateral clear sounds. suctioned for small amount of tan secretions. mdi' administered q4 combivent with no adverse reactions. rsbi=85. am abg' 7.44/50/81/35. ps decreased to 10. vt's 400's. will continue to wean appropriately.
"
722,"resp: pt is  [** **] and vent dependent (see careview for settings) no changes this shift or abg's. bs are coarse which improve following suctioning. suctioned for small to moderate amounts of yellow to tannish thick secretions. mdi's administered as ordered with no adverse reactions. pt is able to suction oral cavity and prefers too. no rsbi due to vent dependency. 02 sats @ 100. will continue full vent support.
"
723,"resp: [**name (ni) 158**] pt on pcv pinsp 44/5+/rr 32/60%. pt has #8 shiley trach. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg 7.17/156/69/60. no changes noc. will continue with present settings.
"
724,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 14/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration. mdi's administered q4 hrs atrovent with no adverse reactions.  pt complains she can't take it anymore.  rsbi=92 am abg'd 7.37/53/100/32.  continue to wean to extubate.  no further changes noted.
"
725,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bialteral wheezes with some fine scattered crackles. mdi's administered q4 hrs alb with no adverse reactions. suctioned for small amounts of thick yellowish secretions. pt's rr^ to 30, ^ ps to 10.  no further changes noted.
"
726,"0700-1900 npn
see carevue for subjective/objective data.
events of day:  weaning this am, getting ready to extubate when pt became extremely anxious, hr, rr and bp elevated--required ativan for anxiety.  did not extubate due to sedation; pt back on imv for now.  plan is to rest overnoc and reattempt in am.  one unit prbc given, tf resumed, cont'd with vanco enemas q6h however started stooling at 1615-->copious amts liq stool.  ultrasound done to r/o dvt (neg).

neuro:  currently a+ox2.  nodding yes and no, cooperative.  mae ad lib.

cv/pulm:  mp remains st-nsr--lopressor 20mg iv prn given x1 for hr 110's with hr decreased to 90's.  bp returned to baseline after lopressor.  propofol off in anticipation of extubation then restarted when pt placed back on imv.  esmolol remains off.  one unit prbc currently infusing without evidence of adverse reaction--will check cbc 1-2h after completed.  l tlc in place--unable to draw off of cvp line although flushes easily; unable to draw off or flush second port. third port patent.  remains vented at this time with coarse breath sound bil--plan to attempt to extubate in am.  sputum for c+s and gm stain sent.

gi/gu:  tf restarted via ngt at 10ml/hr with no residuals.  one huge liq bm this afternoon--fib applied.  cont with vanco enemas q6h although unable to administer at 1600 as pt actively stooling.  lasix 20mg iv given at 1200 with brisk response--cont to have u/o of >50ml/hr at this time.

id:  tmax=100.7 po.  wbc=33.0.  no change in abx.  sputum sent as noted above.

psychosocial/plan:  emotional support given to pt and fam.  rest on vent overnoc and reattempt to extubate in am.  rpt labs after prbc completed.
"
727,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/+5/35%.  alarms on and functioning. bs ascultated reveal bialteral coarse sounds. suctioned for copious amounts fo bloody secretions as well as plugs. trach site [**name6 (md) **] [**name8 (md) 1290**], rn aware. trach care performed, changed dressings and tie. mdi's administered q4hrs with no adverse reactions.  rsbi=54.  no further changes noted.
"
728,"npn shift 1900-0700:

neuro: intermittently dozes. arouses spon and to verbal stimulus. follows simple commands at times such as, ""open mouth."" makes eye contact at times. generalized weakness, mae. purposeful movement, localizes. off sedation. pt restless, agitated when awake. fentanyl given w/ good effect though caused hypotension. as per ho, ativan 1mg pngt w/ some effect. no adverse reaction. perrla, 3mm, brisk.

resp: oett day #4, 7.5 fr, 26 at lip. pcv fio2 40% rate 14 inp 35peep 10. tv range 600-700.  b/l bs present, diminished and coarse throughout. no s/s of distress. suctioned q3-4hrs mod amts, mod thick, yellow sputum. am abg improved: 7.27/35/110/-[**8-24**]. pt in partially compensated metobolic acidosis. serum hco3=12.

cv: sb-nsr, rare pac's. pt hypotensive post fentanyl 25mcq iv administration, sbp 80's while asleep. easily arousable. ho aware. dopamine started and d/c'd sec to frequent pac's. neosynephrine on standby, hypotension resolved spontaneously. qrs 0.08 pr 0.16 qt 0.40. pt anasarcic. extremities w/ dependent edema, +[**1-9**] pitting, weeping, kept elevated. all peripheral pulses palpable. skin jaundice, sclera ichteric. i/o +718 for shift. wt +5.6kg since admission. vasopressin gtt at 0.04u/min. am serum na+=147, ho aware, no interventions till rounds. k+=4.1 mg+=2.1.

hem: hct stable=30.4 hgb=9.9. plt decreased to 82, ho aware, no interventions till rounds.inr=2.1.

id: afebrile, wbc=10.6.

gi: abd distended, soft sec to ascites. +bs x4, normal. ngt intact, tf increased to target, nepro at 50cc/hr, tol, no aspiration, min residuals. no bm. insulin gtt, see flowsheet.

gu: foley c/d/i draining 70-120/hr, amber, clear. bladder pressure=13. bun increased to 85, cr decreased to 2.8.
"
729,"pt given bronchodilators as ordered with no apparent adverse reactions, midnight tx withheld at rn request.
"
730,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 7/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned moderate amounts of bloody tinged secretions.  mdi's administered q4 hrs alb with no adverse reactions.  am abg's 7.43/45/106/31. rsbi=174. continue to wean sedation. no further changes noted.
"
731,"resp:  [**name (ni) 257**] pt on t/c then placed on [**last name (un) 33**] psv 10/5/40% to rest [**last name (un) **].  suctioned for moderate amounts of thick yellow secretions.  mdi's administered alb/atr with no adverse reactions.  pt placed back on t/c this am @ 6:00 am to proceed to wean.
"
732,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/5/60%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral notable wheeze, related to fluid issues.  mdi's administered q4hr os combivent with no adverse reactions. 02 sats @ 97%. rsbi=30, although rr^ to ^ 30's so no [**last name (un) 607**] initiated.  fi02 decreased to 50%.  no further changes noted.
"
733,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+5/50%.  alarms on and functioning.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral crackles with slight exp. wheeze noted.  suctioned x 3 moderate to copious amounts of thick bloody tinged secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=40, although no [**last name (un) 607**] initiated since ^ rr to 40's.  02 sats remain in ^ 90's @ 97%.  no further changes noted.
"
734,"resp: [**name (ni) 257**] pt on [**name (ni) **] ph28/pl14/th4.5/tl0.5/60%. ett #7.5, 23 lip.  bs have noted aeration with slight exp wheeze on rs. suctioned for copious amounts of thick bloody secretions, then tapered off towards end of shift. mdi's administered alb/atr q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions.  am [**hospital1 **] pending. pt sats fluctuating between 92-97%.

"
735,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for moderate amount of thick tan secretions. mdi's administered q4 hrs combivent with no adverse reactions.  cuff pressures @ 38, rsbi=80, rr ^ to 40's no [**last name (un) 607**] initiated.  no further changes noted.
"
736,"ccu  nursing progress note
neuro:  pt a& slightly confused, pt given ativan secondary to aggitation due to etoh withdral.  pt had adverse reaction to ativan and began to become confused and had increased aggitation.  ativan order changed to valium.  pt mae, however cannot bend, must be supine until 2300.

cardiac:  pt initially on iabp.  pt in st hr 92-116 with occ [**name (ni) **], pt given multiple doses of iv lopressor, with minimal effect.  pt to be started on po b blockers.  bp 89-127/50-75.  pt weaned off dopa, iabp, swan all dc'd.  pt had r fem venous and a sheath, both dc'd keep supine until 2300.  questionable small hematoma in r fem, very soft and supple, however raised, possible swelling from pressure, con't to monitor.  pt has dopplerable dp, and very difficult to fell pt's.  pt given 3g cagluc iv.  con't serial ck and hct, next due at [**2186**].  echo showed ef 40% no other significance.

resp:  bs clear and equal bilaterally, o2 sat 98% on 2l via nc.

gi:  pt npo secondary to gib, pt has r nare ngt to lis with decreased amt (from inintial bleed) of coffee ground out.  +bs, -bm, abd soft nt.  pts hct stable at 0800, then decreased at 1200, by 5 pts, pt given 1u prbc hct now 29, questionable real drop or dilutional.

gu:  pt has f/c good  u/o, urine clear.  pt getting d5 1/2 ns at 75cc/hr x1l.

access:  pt has piv x2.

misc:  iabp, swan, dopa, heparin all d/c today.
labs due at [**2186**].  pt 5 l positive.  v sheath dc'd at 1845 and aibp at 1700.  con't to monitor ms and give valium as needed per ciwa scale.
"
737,"micu nsg admission note
ms. [**known lastname 11491**] is a [**age over 90 **]yo [**hospital3 327**] resident who has been in her usual state of health until past few days when she states she has been ""falling alot"" at home.  multiple old bruises noted on torso, upper arms.  last evening pta she had 2 episoded of brb pr, came to [**hospital1 2**] er.  pmh significant for cad, cva with minimal residual effects, depression, asthma, gerd, diverticulosis by c-scope, paf, pvd, hemorrhoids, h/o falls, s/p appy, glaucoma and htn.  allerg->pcn (rash) and asa (rectal bleeding).  in er pt treated with fluids and prbc.  baseline hct=37; hct in er 29 range prior to prbc.  pt s/b surgery and gi in er.  tagged rbc scan done; results pending.  pt does have a daughter [**name (ni) 3095**] [**name (ni) 11492**] ([**telephone/fax (1) 11493**]) who is involved in her care, lives locally ([**location (un) 3163**]) and pt had a son who was a cardiologist but expired at age 38 due to mi.

current status:

see carevue for subjective/objective data.  pt arrived to icu via stretcher at 0330.  prbc #2 infusing upon arrival.  neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  vss.  mp=nsr, no vea noted.  bp 120's-130's/50's.  periph iv's x2.  prbc second unit hung in er infusing.  room air with coarse breath sounds bil.  no sob or doe noted.

gi/gu:  npo.  abd soft, tender but not tense.  no bm since arrival to icu.  three way foley placed with one attempt; irrigant port clamped.

id:  afebrile.  no abx at this time.

iv:  prbc completed with no adverse reactions noted.  ns 500ml bolus infusing to be followed by d5and [**12-10**] at 75ml/hr.  will rpt hct btw 0530-0600.

psychosocial:  pt sleeping once settled in room.  no visitors with pt.

plan:  monitor vs, hct, ? scope in am.
"
738,"resp: pt rec'd on 4 lpm nc. ^ wob with sob. abg 7.32/78/92/42. re-intubated #8 ett, taped @21 lip as per previous intubation. cp @ 20 cmh20. vent settings; a/c 12/450/10+/40%.  bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.34/65/124/37. no a-line. no rsbi due to ^ peep. will continue full vent support
"
739,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] simv12/600/5/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of bloody tinged thick secretions and some white.  mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=80.  placed pt on psv 15/5/50% and tolerating well, plan to continue to wean today with possible t/c trial. no further changes noted.
"
740,"resp: [**name (ni) 257**] pt on psv 10/5/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi' administered q4 alb with no adverse reactions. am abg 7.43/41/137/28. rsbi=37. no further changes noted.
"
741,"resp: [**name (ni) 158**] pt on psv 12/5/50%.positional trach [**name (ni) 156**]. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with diminished bases. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered with no adverse reactions. rsbi=82. plan to continue trach trials as tolerated.
"
742,"resp: [**name (ni) 257**] pt on psv 10/10/40%. ett #8, 21 @ lip. bs are clear but diminished. suctioned for small amount of thick yellow secretions. mdi's administered q3-4 hrs alb/atr with no adverse reactions. am abg 7.37/60/110/36. no vent changes noc. rsbi=42. plan to wean to extubate this am.
"
743,"resp: [**name (ni) 158**] pt on psv 12/5/50%. pt has #8 portex perc trach. inner cannula changed and was clear.alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick tannish secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=92. attempted abg, pt not cooperative.
"
744,"resp: [**name (ni) 158**] pt on a/c 14/60/+5/50%. alarms on and functioning. ambu/syringe @ hob. suctioned for small-moderate amounts of tan thick secretions. mid's administered as ordered with no adverse reactions. pt has noted cuff [**name (ni) 156**]. rsbi=100. no changes or abg's this shift.
"
745,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 14/500/35%.+5. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. abg's (see careview) fio2 ^ to 50% with abg pending. pt cardioverted tonight and stable. will continue full vent support.
"
746,"resp. care
pt. remains intubated . pt. was weaned down on her fio2 from 70% to 40% per the ip team.sat's are in the low to mid 90s.sx sm amts white secr. mdis given at 0230 with good effect and no adverse reaction.no abgs were drawn during the shift . plan is to go to the or for a y stent then wean as tol.
"
747,"resp: [**name (ni) 257**] pt on a/c 12/350/+5/30%. ett #7.5, 20@ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions as well as oral cavity. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg7.46/37/1741/27. rsbi=68. weaned pt to psv 12/8 for tv's 300-400, ve [**4-19**], rr 16. plan to continue to wean to possible extubation.
"
748,"resp: [**name (ni) 257**] pt on a/c 10/350/+5/30%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick bloody secretions probably due to endo procedure yesterday.  mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.48/38/113/30. rsbi attempted but pt on sedation, results >200. no further changes noted.
"
749,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 24/550/+10/60%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20, ett # 7.5 retaped, secured and advanced 23 @ lip (found @ 21). bs auscultated reveal bilateral aeration with diminshed bases. suctioned x1 for none. mdi-s administered combivent q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see carview) am abg's 7.40/51/68/33. 02 sats @ 92%. pt remians on paralytic noc, but plan to d/c today. no vent changes. plan to continue full vent support.
"
750,"resp: [**name (ni) 257**] pt on psv 12/12/40%. ett #7.5, retaped, rotated and secured @ 23 lip. bs are coarse to clear. suctioned for moderate amounts of thick white/yellow secretions. [**name (ni) **]'d administered alb/atr with no adverse reactions. am abg 7.36/74/115/44. rsbi=155. team to discuss possible extubation even though failed rsbi.
"
751,"npn shift 1900-0700:

pt status quo. pt remains confused, agitated, restless, attempting to self-d/c medical deviced. restraints remain on for safety. neuro otherwise stable. pt conversant, able to verbalize needs though inappropate words at times due to confusion. ativan 2mg iv, ok's by ho, with temorary effect, approx 2 hrs. no adverse reactions. haldol 5mg iv given w/ less effect. fenatnyl patch changed. c/o discomfort. morphine 4mg iv given with good effect. weaned o2 to ra, tol well. coughing productively on command. st 120-140's w/ agitation. when calm, hr spontaneously decreases to 80-90's. no [** **] episodes. sbp 130-150's. autodiuresing, output > 2l. started on ns maintenance ivf at 100cc/hr. am hct 23.1, down from 26.7. some may be dilutional. awaiting prbc x1u. rectal bag off, 300cc [**location (un) 138**] stool. applied new rectal bag. afebrile, tmax 100.4 orally.
"
752,"resp: [**name (ni) 257**] pt on 70% t/c. emergency equipment @ hob. pt has portex #9 trach. pt ^ wob, placed back on psv 10/8/40% to rest noc. bs are coarse bilaterally. suctioning tan thick secretions. mdi's administered atrovent with no adverse reactions. trach care performed/inner cannula replaced and site cleaned. am abg 7.44/39/96/27. rsbi=71. plan to continue with t/c trials in am.
"
753,"resp: pt rec'd on psv 8/8/40%. et 7.5, 23 @ lip. bs are coarse to clear and suctioned for moderate amounts of thick white frothy secretions. [** **]'s administered alb/atr with no adverse reactions.vt's 300, ve's [**7-27**]. 02 sats @ 100%. no abg's this shift or changes. rsbi=120. plan to continue to wean as tolerated.
"
754,"progress notes
neuro= received lethargic, easily arousable, folows commands, confused at times, oriented x2, moves all extremities spontaneously but weakly, complains of right hip/leg pain, h/o right hip replacement, medicated with ultram/mso4 with good result, assisted in turning.

cv= s1 s2 regular with rare apc's, palpable peripheral pulses x4, normal capillary refill to nailbeds, denies chest pains or palpitations, hr 96-118, nbp 120-134/40-76.  on lopressor dosage increased from 1.5 mg to 2.5 mg q6hrs iv.

pulm=received on nc 4lpm, clear bilat breath sounds diminished on the bases, she's an mouth breather and her sat's dropped to 80's when she's asleep, placed her on face tent at 40% with spo2 readings 92-97%. had occassional expiratory wheezes relieved after coughing. unproductiove cough. encouraged deep breathing and coughing, she's complaint.

gi= soft, slightly tender to deep palpation, normoactive bs x4, no bm, passed out foul smelling flatus x1, attempted to used bedpan x2 but no bm, on clear liquid diet, given ice chips and po cold water for now, nauseous x1, no vomiting so far.  no melena.

gu= foley cath draining dark clear yellow urine u/o= 30-45cc/hr.

skin=dry and intact, no bedsores, turned and position q2 and prn, skin and back care done.

iv= right arm hl intact. no signs of infiltration/infection noted.
     left hand pvl intact, infusing ivf + 60 meq kcl at 100cc/hr. site intact/ no redness/infiltration noted.

labs= last hematocrit at 8:30pm is 29, transfused another 1 unit prbc, no adverse reactions noted post-bt.  will check cbc later this am.
serum k+ at 8:30pm= 4.1.

code status= dnr/dni.

plan= continue with current therapy, pain management, monitor h/h and transfuse as indicated, monitor lytes and replete prn.
"
755,"resp: bs's clear.
gi: appetite improved.
renal: voiding. increased po intake.
neuro: alert and orientated.
hem: premedicated for procedure. no adverse reaction from plasma pheresis. post hct 29.7 and plts 53.
access: groin drsg [**name5 (ptitle) **] and [**name5 (ptitle) **] removed. no further bleeding noted.
endoc: ssi required for bs. k+ repleted.
cv; hemodynamically stable.
id: afebrile.
skin integrity; no rash. bruising diminishing.
plan: transfuse for hct <25. pc's require thawing and washing. recheck cbc at 21pm. possible transfer tomorrow after procedure.

"
756,"micu npn 7pm-7am
neuro: pt. received on ativan gtt @1mg/hr and fentanyl at 50mcg/hour. initially pt. appeared comfortable, able to obey commands, and would withdraw to pain. l pupil reactive to light. very weak cough and gag. pt's ativan gtt increased to 2mg/hr due to pt. stacking breaths with ventilator. pt. currently appears comfortable, does open eyes to pain, and flexing extremeties to nail bed pain.

resp: remains on ac16,+5 tv 500, 40%. am abg pending. lungs are coarse with crackles in the bases. at times pt. is very rhoncorous, and sounds like she has alot of secretions, however she has scant to no secretions when she is suctioned. secretions are rust colored. awaiting results of bronch.

cv: received on 8mcg/kg/min of dopamine. dopamine has been weaned to 3mcg/kg/min and will continue to wean as bp tolerates. nsr with occ pac's and pvc's.

gi: ogt to lis, draining guiac + bilious drainage. ogt clamped this am. active bowel sounds, no stool. ?feed pt. is bleeding has stopped.

gu: voiding adequate amounts of urine >40cc/hr. clear, yellow urine.

heme: hct stable, 30@mn.

misc: per pt's oncologist she received iv ig. pt. initally given a test dose of 5gms and she tolerated it well. bp stable, and temp stable, no signs of adverse reaction. pt. then given remaining dose. pt. tolerated well. see carevue for vss and temp.

social: family member stayed the night in the waiting room. plan is to find source of infection, wean dopamine as tolerated.
code status: dnr
see carevue for further data.
"
757,"resp: pt rec'd on a/c 15/550/+8+50%. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. sucitoned frequently for moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. no changes this shift. rsbi=58. will continue full [** **] support.
"
758,"resp: [**name (ni) 158**] pt on a/c 22/600/+5/50%. ett #8, 23 lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amount of bloody tinged secretions. mdi's administered q4 alb with no adverse reactions. pt is being r/o for tb. am abg pending. will continue will full vent support.
"
759,"resp: [**name (ni) 158**] pt on a/c 15/550/+8/70%. ett #7.5, 24 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick tan secretions. mdi's alb/atr administered with no adverse reactions. [**name (ni) **] changes to decrease fio2 to 60%. abg 7.37/41/100/25. no further changes noted. will continue full [**name (ni) **] support.
"
760,"resp: rec'd on psv 14/+5/40%. ett 7.5 taped @ 23 lip. bs are clear with diminished bases. suctioned for small amount of white secretions. mdi's administered atr as ordered with no adverse reactions. vt's 500's/ve's 11/rr 23. rsbi=90. am abg 7.40/34/147/22. plan to wean as tolerated. no changes this shift.
"
761,"resp: [**name (ni) 158**] pt on a/c 30/400/18/50%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, retaped, and secured @ 25 lip. bs auscultated reveal bilateral clear apecies with diminished bases. suctioned for small amounts of white secretions. mdi's administered as ordered with no adverse reactions. abg's (see careview) vent changes to decrease peep to 16, rate to 28 with am abg pending. will continue to wean as appropriate.
"
762,"resp: [**name (ni) 158**] pt on a/c 14/600/10+/50%. retaped tube ett 8.0 @ 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no aline/abg's noc. no changes or rsbi due to ^ peep. will continue full vent support.
"
763,"resp: pt remains vented on psv 5/5/50%. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered q 4h alb with no adverse reactions. rsbi=68. am abg's pending. o2 sats @ 100%. plan to wean to t/c as tolerated.
"
764,"resp: [**name (ni) 158**] pt on a/c 30/400/+20/60%. ett retaped by rn, then found at end of shift @ 23 lip, retaped, advance and secured @ 25 lip. bs are clear bilaterally, with diminished bases. suctioned for small to moderate amounts of bloody tinged to rusty plugs. abg 7.39/41/78/26.mdis administed as ordered alb/atr with no adverse reactions. pt had episodes of desaturation to 80's then ^ fio2 to 70%. no further changes noted. esophageal balloon in place. will continue to wean fio2 as tolerated.
"
765,"resp: pt rec'd on psv 10/5/40%. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.46/29/103/21. rsbi=74. plan to possible trach today. will continue to wean appropriately.
"
766,"resp: [**name (ni) 158**] pt on 40% t/c with humidification. 02 sats @ 99%. bs are coarse bilaterally and pt is able to expectorate secretions. mdi""s administered q4 hrs alb/atr with no adverse reactions. pt has #8 shiley trach with cuff deflated. no abg's or distress this shift. pt scheduled for pmv [**name (ni) **]. will continue to follow.
"
767,"resp:  [**name (ni) 158**] pt on 7200 psv 5/+5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 for small amount of whitish secretions.  mdi's adminintered q4hrs with no adverse reactions.  rsbi performed this morning resulting @ 71.4 and sbt initiated.  02 sats remain in ^ 90's and rr @ 24.  no further changes noted.  possible extubation today, awaiting sons arrival at hospital.

"
768,"resp: [**name (ni) 158**] pt on simv 10/600/12/+12/50%. ett#7.5, 25 lip.  bs reveal bilateral crackles. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs of atrovent with no adverse reactions. abg drawn; results 7.34/49/179/28. vent changes to decrease rr to 8, fio2 to 40%. no further changes noted.
"
769,"resp:  [**name (ni) 158**] pt on a/c 14/550/+8/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan with green plugs. mdi's administered as ordered with no adverse reactions. no changes or abg's this shift. 02 sats @ 100%.
"
770,"[**name (ni) 158**] pt on [**last name (un) 647**] psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration noted in apecies with diminished bases.  mdi's administered q4 hrs combivent with no adverse reactions.  abg's drawn with worsening acidosis, placed on simv 22/600/+5/5/50%.  am abg's 7.37/31/178/19 with no further changes noted.
"
771,"resp: [**name (ni) 158**] pt on psv 10/10/40%. ett 8.0 retaped, rotated and secured @ 23 lip.  alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally.  suctioned for large amounts of thick bloody secretions/clots. heated wire circuit changed. mdi's administered alb/atr as ordered with no adverse reactions. vt's 700's with occasional drop in ve's to 3l then back up to 8-9l. no rsbi due to 6 peep. am abg 7.46/41/84/30. no changes noc. [**name (ni) 4812**] started.

"
772,"resp: pt rec'd on a/c 14/550/50%/8+. bs are coarse bilaterally. suctioned moderate amounts of thick greenish secretions. mdi's administed as ordered with no adverse reactions (see careview) no abg's/no aline. weaned to psv but didn't tolerate and placed back on original a/c settings. rsbi=68.
"
773,"resp: [**name (ni) 158**] pt on simv 8/500/12/+12/40%. ett #7.5 retaped and secured 25@lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions with occasional tannish plug. mdi's administered q4 atrovent with no adverse reactions. no changes or abg's this shift. no rsbi due to ^ peep. will continue full support.
"
774,"resp: pt rec'd on 50% t/c. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. nebs alb/atr administered with no adverse reactions. no changes noc.
"
775,"resp: [**name (ni) 158**] pt on a/c 12/500/+5/50%. [**last name (un) 3028**] #8 trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick tan secretions. mdi's administered q4 alb/atr with no adverse reactions. no changes or abg's this shift. plan to attempt to wean to psv today.
"
776,"resp: [**name (ni) 158**] pt on psv 12/+5/40% then placed on a/c 14/450/+5/40% to rest noc. ett #7, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amounts of bloody secretions. mdi's administered as ordered of combivent/flovent with no adverse reactions. pt has a tendency to bite on tube. no abg's this shift. 02 sats @ 99%. plan to tap bilateral pleural effusions today. will continue full vent support.
"
777,"resp: [**name (ni) 158**] pt on a/c 14/550/+10/60%. bs are coarse bilaterally. suctioned for thick greenish secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease peep to 8, fio2 to 50%. no a=line, 02 sats @ 99%.
"
778,"resp: pt rec'd on psv 16/8/50%. ett retaped, rotated and secured. alarms on and functioning/ambu/[**e-mail address 4476**] are coarse bilaterally. suctioning for moderate amounts of thick tannish secretions. mdi's administered q 4 alb/atr with no adverse reactions. pt ordered for potassium iodide, after consulting pharmacy was advised not to administer down ett, just po. pt placed on a/c 20/500/+8/50% to rest [**e-mail address **]. am abg 7.47/30/182/22. decreased rate to 14, fio2 to 40%, peep+5. plan to wean back to psv today.
"
779,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/500/50%/+5. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned a moderate amount of thick yellowish secretions. mdi's given q4 alb with no adverse reactions.  [**last name (un) 353**]=135, cuff pressure @ 22cmhc0 with no further changes noted.
"
780,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi""s administered q4 combivent with no adverse reactions. rsbi=98, no am abg. plan to continue to wean as tolerated.
"
781,"resp: pt remains intubated on psv 10/5/50%. alarms on and functioning. pt had periods of desating to 80's, increased vent setting temporarily then returned to present settings. bs auscultated reveal bilateral clears sounds, suctioned for small amount of tan thick secretions.  mdi's administered alb/atr q4hrs with no adverse reactions. abg's 7.45/30/116/21. rsbi=76. vt' 500's, ve 13l, rr 25. will continue to wean appropriately.
"
782,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 12/550/40%/+5.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with some coarseness noted on ls, diminished bases bilaterally.  mdi's administered q 4hr combivent with no adverse reactions. suctioned x3 small amounts of thick white secretions.  sputum sample obtained this am.  rsbi=172 and no sbt initiated.  no further changes noted.  02 sats remain in ^ 90's.
"
783,"resp: [**name (ni) 158**] pt on a.c 14/550/5+/60%. ett #8, 24 @ lip. alarms on and functioning. ambu/syringe 2 hob. bs are clear bilaterally in apecies with diminished bs on lll. xray shows improvement from prior. mdi's initiated and administered as ordered atr/alb with no adverse reactions. suctioned for small amount of thick white secretions. pt is still tachycardic and may require cardioversion??. vent changes noc (see carview) am abg 7.44/44/119/31 at present settings. no rsbi due to hemodynamic issues.
"
784,"resp:  [**name (ni) 158**] pt on psv 12/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilteral aeration with a noted wheeze. mdi's administered q4 hrs combvient with no adverse reactions. suctioned for small amounts of bloody tinged secretions. am abg's 7.42/61/98/41.  no further changes noted.
"
785,"micu npn
see carevue for subjective/objective data.  neuro:  unresponsive to verbal stimuli, withdraws to tactile/painful stimuli.  no attempts to communicate or speak around ett.  minimal movements of arms, hands noted; no leg movements noted.

cv/pulm:  vs labile.  dopa titrated to maintain map>60--overnoc dopa max 12mcg/kg/min, currently at 9mcg/kg/min with map 60-64.  swaned at 1900--pa catheter at 65cm, intermittently wedges with 1and [**1-7**] ml air. pa's 20's/10's with cvp 11 to 5.  pcwp 13-11.  initial co/ci low at 4.5/1/5.  dobutamine added at 2.5mcg with co/ci improved to 5.3/2.5.  sensitive to dopa-->bp drops rapidly during even brief interuptions of infusion (bag change), takes 15-30min to return to baseline.  mp=nsr with occ pvc's at beginning of shift, now no ectopy noted.  completed prbc's hanging at 1900, hung third unit prbc's (total of 4 units including prbc rec'd in er).  no adverse reactions noted with blood transfusions.  maintained on vent-->ac12x700x50%x5peep.  bs coarse with bibasilar crackles.  lasix 40mg iv given prior to last unit prbc's with good diuresis; continues to diurese.  sputum sent for c+s.
suctioned for scant thick light yel sec via ett.

gi/gu:  ogt-->lcs drng bilious material.  bs absent.  abd soft, non-tender.  u/o qs via foley with brisk diuresis following lasix.  no bm.

integ:  incision on upper back noted (cyst removed pta)--drng sm amts light yel drng.  dsd applied/changed.  coccyx pink with sm area ""rough"" but not open--duoderm applied.  no other open areas noted however heels pink--elevated off of bed as much as possible.

id:  tmax=100core.  bc, urine cultures sent in er; sputum culture sent in micu.  started on vanco and levo (per pharmacy levo needs id approval following initial dose).

psychosocial:  emotional support given to pt.  no visitors or [**name2 (ni) **] contact thus far this shift.
"
786,"blood administration
pt given one unit of prbcs for hct of 22.7.  pt tolerating procedure well at this time, no adverse reactions.  rn to follow up by checking hct and obtaining new iv access.
"
787,"resp: [**name (ni) 158**] pt on t/c and place back on [**last name (un) 647**] psv 5/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral areation noted. some fine crackles.  suctioned for small amounts of yellow thick secretions. mdi's administered q 4 hrs of combvient with not adverse reactions. md [**first name (titles) 1531**] [**last name (titles) 2435**] today.  place back on t/c this am. tv low 300's.
"
788,"resp: [**name (ni) 158**] pt on a/c 18/550/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amounts of thick secretions. mdi's administered 2p atr with no adverse reactions. trip to ct without incident, with results pending. am abg 7.40/41/75/26 with no changes noc. rsbi=no resps. will continue full vent support.
"
789,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 10/500/10+/50%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. mdi's administered q4 hrs [**last name (un) 741**] with no adverse reactions. no vent changes noc. plan trach/peg tomorrow.  no rsbi due to peep.  am abg's 7.53/34/148/29.  no further changes noted.
"
790,"resp: [**name (ni) 158**] pt intubated via or ett 7.0 retaped and secured 19 @ lip. place on a/c 18/550/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered 2p atr with no adverse reactions. vent changes to decrease fio2 to 40%. am abg 7.28/41/107/20. no further changes noted. will continue full vent support.
"
791,"resp: [**name (ni) 158**] pt on psv 10/8/40%. ett #8, 27 @ lip. bs are coarse to clear and suctioning moderate to copious amounts of thick rusty/plugs secretions. mdi's alb administered with no adverse reactions. am abg 7.48/37/76/28. rsbi=43. plan is to extubate in am.
"
792,"resp: [**name (ni) 158**] pt on psv 10/8/40%. ett #8 taped @ 27 lip. bs are coarse to clear. suctioned for large amounts of rusty/plug thick secretions. mdi's administered as ordered alb with no adverse reactions. rsbi=31. am abg 7.46/37/80/27. plan to wean as tolerated.
"
793,"tsicu nursing admit note
pt s/p unwitnessed fall at home, possible mechanical cause.  no loc per family.  pt taken to [**hospital3 **] where scans revealed c1, c2 fx.  transfered to [**hospital1 41**].  initially given steroid bolus, stopped per trauma.  head ct revealed possible evolving stroke, to be evaluated by mri.  bilateral shoulder injury to be evaluated by ct.

pt with extensive hx including dementia (etoh vs alzhiemers), cad s/p ami, chf controlled with dialysis, htn, a-fib, copd, gi-bleed, esrd with hd 3x per week.  pt with multiple hospitalizations with fistula problems, line sepsis, now with graft.  baseline dementia generally exacerbated with delerium during hospitalizations.  pt with code purple previous hospitalization.  adverse reaction to haldol in past.  given sl zyprexa.

pt stating he has considered stopping dialysis treatments and ""throwing in the towel.""  he stated that he does not want to continue to live this way.  family will need to discuss pts wishes in light of significant dementia.

dr. [**last name (stitle) 898**] in to meet with family.  discussed collar vs. halo vs. surgery.  family does not believe collar is an option as pt would remove it.  family is requesting rehab placement as pt requires extensive care from wife at baseline.  dr. [**last name (stitle) 898**] to continue to discuss options.

ros:

neuro - aao x2.  pt knows name and that he is in the hospital.  [**name (ni) **] unclear why he is hospitalized.  unclear as to date.  asking to go home, easily redirected discussing x-rays planned before he can go.  mae with equal stregth.  sensation intact.  collar on with good fit, pt has not tried to remove collar over noc.  no restraints needed.  pt c/o right shoulder pain, reports good relief with tylenol.

cv - sr with [**name (ni) **] pvcs, pacs.  rate 60s to low 70s.  hypertensive at times with sbp 120s to 170s.  given po antihypertensives.  toprol held per dr. [**last name (stitle) 1859**].  peripheral pulses stronger in rle vs lle.

resp - lungs cta.  eupnic.  o2 sat dipped to 91% with deep sleep.  placed on 2l nc with o2 sats >97%.

gi - abdomen soft, flat, + bs.  tolerated sips of water with meds.

gu - does not make urine.  missed dialysis today because of fall.  will have dialysis today.  hold antihypertensives until after dialysis.

endo - elevated blood sugar since admission.  no known hx.  riss.

social - wife, [**name (ni) 1736**], is caregiver [**first name (titles) **] [**last name (titles) **].  family is caring and appear to have reasonable expectations.  they will continue to talk with neurosurgery re: plan for cervical fracture.  await plan of care for shoulder injury.  family requesting case management input re: rehab placement.  upon chart review, pt was dnr/dni during previous hospitalization.

a - neuro status intact, stable s/p c1, c2 fx.  dementia apparently at baseline.  good pain relief with tylenol.

p - continue serial exams.  mri of head to evaluate stroke.  ct to evaluate shoulder injury.  consult case management.  discuss code status with family.  dialysis treatment as needed.  sw consult for family coping in light of pt's statements re: quality o
"
794,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett #7.5 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration with diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift or changes. rsbi=27.
"
795,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett #7.5, retaped and secured @ 21 lip. alarms on and functioning. ambu/syringe @ hob. suctioned for small to moderate amounts of thick tan secretions as well as copious oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sat @ 100%. rsbi=28. no changes or abg's noc.
"
796,"pmicu nursing progress note 7a-7p
review of systems

[**name (ni) 248**] pt is responsive to stimuli, both voice and pn. she still does not move her extremities, but opens her eyes inconsistently when asked. she was not given any medication for sedation today, both scheduled doses of valium were held due to hypotension.  she has cont to recieve 300 mcg/hr of fetanyl, the plan following evening rounds is to start to slowly wean the fetanyl. the pt is planned to have a pancreatic needle aspiration [**last name (lf) **], [**first name3 (lf) **] will cont. to need pn medication.

resp- ac 400/40%/18/5 peep.  has maintained sats btw 97-100% since the peep was decreased from 8to5.  ls coarse bilaterally, suct. scant amts of thick, white sputum.  ett rotated, 25 to lip.  significant amt of thick yellow drainage suctioned from nares. team aware.

cv- hr btw 102-122 today, b/c more tachycardic w/ inc temp.  no ectopy noted.  nbp 90's-102/40-60's. hypotension was tx w/ 1 u of prbc to inc. intravascular vol.  received 2 gm of ca today.

gi-  bs, present, stooling loose green stool per mush cath.  cont. to receive tpn, lipids have been added per dietary recommendations.  tf cont to be held due to severity of inflammation in pancreas, residuals have been < 20 cc on q 4 hr checks.

gu- 100 cc/u/o/hr, clr, yellow. 24 hr net body balance + 1114.3. given 1 l bolus of ns for dehydration per teams request.

heme/[**name (ni) 998**]  pt transfused w/ 1 u prbc to inc. intravascular vol. and for hct of 27.4.  prbc's infused without evidence of adverse reactions.  plan to dc insulin drip when last l of d5 finishes infusing.  sliding scale orders in chart for coverage.

id- febrile today w/ temp ranging from 100.5-101.7; pt received q 4 hr tylenol and remained on a cooling blanket. day # 10 of imipenim.
fungal isolators sent.

plan- social work met w/ pt's fiance and spoke w/ pt's sister today over the phone and a meeting is to held tomorrow with all members. please refer to note in chart.  cont to monitor resp, cv, fever status.  tomorrow ir is scheduled for a pancreatic needle aspiration.


"
797,"12p-7p
pt readmitted from [**hospital ward name **] 2, ct draining bile ? anastomosis leak ([**11-14**] s/p esophagogastrostomy and jtube placement). pt went to ct prior to being transferred.

neuro: pt alert and orientedx3. mae. perrla. using dilaudid pca appropriately for pain management see carevue.

cv: hr 102-119 st no ectopy. sbp >90. see carevue. dopplerable pedal pulses. 2+ pitting edema to bilat ankles. porta cath to left cw patent and intact. #20 placed to rh, patent and intact.

resp: ls coarse throughout. face tent applied at 70%, desats to 91% on nc. sats on face tent >95%. rr wnl. ct intact, no air leak noted, see carevue for details of color. md [**doctor last name 6980**] in at bedside on arrival and aware of color and content, barium given down ngt in ct scan by md. [**first name (titles) 6981**] [**last name (titles) 4318**] in ct by md [**doctor last name 6980**] to declot ct to drain. no adverse reactions. ct w/ scant drainage after 1700, md [**doctor last name 6980**] aware.

gi/gu: abd soft, + bs. ngt to right nare, to lis draining bile, see carevue. no manipulation of ngt [**name8 (md) 52**] md [**last name (titles) 6980**]. j tube clamped [**name8 (md) 52**] md [**last name (titles) 6980**]. foley draining [**first name8 (namepattern2) 1074**] [**location (un) 206**] color urine. at 1600, lasix 20mg ivp given for decrease in u/o to 5cc for 1 hour. see carevue for details.

endo: covered per pt's own scale.

id: wbc 22-23. afebrile.

plan: monitor hemodynamics. pulmonary toilet. monitor temp. ? to or/ir tomorrow.
"
798,"resp: pt rec'd on a/c 20/600/40%/5+. alarms on and functioning. ambu/[**e-mail address 5171**] #7 re-taped and secured @20 lip. cp @ 23 cmh20.  bs auscultated reveal bilateral coarse sounds with exp. wheeze noted. mdi's administered q 4 alb with no adverse reactions. suctioned for small- moderate amounts of tan secretions. am abg's 7.31/40/80/21. pt remains on cvvhd. will continue full vent support. no vent changes noc.
"
799,"ccu progress note!  7a-7p
delayed transfusion reaction:
   pt began to feel uncomfortable around 930am, stating he was feeling 'awful'.  at 10am, team in to assess pt on rounds, pt feeling nauseous. droperidol 0.625mg given total of 3 times today w/ little effect. ekg done w/ no changes noted. labs sent, cks flat. pt sob resp rate 20-30s, laboured at times. ls clear, crackles to bases. tmax 100.4. st 1320-130s. milrinone gtt d/c'd d/t ?adverse reaction to drug. pt con't all afternoon w/ nauseous feeling and stating he felt awful. slept in naps most of afternoon. hematuria - u/a sent. unknown about why pt was feeling so awful.
  around 5pm, house staff notified by blood bank that pt recieved blood + for minor antigens that pt has antibodies for.(1 unit prbcs given [**2130-1-10**], checked via ccc and w/ 2 nurses and given over 4hrs - hung 10am-down 2pm. benedryl 25mg po and tylenol prior to transfusion.) blood bank stated that due to missmatch he may have a delayed transfusion reaction.  pt had temp of 100.4 today, nausea, resp distress and hematuria (signs of a transfusion reaction). labs sent. ivf d5w w/3amp naco3 @ 250cc/hr x 1l.


neuro: a+ox3 today. pleasant + cooperative. pt napped most of late morning/afternoon d/t feeling awful. moves self in bed.

cardiac: st 110-130s today. occ pvcs noted. integrillin d/c'd at 11am. post cath fluids stopped at 8am. milrinone d/c'd at noon. ekg showed no changes today. no c/o chest pain. rij swan intact, pad 28-32, pcwp 31->23. co 3.3->4.7, ci 2.2->3.1, svr [**2127**]->1200. dobutamine @ 15mcg/k/min, nitro @ 180mcg/min. for cath lab in am to fix lad, to recieve pre cath fluids tonite.

resp: ls clear, crackles to bases. rr 20-30s, o2 3l n/c. laboured breathing at times this afternoon. cxr unchanged. sats 94-100%.

gu: foley changed today d/t ?clotted catheter. u/a sent. con't w/ hematuria, pink urine w/ clots. poor u/o, noting decrease in u/o since ivf d/c'd at 8am. lasix gtt decreased to 5mg/hr. ns bolus given this afternoon w/ no results. currently recieving d5w w/ 3amps bicarb @ 250cc/hr x 1l to flush out patient (d/t transfusion reaction). last cr 2.6!

gi: abd soft, distented. bm this evening. nauseated most of day, droperidol given x 3 w/ little effect. took small amt dinner this evening since he has started to feel a bit better. npo at midnite for cath in am.


plan: monitor resp status d/t ^ivf. monitor for further delayed transfusion reactions. con't to monitor vs and do cardiac calcs q4h. npo @ midnite for am cath. start pre-cath ivf tonite.
"
800,"resp: [**name (ni) 158**] pt on a/c 24/350/+10/40%. pt has #9 [**last name (un) 3028**] foam filled trach. alarms on and functioning.ambu/syringe @ hob. bs are coarse and suctioning small to moderate amounts of yellow to tannish thick secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's or changes noc. will continue full vent support.
"
801,"7p-7a
neuro: at beginning of shift pt alert,sleepy, following all commands,mae,perrla, nodded yes when asked if wants ""breathing tube out"" able to move head forward. pt resedated after re-intubation, on propofol,perrla, mae to painful stimuli. no indictions of pain.

cv: hr 70-100s. >100 during episode of re-intubation. sr/st. sbp labile on and off neo and ntg. currently off of neo and ntg. sbp 110s. [**md number(3) 5118**]/15-20s. cvp 7-16. svo2 52-64, md bridges aware. ci>2 by fick, see carevue. low svo2 treated w/ fluid bolus x3 and 2 units of prbcs,no adverse reactions, see carevue. epicardial wires attached and on ademand backup, see carevue for settings. +palpable pedal pulses, verified w/ doppler.


resp: at beginning of shift, pt following commands, acceptable abgs on cpap 5/5, md bridges at bedside before extubation and aware of svo2 57-60 before extubation. ok to extubate, extubated at [**2095**], pt sats to 55, pt in resp. distress, pt oxygenation w/ ambu and oral airway w/ improved sats to 90%, anesthesia called stat and at bedside re-intubated 7.5 tube, see carevue for vent settings and changes. abg after re-intubation 7.21/62/108, md bridges aware, rate on vent increased to 18, w/ improved abg 7.32/48/106, md bridges aware. presently on cmv rate 18 tv  700, fio2 70% w/ acceptable abgs, see carevue for details. ls clear diminished at bases. sats 94-100% at present time. suctioned for scant amts of thick white.

gi/gu: abd soft, abesent bs. ngt replaced after extubation draining bilious to brownish drainage. foley draining 40-60cc/hr of clear yellow urine, see carevue.

endo: gtt per protocol.

social: daughter updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. once pt stabilizes, wean vent as pt tolerates.
"
802,"ccu npn 7am - 7pm
s: ""  my anxiety level is so high.""
o:  cvs:  hr 60 -70 sr no vea noted.  bp 140/30 -40's.  continues on labetelol, hydralazine and norvasc.

resp.:  pt. c/o sob this morning. lungs were clear at the time and o2sat was 94 %.  o2 2lnp was placed and pt. is attributing this episode to anxiety and it resolved spontaneously.

g.u.:  creat. is up to 4.9.  u/o is minimal.  presently pt. is 500 cc's neg.  pt. was told that he probably would need some dialysis after the surgery.

g.i.:  pt.'s main complaint today was of nausea.  vomitted x1.  given zofran 4mg iv x2 with relief.  appetite has been poor.  pt. ate very little.  took medications sporadically throughout the day.

d.m.:  blood sugars continue to be high.  ss insulin was increased.  last sugar was 221.

i.d.:  pt. has remained afebrile.  needs to receive vanco in the o.r. tomorrow.  please send down.  continues on ceftriaxone.

mental status:  alert and oriented x3,  very anxious.  h.o. does not want pt. to have any antianxiety meds due to adverse reactions in the past.

a: nausea and vomitting, awaiting valve surgery tomorrow

p:  continue zofran for comfort, monitor blood sugars, monitor u/o, [**doctor first name 4**] tmr ? at 8am.
"
803,"respiratory:  [**name (ni) 158**] pt on 7200 simb8/550/15/5/40.  alarms on and functioning.  ambu/syringe@ hob.  bs auscultated reveal bilateral diminished with a few coarse sounds. suctioned x2 small amount of thick yellowish secretions.  mdi's administered q4 with no adverse reactions. fio2 remains in ^ 90's with no futher changes noted.
"
804,"resp: [**name (ni) 158**] pt on ac 24/350/10+/40%. #9 [**last name (un) 3028**] foam filled trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse which improve following suctioning. suctioned for small to moderate amounts of thick bloody tinged secretions. mdi's administered combivent as ordered with no adverse reactions. no abg's or changes noc. will continue full vent support.
"
805,"nsicu npn
see carevue for subjective/objective data.  neuro:  confused to place and time.  does not attempt to answer questions or nod ""yes"" or ""no"" however does follow commands to ""squeeze my hand"" and ""move your toes"".  mae ad lib.

cv/pulm:  vss.  mp=nsr without vea noted.  face mask in place-->breath sounds coarse bil.  second unit prbc's infusing when accepted pt; remainder bag infused without adverse reactions noted.

gi/gu:  ogt for meds with effect.  fib in place, passing flatus.  bs positive.  no tube feedings at this time.  u/o qs via foley.  rec'd lasix 40mg iv after second unit prbc's at 0230 with good diuresis.

integ:  pink areas noted on both arms, torso.  no worsening or change in skin condition overnoc.  duoderm to coccyx intact.  skin dry.

id:  afebrile.  no change in abx overnoc.

endo:  no sliding scale insulin required at 2400; glucose pending this am.

psychosocial:  emotional support given to pt.  no visitors/[**name2 (ni) **] contact thus far this shift.
"
806,"7a-7p
neuro: pt a+ox3, mae, perrla. oxycontin 10mg for chronic back pain, percocet prn for breakthrough pain.

cv: hr 50-60s sr/sb w/ occasional pvcs. sbp >120-140s.+palpable pulses. picc line in place and intact. 2 units of prbcs given this am w/o adverse reactions. lopressor dose held secondary to bradycardia as parameters are written.

resp: ls rhonchi to clear. sats > 97% on ra. rr wnl. oob to chair.
no c/o respiratory distress.

gi/gu: abd soft, no bm, +bs, +flatus. foley placed as ordered secondary to surgical recommendations to keep strict i+os. u/o as low as 10-30cc/hr after [**name6 (md) **] placed, md [**doctor last name 610**] aware, no new orders at present time.

endo: fs qid , requiring no coverage.

skin: see carevue.

plan: monitor hemodynamics. hct every 4 hours. monitor output. pain control. monitor respiratory status.
"
807,"respiratory:  [**name (ni) 158**] pt on 7200 psv15/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x2 small amount of yellowish secretions. mdi's administered q 4 hrs of combivent with no adverse reactions.  sat's remain ^90's.  no further changes noted.
"
808,"1900-0700
see carevue for assessment and vital signs.

neuro: a&o. perl. mae. following commands. sleepy due to analegesia but easily rousable.

cv: sr 70's. no ectopy noted. sbp 97-125. always >100 when awake.

resp: maintaining sats 94-100% on ra. encouraged to deep breathe. ls clear.

gu: foley draining adequate volumes of clear urine.

gi: good diet tolerated. ssi coverage. made npo from midnight for possible or today. lr @ 125mlsph.

skin: intact. pin sites to l leg clean.

pain: ketamine infusion continues @ 7.5mls/15mg/hr. no adverse reactions/effects noted. dilaudid pca (double strength) continues. 0.5mg/6min lock/5mghr tot. used less since ketamine infusion commenced. pt slept for long periods and pain reported to be better controlled. sharp intermittent l leg pain continues. 2am morphine sulphate sr 130mg held as pt resp rate 12-13, pt comfortable/sleeping and also npo.

id: t max 100.5. 650mg acetaminophen given with effect.

plan: remain npo for possible or for l leg orif.
      monitor neuro status while on ketamine/dilaudid.
      maintain traction to l leg.
      emotional/psychological support of pt.
"
809,"resp: [**name (ni) 158**] pt on psv 18/+5/40%. [**last name (un) 3028**]#9 foam filled [**last name (un) **] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse and suctioned small to moderate amounts of thick yellow secretions. mdi's administered as ordered without adverse reactions. no abg's. will continue to monitor closely.
"
810,"resp: [**name (ni) 158**] pt on a/c 12/450/5+/40%. pt has #9 [**last name (un) **] foam filled trach. bs reveal coarse sounds and suctioned for small amounts of thick white secretions. mdi's administered as ordered of combivent with no adverse reactions and some improvement noted. dr. [**last name (stitle) 1531**] not to drop peep below +5, so no rsbi performed. no abg's 02 sats @ 100%. will continue full vent support.
"
811,"resp: [**name (ni) 158**] pt on a/c 35/500/+14/60%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. vt ^ to 550. am abg's 7.42/47/94/32. esophogeal balloon study to terminate today?. will continue full vent support.
"
812,"ccu nursing progress note 7p-7a
s: ""that new medication is making me feel off"" (captopril)

o: please see careview for complete vs/additional objective data.

ms: received pt [**name (ni) 465**]3. clearly more frustrated and aggitated than prior night. pt stating he felt figgity since receiving new med (captopril). at 2200 pt c/o body ache. given 1 tablet percocet and 0.5mg iv ativan for figgitiness. pt asleep until 0230 when iabp alarm was heard and pt was found oob attempting to put on pants. pt had managed to do this even though all side rails were up. none of his invasive lines or ivs were disconnected. pt was disoriented at that time but clearing up by morning.

cv: vss. pt remains on 1:1 iabp support w/good augmentation. as mentioned above pt found oob w/ iabp still intact. augmented wave slightly more rounded but otherwise no s/s of vessel rupture or dislodgement. cxr obtained and no change in positioning noted. pt remains off all pressors and tolerating lopressor 25mg and increased dose of 25mg captopril. hr 68-85. nsr. rare-occ pvc noted. bp 85-97/49-67 via abp. maps 70-80s. pap 40-50/20-29. cath lab swan remains in right groin. no wedge attempted. co/ci following increased captopril dose to 25mg (12.5 mg) 8.9/3.98 w/ mv 73. repeat this am 5.0/2.43 w/ mv 70. pt cont on heparin at 500u/hr while iabp remains in. palpable pulses. warm extremeties. following diuresis last pm k+ 3.3 and ionized ca 1.0. repleted w/ 40 meq kcl and 4 mg cagluc. repeat this am k+ 4.9/ mg 1.21.

resp: ls cta. pt denies sob/difficulty breathing. pt tolerating lying flat. rr 16-20. o2 sats 94-100%. reapplied 4l supplemental o2 via nc for desaturation to 94% while asleep.

gi/gu: abd soft. +bs. no n/v. tolerated dinner per prior report. no stool. f/c to gravity. diuretics given prior to shift change. pt responded w/ approx 700cc over 2hrs. uo 90-120cc q 1-2 hrs [**name (ni) **]. -50cc for past 24hrs. pt remains -4l los.

id: afebrile. no abx.

skin: intact.

social: no calls or visitors [**name (ni) **].

a/p: presented to osh ^doe/ pnd w/ chest discomfort. transferred to [**hospital1 41**] for cath which revealed 3vd. iabp placed for support until surgery w/ or without mvr. pt refused surgery/ pci. weaned iabp but ci depressed. started on bb/ace-i and resumed 1:1 w/ heparin gtt. co/ci improved following ace-i dose. wean iabp today and cont to titrate bb/ace doses. cont to diurese as indicated. follow electrolytes and cont repletion as needed. ? adverse reaction to captopril. pt stating he doesn't feel right since initiation of med. ? change to lisinopril. cont to advance diet and activity as tolerated. medically manage and discharge home. discuss 3vd/ possible readmission given ds process and code status w/pt. cont to support pt and family as indicated.
"
813,"resp: [**name (ni) 158**] pt on a/c 22/600/+10/50%. #7 [**last name (un) 3028**] trach. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds. suctioned for moderate amounts of thick tan secretions. mdi's administered q 4 alb/atr with no adverse reactions. nebulized tobra in line (filter used/removed) and tolerated well. rsbi=^ peep. abg's pending. will continue full vent support.
"
814,"resp: [**name (ni) 158**] pt on psv 10/10/40%. bs auscultated reveal bilateral clear with diminished bases. suctioned for small to moderate amounts of bloody tinged secretions. mdi's administered q4 hrs alb with no adverse reactions. pt complains of ^ wob, and placed on a/c 18/360/+5/40. am abg's 7.48/32/151/25. will continue to wean appropriately.
"
815,"nursing progress note for 7p-7a:
neuro: pt is a&ox3, mae, follows commands.
pain: epidural gtt in infusing at 2ml/hr with good pain control and no adverse reactions noted.(changed dose, see [**month (only) **])
cv: hr is nsr 60-70's, rare pac noted. sbp 90-100's with maps 55-65.
skin is warm and dry, color pink, ppp. pt asymtomatic. remains on neo gtt at .4-.6 mcg/kg/min. bp does drop when attempts made to decrease neo gtt. lr at 10 ml per hour, cvp at 5. no fluid [**name8 (md) 52**] md's.
resp: pt's sats dropped to 88% while on 4l/nc, changed to 50% face mask with sats now 92-96%. wean non-productive cough. uses is with encouragement. 2 rt pleural [**last name (un) **] ct's to 20 cm sx. low amt of drainage. small airleak, no crepitus. md aware. dressing cdi.
gu/gi: npo, bs absent.  foley to bsd with adequate hourly o/u.

s/p thoracotomy with wedge resection, bx, lobectomy, esophageal mass removal and repair to trachea.  plan to keep pt dry to prevent re-intubation and attempt to wean neo gtt to off. encourage is.
"
816,"resp: [**name (ni) 158**] pt on a/c 14/600/10+/40%. ett 38, 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. no rsbi due to ^ peep am abg 7.40/48/165/31. vent changed to decrease peep to 5. no further changes noted. plan to wean as tolerated.
"
817,"resp: [**name (ni) 158**] pt on 7200 psv5/+5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilat coarse/rhonchi that clear after sux.  suctioned x3 small-moderate amount of thick yellowish/green secretions.  mdi's administered q4 hr alb/atr with no adverse reactions.  rsbi performed = 78.1 and sbt initiated.  rr 25, 02 sats remain 96-98% with no disress.  no further changes noted.
"
818,"resp:  [**name (ni) 158**] pt on 7200 psv 5/5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds in apecies with diminished bases.  suctioned x3 small amounts of thick whitish/yellow secretions which tend to pool in the oral cavity.  mdi's administered [**3-4**] p albuterol with no adverse reactions.  no further changes noted.
"
819,"resp: [**name (ni) 158**] pt on psv 15/+8/30%. pt has [**last name (un) **] (airfilled) trach secured 12 @ flange. bs are coarse bilaterally. suctioned for small amounts of yellow secretions. mdi's administered as ordered combivent with no adverse reactions. am abg 7.41/35/108/23. rsbi=71. no changes noc. plan to continue to wean as tolerated.
"
820,"resp:  [**name (ni) **] pt on 7200 psv10/50%/+7.5.  ambu/syringe @ hob.  auscultated bs reveal bilat coarse, no wheeze noted.  suctioned small amount of thick yellow/whitish secretions.  mdi's administered in line alb/atr q4hrs.  pt sats remain 98-99% with no adverse reactions or distress noted.  ps ^ to 12 but all previous vent settings remain the same.  no further changes noted.
"
821,"resp:  [**name (ni) **] pt on 7200 psv 5/+5/50%.  ambu/syringe @ hob.  bs ascultated reveal bilateral rhonchi which clear with suctioning.  suctioned x3 small amount of whitish/yellowish thick secretions. mdi's administered q4 hr alb with no adverse reactions.  no further changes noted.
"
822,"resp: [**name (ni) 158**] pt on psv 15/8/30%. pt has #8 [**last name (un) 3028**] (air filled cuff) [**11-12**] @ flange. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions,x1 for plug. mdi's administered combivent as ordered with no adverse reactions. am abg 7.34/42/86/24. rsbi =82. plan to wean as tolerated.
"
823,"resp:  [**name (ni) 158**] pt on psv 12/8+/30%. pt has #8 [**last name (un) 3028**] (air filled) trach 12.5 @ flange. bs are coarse bilaerally with diminished bases. mdi's administered combivent as ordered with no adverse reactions. suctioned for small to moderate amounts of thick yellow secretions. no changes noc. am abg 7.35/42/1204/24. rsbi=98.  plan to continue with t/c trials as tolerated. discussions on possible dialysis and plan for rehab.
"
824,"12a-7a
pt is a 66 year old male readmitted from sinia w/ increased sob,
fever. s/p cabg x3 on [**2174-9-29**], wound dehiscence, trach on [**2174-11-4**]. vent dependent. wbc on readmit 42.

neuro: pt a+ox3, forgetful at times. mae. perrla. morphine 2mg iv prn.

cv: hr 90-110s st w/ rare pvcs. increased hr w/ aggitation. sbp 150, nitro gtt started keeping sbp 110-130 map >60. 1 unit of prbcs given for hct 26, no adverse reactions. + palpable pulses. left a line placed at bedside by dr. [**first name (stitle) **]. +csm. double port picc to left ac, flushing well.afebrile 96.4-98.0.

resp: ls coarse, diminished at bases. trach [**first name (stitle) 657**], fio2 50% on cmv mode rate 20 tv 600 peep 5. abgs drawn on admission, md [**doctor last name 2641**] aware. sats 99-100%. suctioning small thick yellow via trach.

gi/gu: abd soft slightly distended +bs. ngt patent and [**doctor last name 657**] from rehab. pt states foley was placed today. foley draining adequate amts of yellow urine. urine cx sent in er.

[**doctor last name **]: sternal wound open w/ wound vac dsg [**doctor last name 657**], last change on [**12-23**]. see carevue.

plan: monitor hemodynamics. pulmonary toilet. ? ct today. pending cultures. ? id consult.continue triple antibiotics.
"
825,"resp:  [**name (ni) 158**] pt ond simv 18/750/5/5/50%.  alarms on and functioning. ambu/syringe @ hob. during positioning of pt, ett tube dislogged from trachea, stat anesthesia called to re-intubate.  size 8 ett taped and secured  24@lip. bs auscultated reveal bilateral clear with diminished bases. mdi's administered q4 alb with no adverse reactions. vent changes reflect abg's.  am abg's 7.47/33/130/26. rr decreased to 16 and fio2 to 40%. additional abg to follow. continue to wean appropiately.  no further changes noted.
"
826,"nursing update
   temp max 100.2.  map maintained >65, neo gtts weaned to off by 0300.  drained lg amount of dark red blood clots via ngt, irrigated q1h with n/saline 50cc.  hct @ 2300 - 26.6.  transfused with 2units prbc's, vs remained stable with no signs of adverse reaction.
   huo remains marginal, receiving ivf ns@ 300cc/h.
   insulin gtts restarted due to bs 161-163, and titrated to keep blood glucose < 150 as ordered.
   remains sedation and comfort status maintained by mso4 and ativan gtts.

plan: transfuse with ffp 2u and platelets 2packs @ 0600. pt will be returning to or @ approx 0730.
"
827,"addendum
   approx 1.5h after weaning off neo gtts, pt spiked temp 101.1, sbp up 170, pas up to  69, tachy 110-116, desaturated to 88%.  seen by dr [**last name (stitle) 619**], neo restarted @0.38 mcg/kg/min for bp support with decreased pt compensation.....effective, resolved almost immediately, bp, hr and pap returned to baseline.  cxr done....ho reported no significant change.  abg returned to baseline. urine, cvl blood, jp fluid sent for cx.  2u ffp, and 2pks platelets transfused without adverse reaction.
"
828,"7a-7a
neuro: pt a+ox3, mae, perrla. oxycontin 10mg scheduled [**hospital1 10**] for pain, and percocet for breakthrough pain for hx of chronic back pain.

cv: s/p mi w/ stent placement in [**month (only) **], hr 50-60s sb/sr w/ pvcs (lytes sent). sbp 130-150. ? endocarditis prior to this admission, picc in place and intact ( at home on continuous pcn gtt), given pcn q4 hours as ordered. received 2 units of prbcs this am, making total of 5 units thus far during this stay. 2 units of ffp given this shift also 1 unit of platelets. no adverse reactions.

resp: ls w/ faint rhonchi. non productive cough. sats greater than 95% on ra. denies sob. no resp. distress noted.

gi/gu: abd soft, +bs. 3 total bms during this 12 hours approx. 300-450cc each time of frank red w/ clots. gi study done w/ positive [**name8 (md) 8**], md [**doctor last name 610**] aware and gi team aware. at present plan to continue to monitor.  pt voiding, hard to assess color secondary to stool.

plan: continue to monitor hemodynamics. monitor resp. status. monitor labs. to get 2 more units of prbcs tonight. monitor gi status.

"
829,"resp: [**name (ni) 158**] pt on psv 5/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for copious amounts of thin white secretions which then became bloody by early am. mdi's administed as ordered alb/atr with no adverse reactions. pt had ^ rr with decrease in sats and placed on psv 12/8/50%. vt 500-600, rr 19 and improvement noted. md notified and order placed. rsbi=84. plan to continue with wean and t/c trials as tolerated. no abg's this shift.
"
830,"resp: [**name (ni) 158**] pt on psv 8/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small amounts of bloody tinged secretions due to trach insertion. mdi's administered as ordered alb/atr with no adverse reactions. abg 7.45/31/76/22. rsbi=73. [**name (ni) **] changes to decrease ps to 5. will continue to wean for trach collar trials.
"
831,"resp: pt remains on psv 12/5/50%. vt's 600, ve's 8-9l, rr 14, 02 sats 100%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr without adverse reactions. am abg's 7.42/47/168/32. rsbi=44. will continue to wean appropriately.
"
832,"resp: [**name (ni) 158**] pt on a/c 12/550/5+/40%. ett#8 24@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered alb/atr as ordered with no adverse reactions. rsbi=81. pt placed on psv 10/5/40%. vt's 450's, ve 8, rr 16. am abg 7.51/50/183/41. ps decreased to 5 with additional abg. plan to wean to as tolerated to possible extubation this am.
"
833,"resp: pt rec'd on psv 20/10/50%. pt has #7 [**last name (un) **] water filled trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. am abg 7.44/57/112/40%. no further changes noted.
"
834,"resp: [**name (ni) 257**] pt on psv 5/5/35%. ett #7, retaped and secured @ 20 lip. bs reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg's (see carview) 7.52/27/106/23. rsbi=34.
"
835,"resp:  pt remains on t/c with cuff deflated noc. minimal secretions. 02 sats in ^ 90's.  mdi's administered via t/c alb with no adverse reactions.  plan to get pt up to chair, and possible ambulate if tolerates.  pmv during the day.
"
836,"resp:  pt remains on t/c noc tolerating well. mdi's administered via t/c with no adverse reactions.  02 sats in ^ 90's noc with minimal secretions. plan to ambulate today if tolerated. pmv during the day.
"
837,"npn 7a-7p
see carevue for specifics:

neuro status unchanged, quadraplegia, speaks both spanish & english attempts to mouth words, diff to understand, appears to nod approp to questions. denies pain. tmax 99.4, hr low 100s-120s, sbp 90s-140s, hct continued to drop 22.9, inr 1.7, 2 units ffp & 2 units prbc given without adverse reaction. to ir for ivc filter placement via r groin, tol procedure well. (+)fem & pps, site c/d/i. no vent changes, trached on ac 600x15, fio2 50%, peep 5, continues with mod amts of oral secretions needing freq mouth suctioning and oral care. ls coarse & diminished at bases spo2 99-100%. abd soft, nt/nd (+)bsx4, no bm this shift, tfs held for procedure, gt flushed without diff. foley with adequate u/o, bs qid with sc coverage. a/p stable,  continue with serial hcts if continue to trend down gi to repeat scope in am, monitor r groin/pulses may remove dsg in 24hrs per ir, pulmonary toileting with freq mouth care, ? restart tfs this evening vs am in case of need for repeat scope. provide emotional support.
"
838,"resp: [**name (ni) 257**] pt on a/c 14/600/50/+5. pt has #8 portex trach. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions, as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes or abgs this shift. rsbi= no resps. will continue full vent support.
"
839,"7a-7p
neuro: a+ox2. mae. perrla. follows commands.

cv: hr 60-70s sr. converted to afib 100-110s at 1500 for approx. 15min, then converted back to nsr. sbp 100-130. weakly palpable dp/pt. 2+ generalized edema. aline positional, unable to draw blood from line, team aware. 1 unit of prbcs given, no adverse reactions noted.

resp: portex #7 trach site oozing w/blood. trach care done. trial on trach collar done, tolerated for 30 min., placed back on ventilator cpap. see carevue for details. ls clear. sats above 95%. suctioned for thick blood tinged secretions via trach. yellow thick secretions via [** **]. left sided pleural  effusion by xray, lasix ordered.
tolerated oob to chair x3hours.

gi/gu: abd soft, hypoactive bs. tf restarted at 20cc/hr. minimal residuals. bm x1 formed brown stool. foley draining adequate clear yellow urine.

skin: rash noted on back.team aware. cont. vanco.

plan: pulmonary toilet. rehab screening. diurese.
"
840,"resp: [**name (ni) 257**] pt on a/c 12/360/10+/40%. #7 [**last name (un) 4254**] (water filled) trach. ambu/syringe @ hob. alarms on and functioning. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered, alb/atr/[**last name (un) **] with no adverse reactions. no rsbi due to ^ [**last name (un) **]. no changes or [**last name (un) **]'s this shift. will continue full vent support.
"
841,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 12/400/100%/+5.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with slight crackles over r base.  suctioned for small amounts of white secretions. mdi's administered q4 hrs combivent with no adverse reactions. cuff pressure @ 23 mmhz.  rsbi=>200. present vent settings;a/c 14/400/+5/30% with am abg's;7.44/49/89/34.  no further changes noted.
"
842,"ccu nursing admission note  [**2081**]-0700
please see fhpa for complete history and sequence of events.  briefly, pt is a 77 yo male transferred from va to [**hospital1 2**] intubated and hypotensive after receiving diltiazem and lopressor for af with rate of 130's. in [**hospital1 2**] ew received 5 l ns and started on a levo gtt.

s:  shakes head ""no"" when asked if in pain.

o:  see ccu flow sheet for complete objective data

cv:  pt admitted in nsr, rate of 60's, pr 0.21.  hr slowly came up over course of shift to 70's-80's.  had 37 beat run of vt, broke without treatment, in the setting of a low k+.  k 3.1--> was receiving k replacement therapy at time of vt.  hands of defib in place.  received a total of 20meq iv k and 60 meq po k.  repeat k pnd.  also had ~ 1minute run of narrow complex regular psvt.  strips of both runs in chart.  bp 83-112/65-73, map 69-86, sbp transiently down to 70's.  arrived from the ew on levophed, weaned down from 0.25 mcg/kg/min to off @ 0200.  also given 1 l ns over one hour, but sbp had increased to 90-100 prior to receiving fluid.  bp equal in both arms, nibp comparable to cuff pressure.  heparin gtt started @ 1650 units/hour without bolus.  ptt pnd.

resp:  intubated on 100%/600/ 14 cmv, on 5peep.  attmepted ps trial shortly after admission, but periods of apnea, therefore placed back on a rate abg on 80% fio2 and above settings, breathing a few breaths over vent:  7.40/27/205/17/-5.  fi o2 weaned down to 40%, maintaining sats 99-100%.  ets--> no sputum.  spontaneous breathing trial done, rr 35  with tv 400 cc's.  lungs clear.

id:  on admission, t 91.1 po, 90.8 ax, and rectal temp not registering on rectal probe.  bare hugger placed on pt, with gradual ^ in temp.  by midnight t 99.8 rectally, bare hugger removed. pt c/o feeling hot, removing [**doctor first name 706**].  blood cultures x2 sent, urine sent. wbc 8.2.

gu:  cudette foley catheter placed in ew.  only 2cc pink urine in urimeter on admission.  foley irrigated--no resistance to irrigation, no clots.  bladder scan done, no urine in bladder.  bladder scan repeated at midnight-->19cc in bladder.  urine output improved over course of shift, but still only 16 cc/hour, intern and resident aware. bun 25, cr 1.6.

gi:  ng tube out of position on arrival to ccu.  re-inserted, placement confirmed by cxr.  ng asps light brown, ob +.  no stool.  abdomen soft, +bs

neuro:  pt arrived very sedated after versed in ew.  now opens eyes spontaneously, shakes head yes/no to questions.  mae.  inconsistantly follows commands.  pupils 3mm bilaterally, now briskly responsive to light.  on versed gtt at 1 mg/hour, and given 1mg iv bolus x3.  bilateral wrist restraints to protect inadvertant removal of ett.

skin:  no breaks.  feet dry bilaterally.  has old healed wound on left lower leg.

access:  left femoral tlc, r #20 piv, l #20 and #18 piv.

social:  md spoke with wife and updated her on pt's condition and poc.  do not know if pt. has a hcp.  [**name (ni) 25**] wife is reported to be a paraplegic.

a:  ? etio of hypotension--? adverse reaction to calcium channel bl
"
843,"resp:  [**name (ni) 257**] pt on 7200 psv 15/15+/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small-moderate amounts of thick yellowish secretions.  mdi's administered q4 hr alb/atr (6 p  ea) with no adverse reactions.  rsbi=108.6 and no sbt initiated.  pt scheduled to receive trach today.  no further changes noted.
"
844,"resp: [**name (ni) 257**] pt on a/c 12/360/10+/40%. pt has a #7 [**last name (un) 4254**] water filled trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/light greenish secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. no changes or [**last name (un) **]'s this shift. no rsbi due to ^ [**last name (un) **]. will continue full vent support.
"
845,"resp: pt rec'd on a/c 12/360/+10/40%. pt has [**initials (namepattern4) **] [**last name (namepattern4) 4254**] #7 water filled trach. bs are coarse bilaterally. suctioned for small-moderate amounts of white/yellow secretions. mdi
"" administered as ordered  with no  adverse reactions. no [**last name (namepattern4) **]'s or changes noc. will continue full vent support.
"
846,"resp: [**name (ni) 257**] pt on a/c 14/600/5+/50%. pt has #8 portex trach in place. alarms on and functioning. ambu/syringe @ hob. bs are coarse to diminished bilaterally. suctioned small amounts of white to yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi= no resps. no changes or abg's this shift. will continue full vent support.
"
847,"resp: [**name (ni) 257**] pt psv 5/5/40%. bs are clear bilaterally. suctioned for scant - small amounts of tan secretions. mdi's administered q4 hrs with no adverse reactions. last abg 7.42/45/117/30. plan to place on t/c trials today as tolerated.
"
848,"resp: [**name (ni) 257**] pt on ffv psv 10/5/60%, then placed on 60% f/t for about 3 hrs. hhn administered alb/atr with no adverse reactions. bs are coarse with occasional exp wheeze noted. pt placed back on ffv psv 10/5/50% due to ^ wob. pt tolerating mask, 02 sats @ 100%. will continue to wean to f/t as tolerated.
"
849,"resp: [**name (ni) 158**] pt on pcv 40/25/55%/0+. pt has shiley #8 trach with audible leak noted. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes this shift. vt's 400's/ve's9. no rsbi pt is vent dependent. abg's (see careview) co2's still consistantly >100. will continue with present vent settings.
"
850,"resp: [**name (ni) 158**] pt on pcv pinsp 44/32/55%/0+. pt has # 8 shiley trach with audible cuff leak. bs are diminished bilaterally. sucitoned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's or changes this shift. no [**name (ni) **] due to vent dependent. plan to continue full vent support.
"
851,"resp: [**name (ni) 257**] pt on a/c 12/360/+10/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of yellow secretions. mdi's administerd q4hrs alb/atr with no adverse reactions. vent changes to ^ rr to 20, fio2 to 50%. am abg 7.46/55/87/40. no further change noted.
"
852,"resp. care
pt. remains on mech. vent with a 8.0 portex trach secured and patent. pt being sx for copious amts of thick yellow secr. b/s are scat rhonchi t/o clearing with sxing. mdis given with min. effect but with no adverse reaction.pt. was given hyoscyamine todry up his oral secr. and had a great effect in the amt of oral secr. he was producing.abgs were 7.47/36/149/27/3 with a rsbi of 160 at 0430.
"
853,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 22/550/50%/+5. alarms on and functioning. ambu/syringe @ hob. ett #8.0, retaped and secured @ 26 lip. bs are coarse with diminised lll. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 alb/atr with no adverse reactions. abg's (see careview) which vent changes refect. am abg's 7.42/32/89/21 on ^ peep to 10.  will continue full vent support.
"
854,"resp: [**name (ni) 158**] pt on psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob. ett retaped and secured @ 25 lip. vt's 600's/ rr 15. bs auscultated reveal bilateral clear apecies with some coarse sounds. suctoned for moderate amounts of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions. some periods of decreased rr with drop in ve, suggested mmv during noc. plan to trach today @ 11 am. will continue vent support.
"
855,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] 14/600/5/5+.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with coarse bases.  suctioned for moderate amounts of yellow secretions.  mdi's administered q4 hrs alb/atr 4 p with no adverse reactions. am abg's 7.42/36/110/24.
"
856,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/500/10+/40%. alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions.  mdi's administered q4 hrs atr and [**last name (un) **] [**hospital1 10**] with no adverse reactions.  no rsbi due to ^ peep. am abg's pending.
"
857,"resp:  [**name (ni) 158**] pt on (mmv) psv 10/7/40%. alarms on and functioning. ambu/syringe @ hob. 8.0 ett, taped and secured @ 25 lip. 23 cmh20 cp. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions. vt's 400-500's. plan to trach today. no abg's or changes noc. will continue support.
"
858,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/600/50%/5+.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned moderate amounts of thick yellow secretions.  mdi's administered q4hrs alb/atr with no adverse reactions. no spont resp for rsbi. am abg's 7.38/36/140/22.  no further changes noted.

"
859,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 18/600/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate to copious amounts of secretions tannish/white thick, as well as oral secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi-180. scheduled for trip to o/r today for additional wound graft.  no further changes noted.
"
860,"resp: [**name (ni) 158**] pt on simv 10/600/15/+5/40%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20, ett @ 23 lip. bs auscultated reveal bilateral coarse sounds. suctioned for small amount of thick yellow secretions. mdi's administered q4hrs combivent/[**last name (un) **] [**hospital1 10**] with no adverse reactions. am abg's 7.44/37/116/26. no changes noc. 02 sats @ 97%. plan to continue full vent suppport.
"
861,"resp: [**name (ni) 158**] pt n a/c 16/500/5+/50%. bs are clear with diminished bases. suctioned for scant amount of white secretions. [**name (ni) **]'s administered as ordered combivent with no adverse reactions. 02 sats @ 100%, fio2 titrated to 40%. no a-line. rsbi=63. plan to wean as tolerated.
"
862,"resp: [**name (ni) 158**] pt on 40% t/c cool mist.  ambu/syringe/spare trach @ hob. bs auscultated reveal coarse bilateral sounds which clear after suctioning.  trach care performed x3, pt tends to plug up inner cannula.  sux x 3 for small to moderate thick bloody plugs/secretions.  mdi's administered q 4hrs alb/atr (4p) via air chamber through trach and pt tolerates well with no adverse reactions.  02 sats remain 99-100% with no distress.  no further changes noted. cuff remains deflated.
"
863,"nursing care note
see careview for specifics.

neuro: propofol weaned to 50mcg/kg/min. pt arousable. oriented. follows commands. writing for communication. perl. strength in all four extremeties improving. lue remains weak. unable to lift and hold. unable to move neck, requiring repositioning of head.

resp: remains on cmv mode of ventilation. 40% 18x400, peep5. attempted a short trial of cpap +15ps. abg acceptable, obtained adequate tv's, but fatigued after 2 hours. suctioning for small amounts of thick yellow material. suctioned frequently for moderate amounts of oral secretions. lungs ctab.

cv: afebrile. vss.  rec'd ivig with no adverse reaction.

gi: abdomen soft with present bs. no bm this shift. ogt to lcws putting out moderate bilious material.

gu: autodiuresing.

labs: all noon lab results reported to dr [**last name (stitle) **].

plan: most iv meds changed to po as access is an issue. pt has 2 piv. provide support to pt & family. monitor neuro status. ? social work involvement.



"
864,"resp:  [**name (ni) 158**] pt on 7200 a/c 24/450/50%/+5.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse/rhonchi which clear with suctioning.  pt suctioned x3/4 for copious thick tan secretions/plugs.  [**name (ni) **]'s administered q4 alb/atr with no adverse reactions.  abg's drawn throughout the noc with improvement noted.  sputum sample obtained.  vent changes noted, rr @18 with abg's pending.  no further changes noted.  pt resting comfortably.
"
865,"7a-7p
neuro: pt alert and oriented x1, to self.anxious at times. reassured and reoriented many times during shift. pupils 7mm, left sluggish compared to right. np [**doctor last name 599**] in at [**doctor last name 302**] and assessed no new orders. pt moves all extremeties on command. percocet via gtube for pain this am w/ good effect.

cv: hr 80-100s. sr/st, w/ rare missed beat. sbp>90. see carevue for details. +weak palpable [**doctor last name **] pulses. agratroban infusing at 2.25mcg as per protocol, ptt 60s within range, no change as per protocol. 1 unit of prbcs infused w/o adverse reaction. generalized edema.

resp: ls coarse w/ insp. wheeze, nebs given as ordered. sats 99-100%. 4lnc. weak npc. rr 20-30s.

gi/gu: abd soft, round, +bs. no bm. tolerating tf promote w/fiber at goal of 60cc/hr. foley draining yellow urine. see carevue for hourly outputs. on lasix 80mg ivp tid, received extra dose of lasix 80mg this am approx. 5am.

activity: oob to chair x 2 hours via [**doctor last name **].

skin: dry scaly skin: creams applied as ordered. sternum dsg changed by thoracic team this am. see carevue for further details.

endo: as per own scale.

plan: monitor hemodynamics. monitor resp. status. oob to chair. monitor labs and treat as appropriate.
"
866,"resp: [**name (ni) 158**] pt on a/c 14/550/5+/40%. ett #7, retaped and secured @ 23 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally and suctioned for small amount of white thin secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbt=71. attempted to place on psv although pt still sleepy. will wean in am to psv as tolerated to extubate today.
"
867,"resp: [**name (ni) 158**] pt on psv 16/8/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/white thick secretions, as well as oral cavity. mdi's administered alb q4 with no adverse reactions. vt's 500-600, ve's 13-15, rr 24-27 with 02 sats @ 100%. no aline or abg's this shift. no changes noted.
"
868,"resp: [**name (ni) 158**] pt on psv 16/8/50%. pt is trached #9 extra long portex. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white/clear secretions. mdi's administered q4 hrs alb with no adverse reactions. vt 500-600, ve [**11-4**], rr 18-25. rsbi=100. no abgs (no aline).
"
869,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 24/450/+5/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. ett rotated re-taped and secured. suctioned small to moderate amounts of tannish secretions. mdi's administered q4 alb with no adverse reactions.  rsbi=110, ^ hr to 107/rr an exihibted atrial fib rsbi terminated.  am abg's 7.29/43/98/22.  no further changes noted.
"
870,"micu npn

see carevue for subjective/objective data.  neuro:  initially sedated with propofol/morphine while intubated.  propofol off at 1140--pt moving in bed, semi-awake prior to shutting propofol off.  pt awake within 10min of propofol off, able to hold head off pillow, nodding ""yes"" and ""no"" appropiately, mouthing words around ett.  mae ad lib before and after extubated.  once extubated pt speaking clearly, continues to mae ad lib.  a+ox3.

cv/pulm:  vss per carevue.  hct 23 down from 25 this am--two units prbc ordered.  first unit infused without adverse reactions, second unit currently infusing without adverse reactions thus far.  serial hcts q4h.  k=3.4, currently being repleted with 20meq over 2hrs x2 for total of 40meq over 4hrs--(pt has only periph access).  iv d5lr with 20meq kcl at 125/hr except during prbc's then kvo'd.  afebrile.
pt intubated this am then rapidly weaned and extubated once propofol off.  placed on cmm at .40%; sats 100%.  pt continuously removing mask with sats remaining 99-100% even with o2 off.  pt agrees to keep mask near mouth and nose but not tight until this afternoon and has complied--currently on room air with sat 100%.  no sob or doe noted.  bs clear upper lobes, coarse lower lobes in am, clear bil this pm.  pt moving ad lib in bed (restless) and coughing without encouragement--thick/clear secretions, occ blood tinged.

gi/gu:  ngt removed this am when ett removed.  abd firm but not tense, sl tender, bs absent.  abd dsg d+i.  no flatus but pt does burp frequently.  u/o qs q1h via foley.  vaginal bleeding slowed this shift-->one pad q4h.  s/b ob/gyn this am and this [**name8 (md) 8972**] md spoke  with pt re: events of past 24hrs.  pt states comprehension of events.

integ:  intact.

id:  afebrile.  no change in abx.

psychosocial:  pt crying much of afternoon, restless, states ""i need to get my butt comfortable"".  pt stated concerns re: children at home. offered to call pts home but pt refused, stating she does not want to ""talk to anybody or see anybody"".  brother (? name) and son [**name (ni) 8973**] in to see pt--pt crying, moaning.  much emotional support given to pt and fam.  visitors left, attempted to assist pt with comfort and emotional needs.  med with ativan 1mg iv with little-->no effect.  remains on morphine at 1mg/hr cont.  will cont to provide emotional support and comfort measures.
"
871,"resp: [**name (ni) 158**] pt on a/c 14/550/+5/40%. ett #7, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. suctioned for scant amounts of tanish/white secretions. mdi's initiated and administered alb/atr as ordered with no adverse reactions. rsbi=85. plan to wean to psv, then extubate this am.
"
872,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett 7.5, taped @ 22 lip. bs are coarse to clear bilaterally and suctioned for moderate amounts of thick yellow to white secretions. mdi'd administered of alb as ordered with no adverse reactions. pt remains on sedation, when lightened is extremely aggitated. rsbi=36 no abg's/no a-line. vt's 400-500, 02 sats @ 99%. plan: wean to extubate today?
"
873,"resp: pt rec'd on 14/600/+5/40%. bs are clear with occasional wheeze noted on ls. suctioned for small amount tan thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. ett #7.5. 25 lip. 02 sats @ 100%. am abg 7.37/46/108/28. rsbi=53. plan to possible psv today if tolerated.
"
874,"resp: [**name (ni) 158**] pt on psv 8/5/40%. ett #7.5, taped @ 22 lip. bs are coarse bilaterally and suctioning for copious amounts of thick white/yellow secretions.circuit changed to heated wire circuit. mdi's administered atr with no adverse reactions. no changes noc or abg's. rsbi=42. plan: wean as tolerated.
"
875,"resp: pt rec'd on a/c 14/450/+8/40%. ett#7.5/23 lip. bs auscultated reveal notable improvement w/o wheeze, with clear apecies bilaterally. suctioned for small amount of thick secretions. sputum sample sent. mdi's administered q4 alb/atr with no adverse reactions. no abg's (no a-line). rsbi=200. no changes this shift
"
876,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] simv 20/500/ps15/+10/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with i/wheeze noted. suctioned for moderate amounts of thick yellow/tannish secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. 02 sats @ 96% with no further changes noted.
"
877,"resp: [**name (ni) 158**] pt on psv 12/5/40%. ett retaped and secured.bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=79. md [**first name (titles) 7856**] [**last name (titles) 2377**]. place pt on psv 5/0 for 30-45 min and pt ^ wob,^ sob with 02 desaturations to 80's. abg 7.18/78/96/31. [**last name (titles) 2377**] terminated.(see carview for multiple vent changes)pt place on 100% temporarily, then decreased to 50%. bs reveal bilateral crackles and suctioning copious amounts of thick white frothy secretions. lasix given with good effect. present settings. 18/500/+10/50%. additional abg's to follow.
"
878,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 14/500/5/+5/40%. alarms on and functioning.  ambu/syrnge @ hob.  cuff pressure @ 21.  pt trached and peg today.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 small to moderate amounts of thick bloody tinged secretions.  mdi's administered q4 hrs alb with no adverse reactions.  02 sats @ 100%. no further changes noted.
"
879,"7a-7p
neuro: pt sedated on [** **], as low as 10mcg/kg/min, following commands increased for ir procedure as high as 80mcg for comfort at present at 20mcg to keep pt comfortable. perrla. mae. nods no if asked in pain.

cv: hr 80s. sbp labile. 90-110s. keep map>60. received total thus far 4 units of [** 458**], 1 unit of plt, 2 units of prbcs, no adverse reactions. afebrile. ordered for cryoprecipiate and more plt, to be given. see carevue. cvp 12-20[**street address(1) 7840**] aware of cvp. to ir w/ monitor and rn see ir notes for vs, angio site cdi, w/ pressure dsg+ saline bag over site. palpable pedal pulses. no aline put in from micu team secondary to bleeding issues. to lie flat until 9pm.

resp: no aline. venous gases [**street address(1) 7841**] aware of all labs including 7.55 ph repeat when back from ir 7.48 on cpap 50%, 5peep/15ps. ls clear diminished at bases. sats >98%.

gi/gu: abd soft, but distended absent bs. ogt + placement, receiving lactulose as ordered. ogt draining brownish in color. mushroom cath in place ok [**name8 (md) 52**] md [**doctor last name 1055**] for blackish brown liquid stool. foley draining iteric urine minimal amts 10-15cc/hr md [**name6 (md) 1055**] [**street address(1) 7842**] aware.

labs: see carevue for details. k repleted w/ 60meq iv kcl, 3 separate  20meq bags over an hour [**street address(1) 7843**] updated w/ labs and u/o and angio site when back from ir.

plan: monitor hemodynamics. monitor resp.status. improve coags so tomorrow ? stent placement to hepatic/bile duct, ir unable to find source of bleeding. monitor angio site and pulses


"
880,"resp: [**name (ni) 158**] pt on psv 12/8/40% ett 7.5/25 lip.bs are coarse bilaterally. suctioned for moderate to copious amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no abg's or changes this shift. rsbi=80. plan to continue to wean as tolerated

"
881,"resp: [**name (ni) 158**] pt on simv 10/500/15/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of frothy yellow/white secretions.  mdi's administered as ordered with no adverse reactions. pt is vent dependent. no changes noc. plan to be discharged today to rehab.
"
882,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 143/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned for moderate amounts of thick secretions. changed out dry circuit for heated one.  mdi's administered q4 hrs combivent with no adverse reactions.  exutbation still planned for monday [**5-25**].  no further changes noted.
"
883,"resp: [**name (ni) 158**] pt on psv 10/10/40%. bs are coarse bilaterally which improvement with suctioning. suctioned for small amounts of thick yellow secretions. mdi's administered q4 [**name (ni) 741**]/[**last name (un) **] [**hospital1 10**] with no adverse reactions. vent changes to ^ ps back to 15 due to ^ in rr. will continue to wean appropriately.
"
884,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/5/40%. alarms on and functioning. ambu/syringe @hob. bs auscultated reveal bilateral clear apecies with some fine scattered rales, diminished bases bilaterally.  mdi's administered q4 hrs combivent, with no adverse reactions. suctioned/lavarged x3 for moderate amounts of thick white secretions.  x-ray indicates bilateral pleural effusions, questionable tapping. plan to extubate this am.  am abg's 7.45/39/85/28.  no further changes noted.
"
885,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. eet #8 taped and secured @ 24 lip, cuff pressure @20. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick white, pale yellow secretions.  mdi's administered with no adverse reactions. am abg;s 7.43/33/126/23. vt' 900/ve20's. rsbi=22. pt reacts anxiously to any stimuli.  plan to continue to wean appropriately.
"
886,"resp: pt rec'd on psv 10/10/50%. bs are coarse bilaterally which improve following suctioning. suctioned for copious thick bloody secretions with some clots. mdi's administered q4 combivent with no adverse reactions. am abg's 7.37/38/111/23 with no changes noc. rsbi=75. will continue on psv and wean appropriately.
"
887,"resp: [**name (ni) 158**] pt on a/c 14/700/+10/70%. bs reveal bilateral crackles with slight wheezing noted. mdi's administered q4 combivent with no adverse reactions. suctioned for small amounts of bloody tinged secreitons (new trach). abg 7.36/40/161/24, fio2 decreased to 60%. am abg's 7.36/37/98/22. no further changes noted. will continue to wean appropriately.
"
888,"ccu nursing progress note
s-""i feel ok""
o-neuro- alert and oriented x3, very pleasant and cooperative. understands and speaks english fairly well. alitttle sleepy after benadryl po.
cv-one episode of hypotension with sbp 84/40 after benadryl before asa densitization. ho aware and received ns 250cc bolus over 15 minutes.
vss hr 64-70 nsr, 104-135/50-61. received 10 ingremental doses of asa without signs of stridor, sob, rash, hypotension.
resp-ls coarse with occ esp wheeze, freq congested productive cough. sputum sent for c/s. sputum thick dark tan moderate amount.
id afebrile, mrsa precautions.
gu-voiding well in bed without difficulty.
gi-npo for possible heart cath.
skin- ruddy complexion but no rash noted.
activity-bedrest maintained during test.
access-rij tlc dressing changed and piv removed day 4.
dispo-transfer back to [**hospital ward name 3**] 3, health care proxy completed.
a/p-no adverse reaction s/p asa desensitization.
continue to assess and monitor for delayed adverse reaction

"
889,"resp: [**name (ni) 158**] pt on a/c 14/450/+5/45%. bs are coarse bilaterally. [**name (ni) **] for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. pt expected to be d/c to rehab this am.
"
890,"7p to 7a micu progress note

neuro - pt initially sedated with boluses of fentanyl and ativan immediately following intubation. placed on fentanyl drip which is currently infusing at 30mcgs/hr and propofol at 40mcgs/kg/min with greater sedative effect. pt opens eyes spont. localizes pain. mae.

resp - pt remains intubated with vent settings adjusted throughout the noc. see careview for details. currently on ac 600 x 10 with 50% fio2 and 5 peep with abg 7.36/39/140/-[**3-7**]. fio2 decreased to 40% - will draw repeat abg. lungs with inspir and expir wheezing, diminished lll. receiving albuterol nebs by resp therapist. sx initially for thick brownish plug ( specimen sent for c+s and gm stain). secretions eventually became more clear. ultrasound of left thoracic cavity showed small left pleural effusion which was too small to be tapped safely.

c-v - hr 88-111 st, no ectopy noted. bp 88-130/59-78 with map > 60 via aline. + peripheral pulses. pt with repeated needle sticks to right lateral neck and right groin for line placement. in lieu of elevated inr, pressure dssg applied to neck and iv sandbag placed on groin - no hematoma noted at either site.

gi - abd distended but soft, hypoactive bs. ngt placed, placment confirmed by x-ray. coffee-ground emesis noted on lavage, cleared with 200 ccs ns. ngt to lis currently draining bilious fluid. lactulose therapy initiated for ? hepatic encephelopathy. no stool at this time.
abd ct on [**1-8**] showed marked fatty infiltrates of the liver and sm amt of ascites as well as calcifications in the pancreas and colon wall thickening.

f/e - iv ns infusing at 250ccs/hr. pt with minimal u/o. voiding only 6-22ccs/hr via foley cath. given 3 1000 cc fluid boluses with no effect on u/o. md aware. urine lytes sent. initial k 3.0. given 40 meq kcl iv with repeat k of 3.2 at 0100. [**month/year (2) **] with an additional 40 meq kcl iv. ca 6.9. alb 2.1 phos 2.5 bun 4 creat .9. [**month/year (2) **] with 2 gms ca gluc iv.

heme - hct stable at 23.1 initially oozing from lip s/p intub. bleeding resolved.

id - temp sl hypothermic at 97 rectally. pna rx's with vanco q 12 hrs and flagyll q 8 hrs. ceftriaxone dcd. pt given 2 gms ceftaz iv x 1. awaiting id approval for subsequent doses. md aware of hx of allergy to kefzol, dose given without any overt adverse reaction.
pt on contact precautions for hx mrsa sputum.

skin - pt increasingly edematous around neck d/t lg amt of ivf administered throughout the day. already + 4 liters as of 0500 today.
skin intact except for dime-sized area on right buttocks - barrier cream applied.

endo - hx of adrenal insuff and diabetes. receiving hydrocortisone iv q8hrs. [**month/year (2) 770**].

access - r upper arm pic, multi-lumen r fem line, r radial aline.


social - numerous family and friends visited last eve. son slept overnight in the visitors lounge. updated on pt's condition by rn and md.



"
891,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/460/+14/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with noted aeration in apecies. suctioned for small amount of tan thick secretions. mdi's administered q4 alb with no adverse reactions. fio2 decreased to 40%, with am abg's 7.28/58/115/28. no further changes noted.
"
892,"[**2126-8-27**] admission note:

pt arrived from [**location **] at 645am. she reports a few days of having a cold and fever.  came to ed with increasing sob,wheezing,t=102.  in ed she received 4l iv fluid.  sbp=70's iv dopamine drip started at 2.5mcg/kg/min.  received tylenol after which temp =98.6po.  blood and urine cultures sent. cxr done.  received:  flagyl,levofloxacin,vanco-
mycin,benadryl,decadron, and neb treatments.

she arrived on 100%nrb with no sob or wheezing noted.  lung sounds coarse, sats=97%.  hr=84sr no ectopy.  sbp=128.  skin warm dry and intact.  +bowel sounds, abdomen soft nontender.  pulses palpable. alert and oriented but sleepy, follows commands and answers all questions appropriately.  pmh=asthma, copd, ms.[**first name (titles) **] [**last name (titles) **],g-tube placement.  allergies:  azmacort,clindamycin,clarithromycin,ceftri-
axone,optiray.   she also reports difficulty with versed,fentanyl and morphine but has received these at times with no adverse reaction also.  she lives at home with her husband, [**name (ni) 1717**] and expects to return home upon discharge.
"
893,"resp: pt is on h/f02 @ 80% with 6 lpm n/c. bs are coarse bilaterally, pt able to expectorate some secretions. nebs administered q6 hrs atrovent ud with no adverse reactions. will continue to follow.
"
894,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/280/+8/60%. alarms on and functioing. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of white secretions. mdi's administered x1 of alb with no adverse reactions. pt had episodes of desaturations to 70's and fio2 ^ temporarily to 100% then titrated down (see carview) to 50%. abg 7.47/49/127/37 with am abg pending. no further changes. will continue full vent support.
"
895,"resp: [**name (ni) 158**] pt on a/c 16/280/+8/50%. alarms on and functioning. ambu/syringe @ hob. ett rotated and secured. bs are coarse bilaterally. suctioned for small to moderate amounts of white/pale yellow secretions. mdi's administered q4 alb with no adverse reactions. rsbi=no resps. plan to attempt rsbi to wean to psv.
"
896,"resp:  [**name (ni) 158**] pt on 7200 simv 16/550/ps12/+5 40%.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned moderate to copious thick yellow secretons.  [**name (ni) **]'s administered q4 hr alb/atr with no adverse reactions.  no further changes noted
"
897,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 14/600/10+/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminshed bases. suctioned for small amount of thick bloody tinged secretions.  mdi's administered q4 hrs combivent with no adverse reactions. rsbi=55. am abg's; 7.44/40/109/28 with no further changes noted.
"
898,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c20/600/10+/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration noted in apecies with diminished bases. re-taped and secured ett. mdi's administered q4 hr alb with no adverse reactions. suctioned moderate amounts of tan secretions early in the [**last name (un) **] with pale yellow in am.  no vent changes [**last name (un) **]. am abg's 7.43/37/121/25.  no further changes noted.
"
899,"resp: [**name (ni) 158**] pt on a/c 18/55/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and suctioned for small amounts of tan secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's or vent changes noc. pt is awaiting bed at rehab. will continue full vent support.
"
900,"respiratory care
non-intubated bronchoscopy preformed on pt without apparent adverse reactions. 1% lidocaine used via atomizer followed by instilling 8cc of lidocaine at 2cc doses via bronchoscope. suctioned for moderate amounts of thick tan colored secreations. pt on 5 liters nasal cannula. sat's from 91%-94%.
"
901,"resp: pt rec'd on psv 8/5/40%. pt has #8 portex trach. bs are coarse in upper lobes bilaterally and suctioned for small amounts of thick yellow secretions. mdi's as ordered alb/atr/[**last name (un) **] with no adverse reactions. abg 7.30/36/116/18 with rsbi=49. possible trach collar trials again today. vt400's ve 9l.
"
902,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 18/550/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. notable leak at times, rn/md aware. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tan secretions. mdi's administed combivent with no adverse reactions.  no rsbi due to ^ peep or abg's no aline. 02sats to 96%. will attempt to wean as tolerated.
"
903,"resp: pt rec'd on a/c 18/550/+8/60%. ett #7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tannish secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift. will continue full vent support.
"
904,"resp: [**name (ni) 158**] pt on a/c 18/550/+8/60%. ett #7.5, retaped, rotated and secured @ 23 lip. 02 sats 97-99%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions, copious oral secretions. mdi's administered as ordered with no adverse reactions. no abg's or changes this shift. plan to trach. will continue full vent support.
"
905,"micu npn
see carevue for subjective/objective data.  neuro:  started on cisatracurium at 1mcg/kg/min as continues to overbreathe vent.  morphine 0.5mg/hr added when paralytic initiated.  remains on ativan 2mg/hr.  pupils remain 6mm, non-reactive.  no movements noted prior to initiation of paralytic.

cv:  remains on levo and neo per carevue.  vasopressin added at 0.04units/min.  bp remains labile--low of 70's/30's with map 50's to high of 110/60's with map 70's.  hr initially low 100's but by 0815 hr 170's--remained 160-170's until swan dc'd then hr immediately decreased to 120's.  remainder of day hr 110's-120's.  mp=st; only ectopy noted during swan removal.  currently levo at 20mcg/min, neo at 10mcg/kg/hr, vasopressin at 0.04units/min.  bicarb gtt on throughout morning then dc'd then restarted.  calcium chloride given per [**month (only) 5**]; calcium gluconate gtt started.  k repleted with 20meq x3 for k of 3.1--rpt lytes this pm. maintenance iv 500-700ml/hr until 1800 then decreased to 10ml/hr.  tylenol for temp of 100 (core); cooling blanked placed on for temp of 101.1 (core).  temp decreased to 99.1, blanket off.  tmax remainder of day=99.7 po (no longer using core temps as swan dc'd).  rec'd 2units ffp and 6units platetes--both ffp and platelets given without adverse reactions.

pulm:  remains vented.  multiple vent changes throughout day; currently on ac28x750x80%x10peep.  bs coarse.  attempted to obtain sputum for c+s; no secretions despite lavaging.  scant oral secretions.  abg's per carevue.  on bicarb gtt as noted above.  ct to 20mm suction until 1500 then placed to water seal.  drained only 5ml straw colored fluid this shift.

gi/gu:  ogt-->lis drng scant amts coffee ground secretions.  remains on protonix.  nothing given per ogt.  bs absent.  no bm.  remains anuric.  quinton cath placed at 1845 as anticipating need for cvvh--no cvvh planned at this time.  bladder pressure done x1-->17.

integ:  extremities cool, mottled (on three pressors).  no open areas noted.  does have scleral edema, generalized edema.

id:  tmax=101.1 core.  tylenol and cooling blanket as noted above.  ceftazadime and vanco added to regime however vanco not started yet as waiting for vanco level.  rocephin dc'd.

psychosocial:  brother, sister and sister-in-law in to visit--updated by [**name (ni) 1302**] on current status/prognosis/plan (potential for cvvh).  emotional support given to pt and family.
"
906,"micu nsg admit note
mr. [**known lastname **] is a 51yo male adm to micu as trans from cc6 s/p laminectomy from [**2176-9-26**].  pmh significant for etoh use, iv drug use, psych hx (on meds), copd, smoker, htn, (+) for hepatitis c, multiple old ortho injuries due to ""bar bralls"".  per family no etoh or drug use since [**month (only) 1279**] of this year; [**name6 (md) 52**] trans rn pt adamantly denies etoh or drug use since [**month (only) **] of this year.   pt had fusion of l5 and s1.  post op pt noted to be restless but no mental status changes.  friday he had increasing mental status changes, placed on ativan.  over w/e he cont'd on ativan.  mon am he was transferred to medicine.  mon am he also developed hypotension with o2 sats 80's; anesthesia paged to floor, pt intubated, sent to micu.

overview of day:  upon arrival pt intubated, hr elevated 150's->180's. lopressor 5mg iv with no effect given be dr. [**last name (stitle) 4952**].  bp low but map's greater than 60 until early afternoon when map dropped to 50's.  placed on neo, titrated for map of 60.  by mid afternoon levo added to maintain map.  multiple ns bolus' given, d5w given, ffp given, prbc's hung.  swan'd, cooling blanket on pt.  tmax=108.0 orally and rectally. ice under axilla, in groin and under head/around head.  minimal u/o.  hr remains elevated, temp remains elevated.

current status:  see carevue for subjective/objective data.  neuro:  pupils 5-6mm, non-reactive.  did note slight grimace in response to brother calling pts name.  no arm or leg movements noted.

cv/pulm:  vs remain labile with neo at 7mcg/kg/min and levo at 3.2mcg/min.  initial swan readings ra 15, rv 35/11, pa 37/14, wedge 5. have attempted to wedge post insertion-->unable.  pcxr post insertion no pneumo, line in good position [**name8 (md) 52**] md.  pa at 52cm.  remains vented on cpap+ps 20/5, 100%, tv600.  bs coarse bil.  suctioned initially for copious amts thick/tenacious tan sputum both orally and via ett.  now no secretions when suctioned.  prbc's #1and #2 currently infusing; no adverse reactions noted.  tmax=108 both orally and rectally.  axilla, groin, head and neck packed in ice with cooling blanket on.  current temp=107.1 core.

gi/gu:  ogt placed by md-->lg amts coffee ground material obtained.  lavaged till clear, intermittently lavaged.  on protonix.  u/o scant; md's aware.  urine concentrated.

iv access:  swan placed, r groin triple lumen catheter and 20guage periph iv.

id:  tmax=108 po and rectally.  on rocephin, vanco, flagyl and levo.  bcx2 sent, urine for c+s sent.  unable to obtain sputum for c+s.

psychosocial:  sister and brothers in to visit.  emotional support given to pt and fam.  fam updated by md--aware of grave prognisis.  pt is full code.
"
907,"respiratory care note:
   patient presently on break from mask bipap via vision (see carevue flowsheet). she is s/p dialysis. bs=bilat, coarse. patient awake, alert, pleasant with no c/o sob though respirations appear shallow and rapid at 34-38bpm. placed now on a high flow neb at 80% unitl next round of bipap.
    nasal washing done arouond 2pm today with cultures sent via md. [**first name (titles) **] [**last name (titles) **] procedure well without adverse reaction.
"
908,"resp: pt remains intubated on a/c 28/350/+5/40%. bs are slightly coarse with notable improvement from yesterday. suctioning small amounts of tan secretions. mdi's administered q4 alb with no adverse reactions. ve's 10l, 02 sats @ 99%. peep decreased from 10 to 5 this shift. rsbi attempted but no resps. am abg's 7.32/43/144/23. will continue full [** **] support.
"
909,"resp: [**name (ni) 158**] pt on pcv pinsp 19/r18/+5/40%/dp 10. [**last name (un) 3028**] trach @8, 8 @ trach site. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amount of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. while performing trach care pt began to forceful cough and trach was disloged. re-inserted with 4cc sterile water for 30 cmh20 to seal, no cuff leak noted. x-ray reveals trach to be approx 2-3 cm above carina. md verified. vent changes to ^ pinsp to 22 with dp of 19. vt's 300-400. no further changes noted.
"
910,"resp: [**name (ni) 158**] pt on a/c 20/500/10+/40%. ett 7.5, rotated, and secured @ 24 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow secretions. changed circuit to heated wire. mdi's administered as ordered with no adverse reactions. am abg 7.48/38/130/29. vent changes to decrease peep to 5 and rate to 16. rsbi attempted and bp ^ to 190 and terminated. plan: continue to wean as tolerated.
"
911,"resp: pt presently on 5 lpm n/c maintaining 02 sats 94-96% and comfortable. nebs administered alb/atr with no adverse reactions. continue to monitor pt with bipap @ bedside when needed.
"
912,"resp: [**name (ni) 158**] pt on ps 8/40%/0+.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. rsbi=47. pt presently on ps5/40%. 02 sats @97% rr 19. will continue to wean. possible t/c trial today.
"
913,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] ac 18/600/13+/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases. mdi's administered q4 hrs combivent with no adverse reactions. suctioned small to moderated amounts of tannish thick secretions.  plan to lighten up on sedation and proceed to wean.  possible psv today? no rsbi performed due to level of peep. am abg's 7.47/33/118/25.
"
914,"resp: [**name (ni) 158**] pt on pcv 18/12/dp 13/+5/40%. [**last name (un) 3028**] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white/yellow secretions. mdi's administered alb/atr with no adverse reactions. attempted psv although pt did not tolerated. no abg's rsbi=>200.
"
915,"resp: [**name (ni) 158**] pt on a/c 22/550/10+/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amount of bloody secretions. mdi's administered q4 hrs alb with no adverse reactions. ett 7.5, 24 @ lip, 22 cp. pt had episode of desating, temporarily placed on 100%, then returned to 50%. [**name (ni) **] changes to decrease tv to 350 and ^ rr to 28. last abg 7.32/40/196/22. am abg pending. no further changes noted.
"
916,"resp: pt intubated for impending respiratoy failure. bilaterally insp/exp wheezes with no improvement following nebs. ett #8 secured @ 22 lip. planced on a/c 18/500/+5/60%. mdi's administered alb/atr with no adverse reactions. abg 7.44/31/161/22. rsbi=54. wean rr to 14. plan maintain present settings.
"
917,"resp: [**name (ni) 158**] pt on simv 6/400/15/5+/40%. ett 7.5 retaped, rotated and secured @ 23 lip.  bs are coarse with diminished bases. suctioned for small amounts of yellow/white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.45/37/123/27. rsbi=153. plan to continue to wean as tolerated.
"
918,"resp: [**name (ni) 158**] pt on psv 10/5/40%.ett#8, 22 lip. bs are clear with diminished bases. suctioned for small amount of white secretions. mdi's administered q4 hrs combivent with no adverse reactions. abg's indicate uncompensated metabolic acidosis. am abg pending.
"
919,"resp:  [**name (ni) 158**] pt on [**last name (un) **] a/c 12/450/10+/35%.  alarms on and functioning. ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x2 for small amount of  thick whitish/tan secretions. cuff pressure checked and noted positional leak.  mdi's administered q4 hrs of alb/atr with no adverse reactions. vent changes to psv 10/10/35% with 02 sats in ^ 90's. no rsbi performed ^ peep.  no further changes noted.
"
920,"resp: pt rec'd on psv 15/5/40%. ett 7.5, 23 @ lip. bs reveal bilateral clear apecies with diminished bases, occasional coarseness noted. suctioned for small amounts of thick yellow and rusty plugs. pt circuit changed to  heated wire circuit. mdi's administered alb/atr with no adverse reactions. abg 7.41/43/94/28. pt ^ wob with rr's to 45 then placed on a/c 14/500/+5/40%. pt continues on cvvhd. plan to maintain present setting and monitor to wean back on psv when appropriate. rsbi=>200
"
921,"resp: [**name (ni) 158**] pt on a/c 14/500/+5/40%. bs reveal noted aeration with some coarse sounds. suctioned for large amount of thick bloody tinged secretions with plugs toward end of shift. mdi's administered alb/atr with no adverse reactions. vbg's (see careview) which vent changes reflect. present settings a/c 8/400/+5/40%. rsbi=>200. family meeting to discuss cmo status. will continue full vent support. pt continues on cvvhd.
"
922,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 14/+10/35%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick yellow secretions.  mdi's administered q4 hr of alb/atr with no adverse reactions.  cuff pressure @ 21 cmh20. 02 sats @ 98%.  no further changes noted.
"
923,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/10/35%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suction x2 small amount of whitish/yellow thick secretions.  mdi's administered q4 alb/atr with no adverse reactions.  02 sats in ^ 90's.  no rsbi due to ^ peep.  no further changes noted.
"
924,"resp: [**name (ni) 158**] pt on a/c 14/600/+5/30%. bs are coarse bilaterally which clear with suctioning. pt has strong cough/gag reflex.  suctioned for moderate to large amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. [**name (ni) **] changes to decrease rate to 10. no abg's pending. will continue to wean as tolerated.
"
925,"resp: pt was extubated on [**3-29**] and placed on n/c @ 2 lpm. 02 saturation in 80's then ^ to 4 lpm.  ordered hhn ud atrovent q6 hrs and administered with no adverse reactions. pt is mouth breather so placed on humidified f/t @ 70% without n/c. 02 sats 95-97%. will continue to follow.
"
926,"resp: pt rec'd on [**last name (un) 647**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20. ett re=taped and secured @ 24 lip. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered combivent q4 hrs/[**last name (un) **] [**hospital1 10**] with no adverse reactions. vent changes to +5 with am abg's 7.40/43/157/28. plans to wean to extubate, although secretions still copious. continue vent support.
"
927,"npn7a-7p
neuro: pt using voc board to com. needs. dozing on & off all day, but easily arousable. anxious in am. tx'd w/ repos. 1mg ativan & 50mcg of fentanyl w/ good effect.
resp: recent abg's per pt's baseline. cont. to monitor sats & abg's as ordered. sxn' prn.
cv: hypotensive to sbp 80's following 50mg lopressor via ngt. team aware. bp corrected w/out need for ivf bolus & ivgtt. afebrile. nsr hr 90-106. no ectopy noted. +doppler bilat le pulses, cool to touch cyanotic in appearance. +2 edema r>l. rece'd ivig over 41/2 hr w/out adverse reactions.
gi/gu: npo. nepro tf @ goal of 40cc/hr. +bs +bm soft brown. foley draining adequate urine clear & yellow in color.
integ: skin tears w/ tegaderm drsgs reapplied over face & cocyx. staples in tact over lami inc site. no drainage noted.
endo: bs wnl. no coverage required w/ riss.
plan: goal for i/o negative to help prepare for possible extubation [**7-8**]. monitor hct, abg's as needed.
"
928,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 12/5/50%/ alarms on and functioning.  ambu/syringe @ hob. minimal leak tech for notable leak in cuff.  bs auscultated reveal rs clear with ls diminished bs.  mdi's administered q4 alb with no adverse reactions noted.  suctioned x3 small to moderate amount of thick bloody secretions.  vt returned 400-500/ve [**7-29**].  02 sats remain in ^ 90's.  rsbi= 115. no vent changes noted.
"
929,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/10/35%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small amount of thick white secretions. mdi's administered q4 hrs with no adverse reactions. pt does continue to have periods of bronchospasms, but no resp distress noted.  rsbi=163.  decreased peep to 8.  no further changes noted.
"
930,"resp: [**name (ni) 158**] pt on a/c 12/500/5+/60%. ett #7.5, 23 @ lip. bs auscultated reveal bilateral exp wheeze. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered alb q4 with no adverse reactions. am abg 7.35/37/89/33. rsbi=115. plan is to wean as tolerated and extubate if possible.
"
931,"resp: [**name (ni) 158**] pt on psv 16/8/50%. pt is trached #8 portex. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. pt has periods of anxiety with ^ rr to 40's. rsbi=65. am abg 7.45/42/108/30.
"
932,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 10/5 50%. alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal increase in aeration with improvement noted.  suctioned small to moderate amounts of thick yellow secretions.  mdi's administered with no adverse reactions.  rsbi=58,sbt initiated.  pt [**name (ni) 6577**] 20minutes ^rr. ^bp, ^hr then returned pt to present settings of [**9-23**] where they remain.  no further changes noted.
"
933,"resp: pt rec'd on a/c 30/380/16+/50%. bs are coarse bilaterally. suctioned for large amounts of bloody tinged thick secretions. ambu @ hob. mdi's administered as ordered alb/atr with no adverse reactions. no changes this shift. pt remains on cvvhd. no platetles given. no rsbi=^ peep. will continue with present mode of ventilation.
"
934,"resp: [**name (ni) **] pt on a/c 30/380/15+/60%. ett 7.5, taped @ 23 lip. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of rusty/bloody tinged thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg's (see carview). vent changes to decrease peep to 14. am abhg 7.37/44/89/26. no rsbi due to ^ peep. pt remains on cvvhd. will contine to wean as tolerated.
"
935,"resp: [**name (ni) **] pt on psv 10/5/40%. ett#8, retaped and secured @ 22 lip. bs are clear with diminished bases bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. rsbi=66. no changes this shift.family meeting today?  plan to wean as tolerated.
"
936,"nursing note 7a-7p
neuro-sedated, when weaned off propofol pt is able to follow commands,and deny pain.  perrla.

cv- hr 60's, v-paced with frequent fusion of intermittant underlying a-fib.  pedal pulses l>r. rle cool, pale, md notified.  right groin angio site intact with bandaid.  us on ble's wnl.  bp's 120's 40's. right radial line zero'd and level'd.  cvp line zero'd and leveled. compression boots on, tol well.

resp- vented on assist control fi02 40% sat maintained at 100%. suct x3-scant thick clear, some blood tinged sputum noted.  lung sounds-rhonchi. see carevue for gases and lab results.

gi/gu- abd grossly distended, soft, nontender.  +bowel sounds.  rectal bag in place, maroon colored liquid stool noted.  scant amt from this shift.  foley patent-drg dk yellow clear urine. output is poor. < 150ccs this shift.  md is aware.  ng tube-cont low suction-bilious drg.

heme- mtemp 98.7ax. this shift.  this am temp 95, 96 po, intervened with bair hugger blanket, and fluid warmer.  temp is stable at this time.  pt received 6 units of prbc, 4 units of ffp and 1 unit of platelets, no adverse reactions noted.  hct previous to infusion was 19.5 post transfusion 26.4.  see carevue for more details. bc-still pending.

endo- propofol infusing at 40mcg/hour, insulin gtt infusing at 1.5units/hour.  last blood glucose at 1600 was 93.  pt was weaned off propofol twice this shift to assess for pain, denies pain and able to follow commands.

pt had an exploratory laparoscopy this am - bleed ruled out.  ct scan done at 1330 results- right groin, small hematoma found. rle us done- results wnl. left and right wrist iv's infiltrated, and dc'd.  l ac #18 wnl. right ij wnl. flagyl, levaquin, and vanco started secondary to ? sepsis.

assess- 83 yo w/acute lower gi bleed, s/p embolization; complicated by acute resp distress, intubation; s/p diagnostic lap. ? arf.

poc-will cont to attempt to wean 02, insulin and propofol gtt's. will cont to monitor hct & coags,stools,and urine output.

"
937,"resp: pt remains intubated #8 ett, 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no abg's this shift or vent changes. rsbi=36. plan to trach/peg today in or.
"
938,"resp: pt remains mechanically vented on simv 16/650/+5/10/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated with mostly clears sounds, and occasional rs wheeze noted. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. suctioned minimal amounts of white secretions. am abg's 7.41/32/119/21. reduction in temp. will continue to wean appropriately. no further changes noted.
"
939,"npn 1900-0700:

ros:
neuro: pt remains paralyzed and sedated on same doses of cisatracuriun, versed, and dilaudid. no obvious adverse reaction to dilaudid. [**2-24**] twitches at 60mv on tof. no spontaneous movement; perrl.
resp: remains on pcv with driving pressure decreased to 23, peep decreased to 14; rate unchanged at 24. i:e 2:1. able to wean fio2 to 60% with most recent abg 7.38/36/104/22/-2. unable to obtain sats d/t peripheral vasoconstriction. ls coarse t/o; suctioned once for very scant thick bloody secretions.
c-v: hr 90's-100's, sr/st, no ectopy. bp via a-line generally correlating with [**month/day (4) 781**], though occasionally positional. able to wean levo significantly; remains on same dose of pitressin. .
id: temp >101 all night despite tylenol. cooling blanket added at 0500. wbc down to 17.5 with 5% bands. ceftaz added to abx coverage; bc x 2 sent from lines.
gi: tpn and tf's on hold. 25-500cc's bilious aspirates from ogt q6 hours; + placement by auscultation. pt regurgitating significant amts gastric contents to back of throat (ho aware); suctioned very frequently. belly firm, distended, hypoactive bs. no stool.
gu: u/o very poor much of night. given 40mg, then 80mg iv lasix with minimal response. now has become essentially anuric (ho aware), with bun/creat rising to 67/1.8.
heme: hct down a bit to 28.8; plt's down from 147 to 84, though the current level is much more consistent with where he's been. inr up a bit to 1.8. oozing from right femoral line site; otherwise no evidence of bleeding.
endo: no need for insulin coverage
skin: skin remains intact; eyes taped shut and given frequent eye care with natural tears alternating with lacrilube.
social: family members present in room till mn, then slept in waiting room. asking appropriate questions; unclear if they truly understand the irreversible nature of his disease. remains a full code.

a: a better night, though prognosis remains very poor.

p: continue sedation/paralytics as needed; wean levo as able; follow temps, wbc, cx results; tylenol, cooling blanket prn; ? reglan or other therapy for regurgitation; keep hob up and sxn frequently to prevent aspiration; follow up w/team re: renal fxn; monitor for evidence of bleeding; will tx for hct <27; continue skin care as we are doing; continue to inform and support family.
"
940,"micu nursing progress note

pulm: pt to ct angio to eval pe. once on  ct table noted to have brb per ett, large thick amt. maintained o2 sats > 95%, airway remained patent. cont'd to sx moderate amts of bright red sputum during test. labs revealed hct drop from 35 to 30, inr 1.6-> rec'd ffp(2), vit k x 1. 4am labs revealed drop in hct to 26.2. cont to have bloody secretions overnight mod to large amts, appears to contain tissue, and to be less bright red than earlier in evening. now ordered for 2 additional units ffp (being thawed) and 2u prbc's typed and crossed. pt rec'd on a/c 450 x 20 peep 5, fio2 inc'd to 50% to maximize o2. am abg -> 195/31/7.45.

cv: sbp 80(sleeping)-126. hr 70's(nsr). repleted for k+, mgso4 and ca+. am labs drawn immediately after finishing repletion of lytes (md aware)

id/heme: spiked to 101.4 between rec-ing 2u of ffp. md [**doctor last name **] informed, bbank called. decision made to give apap and cont infusion d/t greater risk of bleeding vs probability(low) of adverse reaction. now ordered for 2 additional units-will pre medicate. pan cx'd, bc x 2 +fungal, urine sent. abx regimen un-changed.

gi/gu: no s or sx of bleeding via ogt. stool ob-. tolerating tf w/o difficulty though does cont to have large amt of diarrhea via mushroom cath. hypoactive bs. abd ^^girth though soft. u/o ~100-200cc/h.

skin: mediastinal,sternem dry and intact. r arm infiltrate site w/ some weeping, escar sloughing off.

social: aunt called for update, pt's mother has note been called by intern -needs to happen today.
"
941,"resp: pt rec'd p/o intubated ett #7.5, 19@ lip retaped and secured. bs reveal coarse sounds bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. pt desated to 92, then ^ peep to 8, abg's 7.42/44/204/30. decreased peep to 5 with 02 sats 98%. rsbi=no spont resp. will continue full vent support.
"
942,"resp: pt remains intubated/trached #8 portex. bs are coarse and suctioning moderate amounts of thick bloody tinged secretions. mdi administered q4 alb/atr with no adverse reactions. vent settings psv 5/5/50%. rsbi-43. no abg this shift.
"
943,"resp: pt remains intubated on psv 10/5/30% with no changes noc. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. sputum sample obtained and sent. mdi's administered q4 hrs with no adverse reactions. pt remains on [** **]. possible trach this week. will continue on psv. no abg's, aline removed.
"
944,"1900-0700a  nursing note


event-- @ 0330a pt developed [**4-15**] non-radiating left sided cp.  pt states this is a chronic problem for him and happens at rest at home. ekg obtained, cardiac enzymes sent and 1 ntg sl given.  within 5 min, cp resolved.  ekg reviewed by dr [**last name (stitle) 3381**] and no changes noted.  hct dropped 26 to 22.9.  pt transfused w/ 1uprbc, no adverse reaction noted.  repeat hct will need to drawn.

(c/v)-- remains in sb, hr 40-50's w/ pac's. on review of [**name (ni) **] pt is having intermittent episodes of 1st degree a-v block(hr 35-38)  asymptomatic.  pt occas dropped hr to 30's when sleeping.  +[**1-8**] pitting lower extremity edema.  b/p stable  98-114/44-54.  monitor cardiac enzymes and hct.  bc sent/pending.

(resp)--lungs remain clear after fluid bolus and blood.  pox 96-99% on ra.

(g/i)--  abd soft, med loose stool x1.  trace pos guiac stool.

(g/u)--outpu needs to be watched. only 500cc out but >1500cc in.  urine spec sent.  voids via urinal.

plan c/o  today
"
945,"respiratory care note:
   patient s/p rml lobectomy now with white out of r lung despite daily bronchoscopies.  reintubated today (difficult intubation- multiple attempts without adverse reaction. tube guide used and a # 8.0 et tube placed 23cm @ lip). bs present bilat anteriorly, very decreased rll. suctioned for large amounts of tan and blood tinged mucous.  pt., sedated via peripheral line with propofol. +epidural. see carevue flowsheet for settings and abgs.
"
946,"resp: [**name (ni) **] pt on psv 12/5/40%. ett#7.5 taped @ 25 lip. bs are clear with diminished bases. vent changes reflect abg's (see carview) suctioned for small amounts of yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.30/45/113/23. present settings psv 14/5/50%. vt's 350-400. plan to trach/peg in or today.
"
947,"[**2192-11-28**] ""b"" nsg progress note:

cvs:  t=98.6-99.2 ax. hr=99-109 sr no ectopy. [**month/day/year **] down to 83, iv neo drip restarted and up to 0.75mcg/kg/[**month/day/year 199**]. iv fentanyl drip at 100mcg/hr, iv ativan drip at 0.75mg/hr.  received iv ig 800cc last night with no adverse reaction noted.  started on iv bactrim also which is 1000cc.  [**month/day/year **] kept>90 with neo. cvp=14-18.

resp:  vent tv 550 fio2 was at 50% peep5 on ac 14, abg's with ph=7.20. serum hco3=18, given 1 amp nabicarb iv. changed to ac 28 tv 550 fio2 100% peep8 with improvement of abgs. suctioned for small amt thin reddish sputum.  lung sounds very diminished at bases.  trach site draining thick tan [**month/day/year **]. sats=93 down to 83%.  then on new settings sats=95-99%.  sputum sent for cult.

gi:  tf [**month/day/year **] with no residual. banana flakes tid.  +bs.  moderate formed brown stool noted.

skin:  red pustules all over body.  [**month/day/year **] dsg changed with aquacel, area is necrotic in center, red at edges, no [**month/day/year **].  duoderms at various areas on arms and legs. wound vac dsg [**month/day/year 468**] to [**month/day/year 3522**] wound.
jp=10cc. chest tubes with small amt [**month/day/year **] both to waterseal. left leg edema noted.

neuro:  opens eyes, does not follow commands, very little movement of extremities.  smiled at wife but mostly does not interact.

labs:  mg,kcl,ca all repleted. bs coverage per ssri.

plan:  redialyze today.  try weaning vent settings.
"
948,"resp: [**name (ni) **] pt on a/c 20/600/+5/50%. bs are clear bilateral. suctioned for scant amounts of white secretions. mdi's combivent q4 with no adverse reactions. vent changes relfect abg's (see carveiw) pt remains paralized/sedated. present settings. a/c 12/550/+5/30% with am abg's 7.41/40/121/26. no further changes noted.
"
949,"resp: [**name (ni) **] pt on psv 8/2/40%. #8 portex trach. bs are coarse bilaterally with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. no abg's this shift. rsbi=39. will continue to wean as tolerated.
"
950,"resp:  [**name (ni) **] pt on [**last name (un) 205**] cpap/ps [**11-20**] 40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral mild coarse sounds which clear with suctioning.  suctioned x3 scant-small amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  ett re-taped & secured.  no distress noted. rsbi=32, sbt initiated and maintaining tv's 500-600, with 02 sats ^90's.  no further changes noted.
"
951,"resp:  [**name (ni) **] pt on [**last name (un) 205**] ps 5/+5/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse bs which clear with suctioning.  suctioned x3 small amount of thick yellow secretions, and oral cavity. mdi's administered atr/alb q4 with no adverse reactions.  rsbi=26 and sbt initiated.  no further changes noted.

"
952,"resp: [**name (ni) **] pt on 7200 psv 10/+5/40%.  alarms on and functioning.  amubu/syringe @ hob with spare trach.  bs auscultated reveal bilateral coarse apecies with diminished bases.  suctioned x3 small to moderated amoutn of tanish thick secretions. mdi's administered q4 combivient with no adverse reactions. pt's trach positional.  pt is out of bed sitting in chair.  rr at base line 30's increases when anxious.  rsbi=112.5 with no further changes noted.
"
953,"addendum to above note
labs back--plat low, pt to have 1unit plat and 2units [** 1684**].  plat infusing at this time without evidence of adverse reaction thus far.
"
954,"resp:  [**name (ni) **] pt on [**last name (un) 205**] cpap/ps 12/10/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small amounts of thick yellow secretions, and oral cavity.  mdi's administered alb/atr 6p q4 hrs with no adverse reactions.  vent changes as follows; peep decreased to 8, where it remains.  rsbi performed =70.  no further changes noted.
"
955,"resp care
pt remains on vent. changes made according to protocols. mdis given with good effect: decreased vent pressures.  no adverse reactions. will continue to mointor
"
956,"resp: [**name (ni) 158**] pt on a/c 14/650/+5/40%. ett 7.5 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow to tannish secretions with some bloody tinged.  mdi's ordered alb/atr q4 and administered with no adverse reactions. large amounts of thick clear to white oral secretions as well. no aline, vbg's (see careview) vent changes to decrease vt to 550, ^ rr to 18. 02 sats @ 100% with am vbg  7.41/44/29. rsbi=70. no further changes noted, pt in/out of a-fib.
"
957,"pt. completed asa desensitization protocol. last asa dose 2355. tol process well with no known adverse reactions at this time. slept well throughout the night being npo after midnight for ? cardiac cath today. one mod loose stool. voiding in commode.
plan cardiac cath today. ? plavix [**hospital1 **] vs. qd now pt. on asa. needs to be clarified. plavix was [**hospital1 **] at home and pt. got it [**hospital1 **] yesterday.
plan transfer to floor if needed. pt. stable. repeat k=3.8 not hemolized.
"
958,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 10/550/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal diminished bases. mdi's administered q4 alb/atr with no adverse reactions. suctioned for small amounts of tan thick secretions. am abg's 7.32/47/111/25.rsbi attempted with no spont. resp. noted.  plan to wean sedation this am and place on psv when appropriate.
"
959,"npn 7a-2p

events:  pt. restarted on heparin (at 800u/hr), sent to cath lab for cardiac cathertization at 1400.  pt. with transient hypotension and low u/o today.  c/o of cp x 1 resolving without intervention.

neuro:  a+o x 3.  pleasant and cooperative.  anxious about cath.  medicated x 1 w/ 1 tab vicodin for lower back pain; [**8-23**].  pt. takes vicodin at home per her report despite hx. stating she has morphine allergy.  pt. without adverse reactions and pain dissapated; 0/10.  pt. decribes that her pcp believes her to have sleep apnea with insomnia; takes ambien at home as well for sleep.

resp:  sat's maintained >95% on 4l nc.  + smoker 1/2-1 pack/ day.  ls- clear/ diminished bases.  productive cough.

cv:  team describing weekends' events as ischemia, not infarction d/t unstable angina.  cp x 1 with no other associated symptoms; denied sob.  of note, pt. reported cp when asked.  30 minutes prior to onset of cp, pt. received vicodin for back pain.  no further narcotics were administered as pt. stated that cp or ""pressure"" was resolving on own.  no nitrates administered.  sbp 90's (manually/ doppler).  ho called immediately.  pt. started on heparin prior to onset of cp as well at 800u/hr with no bolus.  pt. sent to cath lab at 1400 after consent obtained by pt. and son.  [**name (ni) **] at bedside.    hr 60's.  bp 90's.  ivf started prior to cath at 125cc/hr of ns with 500cc fb.

gi:  pt. encouraged to drink po's d/t poor u/o, then made npo for cath.  abd wound dressings done at 8am; packed with several yards of nu-gauze; wounds tunnel.  wounds with serosanginous output.  no bm.  + bs.

gu:  u/o minimal.  ivf started prior to cath.

id:  pt. receiving pcn and flagyl rtc.  afebrile.

plan-  s/p cath care, hct s/p cath with wbc.  check ptt on 800u at 6:30pm.
"
960,"resp: pt rec'd on simv 18/500/12/+8/40%. ett 7.5, retaped, rotated and secured @ 23 lip. alarms on and functioning. ambu/syringe @ hob. bs reveal slightly coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. cuff pressure @ 20 with no notable [** **], foul odor still exists from oral cavity. no rsbi due to hemodynamic instability. no changed noc. will continue full vent support.
"
961,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] psv 12/8/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear apecies with diminshed bases. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. ett @ 24 lip, cuff pressure 20. am abg's 7.43/47/73/32. rsbi=142. will continue to wean appropriately.
"
962,"micu nursing progress note 11am-11pm:
neuro: pt having what is felt to be adverse reaction to the haldol which was given in previous 12hrs. periods of muscle stiffness and ridgidity noted felt to be dystonic reaction. each episode treated successfully with benadryl. twice given 50mg with good effect. third time was treated with 25mg iv benadry then 1mg po cogentin. seems  to be working fairly well. he is confused at times, thinks he can get up oob by himself and go to the bathroom. twice assisted back to bed and requires frequent reminders to stay in bed for safety. he was assisted bed to chair twice and tolerated this well. his family have been present on/off throughout the day. he is angry and rude to them at times. very short tempered. he seems to be easily agitated and bears watching for the same episodes of sundowning that has been occurring on previous shifts. ciwa scale has been followed but no ativan has been ordered as we usually treat for scale greater than 10. his intern is reviewing the order and may need to order ativan or valium prn.

cardiac: bp stable. hr elevated into 110 with agitation.

resp: o2 4l n/c most of the shift. rr high in the 35-40 range most of the time. good sat 94%-99%.

gi: eating small amts po's. has not moved his bowels since admission. given colace and ordered for dulcolax which i will give him soon.

gu: foley draining well. urine is slightly bloody tonight from him trying to get oob himself this afternoon and pulling which occurred. i can d/c foley tonight and pt will be dtv in am.

social: family was spoken to today by case management who mentioned that pt may be a candidate for drug rehab. they were not receptive to this and state that they are overwhelmed, just almost lost their son and do not want to talk about this at this time. this does need to be addressed but can wait till tomorrow when team are able to address these issues with him and his family.
"
963,"resp: pt on 40% hiflow. bs are clear. nebs administered q6 hrs alb/atr. plumicort [**hospital1 **] with no adverse reactions. will continue to follow and treat.
"
964,"respiratory: [**name (ni) **] pt on 7200 psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse bs which improve with suctioning.  mdi's administered q4hr combivent with no adverse reactions.  suctioned x3 small to moderate amounts of thick yellowish secretions.  rsbi=117.6 no further changes noted.










































"
965,"1100-2300 npn
see carevue for subjective/objective data.
neuro:  a+ox1 only--not oriented to place or time.  attempted unsuccessfully to reorient.  moving arms ad lib; no leg movements noted.  l leg in alignment (l hip fx).  perl, 3mm, brisk.  speech garbled but occas able to understand single words.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  remains on heparin at 1000units/hr with next ptt due at 2400.  r cvp patent, zero'd and cal to monitor with good waveform.  remains on np at 3l with sats high 90's.  bs coarse bil.  one unit prbc infused without evidence of adverse reaction; rpt hct=30.6.

gi/gu:  remains npo even though hip surgery cancelled--will remain npo until speech/swallow evualated per intern.  no flatus, no bm noted.  u/o remains hematuric--urology consult to be ordered by micu team.

integ:  intact.  some lesions noted on skin.

psychosocial/plan:  emotional support given to pt and fam.  surgery re-scheduled for wed per ortho; pt to remain on heparin at 1000units/hr with next ptt at 2400--page ho with results.  cont to monitor vs, bs, mp, i+o, labs and provide emotional support.
"
966,"addendum to transfer note
d.today pt is afebrile,sr 90 down to 80 after increase in lopressor.(it was determined that pt does not have an allergic reaction to lopressor but possibly an adverse reaction to dose thus removed from allergy list and explained to patient)bp by cuff 140-160/50-60.rr=14-20,o2 sat 98 on 4l np.pt started on asa and heparin continues at 250 units/hr.
 no chest pressure or pain today.no c/o sob..lungs remain clear.
 no hemodialysis today per renal and transplant teams..urine replacements and maintainence fluid discontinued .pt started on diabetic and renal diet and fluids ad lib.after 18 hrs..fluid balance pos by 1200.huo 30-80ml of pink urine.
 pt was medicated x1 with morphine with stated relief.
 activity was increased to oob to chair with assistance of 2.pt tolerated activity well despite 2+ body edema.
 abd incision d&i.abd. jp draining minimal sero-sang and a small amt around jp.
 bowel sounds present.pt eat a sm amt of toast but is drinking moderate amt of fluids.[**month (only) 12**] need a nutrition consult if appetite does not return in near future.
 pt received atg after steroid dose..
  see flow sheet for current labs..wbc down to 3.6(transplant team aware.hct stable at 29.5..bs 140-147 and has received insulin per sliding scale..ptt 29-30.
a.pt was encouraged to increase deep breathing and coughing..transfer to floor when bed available.
r.stable
"
967,"pt update:
neuro:grossly intact see flow sheet.
cv:chest pain free, ekg repeated and back to baseline per cardiologist. lopressor started after it was determined her allergy to lopressor was probably an adverse reaction. pt had no untoward effects from lopressor given last night.
gi: sips of water tolerated
gu:urine is less bloody now pink 70mls at 0600.
resp:no difficulties last night. pt instructed on the importance of c/dbing. good cough effort.
              [**first name8 (namepattern2) 1257**] [**last name (namepattern1) 1258**]
"
968,"1900-0700

general: pt remains sedated with cont'd mechanical ventilation. prbc transfusion completed with no adverse reactions: repeat hct-30.8,wbc-16.5. no changes made to vent through night, o2sat 92-97%.

neuro: pt reamins sedated, eye twitching noted to painful stimuli. minimal to no movement of ext noted. pupils 3mm bilaterally with r-brisk and l-sluggish.

resp: pt remains orally intubated with # 8.0 ett 24cm @ lip line. vent settings remain ac tv 600, 70% 35, peep 20. mv-22.o2sat 92-97%. suctioned for scant thick blood tinged secretions. abg 4am: 7.24, 69, 60, 27, lactic acid-2.2. lungs on r-rhonchi,l-coarse through lung field. oral cavity with bleeding gums and sinusitus noted.

cv: nsr-s.tachycardia with rare pacs noted. max temp 99.8 orally, bp 120-165/50's. hr 90-110. cvp-[**9-23**]. generalized edema noted to ext. pulses to lower ext by doppler. triadayne bed in use with rotation and percussion. compressive boots/foot drop splints on.

gu/gi: abd firmly distended with + bs noted. liquid diarrhea noted, occult neg-fecal incont bag applied with double skin barrier. ogt to liws draining bilious fluid, irrigated for questionable internal bleeding-negative. foley catheter to bsd draining clear yellow urine. lasix given at 2300. pt -800 at this point for 24hrs. na-152, bun-79, cr-1.7,

endo: insulin drip remains titrated to bs. bs 120-150.

iv: r radial aline zeroed and calibrated with sharp waveform. l ij tlc intact with [**month/year (2) **] @ 5mg/hr, fentanyl@ 80mcg/hr, lr@ 10cc/hr, insulin@3u/hr, [**e-mail address 6573**]/hr.

plan: continue supportive measures. family meeting today.

                       [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
969,"resp: pt remains intubated on psv 10/5/50%. bs are clear in apecies with diminished bases. sucitoned for small amounts of thick white secretions. (see careview for abg's) rsbi=55. mdi's administered q4 alb/atr with no adverse reactions.
"
970,"altered cardiac status
d: neuro: fentanyl gtt decreased to 60mcg/hr and versed gtt remains at 1 mg/hr. pt occasionally noted to move r arm  and left leg but does not follow simple commands. facial grimacing to sternal rub and attempts to open his eyes. at 1230 pt noted to be rigoring. at 1200 temp had been 99.5 orally and at that time temp noted to be 100.8 orally. medical team notified. pt medicated with demerol 50 mg ivp with resolution of the sxs.because pt is sedated on fentanyl and versed gtt medical tema was concerned that this might be seizure activity. neuro was consulted and eeg done  at the bedside  and results are pending. no further episodes have occured. neruo ffels that this  was not seizure activity. will continue to wean sedative gtts on daily basis and assess his neuro status. pupils equally reactive to light.

resp: orally intubated with vent settings of 40%/500/ac 24 with 5 peep. o2 sats> 98%. coarse bs bil on auscultation but diminished at the bases. suctioned for sm amts of thick yellow sputum and orally for copious clear secretions.plan is to optimize [**hospital **] medical status and if we are not able to wean vent and extubate pt by this weekend will plan for tracheostomy early next week.


cv: hr ahs been variablkel throughou the day and as high as 150's. this am occasionally pt was in atrial bigeminy but most of the day pt has been in afib. amioderone gtt d/c'd and pt now started on amioderone 400 mg po bid for 7 days and then will be changed to qd. ion ca=1.02 and repleted with 2 gm ca gluconate. received pt on neosynephrine gtt for bp support but that has been weaned off. with episode of rigors sbp had climbed to as high as 220. see careview for  specific vs. it appears that when pt is f ebrile he becomes more hypotensive. will continue to follow hemodynamics closely. pt was medicated with 5 mg ivp lopressor with little effect. goal is to keep map> 60.

gi: ogt in place and pt receiving criticare tube fdgs at 30cc's/hr with minimal residuals. reglan now d'c'd b/cause of fever  nad the adverse reaction that can be caused by reglan- neuroleptic malignant syndrome. abd soft and distended. hypoactive bowel sounds on auscultation. fecal incontinence bag in place with minimal liq brown stool. will send spec off for cdiff cx when available. checking blood sugars q 6 hrs and treating as needed with ssi. plt ct=16 nad pt was transfused with 1 u plts. plan is ot transfuse for plt ct<20. abd u/s done at the bedside and unremarkable.


gu: lasix 60 mg ivp given with neg fluid balnce. bun=137 and creat=4.6. renal consult team continues to follow pt on daily basis.  pt with metabolic acidosis and has received 2 amps of sodium bicarbonate. fluid balance for los still pos by 19 liters.

id: temp spiked to 104.2. blood cx's x 2 sent off. wbc=6. spource of fever still undetermined. ? drug fever vs infection vs neurological expalnation. pt startd on diflucanazole 200 mg ivpb q 24 hrs.id consult team also following pt on daily basis. follow fever curve await all final r
"
971,"npn 7a-7p

events-  abd ct done with gastrografin (not barocat), results pending, conts to stool (500 out this shift), transitioned to psv this afternoon, hct stable, wbc increasing again...

review of systems-

[**name (ni) **]  pt. nodding appropriately, eyes closed most of the shift, denying pain except x 1 when she was medicated with 2mg of mso4 w/ good effect.  family cautions use of versed/ ativan d/t adverse reactions to benzo's in the past- pt. reportedly becomes confused and disoriented.

resp-  received on a/c, transitioned to psv- will obtain evening abg.  ls- diminished throughout... sat's stable.  sx'd for thick white secretions.  would obtain sample if turns purulent- appears to be nasalpharyngeal ? sinusitis...

cv-  hr 80's-90's sometimes appears to be in nsr, others appears to be in aflutter- conts on amiodorone iv d/t poor tolerance of pos. bp stable via arterial line.  pm hct stable >32.  e-lytes repleted this am received 80meq of kcl, ca+ and mg+.  skin appears distressed and friable, oozing from extremeties.

gi-  abd conts to be firm and distended, tender to touch.  flexiseal device inserted and appears to be draining and containing stool well- 500cc output thus far.  no further go-lytely given today, would consider after ct results interpreted.  lactulose d/c'd as it could be causing increased flatus.

gu-  u/o adequate.  d5w changed to po 250cc q 4hours to save on input. tpn also adjusted to decrease sodium and improve e-lyte imbalance.  nutritionist recommending we not replete imbalance tom'row am as new bag of tpn should correct.

id-  afebrile.  off abx.  ? sinus drainage causing secretions.

[**name (ni) 4**]  husband and youngest dtr, [**name (ni) 169**] to visit and updated on plan of care.  also talked with dtr, [**name (ni) **] and plans to meet w/ fellow dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 5901**] tom'row to discuss timeline.
"
972,"resp:  [**name (ni) **] pt on a/c 16/500/+5/50%. ett #7.5 found @ 24, retaped,pulled badk to 22 as charted @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small amounts of white secretions. mdi's administered as ordered atr/alb with no adverse reactions. am abg 7.41/41/147/27. no changes noc. rsbi=50. plan to wean to psv as tolerated.
"
973,"resp: [**name (ni) **] pt on niv psv 14/4/50%. placed pt on 50% cam and tolerated well for 2-3 hrs then ^ wob with ^ co2. mdi's administered a/b/atr and hhn with no adverse reactions. bs are clear bilaterally. placed back on niv am abg 7.38/45/147/28. will attempt to wean as tolerated.
"
974,"respiratory care
pt remains trached (#8.0 portex) with cuff inflated and no [** **] present. pt remains on fio2 0.35 via trach mask. lung sounds were course to clear and dim in the bases. suctioned for sm-mod thk yellow and once for small thin bloody secretions. nebs were given with no adverse reactions. no abg's were drawn during shift. care plan is to continue nebs as ordered and continue to suction prn. rehab screen started. will continue to follow pt.
"
975,"resp: [**name (ni) **] pt on psv 12/5+/40% bs are coarse bilaterally. suctioning small to moderate amounts of thick white to yellow secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. rsbi=28. plan to continue to wean down psv, with possible t/c trials as tolerated.
"
976,"resp: [**name (ni) **] pt on simv 24/550/ps5/+16/50%. ett 7.5, retaped and secured @ 23 lip as per xray correct placement, although being charted at 21. bs are diminished with noted aeration in apecies. suctioned for scant amounts of white/yellowis secretions. mdi's administered combivent as ordered with no adverse reactions. cuff pressure @ 25 cmh20. am abg 7.42/44/101/30. no vent changes noc. no rsbi due to ^ peep. possible ct trip today?
"
977,"resp: [**name (ni) **] pt on [**last name (un) 205**] simv6/650/5/+5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4hrs combivent with no adverse reactions. weaning initiated with vent settings @ psv 10/5/40%. am abg's 7.40/36/102.23. plan to continue to wean then extubate this am.
"
978,"resp: [**name (ni) **] pt on psv 15/10 and pt became hyertensive then placed on a/c 16/500/+10/50%. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi' administered q4 (seecarevew) no adverse reactions. am abg's 7.39/378/111/24. plan to wean to psv this am
"
979,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 16/500/+10/40%. alarms on and functioing. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate-copious amounts of thick yellow secretions. cp @ 22 cmh20. mdi's administered q4 hrs combivent q4/flovent [**hospital1 **] with no adverse reactions. vent changes reflect abg's (see [**hospital1 673**]) am abg's 7.39/39/97/24 on a/c 16/5///+5/40%. plan to continue full vent support.
"
980,"resp: pt ordered for nebs alb q2 hrs/atro q6 hrs. pt on 2.5 lpm n/c. bs auscultated reveal bilateral insp/exp wheeze which improve following tx. had one short episode of bronchospasm with cough. no adverse reactions following administration of meds. 02 sats @ 99%. md to change order to q3 hrs alb.  will continue to follow. see carview
"
981,"resp: [**name (ni) **] pt on psv 15/5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for copious amounts of thick bloody secretions/plugs. inner cannula changed. mdi's administered with no adverse reactions. am abg 7.42/35/85/23. plan to change trach to [**initials (namepattern4) **] [**last name (namepattern4) **] today.
"
982,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with diminished bases. suctioned for small to moderate amounts of thick bloody tinged plugs. mdis administered q 4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. most recent abg 7.36/38/92/22. rsbi=52. no changes noc.
"
983,"ccu npn
see carevue for subjective/objective data.  neuro:  confused to place and time, is oriented to self/family.  mae ad lib although weakly.  speech clear.  re-oriented frequently.

cv/pulm:  bp 90's-120's/30's-40's.  mp=afib 70's-80's with occ->freq mf pvc's.  cycling cpk's and hct's.  second of three units prbc currently infusing.  no adverse reactions noted during first unit, no adverse reactions noted thus far second unit.  developed bibasilar crackles, lasix 20mg iv given at start of second unit prbc.  rpt hct at 0200 done. hct 22.1 up from 19.9 (but done with blood infusing on opposite arm).  hct reported to dr. [**last name (stitle) **], third unit prbc ordered upon completion of current unit.  pt on room air with sats consistently 99-100%.  no sob or doe noted.

gi/gu:  npo.  two melena stools, liquid, approx 50ml each.  starting to diurese from lasix.

integ:  impaired--ecchymotic area noted l hip--pt states he ""falls alot"".   ecchymotic areas also noted on abdomen.  no open areas noted.

psychosocial:  daughter is rn w/vna of [**location (un) **].  emotional support given to pt and daughter.  sleeping in long naps.
"
984,"resp: pt rec'd on psv 15/5/50%. pt remains on cvvhd. bilateral coarse bs. suctioned/lavarged for copious amounts of thick bloody/brown plugs. mdi's administered as ordered without adverse reactions. am abg 7.39/43/117/27. no further changes noted.
"
985,"resp: [**name (ni) **] pt on psv 5/5/40%. #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for large amounts of thick tan secretions. mdi's administered as ordered alb with no adverse reactions. rsbi=62. am abg's 7.40/31/94/20. plan is to continue on trach trials as tolerated.
"
986,"resp: [**name (ni) **] pt on a/c 10/500/+8/40%. trach #8 portex.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds. suctioned small amounts of white secretions. mdi's administered q4 hrs 6p alb with no adverse reactions. rsbi=67. placed pt on psv 10/5+/40% obtaining vt's 400-500's, rr 15, ve 6l. no further changes noted.
"
987,"resp care

pt followed by respiratory for q6 neb treatments. atrovent given x2 via aerosol mask tol well with no adverse reaction. bs essentially clear/dim at the bases. no changes noted post tx, pt adequately oxygenating on 2l nc. will cint to follow as needed.
"
988,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 20/600/+5/60%.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse bs which clear with suctioning.  suctioned numerous times for thick copious yellow secretions, as well as in oral cavity.  re-taped & secured ett.  mdi's ordered this am alb/atr given @ 6:00 with no adverse reaction.  02 sats at this time remain 93-95%.  vent changes as follows: tv ^ 600, rr^ 20, and fio2 decreased to 60%.  am abg's 7.39, 46, 96, 26, -0.  rsbi=32.  no further changes noted.
"
989,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] on a/c 550/15/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of white thick secretions. mdi's administered q4 hrs of alb with no adverse reactions.  ett re-taped @ secured 21 lip line. cuff pressure @ 21. 02 sats 93, increased fio2 to 60% fio2 97%.  rsbi=136, no further changes noted.
"
990,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/600/+10/60%.  ambu/syringe @ hob.  bs auscultated reveal ls clear with rs diminished.  suctioned x 3 small amounts of thick yellow secretions.  mdi's administered q4 hr alb/atr with no adverse reactions.  rsbi=26 and no further changes noted.
"
991,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/500/+5/60%. alarms on and functioning. ambu/syringe @ hob. ett 7.5 retaped and secured @ 22 lip. cp @ 23 cmh20. bs auscultated reveal bilateral rhonchi, suctioning copious amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions.vent changes to ^ rr to 21, decrease fio2 to 50%.  am abg's 7.35/44/102/25. rsbi=54. no further changes noc. plan to bronch today in am. will continue full vent support.
"
992,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/350/+14/70%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration in apecies with diminished bases.  mdi's administered q4hrs alb/atr with no adverse reactions.  fio2 ^ 90% due to desaturation in 80's.  abg's drawn (see careview) fio2 decreased to 70% were they remain. am abg's 7.29/69/88/35.  02 sats @ 97%.pt remains on ards protocol.
"
993,"resp: [**name (ni) 158**] pt on a/c 21/500/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions, some improvement noted. mdi's administered q4 hrs. combvient with no adverse reactions. am abg's 7.40/45/96/29. rsbi attempted but no spont resps.  will continue full vent support.
"
994,"resp: rec'd on psv 10/5/40%. bs reveal bilateral wheezing. suctioned for small amounts of thin white secretions. mdi's administered as ordered with no adverse reactions. vt's 450's, ve's 11, rr 22. am abg 7.42/37/105/25. rsbi=89. no further changes noted.
"
995,"resp. care
pt. remains on mech vent. flipped from simv/ps to cpap/ps at 0500. pt. has a patent 7.0ett secured at 21 at the lip and is being sx for mod amts of bloody secr. b/s are dim with a few scat wheezes. mdis given with good effect and no adverse reactions. aeration was better bilat. post rx.plan is to wean as tol. and extubate.
"
996,"0200-0700
neuro: pt alert and oriented to self and place, confused at times. perrla. mae weakly, stiff. medicated w/ fentanyl gtt at 25mcg/hr, appears to be comfortable, except w/ hands on care, continues to yell at staff w/ bathing turning and repositioning.

cv: hr 60-70 sr rare pac occasional pvcs. k infusing through ivf at 75cc/hr. mg to be repleted. sbp 130-140s. hct 22.3, 2 units of prbcs ordered, 1st unit up at 0500, infusing, no adverse reactions see carevue for vs. weak palpable pedal pulses. 4+ pitting edema to ble.

resp: ls clear diminished bases. sats >98% on 2 lnc. see carevue for abgs.

gi/gu: abd soft hypoactive bs. ileostomy stoma pink draining greenish stool scant amts. stoma care done at [**2106**], dsg changed at that time. tf at 30cc/hr presently, goal of 80cc/hr, no residual via jtube. g tube to gravity draining greenish bile. urine and irrigation draining aroung foley balloon, could feel balloon when palpating bottom of penis, pa [**doctor last name 486**] aware, attempted to place another cathether unsuccessful pa [**doctor last name 486**] aware, to keep foley out and urology to see in am per pa [**doctor last name 486**].

endo: no coverage needed.

skin: wound care per wound care orders. see carevue. penis and scrotum very edematous, pa [**doctor last name 486**] aware.

plan: monitor hemodynamics. one more unit of prbcs. monitor resp. status. stoma care. skin care. follow labs and treat as appropriate. urology to see pt to place foley cath.
"
997,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/500/+10/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered q4 hrs alb with no adverse reactions. no wheezes noted. am abg's 7.46/44/131/32. scheduled trip to or for repair of pelvis. no further changes noted.
"
998,"resp: [**name (ni) 158**] pt on a/c 20/450/+8/100%. bs are slightly coarse, and suctioning small amounts of tan secretions, trach site clear. mdi's administered q4 hrs alb/atr with no adverse reactions. abg's (see careview) vent changes to ^ rr to 22, decrease fi02 to 60%. am abg pending. will continue to wean appropriately.
"
999,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] ps5/+10/50%.  ambu/syringe @ hob.  auscultated bs reveal coarse bs on ls with diminished on rs.  suctioned thick copious yellow secretions x3 as well as from oral cavity.  mdi's adminishered q4 hrs alb/atr with no adverse reactions.  vent changes as follows: ac 16/600/40% @ [**2097**] with no further changes during noc.  rsbi=34.
"
1000,"resp: [**name (ni) **] pt on psv 10/5/40%. bs reveal bilateral wheezing. suctioned for small amounts of thin white secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=77. no changes or abg's this shift.
"
1001,"resp: pt rec'd on psv 25/8/60%. bs are coarse bilateraly with noted wheeze. mdi's administered q4 alb/atr with no adverse reactions. am abg 7.37/46/98/28. decreased ps to 20, tv 400's rr, 20, 02 sats 99%. will continue to wean as tolerated.
"
1002,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 15/550/60%/+5.  alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with diminished bases. 02 sats 93-96%.  suctioned small amounts of thick white secretions, clear from oral cavity. mdi's administered q4 hr alb with no adverse reactions. am abg's 7.26/40/108/19 with no changes.  family to discuss possible withdrawal of support.
"
1003,"resp:  [**name (ni) **] pt on [**last name (un) **] psv 20/10/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick whitish/yellow secretions,pooling secretions in oral cavity.  pt rr ^ to 30's and pt becoming tired, placed back on simv noc to rest. placed back on psv 20/10/40% this am. mdi's administered q4 hr combivent with no adverse reactions.  02sats ^90's no distress noted.  vent settings remain at present settings.
"
1004,"1600-1900
pt is a 70 year old female admitted s/p cabg x4, see admission h+p for details of history and details of events in or. oozy through chest tube on arrival, act 159,  np [**doctor last name **] and dr [**last name (stitle) 1348**] aware, protamine 50mg iv given,peep increased, labs sent, np [**doctor last name **] aware, plts ordered and given, no adverse reactions.

neuro: pt sedated on propofol gtt. perrla.

cv: received from or w/ hr sr 80-90s. epicardial wires work per anesthesia. ekg done. sbp 110-120s on ntg as high as 1.5, see carevue. goal sbp<130. ci>2. pa 20s/15, cvp 7-11. 1l of lr given and 468cc of plts given for volume. dopplerable pedal pulses. k repeted. np [**doctor last name **] aware of mg and phosphate, repeat phosphate sent.

resp: ls clear. see carevue and ccc for abgs and vent changes. presently on fio2 of 60%, rate 12,peep 10. sats 100%. ct draining sang. drainage on arrival 30-60cc q 15min, np [**name6 (md) **] and md [**doctor last name 1348**] aware, protamine and plts given, at present 10-20cc q15-30min.

gi/gu: abd soft absent bs. ogt +placement, draining bilious secretions. foley draining adequate amts of clear yellow urine.

endo: gtt started at 1845 for glucose 116.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. monitor for bleeding, once stable, wake and wean as pt tolerates.
"
1005,"resp: pt rec'd on a/c 22/400/40%/+5. bs are coarse with diminished bases. suctioned small amounts of thick/thin white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=no spont resp. no changes noc.  will continue full [** **] support.
"
1006,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 20/450/10+/50%. alarms on and functioning.ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of tan secretions, as well as oral cavity. mdi's combivent administered with no adverse reactions. will continue full vent support.
"
1007,"resp: [**name (ni) **] pt on a/c 12/400/5+/40%. pt has #8 portex trach. ambu/syringe @ hob. alarms on and functioning. bs are diminished with occasional wheeze noted. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. abg's (see careview) vent changes to ^ fio2 to 60% following abg. no [**last name (un) 125**] due to hemodynamic status. no further changes noted.
"
1008,"resp:  [**name (ni) **] pt on [**last name (un) 205**] pcv 22/+5/rr 18/50%/dp 17.  alarms on and functioning.  bs auscultated reveal bilateral diminished sounds. suctioned for small-moderate amounts of thick white secretions. mdi's administered q6 hrs combivent/flovent [**hospital1 **] with no adverse reactions. rsbi=124. no abg's drawn (no a-line) plans to transfer to rehab when bed available.
"
1009,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions with occasional plugging noted.  mdi's administered q4 hrs combivent with no adverse reactions.  no further changes noted.
"
1010,"resp: pt remains on aprv 34/8/2.7/0.3.40% with no changes noc. mdi's administered q4 hrs alb/atr with no adverse reactions. suctioned for small amount of white secretions. am abg 7.42/44/176/30. will continue support.
"
1011,"resp: rec'd on simv 16/400/5/5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe 2 hob. bs are diminished bilaerally with scattered occasional crackles. suctioned for scant amounts of secretions. mdi's administered as ordered ofcombivent with no adverse reactions. no changes this shift. no [** **] due to hemodynamic issues. pt 02 sats decrease to 80's as well as bp. will continue on present settings. see careview for abg's.
"
1012,"resp: pt remains intubated on aprv 34/8/2.7/0.3/40%. bs reveal bilateral aeration. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.48/32/169/25. no changes noc. [**month (only) **] initiate wean this am.
"
1013,"micu nursing progress note
addendum;

pt family members entered room this am, and asked if he had rec'd meds they were told that he had rec'd haldol overnight [**name8 (md) 20**] md [**first name (titles) **] [**last name (titles) **] order. family members became very confrontational and angry accusing rn of giving a medication that should, in their understanding, have been discontinued d/t percieved adverse reaction. (further investigation of yesterdays rn --drug in question was morphine) this rn attempted to explain why the drug had been given-family members angry and threatening. md [**last name (titles) **] (covering) called and will be up to talk to family.
"
1014,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv 16/650/10+/5/60%.  ambu/syringe @ hob.  auscultated bs reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 moderate to copious amounts of thick yellow secretions.  mdi's administered of albuterol q4 hrs with no adverse reactions.  [**last name (un) **]=52.  no further changes noted.
"
1015,"micu npn
see carevue for subjective/objective data.  neuro:  alert to person, able to accurately state that is in [**hospital1 10**] however confused to time, events of noc, recent events--answering ""no"" to all questions.  moving arms, legs weakly.  speech clear.

cv/pulm:  vs per carevue--at beginning of shift bp low 80's on dopamine at 10mcg/kg/min.  d5ns at 250ml/hr given with bp gradually increased to 100's.  dopa decreased to 10mcg/kg/min with sbp maintaining 100 range.  np at 4l cont.  bs clear upper lobes, crackles developing lower lobes.  overnoc 4units ffp and 2units prbc's given--all without adverse reactions.

gi/gu:  pt npo.  ngt placed by dr. [**last name (stitle) 1752**].  baricat 900ml given however pt [**name prefix (prefixes) **] [**last name (prefixes) 2332**] 100ml around ngt.  to ct for ct of abd at 2400.  ct revealed ischemic colon-->pt rec'd ffp and prbc prior to transporting to or.  to or at 0430 by anesthesia for resection and ileostomy.  four of five sons with pt prior to leaving for or.  u/o borderline qs prior to fluids and blood/blood products not u/o qs q1h.

id:  tmax=100.7 po.  on gent, ampicillin and flagyl.  cultures pending.  ct positive for ischemic bowel as noted above.

integ:  buttocks excorriated.  stool grossly ob positive (dr. [**last name (stitle) 1752**] aware).  skin dry, no open areas noted.

psychosocial:  sons in to see pt upon adm to icu and again prior to leaving for or.  all pt's belongings (including clothes, purse, dentures and two rings--one yellow ring with green stone and one yellow ring with pink and white stones) sent home with son [**name (ni) 9494**].
emotional support given to pt and family.  trans to or at 0430 via bed with anesthesia.
"
1016,"resp: [**name (ni) **] pt on simv 16/400/5/+5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. inner cannula cleaned. pt remains on cvvhd with improved abg's. 7.39/44/108/28. [**last name (un) **]=113. during [**name (ni) **] pt bp decreased, 02 sats to 80's ^ wob. pt placed on 100% fio2 temporarily. plan to continue with support, no weaning expected today.
"
1017,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 16/10/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of thick whitish/yellowish secretions, as well as oral cavity.  mdi's administered q4 hrs combivent with no adverse reactions.  rsbi=60, sbt initiated.  no further changes noted.
"
1018,"respiratory care note:
     patient remains trached with a #8.0 portex.  cuff pressure measured and maintained at ~30.  bs are coarse throughout.  sx for small to often moderate amounts of thick pale yellow secretions via trach.  [** **]'s administered as ordered with no adverse reactions.  patient remained afebrile this shift.  rsbi this am is 57.6 on 0 peep and 5 psv.  spo2 remains 93-97%.  no abg's this shift.  will maintain current therapy.
"
1019,"resp: [**name (ni) **] pt on psv 10/5/50%. bs reveal clear apecies on ls, rs diminished. suctioned for moderate amounts of thick yellow secretions with some bloody tinged. mdi's administered q6 combivent with no adverse reactions. am abg's 7.33/46/115/25. fio2 decreased to 40%, ps to 5. rsbi=43. plan to continue with wean to sbt this am with possible extubation today.
"
1020,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 15/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds. mdi's administered q4 hrs combivent with no adverse reactions. suctioned for small to moderate amounts of tan thick secretions. fio2 decreased to 30%.am abg's 7.30/42/103/21. rsbi attempted and pt became very aggitated, ^ rr with low tv's. no further changes noted.
"
1021,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 18/10/40%  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned/lavarged for some thick tannish secretions & plugs. mdi's administered q4 hrs alb/atr / flov [**hospital1 **] with no adverse reactions. vent changes; ^ ps to 20 with no further changes noted. 02 sats remain @ 100%.
"
1022,"resp: [**name (ni) **] pt on a/c 14/600/+10/50%. pt has #8 portex trach with notable leak. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned moderate amounts of thick white/yellow secretions. [**name (ni) **]'s administered alb/atr/[**last name (un) **] as ordered with no adverse reactions. abg 7.38/61/119/37. no changes noc. will continue full vent support.
"
1023,"micu nsg admission note
25 y.o. woman admitted w/ drug od, s/p suicide attempt. intubated in ew to manage airway, sedated, narcan, mucomyst, ivf-> micu for management.

allergies: haldol (mother states she gets a rash and adverse reaction)
           thorazine (mother states she has adverse reactions)

phx: hx depression w/ multiple suicide attempts s/p sexual assault.
hx self mutilation, has multiple scars over arms and body. discharged from [**hospital 222**] hospital yesterday.

ros:

neuro: propofol off x 30 min to evaluate. +gag, mae, resedated until am.

resp: intubated w/ ventilatory support. 30%/ 600vt/ 14br/ 5cm peep.
clear resp, equal bs. scant blood tinged secretions, spec sent.

cardiac: 70-80nsr no vea, b/p 120/70

gi: ogt in place, no bs appreciated

renal: decreased u.o., monitoring s/p ivf replacement.

lines: #18 peripheralx2, function appropriately

skin: multiple scarring over body, no open wounds.

toxicology: + tylenol, uncertain about other substances.

assess: stable s/p drug od

plan: q4hr mucomyst, ivf, ekg, restrain prn, sedation and intubation throughout night, to reassess in am w/ probable extubation.
"
1024,"respiratory care note:
     received patient of ac as noted in carevue.  patient trached with a #8.0 portex perc. trach.  no changes have been made this shift.  bs are coarse throughout.  sx for small to often moderate amounts of tan thick secretions via trach.  [** **]'s administered as ordered with no adverse reactions noted.  patient remains afebrile this shift.  positional cuff leak noted.  cuff pressure measured and continues to be 30.  team aware of high cuff pressures for trach.  spo2 remains 98-100%.  will continue to monitor respiratory status.
"
1025,"cvvhd d/c'd at 2300fent <to 125/hr, but remained restless, moving about.  bp up to 150-180 w/ agitation.  no additional sedation ordered.  inr 2.3 this am and in order to d/c intrathecal cath and change rij trauma line over to tlc, need <inr.  pt received 4 units ffp (about 1 liter) and inr down to 1.7, but due to emergencies in the unit, unable to d/c lines.  pt will recieve 2 more units at 0400, repeat coags and if inr ok, will d/c intrathecal cath and change cl.   want to continue cvvhd to take off fluid after these infusions, so at 1700, pfr ^ to 700cc/hr.  (cvvhd to be d/c'd when filter clots anyway).  bp was elevated at the time and actually had started labetalol gtt.  bp came down to 110s/ right after starting labetalol and by [**2151**], bp down to 95-105/ - labetalol d/c'd. will continue to take fluid off as pt tolerates until 2330 when cvvhd will be d/c'd.

abg on cpap earlier in the day was 7.36/45/115/98%.

pt had been given haldolx1 earlier in the day in anticipation of going to mra to see if that would be enough sedation for the procedure.  pt actually had an adverse reaction where she became more agitated.

blood cx x2 sent this am.  urine cx also ordered, but not enough urine.

random vanco level sent - pending for pm dose.
"
1026,"7p-7a
neuro: pt sleepy at beginning of shift, following all commands, mae, perrla. pt presently a+ox3. denies pain.

cv: hr 80-90s sr w/ pacs, rare pvcs. at begiining of shift, pt on neo to keep sbp 90-110, sbp labile, on and off neo throughout shift, also on and off nitro during shift see carevue for details. ci>2. see carevue for details of filling pressures. pa nilssen aware of filling pressure readings and aware of cvp readings 0-6, pt received 1 unit of prbcs, no adverse reactions noted. epicardial wires intact, on v demand backup. +palpable pulses.

resp: ls clear but diminished. post abgs acidotic w/ pco2 50s, encouraged is and coughing and deep breathing, repeat abgs showed improvement, see carevue for details. sats >94%, at present on 6lnc sats 98%. much encouragement needed w/ use of is and coughing and deep breathing. ct at beginning of shift draining >100cc/hr, pa nilssen aware, coags sent, unit of prbcs infused as per order.ct dsg cdi, no crepitus no airleak.

gi/gu: abd softly distended, -bs. tolerating ice chips. foley draining clear yellow urine 100-300cc/hr.

endo: insulin gtt weaned to off. will continue to monitor glucose.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. wean nitro gtt as pt tolerates to keep sbp 90-110 maps <85. follow labs. deline in am, increase activity as pt tolerates. pain control.
"
1027,"resp:  resp pt on [**name (ni) **] a/c 26/500/+15/60% from tsicu.   alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal crackles with diminished bases.  suctioned for moderate amount of thick yellow secretions/bloody tinged from oral cavity.  mdi's administered of alb/atr/[**last name (un) **] with no adverse reactions.  02 sats 95-96%.  vent changes of ^rr to 28.  no further changes noted
"
1028,"resp: [**name (ni) **] pt on a/c 28/500/+10/70%. trach #8. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of rusty secretions at beginning of shift, yellow towards end. mdi's alb/atr administered as ordered with no adverse reactions. am abg pending.
"
1029,"resp: [**name (ni) **] pt on a/c 28/500/+10/70%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with diminished bases. suctioning copious bloody secretions. mdi's administerd as ordered with no adverse reactions. pt rr ^ 30's to 40's. morphine given with minimal affect. ct scan results negative. no changes or abg's noc. will continue full vent support.
"
1030,"resp: [**name (ni) **] pt on simv 14/500/15/+5/40%. ett #9 taped @ 24 lip. bs are clear with diminished bases bilaterally. suctioned for moderate amounts of thick yellow/bloody tinged secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. vent changes to psv 15/5/50% with am abg 7.47/40/80/30. rsbi=90. plan to continue to wean with possible extubation today.
"
1031,"cvvhd d/c'd at 2300fent <to 125/hr, but remained restless, moving about.  bp up to 150-180 w/ agitation.  no additional sedation ordered.  inr 2.3 this am and in order to d/c intrathecal cath and change rij trauma line over to tlc, need <inr.  pt received 4 units ffp (about 1 liter) and inr down to 1.7, but due to emergencies in the unit, unable to d/c lines.  pt will recieve 2 more units at 0400, repeat coags and if inr ok, will d/c intrathecal cath and change cl.   want to continue cvvhd to take off fluid after these infusions, so at 1700, pfr ^ to 700cc/hr.  (cvvhd to be d/c'd when filter clots anyway).  bp was elevated at the time and actually had started labetalol gtt.  bp came down to 110s/ right after starting labetalol and by [**2151**], bp down to 95-105/ - labetalol d/c'd. will continue to take fluid off as pt tolerates until 2330 when cvvhd will be d/c'd.

abg on cpap earlier in the day was 7.36/45/115/98%.

pt had been given haldolx1 earlier in the day in anticipation of going to mra to see if that would be enough sedation for the procedure.  pt actually had an adverse reaction where she became more agitated.

blood cx x2 sent this am.  urine cx also ordered, but not enough urine.

random vanco level sent - pending for pm dose.
"
1032,"npn 7a-7p

events:
pt. spiked to 101.6 this am and 102.3 this afternoon.  pt. pan cx'd x stool and sputum this am.  with this afternoon spike, pt. had resp. distress with hypoxia on abg (70's), tachypnea, htn to 220 and rigors. treated with apap, lopressor 10mg ivp with 25mg po, 12.5 demerol.  currently stablized.

review of systems:

[**name (ni) **]  pt. more lethargic and less interactive today.  conts to follow commands with right hand squeezing.  no spontaneous movements noted on left side.  perrla 3-4mm.  or cancelled in light of fever.  rescheduled for tom'row if not febrile.

resp-  received on fio2 of 35% currently requiring fio2 50-70% to maintain sat's >92%.  abg at 1540.  cxr done at the time of resp. distress, results pending.  sx'd q 4 hours for minimal to no secretions.  no sputum spec. obtained.  ls- clear anterior, diminished bibasilar posteriorly.

cv-  hr 70-100 nsr.  mg of 1.5 repleted with 2g.  received 1u prbc in prep for the or d/t hct <30%.  tolerated transfusion well, no adverse reactions noted.  pt. received tyelenol prior to transfusion.  suture sites appear clean and dry.  lue significantly more edemedous and hot compared to right ? dvt.  however, pt. has [**location (un) 890**] filter in place and could not be anticoagulated.  team considering ultra sound.  no signs of cellulitis noted at this time.  elevated on pillows at this time.

gi-  abd soft/ distended.  no bm this shift.  tf restarted at 1pm d/t cancellation of or.  to be stopped at mn for questionable v/p shunt placement tom'row.  ? start ivf at that time, no order presently.

gu-  u/o adequate 40-60cc/hr.  receiving lasix 20mg po qd.

id-  fever spikes x 2 today with tmax 102.3.  conts on iv levoquin.

[**name (ni) 4**] husband and son in this am and plan to visit again tom'row before surgery... appear to be updated on plan of care.
"
1033,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  remains [** **] on propofol currently at 30mcg/kg/min.  did hold sedation this am, pt making eye contact at that time but no attempts to communicate.  mae ad lib.  does pull hands toward ett while raising head off of pillow.  perl, 3mm, brisk.

cv/pulm:  mp=nsr-sb, no ectopy noted.  one unit prbc's given without evidence of adverse reaction; rpt hct pending.  piv x1 intact, site benign.  central line intact, site benign.  r rad a-line intact, site benign.  did receive all scheduled doses of metoprolol and hydralazine.  bp 106-150's/50's-60's.  remains vented with current vent settings ps20/5, tv's 480-520's, 40%.  bs coarse throughout with scattered intermittent wheezing noted.  increased amts secretions noted-->suctioned q2h for sm amts thick tan secretions.  bronchoscopy done by dr. [**last name (stitle) 2014**] with spec sent to lab.  sputum for c+s sent prior to bronch.

gi/gu:  abd soft, non-tender, bowel sounds present.  did start to stool via mushroom catheter at 1430-->melena stool (team aware).  pt to receive go lightly starting at [**2195**] overnight for colonoscopy in am.  pt remained npo except meds initially due to bronch then due to stooling and start of go lightly this evening.  u/o fair; pt received lasix 40mg iv with poor diuresis.  u/o 30-140 most of time although did drop to 12ml/hr x1hr.

id/endo/integ:  tmax 100.7 po.  pancultured at that time as well as fungal culture sent.  no change in abx.  remains on sliding scale insulin coverage per [**month (only) **].  skin care done per wound care recommendations--coccyx and scrotom remain red, raw.  turned q2h with skin care per flowsheet.

psychosocial/plan:  wife in to visit.  emotional support given to pt and wife.  [**name (ni) 14**] is for go lightly this evening, colonoscopy in am.  maintain vent support, monitor vs, i+o, breath sounds, labs/replete as ordered.  [**name (ni) **] with current nursing/medical regime.  pt remains full code, universal precautions.
"
1034,"respiratory care
patient remains trached with no leak noted.  no vent changes made this shift.  mdi's administered as ordered.  no adverse reactions noted.  sx'd for a small to moderate amount of thick tan secretions.  will continue to monitor as needed.

"
1035,"resp: pt rec'd on simv 14/550/+5/5/50%. ett 8.0, taped @ 22 lip. bs are clear with diminished bases. suctioned for moderate amounts of thick brown plugs at start of shift but subsided toward morning. sample sent. mdi's administered alb/atr administered q6 as ordered with no adverse reactions. pt pa02 @ 77 then increased fio2 to 60%, rr ^ to 18 due to ^ co2. am abg 7.28/44/107/22. rsbi=>200. plan to maintain present settings.
"
1036,"resp:  [**name (ni) **] pt on 40% t/c and sitting in chair. pt put back to bed and placed back on [**last name (un) 205**] psv 14/5/40%.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned small to moderate amounts of tan/bloody tinged thick secretions.  mdi's administered q4 hrs/hhn with no adverse reactions. tv's remain in 300's with 02 sats @ 98%. no further changes noted.
"
1037,"resp: [**name (ni) **] pt on psv 14/5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered combivent with no adverse reactions. vt's 400. ve's [**6-29**]. rsbi=57, decreased ps to 10 with 02 sat's @ 96%.
"
1038,"respiratory:  [**name (ni) **] pt on 50% cam.  pt placed back on [**last name (un) 205**] @ noc with settings simv 20/250/5/+5/40% as per dr. [**last name (stitle) **].  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small amount of thick yellow secretions.  mdi's administered q 4 atr with no adverse reactions. rsbi=40. no further changes noted.
"
1039,"resp: [**name (ni) **] pt on psv 18/5/40%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick white secretions. mdi's administered combivent with no adverse reactions. no abg's/no aline. code status changes, plans to be trached.
"
1040,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilater aeration noted. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions.  am [**last name (un) **]'s 7.43/44/97/30. rsbi=88.  continue to wean with possible extubation today.
"
1041,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv12/500/15/+5/40%.  alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small amounts of thick yellowish secretions.  mdi's administered q4 atrovent with no adverse reactions.  pt gets  very anxious at times ^ rr. 02 sats remain in ^90's. ps decreased to 10 where it remains.  no further changes noted.
"
1042,"1900-0700 csru npn
neuro: alert, ox2 at beginning of shift. accusing nursing staff of trying to kill her. ""tell me the nurse's oath so i know you aren't trying to kill me!"" given 1 dose haldol 2 mg iv with good effect. no dilaudid given as pt has denied pain. spoke with niece ""pat"" - strong family hx of adverse reactions to narcotics (i.e. change in ms, hallucinations, aggitation). new order for ibuprofen prn, however pt refusing to take po's at this time. did get pt to take po lopressor. remains wrist restrained for safety as when unrestrained, pt reaches for swan line & chest tubes despite reorientation.

cv: sr, rare pvc's. ntg weaned to off. started on scheduled doses of hydralazine iv & lopressor po. sbp <150. pacer wires attached & functioning - no pacing required. serosang drainage from chest tubes. co/ci by thermodilution wnl. continues on amiodarone iv for ventricular ectopy. filling pressures slightly elevated, see carevue for detailed assessment/vitals/i&o.

resp: o2 weaned to 4 lnc, abg wnl's. no cough/congestion. l/s clear with dim bilat bases.

gi: no bs. took small sips of clears without difficulty. pt refusing ice chips/sips at this time ? d/t orientation.

gu: foley cath not draining. flushed with 40 ml sterile water, only got return of 20 ml. foley cath changed, now draining without difficulty. u/o marginal - hx of 1 kidney. urine clear, no sediment.

lytes: k+ & ca++ repleated as indicated.

endo: insulin gtt on for short time, but now off. last glucose 80.

social: spoke to niece/spokesperson ""pat"".

plan: ? d/c swan & transfer to [**hospital ward name **] 2. monitor glucose/lytes and treat as indicated. oob>chair today in anticipation of transfer. ? po amiodarone when pt more alert & coherent.
"
1043,"resp: [**name (ni) **] pt on a/c 18/450/+5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody secretions to tannish. mdi's administered as ordered combivent with no adverse reactions. no abg's this shift. rsbi=169. will attempt to wean as tolerated.
"
1044,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 23/12/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x 3 small to moderate amounts of thick yellow secretions/bloody tinged/tannish plugs after lavarge.  02 sats @ 100%. mdi's given q4 alb/atr with no adverse reactions/ flovent [**hospital1 **].  vent changes: decrease ps to 18/peep to 10/fio2 to 40%.  am abg's 7.38/38/151/23.  no further change noted. family meeting expected today.


"
1045,"resp: [**name (ni) **] pt on psv 12/8/40%. ett#8.0 retaped and secured @ 23 lip. bs are clear in apecies with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's administerd q4 hrs alb/atr with no adverse reactions. abg's 7.33/52/83/29. rsbi=52. no further changes noted.
"
1046,"respiratory:  [**name (ni) **] pt on 40% t/c.  pt began to tired and was placed back on [**last name (un) 205**] psv 10/5/40%.  bs auscultated reveal bilateral diminished with scattered coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of thick yellowish secretions.  mdi's administered q4h with no adverse reactions. no further changes noted.
"
1047,"resp: pt rec'd via or on psv 22/12/40%. pt has #10 [**first name9 (namepattern2) 10396**] [**last name (un) 482**] trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4hrs with no adverse reactions. no abg's this shift. line not placed in or. plan is to place line today and dialysis before discharge to rehab.
"
1048,"resp: [**name (ni) **] pt on psv 16/10/35%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. no rsbi due to ^ peep. will continue to wean as tolerated.
"
1049,"resp: [**name (ni) **] pt on aprv 34/8/2.7/0.3/40%. ett #7.5, retaped and secured @ 21 lip. bs are clear bilaterally with diminished bases. suctioned for moderate amounts of white secretions. mdi's administered q 4 alb/atr with no adverse reactions. pt has strong cough. no [**name (ni) **] changes noc. am abg 7.41/40/181/26. will continue full [**name (ni) **] support. no schedule for trach as yet.
"
1050,"(continued)
 with gelfoam; no other obvious bleed.
gi: belly softly distended, active bs, no stool. nepro tf's at goal of 30cc/hr with no residuals.
endo: insulin gtt initiated for fsbs 180's; have achieved good control on current rate of 2u/hr (was as high as 5u/hr). cont's on hydrocortisone.
skin: bilateral ue's erythematous, edematous, weeping; elevated on pillows. no other skin breakdown.
social: several children and grandchildren visiting at start of shift; one dtr stayed the night in the room.

note: pt has doumented allergy to several drugs, including heparin and levoquin, both of which she is on. md's made aware, checked with family; apparently reactions not serious and pt wil remain on both, no adverse reactions noted.

a: remains critically ill with poor prognosis

p: continue all supportive measures; anticipate renal consult with possible initiation of cvvhd; support family; pt remains dnr but fill treat.
"
1051,"resp: [**name (ni) **] pt on a/c 22/450/+5/40%. pt has #8 portex trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift.02 sats @ 98%.  [**name (ni) **]=136. plan to wean to ps as tolerated.
"
1052,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv 18/550/10/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral crackles with slight coarseness which improve with suctioning.  suctioned x3 moderate to copious amounts of thick yellow secretions, as well as oral cavity.  mdi's administered q4 hrs combivent with no adverse reactions.  vent changes as follows:  fi02 decreased to 40% with o2 sats in ^ 90's where they remain.  no rsbi performed as [**name8 (md) 20**] md. no further changes noted.

"
1053,"resp: pt rec'd on psv 22/12+/40%. pt has #10 air filled [**last name (un) **] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administerd as ordered combivent with no adverse reactions. pt scheduled for or today for line placement. no abg's or rsbi due to ^ peep. no further changes noted.
"
1054,"resp: pt rec'd on psv 20/5/40%. pt has #8 portex trach. bs are coarse bilaterally. suctioned for small amounts of white thick secretions. mdi's administered combivent/alb as ordered with no adverse reactions.vt' 400-500, ve's 9, rr 25.  [** **]=171. will continue to wean as tolerated.
"
1055,"resp: pt rec'd on psv 24/10+/50%. ett # 7, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally and suctioning for moderate to copious amounts of thick yellow secretions. mdi's administered as ordered of combivent with no adverse reactions. vt's 300's ve's [**9-8**]. plan to trach today in or.  no further changes noted.
"
1056,"resp: [**name (ni) **] pt on psv 20/5/40%. pt has # 8 portex trach. ambu @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. 02 sats @ 100%. vt's 500's. ve 12, rr 24. no changes noc. [**name (ni) **]=196. will continue on present settings.
"
1057,"resp:  [**name (ni) 92**] pt on [**name (ni) **] a/c 14 600/70%/+15. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x 3 for small to moderate amounts of thick bloody tinged secretions.  mdi's administered q 4 of alb/atr with no adverse reactions noted.  minimal air technique used to ^ maintain adequate cuff pressures.  02sats remain  in^ 90's 94-96% with no distress noted.  no rsbi performed dueto high peep pressures.  no further changes noted.
"
1058,"resp: [**name (ni) **] pt on psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. mdi's administered 2 p alb/2p atr with no adverse reactions. pt was extubated without incident and placed on 40% cam.
"
1059,"resp: [**name (ni) **] pt on a/c 20/400/+5/40% alarms on and functioning. ambu/syringe @ hob. pt has #10 portex ([**name (ni) 10396**]) cuff. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. no changes or abg's this shift. will continue full vent support.
"
1060,"resp: [**name (ni) **] pt on psv 20/5/40%. bs are coarse bilaterally. suctioned for small amounts of white thick secretions. mdi's administered as ordered comb/alb with no adverse reactions. no abg's this shift. 02 sats @ 100%. vt's 400's,rr 25-27. [**name (ni) **]=181. no changes this shift. plan to wean as tolerated.
"
1061,"focus: status update
data:
pt much calmer in am and following commands easily and conversing at times. alert and oriented x2. became agitated again early pm and progressing to extreme agitation w/hallucinations,confusion and requiring restraints. ativan per [** 5671**] scale w/some effect.

junky productive cough--tonsil tip sx.

tachy to 120's w/agitation. lopressor and ativan w/effect.

adverse reaction to ambisone noted 5min into infusion start. pt c/o chest pain, dyspnea and became extremely agitated. ekg done w/o changes per dr. [**first name (stitle) **] and ck-iso done. ativan given and ambisone infusion slowed down with some improvement. dr. [**last name (stitle) **] also notified of reaction and wife present at time. agitation is known effect of drug. chest pain relieved with rate reduction.

r neck soft ""bump"" noted this pm--appears lymphatic. dr. [**first name (stitle) **] and dr. [**first name (stitle) 1777**] in to eval. non-line related. will monitor.

urine output bloody for several hours today. foley irrigated x2 clearing this pm. possibly d/t trauma as pt is in constant motion. u/a sent.

plan:
cont [**first name (stitle) 5671**] scale. tx 2u prbc. ct guided drainage postponed per team--f/u in am.
"
1062,"cardiovascular: pt. remains in a controlled sinus rythym in the 60-70's with no noted ectopy. r&l lower ext's require use of a doppler to note pulses, no noted edema at this time. hct:29.3 one unit of prbc's ordered and infused at 2100. tylenol & benadryl given p.o. to aid in adverse reaction prevention. epitaxis remains to saturate gauze every hour.  m.d's are aware and orders to continue integrillin gtt on pt's chart. plans to monitor and educate the pt. regarding adverse  signs. pt. states ""i understand what you are talking about."" pt. is able to repeat these instructions back to the nurse. [**first name (titles) **] [**last name (titles) **]. of hematuria noted in folet collection bag. m.d.'s are aware of this. with no orderes obtained at this time. daughter called last hs to check in on pt. she is a nurse, and is very nice. nasal packing performed once with [**last name (titles) **] [**last name (titles) **]. of petroleum ointment applied to aid in comfort level. no further bleeding is noted at this time. pt. rema1ns in good spirts.
"
1063,"see [**name6 (md) 673**] data, md notes/orders. neuro: very sedated this am, mae, perrl and following commands this pm. propofol and fentanyl gtts decreased as tolerated with [**hospital1 **] haldol initiated. prn ativan dc'd due to pt communicating a reaction to it in the passed, no adverse reaction noted to dose given earlier in shift. had one episode of shaking that accompanied tachypnea, pt nodded head to dt's and then nodded no when asked if he has had them before. shaking resolved spontaneously cv: sr/no ectopy, sbp 130's/80's. cvp 9-13. pulm: vent changes/abg's per [**hospital1 673**]. fi02 incr to 50% from 40% this pm for prolonged tachypnea and drop in 02 sats. tacchypnea  responded to fentanyl bolus but reccurred with activity of suctioning and pts using the bed pan. lungs coarse, decreased at bases, pt suctioned for mod/copious thick tan secretions. left chest tube to water seal, small amount crepitus on left side/abd. gu: uo 45-400cc/hr. gi: abd soft, bs +, passing flatus and large formed and liquid stool which was guiac neg. tube feed currently at 80cc/hr with goal rate 95cc/hr. skin: intact,  4+ pedal pulses. endo: has required no coverage, finger stick glucose decr to [**hospital1 **]. soc: [**hospital1 **] in this pm, updated on progress and poc. p: continue to wean sedation and vent as tolerated, observe for recurring symptoms of dt's, initiate ciwa scale as indicated. increase tube feed to goal rate if residuals <200cc. offer support and encouragement to family.
"
1064,"resp: [**name (ni) **] pt on a/c 22/450/+5/50%. ett #7.0, 22 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with slight coarseness on rml. suctioned for small to moderate amounts of thick tannish secrections. mdi's administered q4 hrs alb/atr with no adverse reactions. vent changes of decrease in fio2 to 40% with abg pao2 @ 76, then increased to 50%. am abg pending. no rsbi due to ^ peep. plan is to wean as tolerated with acceptable abg's,
"
1065,"resp: [**name (ni) **] pt on a/c 15/500/+5/50%. placed pt on psv 12/5/50% and didn't tolerate, placed back on a/c settings. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bialteral crackles. suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr q4 with no adverse reactions. abg 7.45/39/70/28 and no changes noc. rsbi-120. will continue to wean appropriately.
"
1066,"resp: [**name (ni) **] pt on psv 10/5/50%. ett #8 @ 23 lip.alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for moderate amounts of white frothy secretions. mdi's administered alb/atr with no adverse reactions. abg 7.31/68/99/36. rsbi=59.
"
1067,"resp: pt administered mdi's q4  hrs alb with no adverse reactions. some improvement noted following tx.
"
1068,"resp: [**name (ni) **] pt on a/c a/c 22/450/+1/50%. ett#7.0 taped @ 22 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral noted aeration with diminished bases. suctioned for moderate amounts of thick tannish secretions. mdi's alb/atr administered q4 hrs with no adverse reactions. abg's (see careview) am abg 7.29/37/95/19. will continue full vent support.
"
1069,"resp:  [**name (ni) **] pt on [**last name (un) 205**] a/c 10/500/+5/50%.  alarms on and functioning. ambu/syringed @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow/whitish secretions.  mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.36/38/97/22.  pt is full code, md to speak with family today for possible code status change.
"
1070,"resp:  [**name (ni) **] pt on t/c @ 40%.  pt placed back on [**last name (un) 205**] psv 5/5/40% to rest @ [**last name (un) **]. bs auscultated reveal bilateral clears sounds. improvement noted. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=61 this am.  plan to place back on t/c during the day and to get pt out of bed to chair.  will continue to wean appropriately.
"
1071,"nursing admission note:

pt is a very pleasant 51yo man admitted to micu a for pcn desensitization. please see fhpa for further details of pmh, hpi.

all: pcn (rash, ""throat tightenening""), last dose when he was in his 20's.

valuables: pt has cell phone, wallet w/id, watch and some clothing in his room. offered opportunity to lock valuables in safe, but he declined.

ros:
neuro: pt a&o x 3, very pleasant and cooperative. no neuro deficits. pt has intermittent ha which he presented with, which responds well to tylenol. he also has ""spinal ha"" post-lp. he describes this as pain at the back of his neck, radiating up the back of his head. this pain occurs when he is sitting up and is relieved by lying flat.
id: afebrile, wbc 3.1 (4.8). pt given escalating doses of pcn per desensitization protocol. recieved 5 doses without any evidence of reaction. within a couple of minutes of starting the 6th dose (50,000 units), he suddenly began to vomit bilious material, about 300cc's total. dose was immediately stopped, and within a couple of minutes he stopped vomitting. no treatment needed. team notified of this event; after consultation with allergist, doses 4, 5, and 6 were repeated. at this writing, dose 6 is infusing without difficulty, and pt is asymptomatic. plan is to give 7th (full) dose, then start on standing doses if he continues to do well (order not yet written for standing doses).
c-v: hemodynamically very stable; hr 70's, bp 90's-100's. lytes wnl.
resp: pt is on ra with no complaints. ls cta, sats high 90's, rr teens. slight brief desaturation noted at times when sleeping.
gu: voiding clear yellow urine in urinal. bun/creat wnl.
gi: belly benign, no stool. episode of vomitting as described under id.
endo: no issues
heme: hct stable at 31; plt's wnl. no evidence of bleeding.
skin: intact; faint rash on palms and soles of feet.
access: piv x 1.
social: married. wife is spokesperson.

a: tolerating pcn desensitization thus far

p: if he is able to complete desensitizatin protocol, anticipate return to cc7 and continuation of pcn for presumed neurosyphilis. if he has any adverse reaction, will need further desensitization.
"
1072,"addendum: pt has now completed the desensitization protocol without any further adverse reaction. solumedrol, epi, and benadryl at the bedside at all times.
"
1073,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow/white secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  rsbi=54. no a-line.  will continue to wean as tolerated.
"
1074,"admission
pt admitted from or at 1445 s/p maze, asd repair,cabgx4, left atrial appendage repair. to csru in sb 50s, a wires not working appropriately, despite polarities changed, a wires placed in v port to max ma [**name8 (md) 20**] np [**doctor last name **] working appropriately, v wires not capturing appropriatley. v wires secured. ekg not taken at this time d/t pt being paced and sbp decrease when not paced. to csru on neo and propofol. immediatley post-op, u/o 200-1000cc/hr, see carevue. 6 liters total given of crystalloid. 1 unit of prbcs no adverse reactions noted. ci > by fick, see carevue, np [**name6 (md) **] and np [**doctor last name 54**] aware of co/ci. mixed venous sent, result 54, np [**doctor last name 54**] aware, another liter of fluid given + 1 unit of prbcs.

neuro: pt sedated on propofol gtt. perrla. morphine for pain, noted change in vital signs.

cv: hr, noted as above, 84 apaced, no ectopy. goal sbp 110-120s. see carevue for details on neo gtts. see carevue for filling pressures and ci/co. np [**name6 (md) **] and np [**doctor last name 54**] aware, fluid and prbcs given. +dopplerable pedal pulses. right groin ecchymotic w/ small hematoma near right groin from old cath site, team aware.

resp: ls clear diminished. see carevue for details of abgs and vent changes. peep not needed to be increased to 10 [**name8 (md) 20**] np [**doctor last name 54**]. sats >96%.

gi/gu: abd soft, absent bs. ogt +placement, draining bilious/clear secretions, minimal drainage. ct oozy, see carevue for details, received protamine 50mg iv. foley draining clear yellow urine 200-1000cc/hr, np [**doctor last name **] aware, received total of 6 liters of crystalloid, np [**doctor last name 54**] aware.

endo: gtt not needed. fs 101.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. pain control. monitor ci.
"
1075,"resp: [**name (ni) **] pt on psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. mdi's adminisered comvbivent/flovent as ordered without any adverse reactions. suctioned for small amounts of white secretions. rsbi=81. am abg 7.39/45/85/28. plan to continue with wean to extubate.
"
1076,"7a-7p
neuro: pt alert and oriented, disoriented to time only. mae weakly, stiff when tuning pt. see carevue for details of pupils. tylenol po via dophoff for pain, generalized and c/o bilat back of knees aches, np [**doctor last name 54**] aware no new orders.

cv: at approx. 1230, pt to afib rate 80-100s. np [**doctor last name 54**] aware, iv lopressor given total of 10mg ivp [**name8 (md) 20**] np [**doctor last name 54**]. converted at approx. 1500, sb 50s, np [**doctor last name 54**] aware. pt on po dose amiodarone 400mg daily. sbp >90, pt did not tolerate afib sbp 80s, neo as high as 2mcg/kg/min, able to wean neo when pt in sinus rhythm. cvp 9-16. received 1 unit of prbcs, no adverse reactions. aline femoral right intact. see carevue for details. + dopplerable pedal pulses. dusky toes.

resp: ls coarse clears after nt suctioning. nasal trumpet to right nare for frequent nt suctioning. suctioning thick tannish secretions small to copious amts via nasal trumpet. sats >98% on 4-6lnc. see carevue for abgs.

gi/gu: abd soft obese +bs, passing loose dark brown stool via fib. pt failed swallow eval, dophoff placed by np [**doctor last name 54**], ok to use [**name8 (md) 20**] np [**doctor last name 54**]. tf changed to impact w/ fiber goal 60cc/hr at present tolerating 50cc/hr, no residuals. straight cath for amber cloudy urine 15cc. cvvhdf goal -50cc/hr. filter changed secondary to filter clotted while pt in chair. goal 1liter neg for 24 hours. blood given not taken off output [**name8 (md) 20**] np [**doctor last name 54**], goal try to get neo gtt off, then may increase cvvhdf to -100cc/hr. see carevue for details of quinton cath.

endo: riss + lantus dose given sc in am as ordered.

skin: bullae to pt's back, derm into assess pt. broken blisters to bilat legs, groin and labia. groin w/ blisters. see carevue for details of skin assessment. when straight cath, yeast vaginal discharge noted, np [**doctor last name 54**] aware, miconazole ordered.

activity: ok to get pt oob [**name8 (md) 20**] np [**doctor last name 54**] even w/ fem a line by [**doctor last name **]. bed changed to air bed.

plan: monitor hemodynamics. monitor resp. status. nts prn. -50cc/hr via cvvhdf. pain control. wean neo to keep sbp>90.
"
1077,"resp: rec'd on a/c 20/600/+5/40%.ett #7.5 retaped and secured @ 21 teeht. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse which clear following suctioning. suctioned for small-moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. am abg 7.40/52/110/33 with no changes noc. will continue full vent support.
"
1078,"resp: [**name (ni) **] pt on a/c 18/800/+5/70%. bs are diminished throught. suctioned for small amounts of thick tan secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg's 7.45/43/83/31 with no vent changes noc. plan trip to mri today to r/o osteomyletitis.  will continue full vent support.
"
1079,"npn 7a-7p

[**name (ni) **]  pt. remains febrile with low grade temp 100.7 pr tmax.  conts on a/c without vent. wean today d/t febrile state [**name (ni) 87**] as well as cardiac decompensation considerations.  sx'ing needs are diminished compared to yesterday's descriptions. will attempt to turn off propofol gtt tom'row and wean to psv if remains stable [**name (ni) 87**].

review of systems-

neuro-  on 60mcg/kg/min of propofol easily arousable to voice, does not follow commands, makes eye contact, appears frustrated but unable to nod appropritately when interviewed.  moves all extremeties.  occasionally rigid when temps are higher.  will intiate weaning of prop/ventilator tom'row.

resp-  a/c 650 x 24 40% peep 10.  abg on 50% 7.45/36/178/26 this am.  mv 18.5l to maintain pco2.  considerable dead space ventilation.  ls cont to clear with some coarse rales heard bibasilar and crackles prominent on left side.  sat's remain stable.  sx'd q3-4 hours which is much less than yesterday's requirements.  will attempt psv tom'row.

cv-  hr 89-100's sinus rhythm.  bp 110-130's via nbp cuff.  conts on ntg gtt at 1.7mcg/kg/min, lopressor 20mg qid, heparin stable at 1600uhr with [**name (ni) 490**] ptt checks.  edema throughout lower extremeties and dependent regions +[**2-5**].  will be dialyzed tom'row and saturday to remove 4+ l in total.

gi-  abd soft/sl. distended.  sm. smearing of stool this am.  mushroom cath d/c'd d/t low volume of output.  reglan d/c'd d/t possible drug adverse reaction (fever) with consideration that pt. had 1100cc of stool out yesterday and already 300 today.  tf advanced to 20cc/hr and appears to be tolerating.  would consider increasing to 30 this evening.  tpn conts.  need to send next stool for c.diff- toxin b. ? colitis on ct scan.

gu-  minimal urine out.  hd tom'row and saturday as mentioned.

id-  fever w/u persists, all recent culture data negative to date, negative abd ct scan from yesterday.  id following.  restarted zosyn and vanco dosed by level yesterday (31.7 today).  lactate 1.5.

[**name (ni) 4**]  father in today and updated by nursing and sub-i.  would like to speak with cardiology about recent findings before he returns to [**country 8754**] on the 20th.  dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] emailed about this request and should meet with him tom'row.  sw and cm working closely with pt's father to find placement in home country.  father is staying at [**doctor first name 8762**] apt. in [**location 8763**] and is using public transit system- appears comfortable with accomodations.
"
1080,"resp: [**name (ni) **] pt on psv 15/10/50%. bs are coarse bilaterally. suctioned for copious to moderate amounts of thick yellow secretions. mdi's adminstered q4 with no adverse reactions. no rsbi=^ peep or abg's this shift. plan to continue on present setting.
"
1081,"resp: [**name (ni) **] pt on psv 15/10+/50%. ett #7.0 taped @ 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered as ordered of alb with no adverse reactions. pt has episodes of ^ rr to 40's then settles down. am abg 7.50/36/79/29. no rsbi due to ^ peep. will continue to wean as tolerated.
"
1082,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 24/500/+15/65%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse. suctioned for moderate amounts of tan thick secretions. mdi's administered q 6 hrs with no adverse reactions. am abg's 7.40/50/108/32.  decreased fio2 to 50%.  questionable for ards protocol.

"
1083,"resp: [**name (ni) **] pt on psv 15/10/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged to tan secretions. q1-2 hrs. mdi's administered as ordered alb with no adverse reactions. no abg's this shift or changes. no rsbi due to ^ peep.
"
1084,"resp: pt rec'd on psv 15/10+/50%. alarms on and functioning.ambu/[**e-mail address 9422**] are coarse bilaterally. suctioned small to moderate thick yellow to greenish secretions. mdi's of alb administered as ordered with no adverse reactions. vt's 400-500, ve's 11, rr ^ 30's at times. no rsbi due to ^ peep. no abg's this shift. no changes. will continue with present settings. family meeting expected to determine [**e-mail address **] status.
"
1085,"nsg admit note npn
respir: arrived via eu s/p transfer from [**first name8 (namepattern2) **] [**last name (titles) **], with pnx.   had 100% nrb in place o2sats in eu 90-94% on 100% nrb with abg- 7.41/29/74/19, lactate up to 5.8. cxr- r ll pnx, l/s crackles on r clear to diminished on l. was @ first going to be admitted to the floor but with high lactate and rr, and hr was placed on sepsis protocol. central line placed, and was started on iv antibx's. wbc-18. does become very doe and desats very easily with any mask movement. rr 24-30. will be intubated if needed. no abg drawn since admit to micu does not have an a-line. last vbg- 7.36/37/38/22

c/v: sepsis central-line placed with cvp 4-6, in eu and since admit to micu- [**1-12**], did rec 2l's in eu, but with poor respir status and stable hemodynamics, cannot follow the protocol to keep cvp's-[**7-21**], would not tolerate them. has rec'd two 500cc ns boluses since admit, last one just given @ 1830 in attempt to have cvp-8, and to treat high cre. bp- 106-118/70, hr 98-110's st with occ apc's and pvc's. no c/o's cp.

id: temp max 98.8 ax with wbc- 18, was started on iv ceftriaxone and azithromycin, q24 given in eu. was also started zigris iv study, is a double blind study and is to remain continious infusion for 4 days. cultures were drawn @ [**hospital1 **]. [**location (un) **], still awaiting a sputum spec.

gi: is npo @ present is swabbing mouth with ice water. no stools.

gu: u/o 50-75cchr, bun/cre 72/2.4, rec'ing ivb's in attempt to decrease cre.

neuro: is alert and very pleasant. has(2nd) wife, and his daughter that are [**name (ni) **], are involved and very supportive.

lines: central sepsis protocol line r ij and #20 r arm.

a/p: continue to monitor respir status, assess o2 sats and abg's, cxr, aggressive pulmon toilet. monitor i&o's, and cvp's levels. administer iv antibx's. assess for adverse reaction to study drug.
"
1086,"resp: pt rec'd on ffv psv 8/5/50%. vt's 500's ve's [**12-5**], rr 20-22. placed on 70% f/t with cool humidification as tolerated. (see careview for series of abg's) following abg, pt placed back on psv 8/5/50%. hhn administered alb/atr with no adverse reactions. bs are coarse bilaterally. pt has r nasal trumpet. suctioned for moderated amounts of thick yellow and bloody tinged secretions. am abg 7.28/45/142/23. will continue alternating between ffv and f/t to hopefully avoid pt being trached.
"
1087,"resp:  [**name (ni) **] pt on a/c 20/600/+5/40%. ett #7.5,  retaped and secured 21 @ teeth. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally which improve following suctioning. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. no change noc, am abg pending.
"
1088,"micu nursing progress note 7a-7p
pt with increased work of breathing, rr 40s-50, pt increasingly rrestless. intubated for resp failure with 120 succ and 20 etomidate. pt sedated on propofol gtt initially, changed to fentanyl and versed d/t hepatitis. pt became increasingly hypertensive 180s/90s with increased doses. changed back to propofol for ? better sedation but not effective. pt t rapidly increasing to 103.8, rigoring and hr 150. demerol 25 x 2 with no effect. changed sedation to fentanyl and versed with increasing doses for sedation. abg 7.28/25/117/12. 2 amps bicarb given. cont tachycardic, hypertensive. dr [**last name (stitle) **] in to evaluate pt, will also consult toxicology.

neuro - currently on fentanyl 600 mcg/hr, versed 8 mg/hr. [**last name (stitle) 532**], brisk, no spontaneous movement. cont with rigoring but a little less so.

resp - ac 20x600, +5, 60%. rr 25 with sedation, was in high 30s before sedation increased. resp pattern pulling large volumes about 1 lite, mv 27. last abg as above, cont in metabolic acidosis. lungs coarse throughout. very thick, tenacious secretions at time of intubation, now sm/mod thick white secretions. cxr shows worsening pna l>r. zosyn added to antibx regime. sats 96%.

cv - bp 180s/90s. st 160s, ekg shows st. lytes from am repleted. pm lytes have not been repleted. hct stable, wbc 12.2. cvp 14. skin flushed, +[**2-5**] edema, facial edema.

gi - abd soft, + bs. no stool + flatus. ngt to lcs as pt vomitted after intubation, draining dark green bile, ob (+). na increasing 151, ivf changed to d5w with 150 bicarb.

gu - uop borderline 20-50/hr. creatinine increasing.

social - sister and [**name2 (ni) 163**] called and aware of pts worsening condition.

plan - worsening septic picture, ? adverse reaction to meds given peri/post intubation. will cont to follow abgs/labs. toxicology report. replete lytes prn, sedation.
"
1089,"resp:  [**name (ni) **] pt on [**last name (un) 205**] a/c 18/500/+10/60%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of white thick secretions.  mdi's administered q4 alb with no adverse reactions. am abg's 7.34/36/68/18. following family meeting pt is [**name (ni) **]/dni.
"
1090,"resp:pt remains intubated #8 ett, 22 lip and rec'd from or on a/c. bs are coarse with diminished rs.mdi's administered q 4 alb/atr with no adverse reactions. abg's 7.46/39/80/29. vent changes to psv 10/10/60% with additional abg's pending. will continue to wean appropriately.
"
1091,"admission
pt is a 77 year old male s/p cabgx3 and asd repair, see admission h+p for details of pmh and or events.

neuro: pt sedated on propofol. reversed per protocol as 1730, during pm rounds ? wean and extubate d/t earlier issues w/ low ci. pupils 2mm briskly reactive left slightly larger np [**doctor last name **] aware. demerol given x2 for shivers as ordered, resolved after 2nd dose.

cv: received av paced from or-> ekg done nsr pr 0.20- np [**doctor last name **] assessed. presently a paced 80s for sbp. sbp labile, on and off ntg and neo, presently on neo gtt w/ goal sbp 100-110 [**name8 (md) 20**] np [**doctor last name **]. ci<2 by thermodilution, fluid bolus x2 given bringing ci >2 by thermodilution briefly, see carevue for details, fick sent, ci>2 by fick. svo2 62-63%, see carevue, np [**doctor last name **] aware. 1 unit of prbc s given w/ no adverse reactions [**name8 (md) 20**] md [**doctor last name **] for low filling pressures. cvp 6-12. pa 25-30/15-20s. sternal dsg cdi, medistinal dsg cdi. + palpable pulses.

resp: ls clear. sats >98%. see carevue for abgs and vent settings. ct w/ minimal sang. drainage, see carevue.

gi/gu: abd soft absent bs. + placement of ogt. foley draining clear yellow urine 60-400cc/hr, see carevue.

endo: gtt per protocol.

social: son and daughter into visit and updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent, following ci.
"
1092,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 20/400/50%/+10.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of thick yellow secretions. mdi's administered q4 combivent/flov [**hospital1 **] with no adverse reactions. pt appreared rested and comfortable today. rsbi=37 with am abg's 7.37/47/101/28.  pt expected to go to or today for stent procedure.  no further changes noted
"
1093,"ccu nursing progress note
s:  nodding head ""yes"" when asked if in pain, and ""yes"" when asked if the pain was in her hip.

o:  see ccu flow sheet for complete objective data

right hip fracture:  given 1 u ffp and iv vitamin k to correct pt/inr prior to surgery.  repeat pt 14, inr 1.3.  surgery postponed until tomorrow in attempt to get inr <1.1. received 1u prbc over 4 hours, with adverse reaction.  repeat hct 26.1. turned from back to right side, with pillow between legs.  given 25-50 mcg of fentanyl iv prior to position changes.  hr increases to 80-90 with position change, but then quickly returns to patient's baseline 70-80.  remains on propofol 35 mcg/kg/min.

neuro:  shaking head yes, when asked if she can hear me.  also shaking head in regards to pain.  moving arms.  moves hands towards hip during position changes. does not attempt to pull at any iv's or ett.  wrist restraints removed, have remained off during this shift.  spoke with health care proxy today.  [**name2 (ni) **] states that at baseline, ms. [**known lastname 6703**] can ""carry on a conversation"" and ""exercises good judgement, but memory is very poor and would get lost if left on her own.""

resp:  remains intubated, 50% ac x14- 450cc, 5 peep.  pp 19-21.  breathing in phase with the vent.  rare spontaneous resp effort.  o2 sats remain 98-100.  lungs with coarse bs, ets-->small amount of tan secretions.

cv:  remains in nsr, 70-80's transiently up to 90 with position changes.  rare apc.  bp 92-162/48- 83 map's 62-109, with higher numbers occurring with position change.

id:  t max 101.8 rectally.  has been cultured in past 24 hours.  given tylenol via ogt q 4 hours-->t 99.6 rectally.  wbc 11.6 (9.4)  started on levofloxacin iv.

gu:  foley in place, u/o 60-80 cc/hour.  receiving ns @ 100 cc/hour.  bun/cr  22/1.1

access:  tlc in place, dressing changed, only old blood at site.  transparent dsg on, site, clean.

skin:  decube on left glute.  1cmx 1.5 cm, 2 mm deep.  cleansed with wound cleanser, duoderm applied.

a:  s/p right hip fracture, surgery on hold until tomorrow until inr improved.  pain controlled with fentanyl iv q 1 1/2-3 hours.  t controlled with tylenol.  old decube. o2 sats within good range, breathing in phase with vent.

p:  ffp and vitamin k as per team in prep for or in am.  continue position changes, pre-med with fentanyl.  assess response to fentanyl  monitor hct. follow temp, cultures pnd.  monitor lungs, follow o2 sats.

"
1094,"npn 1900-0700

neuro: awake and [** **] throughout night.no appparent nuero changes.recieved 5 mg of ambien @ 0300 to aid  w/ sleep.

resp: continued on cpap,was originally down to ps 12/5 55%fio2 w/ mv's [**1-2**].began slowly dropping sats down to 88-90.attempted suctioning w/ min return.increased fio2 and peep w/ min response.abg on ps 14/8 w/peep of 8 and 100% fio2 was 7.52 pao2 73 pco2 33.continues to go up on peep to possibly re recruit .presently on psv 16/10 fio2 80%. attmpting to wean down fio2 by 10% q hr, following sats.

c/v: aflutter occ pvc's bp low 100's , gave lopressor at this lower systolic rate for better hr control. no adverse reaction to bp.

f/e/n:recieved 10 mg lasix iv w/ brisk response. tol tf @ goal, no stool overnoc.

plan: cont to wean vent settings as tol, cont ab tx, monitor hemodynamics.
"
1095,"resp:  [**name (ni) 97**] pt on simv 26/700/10+/80%.  ett 8.0 24 @ lip.  alarms on and functioning. ambu/syringe @ hob.  bs are diminished bilaterally, with some aeration noted in upper lobes. suctioned for small amount of white secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. pt was bronched yesterday, then recruitment maneuver and became hypotensive.  fio2 ^ to 80%.  vent changes and abgs(see careview for settings and results) present settings simv 18/700/70%/12+.  am abg pending. possible bronch again today?
"
1096,"neuro:

neuro status remains unchanged; pt opens eyes but doesn't track this am. perl mae does not follow commands but is in constant motion in bed. required increase amts of ativan (6mg) w/o ability to sedate. spoke w/drs [**last name (stitle) 4367**] and [**name5 (ptitle) **] [**name5 (ptitle) **] ordered with hopes of producing sedation and pt's safety. total of 30 mg given in 4hrs w/o much change in behavior.
? adverse reaction to benzos, rash still present although not as firey red ? itching making pt so restless or some other issues of addiction resulting in withdrawal sx's.
? worthwhile consulting [**first name8 (namepattern2) **] [**last name (namepattern1) **] who specializes in addiction issues
"
1097,"micu npn  0700-1500
see [** 3326**] for subjective/objective data.  neuro:  remains unresponsive; intermittently moves head and body.

cv/pulm:  r groin dialysis catheter removed at 0800 by renal fellow, per fellow pressure held x15min.  no bleeding following removal of catheter however 10min later site re-bleeding.  fellow in, site held by fellow for additional 15min by fellow.  no bleeding at that time however approx 20min later approx 200ml brb noted at site.  pressure held, intern notified.  two units ffp given, txm for 2units prbc.  no bleeding for 1and 1/2 hr then re-bled approx 50ml.  intern in, site packed by intern, sandbag applied.  ddvph hung at 1300 x1 dose.  receiving first of two units prbc's (hung at 1130; no adverse reactions noted thus far).  no further bleeding at site noted.  remains on levo at 0.7mcg/min.  remains vented per [** 3326**] (on ps).  bs coarse bil.

gi/gu:  tol tf at goal.  fib in place.  receives hemodialysis.  dialysis catheter removed as noted above due to purulent, fowl smelling drainage at site.  to go to ir for new dialysis cath [** **] in am, to have dialysis following [** **] of new catheter.

integ:  see [** 3326**]--healing herpatic lesions, decub on coccyx-->
duoderm applied.

id:  afebrile.  no change in meds.

psychosocial:  social work involved.  no visitors this shift thus far. emotional support given to pt.
"
1098,"micu addendum
no further bleeding from r groin site.  to ir at 1415 for [** **] of new dialysis catheter.  first of two units prbc's infused without adverse reactions; ffp completed without adverse reactions.  remainder assess per [** 3326**]/unchanged.
"
1099,"resp: pt rec'd on psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. suctioned for small amounts of  bloody secretions. mdi's administerd as ordered with no adverse reactions. rsbi=28. will continue to wean as tolerated.
"
1100,"respiratory:  [**name (ni) 97**] pt on servo simv 16/650/12/+5/50%. alarms on and functioning. ambu/syrnge @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning.  pt [**name (ni) **] tonight for a moderate amount of thick bloody secretions.  mdi's administered of combivent q4/flovent [**hospital1 **] with adverse reactions. 02 sats 95-97% with no distress noted.  no further changes.
"
1101,"resp: [**name (ni) 97**] pt on a/c 22/650/10+/55%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, taped @ 22 lip. bs are coarse bilaterally. suctioned for moderate amounts of tan/yellow thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to wean as tolerated with present settings a.c 18/550/+8/55%. abg obtained with results 7.38/50/83/31. plan to trach today.
"
1102,"micu  npn
see [** 3326**] for subjective/objective data.  neuro:  opens eyes to verbal stimuli/tactile stimuli.  reaching r hand toward trach-->r hand restrained (see [** 3326**]).  no attempts to speak.

cv/pulm: bp low this pm-->72/40 with map 51.  intern notified, ns bolus 500ml over 2hrs hung with bp increased to 86-90/30-40, map high 50's to 60.  ns currently infusing, to be completed by [**2081**].  two lumen picc dsg changed.  rec'd 2units ffp prior to [**year (4 digits) **] of peg.  r ej dialysis cath dsg d+i.  remains vented on cpap+ps.  suctioned for sm amts thick yel-->clear sec via trach.  bs clear upper lobes, coarse lower lobes.  trach care done with 1/2 str h2o2.

gi/gu:  peg placed by dr. [**last name (stitle) **] at 1230 without incidence.  med with versed and [**name6 (md) **] by md; tolerated meds without adverse reactions.  peg may be used for meds this pm; to resume tf in am.  rec'd hemodialysis this am-->two liters off [**name6 (md) 9**] hemodialysis rn.  next dialysis due sat [**2153-11-17**].

integ:  healing zoster areas.  packing to r groin changed-->sm amts ser-sang drng on old dsg.  red area at base of coccyx; not open.  multi-podis boot [**month/day/year 3333**] r/l.  hand splints [**month/day/year 3333**] on/off.

psychosocial:  no family contact this shift.  emotional support given to pt.
"
1103,"resp: [**name (ni) 97**] pt on psv 5/5/50%. bs are diminished bilaterally. suctioned for small amounts of secretions. ambu/syringe @ hob.alarms on and functioning. mid's administered as ordered with no adverse reactions. no changes noc. plan is for pt to be trach possibly today.
"
1104,"resp: [**name (ni) 3373**] pt on a/c 28/500/+15/100%. alarms on and functioning. ambu/syringe @ hob. ett #7.5 rotated, retaped and secured @ 22 lip. bs are coarse with diminished bases. suctioned for scant to small amounts of bloody tinged secretions. mdi's administered alb with no adverse reactions. several attempts to place a-line without success. circuit changed to heated. vent changes to decrease fio2 to 80% and maintaing sats @ 96-97%. possible trach today? will continue full vent support.
"
1105,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 14/650/50%/+10.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases.  mdi's administered q4 alb/atr with no adverse reactions. suctioned small amount of thick pale yellow secretions. abg's=7.37/40/82, then increased fio2 to 60%, following abg's 7.37/40/103/24.  no further changes noted.
"
1106,"resp:  pt rec'd on [**last name (un) **] simv 14/550/5/+5/40%. ambu/sryinge @ hob.  auscultated bs reveal increased aeration bilaterally with a few scattered crackles which cleared with suctioning.  suctioned x3 small amount of thick yellowish secretions. mdi's administered q4hrs with no adverse reactions.  rsbi=24.  02 sats@ 100%. no further changes noted.
"
1107,"resp: [**name (ni) 97**] pt on simv/ps 26/700/18/+7/60%.  alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with diminished bases. suctioned for moderate amounts of thick white secretions. mdi's administed q6 hrs combivent/flovent [**hospital1 **] with no adverse reactions. am abg 7.40/32/82/21. no rsbi due to ^ fio2. plan to wean as [**name8 (md) 9**] md.

"
1108,"resp: [**name (ni) 97**] pt on a/c 15/500/+10/50%. trach 10 o.d/7 i.d. alarms on and functioning. ambu/syringe @ hob. bs are coase bilaterally. suctioned for moderate to copious thick yellow secretions. mdi's administered q4 hrs atr with no adverse reactions. no abg's or changes this shift. will continue full vent support.
"
1109,"admission note:

pt is a 83 yo healthy female admitted to [**hospital1 95**] with an embolic r stroke. pt was performing daily stretches this early am, felt weak and heavy on her left side, pt called her daughter then called ems, sent to er code stroke at 0945, ct scan showed embolic stroke to punctate areas of r parietal and frontal lobes (per er). tpa administered in er, focal sz activity noted in lle, mri obtained during sz activity, eeg leads placed after mri, 1 mg of ativan given---> resolution of focal sz activity, arrive in the tsicu at 1400.

neuro: alert and oriented to person place time and situation, slow to respond at times, l sided hemiparesis versus ataxia improving each hour, decreased l sided coordination and proprioception initially, decreasing l pronator drift, resolving l ptosis and facial droop, eom intact, no visual field deficits noted, impaierd sensation to light touch on l side but not deep pressure and pain, improving motor activity on l side in both ue and le, perrla 4mm, impaired cognition with simple addition and subtraction, clear speech.

cv: nsr, blp 120-160 systolic, goal bp between 110-180 systolic, easily palp pedal pulses on r, weak palp pedal pulses on l, afebrile, pneumoboot on, on anticoag for 24 hrs s/p tpa infusion, given 2 l ns bolus in er due to bradycardia during phenytoin administration, phuenytoin d/c'd.

resp: 98% o2 saturation on ra, blscta, on cough, + nasal congestion, nl rr and depth.

gi: last bm this am, active bs, soft abdomen.

gu: foley placed, adequate urine output > 100 cc per hour, on d5w with 150 meq of bicarb for 450 ml then ns at 100, labs sent for updated lytes.

endo: closely monitor bs q 2 hrs for elevated bs, 3 units og req insulin administrated for bs of 150.

skin: cdi with varicose veins.

id: afebrile, no wbc count.

assessment: s/p tpa admin for embolic stroke.

plan: monitor ns q 1 hour, maintain blood pressure 110-180 systolic, monitor bs frequently while on d5w, nursing treatments as indicated, watch for adverse reactions to tpa, cont to monitro and assess as ordered.



"
1110,"resp: [**name (ni) 97**] pt on psv 15/12/45%. ett retaped, secured and biteblock inplace. bs are coarse bilaterally. suctioned for moderate to copious amounts of yellow bloody tinged secretions. mdi's administered alb/atr q4 hr with no adverse reactions. am abg 7.44/47/124/33. vent changes to decrease ps to 12 peep to 10. will continue to wean appropriately.
"
1111,"resp: [**name (ni) 97**] pt on psv 10/5/40%. ett 7.5 23@ lip. alarms on and functioing. ambu/syringe @ hob. bs are diminished bilaterally. suctioned moderate amounts of thick tan to bloody secretions. mdi's administered comb q4/[**last name (un) **] [**hospital1 **] with no adverse reactions.  rsbi=68. plan to address code status with family meeting. no changes noc.
"
1112,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 10/500/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminished bases.  mdi's administered q 4 hrs of alb with no adverse reactions. rsbi=112.  will attempt to wean to ps this am as [**name8 (md) 9**] md. no further changes noted.
"
1113,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14 450/30/+5.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned small amount of thick tannish secretions.  mdi's administered q4 hrs combivent with no adverse reactions.  am abg's 7.44/36/130/25.  rsbi=133.  no further changes noted.
"
1114,"resp: [**name (ni) 97**] pt on psv 5/5/50%. ett 7.5, rotated, retaped and secured @ 20 lip. bs are coarse to clear and suctioned for moderate amounts of thick tan to yellow secretions. mdi's administered alb/atr with no adverse reactions. abg 7.36/40/147/24. see careview for rsbi. no changes noted. plan to keep on present settings.
"
1115,"resp: [**name (ni) 97**] pt on 50% t/c. bs are coarse bilaterally that clear following suctioning. suctioned for moderate amounts of thick yellow secretions. pt is able to expectorate some secretions with strong cough. mdi's administered via trach combivent with no adverse reactions. inner cannula replaced, drain sponge and new trach mask replaced. will continue to follow.
"
1116,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/600/+5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral wheezing. suctioned for small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs combivent with no adverse reactions. cuff pressure @ 21. rsbi=124.  vent changes: decreased fio2 to 40%.  02 sats remain @ 100%.  no further change noted.
"
1117,"resp: [**name (ni) 97**] pt on 40% t/c. ambu/syringe @ hob. bs are coarse bilaterally which clear following suctioning and cough. pt able to expectorate secretions.  mdi's administered q4 hr with no adverse reactions. will continue to follow.
"
1118,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with some scattered wheezing. spoke to team and suggested mdi's. mdi's administered q4 hrs atr/[**last name (un) **] [**hospital1 **]. administered with no adverse reactions. suctioned for moderated amounts of thick yellow secretions. rr ^ to high30's and ^ ps to 20. am abg's 7.47/42/192/35.  vent changes: decreased fi02 to 40%, ps to 15. [**hospital1 239**]=116 with no further changes noted.
"
1119,"resp: pt arrived from osh trached w/#6 portex and placed on [**last name (un) **].  02 sats decreasing and bronch performed.  suctioned copious amounts of thick tan secretions with plugs.  02 sats improved.  abg's (see careview) am abg 723/74/103/33 which shows improvment over prior gas.  rr decreased to 14/450/+5/70%.  mdi's administered alb/atr q4 hrs with no adverse reactions.  pt exhibits some auto peeping. no further changes noted.
"
1120,"resp:  [**name (ni) **] pt on 50% t/c. bs auscultated reveal bilateral coarse sounds. suctioned for thick amounts of yellow secretions. mdi's administered q4 hrs of combivent with no adverse reactions. pt rr ^ to 40's then placed on psv 8/5/35% to rest over night. rsbi=57.  will place back on t/c @ 50% this am.  no further changes noted.
"
1121,"resp: [**name (ni) **] pt on psv 10/5/40%. ett 7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick bloody tinged secretions with some brown plugs. mdi's administered q4 hrs alb with no adverse reactions. rsbi=52. am abg 7.44/35/110/25. no changes noc.
"
1122,"resp: pt rec'd on psv 20/5/40%.ett &.5 retaped x2 and secured @ 23 lip.  bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. pt ^wob with desats to 80's placed on a/c 20/500/10+/40%. am abg 7.46/41/83/30. plan to continue on present settings.
"
1123,"1515-1900 nsg admission note
mr. [**known lastname **] is a 70yo male with pmh/psh of lung ca [**51**] yrs ago with reoccurance of lung ca, renal cell ca, brain mets, s/p l nephrectomy, htn, asthma, hypothyroidism, partial resection brain mass l frontal lobe one month ago, s/p hernia surgery.  pta he was feeling poorly with increasing lethargy.  this am brought to ed by wife for inability to ambulate at home.  in ed initially po temp and bp wnl however o2 sat 80% on ra.  rectal temp checked, found to be 101.2 with lactate of 1.9, developed hypotension with sbp 80's.  treated with 3liters of fluid then levophed started.  pcxr in ed revealed lg r infiltrate, lg r pleural effusion.  rec'd zithromax 500mg po and ceftriaxone 1gm iv both at 1100 in ed, code sepsis initiated at that time.  r ij tlc placed.  ekg wnl.  k 6.7, treated with kayexelate and calcium gluconate with rpt k 5.9.  head ct unchanged from previous films.  abd u/s wnl, renal u/s-->hydronephrosis.  started on dobutamine, trans to micu on [**hospital ward name **] 4 (arrived on [**hospital ward name **] 4 at 1515).  remains on sepsis protocol, levophed, dobutamine.  insulin gtt started, one unit prbc started.
current status:
see fha and carevue for subjective/objective data.
neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  bp remains labile--titrated levo to maintain map>60. currently levo at 0.2mcg/kg/min.   remains on dobutamine at 4.7mcg/kg/min.  mp=nsr-st, no ectopy noted.  one unit prbc currently infusing without evidence of adverse reaction.  100%nrb in place with sats mid to high 90's.  bs coarse bil--rll pneumonia per intern.  congested sounding cough, is not expectorating at this time.

gi/gu:  npo.  abd round, soft, non-tender, bowel sounds present.  no flatus, no bm.  u/o qs q1h via foley; urine yel with sediment (urine for c+s sent in ed).

id/endo:  tmax=96.4ax.  remains on rocephin and zithromax.  fingerstick done, 329--[**first name8 (namepattern2) 20**] [**last name (un) 296**] protocol insulin gtt started--see flowsheet.

integ:  intact.  no open areas noted.

psychosocial/plan:  wife in with pt.  emotional support given to pt and wife.  [**name (ni) 14**] is to maintain sepsis protocol, infuse prbc's as ordered, support bp with levo/dobutamine, titrate insulin gtt per protocol, support resp status, administer abx as ordered, monitor i+o.
cont to provide emotional support/cont with nursing, medical regime.

"
1124,"resp: [**name (ni) **] pt on a/c 20/400/10+/30%. retaped and secured ett. bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. am abg 7.40/51/125/33.  plan to continue with present settings.
"
1125,"resp: pt rec'd on psv 15/5/40%. ett 7.5, retaped and secured @ 23 lip. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.49/46/99/36. rsbi=200. will continue with present settings.
"
1126,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%.  alarms on and functioning.  ambu/syringe @ hob.  cuff pressure @ 21.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 small amounts of tannish thick secretions.  mdi's administered q4hrs with no adverse reactions. no rsbi performed as [**name8 (md) 20**] md.  comfort measures only.  no further changes noted.
"
1127,"resp: pt presently on n/c @ 3 lpm. bs are coarse bilaterally with notable exp wheeze. nebs administered q3-6 hrs alb/atr with no adverse reactions.  pt says, ""she feels better following tx's"" although no significant change with tx.  xray shows no pleural effusions.  will continue to monitor and treat.
"
1128,"resp: pt remains on a/c 25/400/+10/60%. suctioning for moderate amounts of thick yellow secretions. mdi's administered q4 hr combivent with no adverse reactions. am abg 7.38/43/68/26. no rsbi due to^ peep.will continue full vent support.
"
1129,"resp: [**name (ni) **] pt on 40% t/c with humification. bs are coarse bilaerally. suctioned for moderate amounts of thick yellow secretions. mdi's adminstered q4 hrs alb/atr with no adverse reactions. pt has #7 [**last name (un) 482**] secured @ 12 flange. no distress noted 02 sats @ 98%. will continue to follow.
"
1130,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds.  suctioned for small amount of white thick secretions.  mdi's administered q4 alb with no adverse reactions.  rsbi perfomred although no spontaneous breaths noted.  02 sats remain @ 100%. no further changes noted.
"
1131,"resp: pt rec'd on [**last name (un) 205**] psv 12/10/40%.  alarms on and functioning. ambu/syringe @ hob. cp @ 20, trach #7 portex. bs auscultated reveal bilateral aeration with diminished bases. mdi's administered @ 4 hrs alb with adverse reactions. suctioned for small amounts of bloody secretions. am abg's 7.48/32/146/25. no rsbi due to ^ peep. no further changes noted. will continue to wean appropriately.
"
1132,"resp: [**name (ni) **] pt on a/c 15/500/+5/30%. ett 7.5, retaped and secured @ 21 lip. ambu @ hob. bs are clear to diminished at bases bilaterally. suctioned for small to moderate amounts of white to pale yellow thick secretions. sputum sample sent. mdi's administered alb/atr as ordered with no adverse reactions. weaned to psv although pt did not tolerated and returned to a/c (see careview) rsbi attempted resulted in no resps, will attempt again in am. am abg 7.35/45/130/26. family meeting today to discuss cmo status.
"
1133,"resp: [**name (ni) **] pt on a/c 15/400/+12/30%. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions. pt had episodes of ^ wob, sedation issues.  xray reveal bilateral hyperinflation slightly worse than previous. abg's (see careview) vent changes to ^ rate to 20. am abg 7.32/52/147/28. plan: family meeting to discuss cmo status.
"
1134,"resp: [**name (ni) **] pt on psv 10/10/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. ps weaned to 8. am abg 7.44/44/107/31. rsbi=111. plan to wean as tolerated. awaiting cmo status.
"
1135,"resp:  admitted to micu via er for resp distress and placed on ffv bipap. transported to micu on 4 lpm n/c and desated into 70's. pt is on home 02 @ 2 lpm. placed on nrb, then 50vm to maintain 02 sats in 90's. hhn given q4 hrs alb/atr with no adverse reactions.  pt became increasingly dyspnic, and tachy then placed on ffv.  pt tolerated most of the night and taken off this am and placed back on 50% vm.  will continue to follow.
"
1136,"resp: [**name (ni) **] pt on psv 10/8/40%. ett #7.5, retaped and secured @ 23 lip. bs are coarse bilaterally and suctioned for copious amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes this shift. pt continues to breath in ^30-40's. rsbi=147. plan to continue with present settings.
"
1137,"resp: [**name (ni) **] pt on psv 10/5/40%. bs are slightly coarse with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=188 am abg 7.43/44/128/30. vt's 300's ve 11, rr 30-50's at times.  bp ^ 200 pt still appears to be uncomfortable. plan to continue with present settings.
"
1138,"neuro: pt sedated with propofol 10 mcg/kg/min and haldol scheduled dose and prn. given 1 prn dose at 0330 for anxiety. any form of stimulus causes increased agitation. ? how much sleep pt has gotten as he moves around in the bed, appears uncomfortable  but denies pain. pt is more alert this morning. he wanted to watch tv, given tv control but has not used it to change the channel yet.

resp: cpap w/ps 12 peep 5 40%.. lungs clear but dim in the bases. sats 95-100%. abg's this am 7.44/53/92.

c/v: hr 80's to 90's with pvc's occasionally. map 60's to 80's but now lower with additional haldol. does require an occasional bolus of propofol of [**1-31**] ml.

gu/gi: foley patent, draining large amts pale yellow urine after 2 doses of lasix 40mg. abd is soft, distended. surgery in to consult on pt for a ?acute abd. pt was thought to be slightly uncomfortable with left abd palpation. pt is making urine and stool and his vs have been mostly stable, without indication of pain. they will be back to round on him in the am. tube feed infusing at goal. fecal incontinance bag in place with no additional stool noted.

social: daughter called last evening. she wanted to know how her father made it through his blood transfusions. she thought the pt was having an adverse reaction with the first xfusion.  assured her that pt was not having any problems, that he was pre medicated with benedryl and was also given lasix between the two units.

plan: labs drawn. repleat as necessary. surgery will round in the am. continue free h2o boluses until na+ under control. haldol when pt anxious and less propofol as pt shows less anxiety. pt is full code.


"
1139,"resp: pt rec'd on a/c 25/400/+12/60%.ett#7.5/21 lip. bs reveal bilateral aeration with minimal suctioning. mdi's administered q6 combivent with no adverse reactions. am abg 7.36/45/118/26. vent changes to decrease fio2 to 50%, and pt desated to 90, then returned to 60% where she remains. will continue full vent support.
"
1140,"resp: pt rec'd on 6 lpm n/c with 70% f/t. bs are coarse bilaterally with npc. hhn [** 860**] ud atrovent with 0.63 xopenex as ordered with no adverse reactions. will continue to follow. no changes noc. 02 sats @ 100%.
"
1141,"resp: pt ordered for hhn ud atrovent/0.36 xopenex and administered q4 hrs with no adverse reactions. pt also odered for advair discus although pt unable to perform and md/rn aware. 02 @ 3 lpm n/c with 50% f/t. bs are coarse with no changes noc. will continue to follow.
"
1142,"nursing progress note:
pt is alert and oriented x 3. no neuro deficits noted. pt does continue to have c/o severe headaches on level [**8-11**] on a [**2-13**] pain analog scale. relief from dilauded 2mg iv. pt refused toradol, states it gave her severe nausea earlier. pt states that she is not allergic to dilauded and no adverse reactions noted. team is aware. pt's assessment is otherwise negative. cv is nsr, no ectopy with sbp 100-120's per rad art line and nibp cuff.  goal is to keep sbp < 150's. this has been accomplished with po lopressor(now decreased to 12.5 mg po q 12 hr) pt on room air. resp even and unlabored. taking reg diet without difficulty. foley drains qs. no bm yet.

ct and cta both negative. hopeful plan for transfer or home soon,
continue to monitor until then.
"
1143,"npn shift 1900-0700:

neuro: a&ox3. restless. mae, equal strength. perrla. ambien for sleep w/ good effect.

resp: b/l bs present, clear. weaned to room air, tol well. sats 95-98%. no cough.

cv: pt in a-fib, rate controlled in the 90's. rare ectopy. no s/s of cardiac distress. no chest pain. sbp wnl, 90-120's. trace edema ble.  am k+=3.6, not repleted as of yet receiving blood.

hem: hct 28.8, down from 32. tx prbc x1, tol well, no s/s of anm adverse reaction. ptt=120 at 0300. hep decreased to 800u/hr from 1100 u/hr at 0400. ptt to be checked at 1000. ho aware. no s/s of bleed.

id: afebrile.

gi: npo. +bsx4. c/o nausea, no vommitting. compazine given w/ no effect. droperidol 0.675 iv given w/ good effect. no bm.

gu: foley intact. autodiuresing. yellow urine, w/ sediment.





"
1144,"1900-0700

general: pt recieved prep for colonoscopy through the night, bm remain tarry ho aware. pt removed ngt accidentally while sleeping @ 2300 pt given zyprexia.pt medicated for anxiety @ 2330 with lorazepam and replace ngt without difficulty, cxr confirmed placement. hct@2200-30. prbc infusing this am.

neuro: pt sleeping, arousable, responds appropriately but seems groggy. oriented x3, following commands well, maes. cataract bilaterally. anxiety noted once last pm. no restlessness noted.

resp: pt using 2l nc after anxious episode @ 2300. o2sat stable 97-100%. lungs clear/diminished at the bases. no cough noted. no sob noted.

cv: c-monitor a fib through the night, without ectopy. no episodes of cp/ hemodynamics stable. lopressor held due to bp 94/40. pt remains on heparin drip @950units/hour. ptt sent in am. pt remains hypernatremic and d5w increased to 150cc/hr @2300 after chemistry panel reviewed.

gi: abd round soft + bs, prep completed and tarry stools continue. fecal incont. bag placed, incont of stools at this time. stool remains guiac positive. ngt to l nare intact clamped for bowel prep. pt receiving prbc transfusion, no adverse reactions noted.

gu: foley to bsd draining clear yellow urine approx. 50-75cc/hr. minimal edema to ext.

iv: r ij tlc intact.

plan: complete prbc, assess pt for possible colonoscopy today. monitor for excessive bleeding.

                           [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
1145,"resp: pt rec'd on a/c 14/450/10+/60%. ett#7.0, 22 lip. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see carview) vent changes to decrease peep to 7, then 5, increase rate to 16. am abg pending. will continue full vent support.
"
1146,"0700-1500 npn

ms. [**known lastname **] is an 83yo female admitted from osh via [**hospital1 10**] ed to [**hospital ward name **] 4/icu this am.  pmh significant for cad, s/p cabg, angina, ef 35%, chronic renal insufficiency, htn, gout, epigastric pain, non-hodgkins lymphoma, hemolytic anemia, mrsa ? source, depression, s/p laminectomy, s/p bil tkr.  at home takes lasix, coumadin, ""heart and gout medications"", presdisone.    overview of events:  vomited vs. spitting up brb this am (pt not sure) as well as melena stools.  two units prbc's given, third unit up at 1430; two units ffp given.  all blood products given without evidence of adverse reactions.  cordis placed after three attempts, anesthesia in to electively intubate pt for endoscopy.  started on levophed for bp 70's/30's in addition to multiple liters of ns and lr.  endoscopy in progress at this time.

neuro:  was a+ox3; currently sedated on propofol at 20mcg/kg/min.  perl, 2-3mm, brisk.  mae ad lib.

cv/pulm:  mp=afib (not new).  serial cardiac enzymes sent.  bp labile, pt remains on lr at 500-1000ml/hr, ns at 500ml/hr and prbc's third unit currently infusing.  access:  r cordis, r triple lumen femoral line and r 20guage periph iv.  intubated, placed on vent at 1245--
current settings ac10x100%x600x5peep.  bs clear on r, diminished on l with fine crackles left base.  sats difficult to obtain however when able to obtain sats are high 90's to 100%.

gi/gu:  abd round, soft, non-tender to palpation.  stooling melena-->
fib applied but ? stool too thick for bag.  endoscopy in progress at this time.  ngt removed by gi for endoscopy; prior to removal was lavaged x2, draining brb with clots-->500ml total this shift.  u/o clear yellow yellow urine, qs.

id/endo/integ:  afebrile.  sliding scale insulin coverage per [**month (only) **].  skin tear r shin (pt reported to previous shift rn that she hit her leg at home).  no other open areas noted.

psychosocial/plan:  md spoke with family re:  pts status.  endoscopy in progress at this time (lg ulcer found, surgery paged).  will continue fluid resuscitation, levo, labs.  cont vent support, sedation as needed.  emotional support given to pt while awake.  pt is full code, on contact precautions for history of mrsa.

"
1147,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 20/600/50%/+[**1-2**].  alarms on and functioning. ambu/syringe @ hob.  ett taped and secured.  bs auscultated reveal bilateral coarse sounds with an exp. wheeze noted.  mdi's administered q4hr alb with no adverse reactions.  suctioned x3 small to moderate tan thick secretions.  vent changes to decrease peep to 10 where it remains. no further changes noted.
"
1148,"resp: pt rec'd on psv 18/8+/50%. ambu/syringe @ hob. bs are reveal bilateral wheeze. suction moderate amounts of tan secretions and copious clear amounts from oral cavit.  administered mdi's atr as ordered with no adverse reactions. some improvement noted, although pt still has notable wheeze. ^ rr to 30's and placed on a/c 21/400/+8/50% as [**name8 (md) 9**] md to rest noc then to place back on psv in am. rsbi=164. pt is easily aggitated, and bites on tube. sedation issues to be addressed?? no plans to extubate today.
"
1149,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 24/600/+12/5/50% alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  mdi's administered q4 alb with no adverse reactions. eet repositioned and secured.  rsbi=190. no further changes noted.
"
1150,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 24/600/5/50%/+12.  ambu/syringe @ hob. alarms on & functioning.  bs auscultated reveal bilateral coarse sounds which clear with suctioning. suctioned x3 small amount of bloody tinged thick secretions.  mdi's administered q4hrs with no adverse reactions.  rsbi=170, no sbt initiated. pt remains comfortable with no further changes noted.
"
1151,"resp: pt rec'd on psv 15/+8/70%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. vent changes to decrease fio2 to 60%. attempted 50% which resulted in pao2 of 72. mdi's administed of alb as ordered with no adverse reactions. vent changed out due to 02 sensor failure. pt placed on heated circuit. am abg on 60% 7.40/39/88/25. no further changes noted.
"
1152,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv10/550/5/5/40%.  ambu/syringe @ hob.  auscultated bs reveal bilateral slight coarse sounds which clear with suctioning.  suctioned x3 small to moderate amounts of thick yellowish secretions.  mdi's administered of alb/atro q4 with no adverse reactions.  rsbi=25. 02 sats @ 100% with no further changes noted.
"
1153,"resp: pt rec'd on psv 10/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of tannish secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg (see carview) vent changes to ^ fio2 to 60%. am abg 7.44/35/74/25. no rsbi due to ^ fio2.
"
1154,"resp:  [**name (ni) **] pt on [**name (ni) **] psv20/10 50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of tan thick secretions.  mdi's administered q4hr alb with no adverse reactions.  rsbi=230, no sbt initiated.  02 sats @97% with no further changes noted.
"
1155,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 10/550/+5/40%.  alarms on and functioning.  ambu/syringe @ hob. cuff pressure @ 22 cm h20.  bs auscultated reveal bilateral coarse sounds that clear with suctioning. suctioned x3 small to moderate thick lite yellow secretions.  increase in areation noted following suctioning., ^ temp noted.  mdi's administered q4 hrs with no adverse reactions.  02 sats remain @ 100%.
rsbi=35 with no further changes noted.
"
1156,"resp: [**name (ni) 97**] pt on psv 14/5/35% then placed back on a/c 16/350/+5/35%, due to periods of apnea. bs reveal bilateral aeration with diminished bases. mdi's administed alb/atr as ordered with no adverse reactions. small amount of yellow secretions suctioned. changed to heated wire circuit. am abg 7.49/51/141/40%. rsbi=no resps. plan to continue with wean to psv as tolerated.
"
1157,"resp:  [**name (ni) 97**] pt on [**last name (un) 444**] psv 10/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral slightly coarse sounds which improve after suctioning.  suctioned x3 small to moderate whitish/yellowish thick secretions.  mdi's administered combivent q4 hrs with no adverse reactions.  eet secured and retaped.  rsbi=80, sbt initiated.  no further changes noted.
"
1158,"msicu npn 0700-1400
 a&o x3. more alert this am. states bed (1st step) has made a big difference in comfort level. plan was to try to give her pain meds atc. in a.m. we started with 2 tabs of darvocet and 4 mg dilaudid po but she was very sleepy all morning. for next dose, in ? 6hrs, we plan to decrease dilaudid to 2mg and depending on pain level and alertness, decrease darvocet to 1 tab. ketamine has been weaned off with no increase in pain at this time.
 given 1st dose of xeloda. had sm amt of emesis 2hrs post dose but no other adverse reactions noted. treated with 0.5 mg iv ativan with relief.
 uo ~30cc/hr. she remains very volume overloaded for los. currently recieving d5.45ns at 50cc/hr. her po intake is very poor and she can't take most of her oral medication. nutrition to consult for ?[** 1466**]. she does not have a clean line for tpn.
 afebrile.
 family very supportive and in most of day. aware of transfer to medical floor.
"
1159,"resp:  pt received from or and placed on [**last name (un) 444**] psv 15/5/30%.  alarms and functioning.  ambu/syringe @ hob.  bs auscultated reveal sl coarse sounds which improve with suctioning.  suctioned x2 small to moderate amount of thick yellow secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=100.  02sats 97-99%. no other changes noted.
"
1160,"resp: rec;d pt on a/c 16/350/+5/35%. bs are clear with diminished bases. suctioned for small amounts of bloody tinged thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's. 02 sats @ 100%. rsbi =150. plan to wean to psv as tolerated.
"
1161,"resp: rec'd on psv 15/5/40%. bs are clear bilateally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. tv's 400. ve 11 with 02 sats @ 99%. rsbi=or procedure for trach/peg today. will continue with present settingss.
"
1162,"resp: [**name (ni) 97**] pt on a/c 14/450/+5/60%. ett #7.5, 19 @ lip. bs are clear with diminished bases. suctioned for small amounts of yellow secretions. mdi's administered alb/atr with no adverse reactions. vent changes (see careview) with abg's. wean to psv 10/5/35%. abg 7.47/45/88/34. rsbi=115. plan to continue to wean as tolerated.
"
1163,"resp: [**name (ni) 97**] pt on psv 5/5/50%. ett #7.5, retaped, rotated and secured @ 20 lip. bs are coarse to clear and suctioning moderate amounts of thick yellow frothy/thick secretions. mdi's administered alb/atr with no adverse reactions. no vent changes noc. am abg 7.38/38/164/23. rsbi=19. plan is to extubate when pt is more awake.
"
1164,"resp: pt rec'd on psv 5/5/40%. ett 7.5 rotated, retaped and secured @ 22 lip. bs are coarse bilaterally and suctioning for small amounts of bloody tinged secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.43/34/146/23. rsbi=29. plan to wean as tolerated.
"
1165,"resp: pt rec'd on psv 16/8/100%. trached #8 portex. bs are coarse bilaterally which improve with suctioning. suctioned moderate to copious bloody thick secretions. mdi's administered q4 hrs combivent with no adverse reactions. abg's (see careview)pt had episodes of desaturation which reflect vent changes. presently on psv 14/8/50%/. 02 sats @ 98%, vt's 700-800, ve 15l, rr 20's. no further changes noted.
"
1166,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. [**last name (un) **] small amount of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  vent changes psv decreased to 10.  rsbi=142, no sbt initiated.  no further changes noted.
"
1167,"npn 7 am - 7 pm

s: "" i don't want to take epogen, it is not good for me""

o: please see caeview for vitals and other objective data

pt sp extubation yesterday for pna and chf. doing well respiratory wise, continues to diurese, able to wean off o2 as pt refuses to wear it most of the time. pt was improving mental status wise this am, with moments of clarity "" i was at [**hospital **] hospital yesterday"", however after his am dose of dilaudid pt awoken and became paranoid, and at times refusing meds, refusing care, able to follow commands but unable to focus on anything. feels ""he has to get up"" unable to say why. team updated, dilaudid now dc'd, may continue oxycodone but perhaps wait until tonight as he is better off with out it currently. pt was at times refusing medication today, however when his wife came in she did convince him to take all his meds. tolerating po meds, refuses any food or liquids except pills with apple juice.

cv- sr, hr 70's up to 90 this afternoon when very agitated, back down to 80's after labetolol. nifedipine held as pt is on alot of bp meds and bp remained 103-120 systolic until 4 pm today. pt was hypotensive last night after nifedipine. edema is markedly decreased but persists
 lower extremities.

respiratory: pt has rll pna and some pulm edema persists, crackes to dim at bases. cxr is improved over last two days. pt coughing up thick
secreations and spits or swallows them. samle from [**last name (un) 1180**] washing pending identification. vanco was dc's today ( level 20.3) and continues on po azythromycin and iv zosyn. afebrile today. pt on 4l nc, but complaint of nasal congestion and removed o2, refused mask,  sats stayed 94-97 percent on room air.

[**name (ni) 554**] pt has several loose stools this afternoon, team updated, slightly quiac positive, send any further stools for c diff per team.

endocrine: fs lower today, 93. 107, 120 spoke with [**name8 (md) 373**] md we will place pt on decreased  lantis at 12 unts per day, given at 6 pm.

a: pt with improving pna and chf, extubated x 24 hours, doing well but having adverse reaction to narcotics ( as pt is prone to this).

p: continue to monitor resp status, cv, q 6 hour bs with ss, continue antibiotics, send stool for c diff if loose stool continues, dc dilaudid, pt may take 0.5 mg ativan for sleep as he does at home. follow neuro status and comfort pt, safety risk, will require [**name8 (md) 3152**] if he goes to floor today.
"
1168,"resp:  [**name (ni) **] pt from [**name (ni) 104**] intubated and placed on [**last name (un) **] simv 10/850/50%/[**4-23**].  alarms on and functioning. ambu/syringe @ hob.  bs auscultated revealed bilateral coarse bs. suctioned for moderate amount of green/yellowish thick secretions.  mdi's given q2 hrs of alb with no adverse reactions.  bs presently are bilateral clear apecies with rs insp wheeze noted.  rsbi=25. no further changes noted.
"
1169,"resp:  [**name (ni) 97**] pt on a/c 18/400/+5/30%.  pt has #7 portex trach. bs are coarse to clear. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. pt had i/d abdominal abscess procedure in or and remains on a/c.  rsbi attemped resulting in no resps. plan to wean to psv as tolerated.
"
1170,"resp:  [**name (ni) 97**] pt extubated and on 70% f/t with 4 lpm n/c in order to maintain sats in 90's.  bs auscultated reveal bilateral coarse sounds with some scattered wheezes noted. hhn given alb/atr q4 hrs with no adverse reactions. pt placed on ffvm @ [**name (ni) **] and remained on psv for a significant amount of time, then placed back on f/t 70%/4 lpm n/c.  questionable mental status? will continue to follow.
"
1171,"resp: [**name (ni) 97**] pt on t/c @ 60%. pt ^ wob then placed back on psv 10/5/50% to rest noc. suctioned for small amounts of thick yellow secreitons. mdi's administered of alb/atr as ordered without adverse reactions. rsbi=89, then ps decreased back to 5. will continue with trach trials today.
"
1172,"resp: [**name (ni) 97**] pt on psv 10/5/50%. portex #7 trach. bs reveal bilateral aeration noted with diminished bases. suction small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. trach care performed, some oozing around trach site. pt does have some episodes of ^ wob to 30's. no a-line/abg's this shift. rsbi=129. plan to wean as tolerated.
"
1173,"resp: [**name (ni) 97**] pt on psv 8/15+/60%. pt has #8 portex trach in place. alarms on and functioning. ambu/syringe @ hob. pt placed on a/c 18/550/15+/60% to rest noc. bs are coarse bilaterally which improve following suctioning. suctioned for moderate amounts of thick tan to bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. no further changes noted. 02 sats 93-96% with no abg's this shift. will continue to wean as tolerated.
"
1174,"0700-1500 npn
see carevue for subjective/objective data.  events of day:  attempted to wean ventilator this am--rsbi 65, pt placed on ps.  tolerating sbt for first 2hrs then developed increased sob, hr 120's.  placed back on ac with resolution of symptoms within 20min.  no further weaning this shift.  single dose vanco given for vanco level 11.5; kphos infusing over 6hrs at this time.

neuro:  at this time pt is [** **], nodding ""yes"" and ""no"" appropiately. mae ad lib.

cv/pulm:  mp=afib, isolated pvc's noted.  hct 25.5 this am; rec'd one unit prbc without evidence of adverse reaction.  rpt hct due at 1600.  remains on heparin gtt at 1700units/hr; next ptt due at 1800.   remains vented ac24x500x40%x5peep.  bs coarse, diminished bil.  suctioned for thick white secretions via ett.  weaning attempt as noted above--no further weaning this shift.

gi/gu:  ngt clamped at this time--will need tf resumed if not extubating soon.  mushroom cath placed for stooling.  anuric--receives hd m/w/f.

access:  l double lumen picc in place.

id/endo/integ:  tmax=99.1 po.  sliding scale coverage for fingersticks.  buttocks-->open area as noted on carevue.  both heels with black areas therefore multi-podis boots applied to both feet.

psychosocial/plan:  family in to visit.  emotional support given to pt and fam.  pt remains full code at this time.
"
1175,"resp: pt remains intubated on a/c 15/500/+10/50%. bs are coarse bilaterally. suctioned for thick amounts of tan secretions. mdi's comb q4 hrs with no adverse reactions. am abg 7.40/35/116/22. no vent changes noc. will continue full vent support.
"
1176,"resp: [**name (ni) **] pt on psv 12/5/50%. ett #7.5, taped @ 23 lip. bs are clear with diminished bases. suctioned for scant amount of white secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.43/45/140/31. rsbi=88. no changes noc. plan sbt in am then extubation.
"
1177,"resp: [**name (ni) **] pt on a/c 20/400/+5/40%. alarms on and functioning.  ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 of combivent with no adverse reactions. no changes or abg's this shift. will continue full vent support.
"
1178,"resp: rec;d pt on psv 15/10/30%. ett #8.0 retaped, rotated and advanced from 20 to 22 cm @ lip as per xray/md. 02 sats @ 100%. vt 600's, ve's 7. bs auscultated reveal bilateral clear apecies with slightly coarse bases. mdi's administered as ordered alb/atr with no adverse reactions. pt scheduled for or @ 1300 today. am abg 7.50/40/90/32. no rsbi due to ^ peep.
"
1179,"resp: [**name (ni) **] pt on psv 10/10/40%. ett #7.5, 23 @ lip. bs are coarse, diminished on rs. suctioned for large amounts of thick white/with occasional plugs. mdi's administered alb/atr with no adverse reactions. vt' 300-400, ve's 13-17, rr 36-47. pt had episodes of ^ wob [**name (ni) **], bolus given, bp issues, pt family meeting to change status to cmo. am abg 7.37/45/126/27. no rsbi due to ^ peep. will continue with present settings.
"
1180,"resp: pt rec'd on psv 7/7/50%. bs are coarse bilaterally. suctioned for small amounts of thick tan secretions. mdi's administered alb/atr/[**last name (un) **] as ordered with no adverse reactions. no abg's this shift with rsbi=99. will continue to wean as tolerated.
"
1181,"resp: pt rec'd on 35% humidified t/c. pt has #7 portex trach with cuff deflated. bs are coarse to clear and able to expectorate secretions. coughing up thick tan to bloody tinged secretions. mdi's administered via trach of combivent with no adverse reactions. or procedure today (stent).
"
1182,"resp: pt rec'd on 35% t/c with humidification. bs are coarse to clear and pt has strong cough. some bloody secretions expectorated, possibly due to aggressive suctioning during day. mdi's administered via trach of combivent with no adverse reactions. pt has #7 portex trach with cuff deflated. no resp distress noted. will continue to monitor.
"
1183,"resp: pt on 40% t/c with portex trach#8. bs are coarse bilaerally and suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. 02 sats continue @ 100% with plans for rehab. will continue to follow.
"
1184,"resp: [**name (ni) **] pt on a/c 16/470/+10/40%. ett 7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with occasional wheeze noted. suctioned for small to moderate amounts of yellow to white thick secretions. mdi's administered q4 combivent with no adverse reactions. no rsbi due to ^ peep. no abg's this shift or changes. plan is to wean as tolerated.
"
1185,"resp: pt remains on a/c 12/500/+10/50%. bs coarse to diminished with noted aeration. suctioned for small amounts of thick yellow secretions. mdi's administerd q4 combivent with no adverse reactions. no changes noc. am abg 7.42/45/124/30. will continue full vent support.
"
1186,"resp: [**name (ni) **] pt on a/c 12/500/+15/50%. bs are clear bilaterally/diminishe bases. suctioned for small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. rsbi= 7.46/39/175/29. will continue full vent support.
"
1187,"resp: [**name (ni) **] pt on a/c 16/500+5/60% ett #8.0 retaped and secured @ 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear to coarse with minimal suctioning required. mdi's started and administered qid 4 p atr with no adverse reactions. no abg's or changes this shift. will continue full vent support.
"
1188,"1900-0700

general: received pt with labored resp and audible exp wheezing noted. abg 7.44/56/41/29/+3. resp treatment administered with minor relief. face tent increased to 70%, o2sat remained 88-100% through evening. intermit. periods of agitation noted. morphine 2mg given at 2230 with minimal benefit. cardizem 10mg ivp given at 2230. lasix 20mg given at 2330. potassium supplement ivpb completed. pt became more comfortable as the evening progressed. ptt 53, 3am bolus of heparin given + increased drip to 600u/hr.am labs drawn.

neuro: pt awake/alert/oriented, perla,follows commands well. moves all ext. uncooperative at times, attempting to remove o2.soft wrist restraints applied as needed. no neuro deficits noted.

resp:labored resp through evening, using accessory muscles. o2 sat 88-100%. lungs with exp wheezing and diminshed bs bilaterally. no cough noted. pt denies sob. multiple resp treatments received throughout the night. face tent remains at 70%.

cv: nsr-st through the evening with occaional pvcs noted. denies cp. weak but palpable pulses to ext. afebrile. bp 170-120, hr 115-88. nitroglycerin drip started and titrated to 2mcg/kg/min. no adverse reactions noted. skin warm/dry/intact.

gi: abd round slightly distended. +bs x 4 quad. receiving tpn for nutritional supplement. guiac neg stool x1.

gu: foley intact draining clear yellow urine.

iv: rij tlc intactdsg changed. heparin@600u/hr, nss@kvo, nitroglycerin@2mcg/kg/min, [**e-mail address 10421**]/hr. r piv d/c'd due to reddness and irritation.

plan: supportive care for unstable resp status. evaluation of fluid balance and treatment.
                          [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
1189,"resp: pt on 40% t/c with #8 portex trach.  [**e-mail address 10312**] reveal bilateral coarse sounds with occasional exp wheeze wi.th forced expiration. pt continues to have periods of anxiousness. mdi's administered via trach alb/atr with no adverse reactions. pt being screened for rehab. will continue to follow
"
1190,"resp: [**name (ni) **] pt on 50% t/c with 02 sats @ 100%. bs are coarse which clear with suctioning. suctioned for small amount of white secretions. mdi's adminisered alb/atr via trach with no adverse reactions. ambu/syringe @ [**name (ni) **]. fio2 decreased to 40% with 02 sats @ 100%. pt remains on t/c through night with no resp distress noted. will continue to follow.
"
1191,"resp: [**name (ni) **] pt on psv 5/5/30%. ett 7.5 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral coarseness which improve with suctioning. suctioning small to moderate amounts of tan-yellow-clear secretions. mdi's administered atr with no adverse reactions. am abg with results pending. rsbi=57. vt's 400-500. ve 11, rr 20-23. plan is to attempt extubation this am.
"
1192,"resp: pt rec'd on a/c 151/550/+5/40%. ett 7.0 rotated, and retaped @ @3 lip.  bs are coarse to clear with suctioning. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. pt remains on pressors. abg 7.42/27/89/18 with 02 sats @ 100%. rsbi=no resps with plan to continue working of guardian/cmo status. pt remains on full vent support.
"
1193,"resp: pt rec'd on simv 10/600/10+15/50%. pt has portex #8 trach. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administerd as order alb/atr with no adverse reactions. (see careview for vent changes and abg's). am abg 7.40/47/115/30. rsbi=68.  will continue to wean as tolerated
"
1194,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500+5/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of tannish thick secretions, later in am greenish/yellow.  pt pushed out biteblock, reinserted, pt biting down on ett, decreasing sats to 88. hr ^ to 140's.  mdi's administered q4 combivent with no adverse reactions. rsbi=140, no further changes noted.
"
1195,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c14/500/10/50%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for thick yellow secretions. mdi's administered q4 with no adverse reactions.  no vent changes noc.  plan to trach today.
"
1196,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500/+5/60%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal ^ aeration on ls with notable decrease on rs. cxr taken revealing eet slipping into r mainsteam.  eet pulled back to 20 cm @ lip. equal bs noted.  mdi's administered q4hr combivent with no adverse reactions.  suctioned x 3 moderate amount of thick bloody tinged secretions.  pt is anxious when not sedated and tried to self extubate.  no further changes noted.
"
1197,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500/50% /+5.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned moderate amount of thick tanish secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi initiated, no spontaneous breath taken.  02 sats @ 97%.  no further changes noted
"
1198,"resp: pt remains on pcv with changes in peep ^18/pinsp ^38 to maintain a dp of 20. multiple abg's (see carview). vt's 350, ve's [**9-4**] with 02 sats mid 90's. suctioned for small amounts of pale yellow secretions, some bloody tinged from oral cavity. mdi's administered as ordered with no adverse reactions. no further changes noted. will continue to wean as tolerated.
"
1199,"resp: [**name (ni) 97**] pt on pcv 42/+22/dp 20/r34/40%. ett #7, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and diminished at bases. suctioned for moderate amounts of [**name (ni) **] yellow secretions. mdi's administered q 4 alb with no adverse reactions. had episodes of desaturation, then increased fio2 to 50% where it remains. no further changes noted. will continue full vent support.
"
1200,"resp: [**name (ni) 97**] pt on psv 12/7/40%. bs are coarse bilaterally.suctioned for moderate amounts of thick yellow secretions. mdi's administered combivent/[**last name (un) **] as ordered without adverse reactions. no abg's this shift. rsbi=85. plan to continue to wean psv as tolerated.
"
1201,"ccu nsg progress note 7p-7a/ s/p cva

s- not speaking, not answering questions

o- see flowsheet for objective data

[**name (ni) 112**] pt remains hemodynamically stable- hr- 70-80's sr, no vea. bp- 140/70-162/81- no need for prn hydralazine this shift.
no issues currently.

resp- clear lungs, resp rate- 16-22- o2 sats on 2l mid to high 90's, no sign of distress, no cough this shift, no sputum production.

id- afebrile- plan for ? lp/tee to r/o endocarditis this monday for (+) wc.

lines- 3rd iv in 2 days- d/c this time d/t infiltration- restarted 4th iv- #20 rt ac- remains patent.

[**name (ni) 87**] pt [**name (ni) 7207**] [**name (ni) 7208**] 3, [**last name (lf) **], [**first name3 (lf) 20**]- rt side weaker grasp than left. to command not holding up rt arm as high, as strong a grip but
when agitated later in shift, moving both arms almost equally- grasping up at the air, etc.
not speaking to wife, to family, nor to staff. early in shift- sometimes tracking and following when speaking to him. later in shift, after ativan iv for ct scan- sleeping,not opening eyes.
ct scan reveals no change from initial no worsening from prelim report.
pt started on dilantin 100 tid iv ,after load of dilantin with level of  14 last evening.

[**name (ni) 89**] pt requiring [**name (ni) 7084**] called ho from ct scan - for agitation, inability of scan to be completed with movement. pt [**name (ni) 57**] 2 mg ativan, then repeated 15 minutes later. able to complete scan finally after 1 hour in ct. see above for prelim results.

upon arrival to room, pt more agitated and wife becoming very upset upon learning pt received sedation meds. pt has a documented ""adverse reaction""- confusion to this class of drugs but it was explained to wife [**name (ni) **] calling the daughter) that this was necessary per medical judgement and clinical status of pt. son came in to pick up pt's wife to bring home and he was very upset as well.

both t sicu and neuromed resident informed as to family's issue with pt receiving med and also with son not being notified as to pt going for ct scan. son also upset over interpreter not being called in ct scan as opposed to pt being medicated, even though it was explained to him that the wife, who speaks portugese as well, indicated the pt was
confused pre - transfer to ct scan.

t sicu resident came up to speak with family. nsg clincal advisor came up to speak with family as son is interested in making a formal complaint- he was referred to pt relations and given insturctions and phone # to call them monday morning.
of note, there is a signed icu consent in chart dated [**7-13**] from phone consent/translation from daughter of pt that gives permission and consent to icu procedures and modes of care, including ""sedation""..

pt son said he clearly stated in er (where pt had first received ativan with a ct scan and became confused) that he had wanted to be called for all meds/procedures and for pt to not get that medication anymore. neither of the icu/neuro medical teams nor ccu nsg staff were apparently aware of this wish of the son.

son, daughter in law and wife via translation understand current plan of care, pt
"
1202,"resp: [**name (ni) 97**] pt on a/c 20/500/+12/40%. bs reveal bilateral aeration with some coarseness, no wheeze noted. suctioned for small amounts of bloody tinged secretons. mdi's administered alb/atr with no adverse reactions. abg's pa02 decreased, then ^ fio2 to 50% with no improvement, then ^ to 60% and ^ peep to 15. am abg on changes pending. will continue to wean as tolerated.
"
1203,"resp: [**name (ni) 97**] pt on psv 10/10/40%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. sample sent. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg 7.34/38/101/21. pt placed on simv 18/600/10/10/40% to rest noc. plan to continue to wean to psv as tolerated.
"
1204,"resp: [**name (ni) 97**] pt on a/c 18/600/+5/40%. ett 8.0 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally which improve following suctioning. suctioned for small amounts of thick yellow secretions as well as oral secretions.  mdi's administered q4 hrs [**last name (lf) 7186**], [**first name3 (lf) **] [**hospital1 **] with no adverse reactions. am abg 7.41/34/110/22. rbsi=98. plan to discuss with family code status. family does not want pt to be trached.
"
1205,"resp: [**name (ni) 97**] pt on a/c 30/550/18+/60%. ett#8, retaped,roated and secured @ 24 lip. esophogeal balloon in place. bs are clear bilaterally in apecies with diminished rs. 02 sats 93-95,then suction for copious amounts of thick brown plugs. vent changes to ^ peep to 20 and fio2 to 70%. (see careview for abg's) mdi's administered q4 combivent with no adverse reactions. am abg 7.44/48/88/31 then decreased peep to 18. will continue to wean fio2 as tolerated.
"
1206,"resp: [**name (ni) 97**] pt on psv 10/8+/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of white thick to thin secretions. much improvement noted. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. no aline/abg's 02 sats @ 100%. rsbi=77. plan to continue t/c trials.
"
1207,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/400/+5/40%.  alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral crackles with a few scattered wheezes.  suctioned x3 for moderate amounts of thick yellow secretions. mdi's given q4 hrs atr/alb with no adverse reactions.  rsbi=144 this am.  pt is alert and awake. 02 sats @ 100%. ett retaped and secure @ 20 cmh20/lip.  no further changes noted.
"
1208,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #8.0 taped @ 25 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for bloody thick secretions. mdi's administered alb as ordered with no adverse reactions. rsbi=43. am abg 7.44/36/111/25.  plan to extubate today.
"
1209,"resp: [**name (ni) 97**] pt on psv 10/8/50%. pt has #8 portex trach. ambu/syringe @ hob. alarms on and functioning. bs are coarse. suctioned for moderate amounts of tan to bloody tinged thick yellow secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. vt's 400's, ve's 11, rr 24. 02 sats @ 100%. no aline/or abg's this shift. rsbi=53. plan to continue with t/c trials today.
"
1210,"resp: [**name (ni) 97**] pt on psv 5/5/50%. pt has #8 portex. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tan secretions. mdi's administered of combvient/[**last name (un) **] as ordered without adverse reactions. pt had episode of ^ wob and rr, then ^ ps to 16, peep 8.  vt's 400-500, ve 12, rr 27. rsbi=92. no abg's (no a-line). will continue to wean with t/c trials as tolerated.
"
1211,"resp: [**name (ni) 97**] pt on 70% t/c and was on all day. bs remain coarse bilaterally. mdi's administered combivent/flovent with no adverse reactions. pt lasted to 3:00 am then became sob, ^ wob, suctioned for moderated to copious thick yellow secretions. pt was lavarged and ambued resulting in removal of plug. placed pt on vent psv 10/5/50% and has been comfortable with 02 sats @ 100%. plan to continue with t/c trials as tolerated.
"
1212,"resp: [**name (ni) 97**] pt on a/c 20/500/+15/60%. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration with occasional wheeze, although improvement noted. suctioned for small amounts of tannish thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg  7.42/44/87/30. vent changes; decrease fio2 to 50%. 02 sats @ 95%. will continue to wean as tolerated.
"
1213,"nsg progress note
overview of history:
ms. [**known lastname 7142**] is an 83 yo female admitted to [**hospital1 95**] [**2172-7-24**] from home following a fall down the stairs, fx r tib/fib secondary to fall.  to or for repair of fx.  in pacu received morphine for pain, became confused, hypoxic, hypotensive.  levophed started, swan'd, trans to micu for further care.  ruled in for mi. pmh significant for old mi with stents placed, htn, as, chf, type ii diabetic, dialysis x5yrs, tia's, old cva without residual effects, rectal ca, fem [**doctor last name **] bpg, osteoporosis and depression.  in micu remained on levo, intubated-->weaned off levo, off vent.  [**2172-7-27**] afternoon developed afib, cardiovered x2 without success, intubated for airway protection then started on amiodorone.  following start of amiodorone converted to nsr, has remained in nsr.
current status
neuro:  sedated with propofol at 20mcg/kg/min.  pt opens eyes to tactile stimuli but no attempts to speak or mouth words around ett.  moving arms on bed, no leg movement noted.  r pupil brisk, 2mm.  l pupil irregular, fixed (many old eye surgeries).

cv/pulm:  mp=nsr, no ectopy noted.  remains on levophed currently at 0.103 mcg/kg/min with map's 60's.  one unit ffp given without evidence of adverse reaction; will hold second unit ffp until transferred to ccu.  r cordis with tlc through cordis intact.  r periph iv capped.  remains vented ac12x500x40%x5peep.  bs clear upper lobes, coarse lower lobes.  suctioned for sm amts thick white secretions.

gi/gu:  ogt in place, clamped.  abd soft, non-tender, bowel sounds present.  no flatus, no bm.  pt rarely voids (0-1x/day), no foley in place (had uti upon admission to hospital).   receives hd 3x/wk; last dialysis mon [**2172-7-27**].

id/integ/endo:  tmax 99.5 po.   no change in abx.  r leg dsg changed by ortho; per ortho incision approximated.  scant amt old ser-sang drainage noted on old dsg and new dsg.  multi podis boot to stay on r leg at all times per ortho.  no open areas noted.  sliding scale insulin coverage.

psychosocial/plan:  fam in to visit, updated on plan of care.  emotional support given to pt and fam.  plan is for pt to trans to ccu; will be swan'd in ccu.  cont pressors, vent support, sedation.
"
1214,"resp: [**name (ni) 97**] pt on psv 5/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow to tan secretions. mdi;s administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt had episode of desaturation and ps ^ to 15 peep ^ 8 02sats % 99-100%. weaned psv back to [**3-27**] with vt 400/ve 9/rr 22. rsbi =75. plan to attempt t/c trials as tolerated.
"
1215,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #7.5, 19@ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. mdi's administered q 4hrs atrovent with no adverse reactions. am abg 7.45/34/121/24. rbsi=40 no changes this shift or gag reflex noted.
"
1216,"resp: [**name (ni) 97**] pt on a/c 18/450/+5/40%. ett#7.5, 19 @lip. alarms on and functioning. ambu/syringe @ hob. bs are clear with occasional coarse sounds which improve with suctioning. diminished bases bilaterally. suctioned for small amounts of thick white secretions. mdi's administered q4 hrs atrovent with no adverse reactions. trip to ct with results pending. am abg's7.50/26/363/21 with no changes. family meeting today to discuss cmo.
"
1217,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett 37.5, 19 @ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear with diminished bases. suctioned for small amounts of yellow secretions. mdi's administered q4 hrs atrovent with no adverse reactions. [**name (ni) 239**]=44. am abg's 7.43/37/110/25. plan today is to wean to extubate.
"
1218,"resp: pt remains on vent a/c 12/500/+8/40% and is vent dependent. bs are slightly coarse which improve following suctioning. suctioned for small amounts of white thick secretions. mdi's administered as ordered with no adverse reactions. no changes or abg's this shift. 02 sats 2 97%. no rsbi due to vent dependency. will continue full vent support.
"
1219,"resp: [**name (ni) 97**] pt on a/c 24/450/+5/50%. alarms on and functioning. ambu/syringe @ hob. pt is [**name (ni) **] with # 8 [**last name (un) **] (foam filled) trach. bs reveal occasional wheeze with slight coarseness. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease fio2 to 40%, rate to 20, and tv 400 reflects abgs. am abg 7.40/58/88/37. no further changes noted.
"
1220,"npn 7a-7p

events- c. diff positive, 2.5l ns bolused, vasopressin added, neosynephrine off, echo done showing suppressed ef consistent with sepsis, le u/s done results pending, abx regimen changed.

review of systems-

neuro-  fentanyl gtt increased from 30mcg/hr to 75mcg/hr (gradually) in the setting of attempting to decrease respiratory drive and manage metabolic acidosis.  pt. remains very alert to voice, easily arouses.  family describes adverse reaction to use of versed, would cont to use fentanyl to achieve desired level of alertness.

resp-  vent changes- tv increased to 600cc from 550, peep increased from 8 to 10, fio2 decreased from 100% to 90%.  latest abg pending, most recent 7.27/43/114/21.  ls- bronchial on right (has rll pna on cxr), diminished on left.  abx regimen changed from ceftriaxone to ceftazadime.  sat's maintained >94%.  currently, unable to obtain peripheral sat.

cv-  hr 80-90's nsr with some ectopy.  map >60 maintained with pressors.  vasopressin started at 11a at 0.04u/min.  neo weaned quickly off thereafter.  levophed is coming down nicely as well.  however, lactate conts to be 3.4 range, and creat has bumped from 1.3 to 1.5.  mixed venous sats 74, 84.  cvp 12,7. echo showing depressed ef (unmeasurable d/t poor study). dobutamine was discussed.  however, given ability to come down off pressors, will hold on inotropy for now.  plan-  goal cvp >12, map >60, decrease pressors as tolerated, bolus for low u/o and higher lactates, consider dobutamine if svo2 drops, cont to follow hct q4, next full set of labs due at 8p.

gi/heme-  abd distended, c.diff +.  conts on flagyl.  highish gut residuals (120 cc at 1600).  tf started at 10cc/hr, not advanced d/t high residuals.  500cc of stool out, [**male first name (un) **] colored, liquid, heme +.  hct stable 38 througout the day.  plt trending down to 44.

gu-  u/o problem[**name (ni) **] today only 5-10cc/hr.  given 2.5l ns.  bun/creat elevated throughout the day as mentioned.

id-  abx changed as mentioned, needs vanco trough tonight.  most likely source of infection is nosocomial pna and c.diff as well as uti from [**1-24**].

social-  multiple family members in today, coming in [**apartment address(1) 5958**] by 2, fellow updated on plan of care for today.
"
1221,"resp: [**name (ni) 97**] pt on psv 8/5/50%. bs reveal noted aeration. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.46/35/91/26 on 40% fio2. rsbi=63, cuff check and adequate leak noted. continue to wean appropriately.
"
1222,"resp: [**name (ni) 97**] pt on a/c 18/450/+5/40%. alarms on and functioning. trach#8.0 shiley with no inner cannula. bs are coarse bilaterally. suctioned copious amounts of thick green secretions. mid's administered as ordered of atrovent with no adverse reactions. am abg 7.38/55/116/34. will proceed to wean as tolerated.
"
1223,"resp: [**name (ni) 97**] pt on a/c 24/500/+5/40%. pt has #8 portex trach. bs are coarse to clear bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. am abg 7.40/50/106/32. rsbi=62. plan: wean as tolerated.
"
1224,"resp: [**name (ni) 97**] pt on 50% t/c. pt became tired and complained of ^ wob then  placed back on vent to rest noc. psv 8/8/40%. suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. no abg's this shift. rsbi=33. plan: continue with t/c trials as tolerated.
"
1225,"resp: [**name (ni) 97**] pt on psv 8/8/40%. pt has #8 portex trach. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no abg's noc. rsbi=57. plan: continue with t/c trials as tolerated. pt being screened for rehab.
"
1226,"resp: [**name (ni) 97**] pt on a/c 32/600/10+/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. pt biting on ett, block placed. ett retaped and secured. mdi's administered as ordered with no adverse reactions. abg's (see careview) vent changes to decrease rr to 28. am abg 7.30/36/146/18. rsbi= no resps.
"
1227,"7a-7p
neuro: pt alert, nodding appropriately, moving all extremeties. following all commands.perrla. morphine ivp given prn pain. denies pain at present time.

cv: hr initially 70-90s sr 1st degree avb. converted to raf 130s-140s, w/ stable sbp 110-120s at 1230, ntg weaned to off. lopressor 5mg given. total of 20mg ivp as ordered per pa [**doctor last name **]. mg 2gm given. amiodarone iv bolus 150mg x 2 given, gtt started at 1mg/hr as ordered. at present still hr 100-130 on gtt, pa [**doctor last name **] aware. during event, pt alert and nodding appropriately. swan placed at bedside, see carevue for filling pressures. ci >3 before af, after af ci>2, pa [**doctor last name **] aware. 1 unit of prbcs given for hct <28, no adverse reactions. repeat hct 33.2. epicardial wires in place atrial ma turned to off secondary to inappropriate atrial pacer spikes. v wires not capturing or sensing appropriately. palpable pulses.

resp: ls coarse. suctioned for scant thick tan. trial on cpap fio2 40%, 5peep, 8ps. abgs 7.30/47/133/24/97%, pa [**doctor last name **] called and aware, vent change to ac 8, improving abgs. see carevue for details.

gi/gu: abd soft hypoactive bs. ogt replaced secondary to tee done in am, +placement verified by two rns. lasix 200mg and diuril 500mg iv given as ordered, bringing u/o >100cc/hr.

endo: insulin gtt restarted, as high as 6units/hr.

social: husband visited and updated, sister called and updated w/poc.

plan: monitor hemodynamics. monitor resp. status. monitor blood glucose. monitor hr. monitor u/o. keep pt comfortable.
"
1228,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/400/+5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with slighlly diminished bases. mdi's administered q4 of alb with no adverse reactions. suctioned small amounts of yellow/white secretions with an occasional plug. am abg's 7.40/62/97/40.  rsbi=26. no further change noted. extubation expected this am
"
1229,"resp: [**name (ni) 97**] pt on psv 15/8/50%. ett #8, 23 @ lip. bs are coarse bilaterally. suctioned for copious amounts of thick tan secretions. mdi's admistered as ordered alb/atr with no adverse reactions. am abg 7.40/45/99/25. rsbi=66. will continue to wean as tolerated.
"
1230,"resp: [**name (ni) 97**] pt on psv 10/10/40%. bs are coarse bilaterally. suctioned for thick amounts of tannish secretions. mdi's administerd as ordered alb/atr with no adverse reactions. pt desat in 80's with ^ wob and placed back on a/c. multiple abg's (see careview) with vent changes to decrease r to 20. rsbi= no resps. am abg pending. will wean to psv as tolerated.
"
1231,"resp:  rec'd a/c 20/600/+12/40%. bs are slightly coarse with diminished bases. suctioned for small amounts.suctioned moderate amounts from oral cavity. mdi's administered as ordered with no adverse reactions. am abg 7.30/43/90/22. no changes noc. no rsbi due to ^ peep
"
1232,"resp: [**name (ni) 97**] pt on psv 12/10/40%. ett 7.5 24 @ lip. bs are coarse bilaerally with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's adminisered as ordered with no adverse reactions. vt's 400-500, ve's 12'[**49**], rr 24 with ^ to 30's at times.  am abg 7.43/44/101/30. rsbi=^peep. no changes noc. continue to wean as tolerated.
"
1233,"resp: [**name (ni) 97**] pt intubated via er for airway protection. placed on a/c 16/500/+5/50%. bs are clear bilateraly with diminished bases. mdi's administered as ordered with no adverse reactions. rsbi=no resps x2.plan to wean as tolerated.
"
1234,"resp: rec;d pt on psv 15/10/50%. ett #8 retaped and secured @ 23 lip. bs are coarse bilaterally. suctioned for small to moderate amounts of thick yellow to tannish secretions. mdi administere as ordered alb/atr with no adverse reactions. pt had episode of tachycardia around midnight, lopressor administred pt back into sinus.  peep decreased to 8. am abg 7.40/45/99/29. rsbi=76. willl continue to wean as tolerated.
"
1235,"resp: pt remains intubated ett#8, 23 @ lip. psv 15/+/50%. bs are coarse bilaterally and suctioning copious amounts of thick white secreitons. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.34/42/160/24. rsbi=66. plan to trach and peg today.
"
1236,"nursing note 7p-7a
s:""can i get some water father"".
o: see flow sheet for all objective data.
[**name (ni) **] pt remains confused to place/time, awake most of noc. restless with periods of calling out names, frequent reorienting needed. given seraquil/olanzapine doses, held ativan d/t ? adverse reaction.
cv- in af with rare pvcs, hr 70s-90, nbp 130-140s/70s. conts on po captopril/lopressor. post transfusion hct 33.1, k+ 3.5, repleated with 60meq po, mg 2.3.
resp- ls clear diminished in bases. conts on 2l nc sats 98-100%. r flank ct site dsg cd+i, no oozing.
gi/gu- tf promote+fiber conts @ 70cc/hr via peg tube, site cd+i. incont of stool x3, [**name (ni) **] pt is on c-diff precautions, drinking fluids. foley patent voiding qs clear yellow urine. diuresed with 100mg iv lasix with good response. i+o neg 1l this shift.
skin- buttocks red/raw, duoderm intact to r cheek.
a/p: 72yo male admitted on [**3-31**] with hypoxia requiring intubation d/t chf exacerbation. s/p r thoracentesis c/b pneumothorax requiring chest tube placement. pt extubated and ct pulled [**4-4**]. hematoma @ ct site requiring sutures. s/p cabg [**1-14**] c/b a long icu stay d/t chf, pericardial effusion and pneumonia, c-diff. [**year (2 digits) **] to monitor i+os, hct and lytes with diuresing. monitor for safety d/t confusion.
"
1237,"resp: [**name (ni) 97**] pt on [**last name (un) **] simv 12/600/5/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs reveal i/e wheezes with rs diminished. suctioned moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr and [**last name (un) **] [**hospital1 **] with no adverse reactions.  abg's 7.34/41/118/23. rsbi=44. no further changes noted.
"
1238,"resp: [**name (ni) 97**] pt on psv 12/10/40%. ett 7.5, 24 @ lip. bs are slightly coarse with diminished bases. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. vt's 500-600, ve's13, rr 28. no changes or abg's this shift. 02 sats @98%. family meeting today to discuss cmo with possible withdraw in afternoon. will continue with present settings.
"
1239,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 18/550/40%/+[**4-23**]. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds with slight coarse bases. suctioned x3 small amount of bloody secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=65, sbt initiated.  02 sats @ 99%.  no further changes noted.
"
1240,"resp:  [**name (ni) 97**] pt intubated from or.  ambu/syringe @ hob. placed on 7200 briefly then extubated and placed on sm @ 6lpm.  bs auscultated reveal bilateral diminished sounds, pt complains of not being able to breath.  02 sats remain 98-100%, rr 16-15. hhn ordered and administered x3 during noc alb/atr with improvement noted. no adverse reactions noted. pt on n/c @ 4lpm with no distress.  no further changes noted.
"
1241,"micu 7 rn report 0700-1900

events: wean to trache collar o2 40%, bleeding from rsc dialysis cath site.

neuro:  [** 19**] oriented x3 periods of anxiety, follow commands. communicated by writing and mouthing words. @ 1600 ^anxiety and adb/incision discomfort [**5-8**] received dilaudid 1mg and ativan 0.5mg w/effect.  mae,equal strength, pupil 2mm brisk.

cv:  hr 50-72 a fib, sys bp 130-180/85, hypertensive episodes sbp>170 noted when anxiety, iv ns kvo. rsc hd tunnel cath bleeding drg changed x3 eval by ir injected site w/fibrin. lt brachial picc working well. rt arm piv.

resp:  received on vent cpap 5/5/40%. @1130 vent weaned to trach mask 40%. spo2 92-98%. tol for shift plan to reamin on tm for noc. lungs coarse bil. productive cough thick yellow sputum.

gi:  abd soft  + bs, tf nutren pulmonary 30 cc/hr tol well. mushroom cath draining brown color liquid stool.

gu:  anuric,during 12 hr shift 10 ml urine drained.hemodialysis done removed 2200cc. no adverse reaction noted. plan for another hd [**6-5**].

endo: fs q6h as per sliding scale

skin: wound coccyx dressing intact. abd surgical wound debridement done by [**doctor first name **] collangenase oint and packing dsd,  no drainage,

social:  relative visited. dnr, dnh

plan: supportive care
      hemodialysis [**6-5**]
      [**hospital 1366**] rehab [**6-5**]
"
1242,"resp: pt rec'd on psv 10/5/40% ett 7.0 18@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick yellow to white secretions. mdi's administered alb with no adverse reactions. abg's (see careview)ativan administered and changes to place pt back on a/c. rsbi attempted. will try again in am when sedation lightened. plan to wean to psv as tolerated.
"
1243,"resp: pt rec'd on psv 5/5/40%. ett #8, taped @ 24 lip. ambu/syrine @ hob. bs are clear with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. vt's 500-600, ve [**11-10**], rr 25. 02 sats @ 100%. am abg 7.38/40/114/25 with rsbi=74. plan to continue to wean as tolerated.
"
1244,"resp: [**name (ni) 97**] pt on psv 2/5/40%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, taped & secured @ 23 lip, 23 cp. vt's 500, rr 16. bs auscultated reveal bilateral crackles. suctioned small amounts of thick white secretions. mdi administered q4 hrs with no adverse reactions. will continue full support.
"
1245,"resp: pt remains intubated on a/c 18/650/+10/50%. bs are clear bilaterally. suctioned for small amounts of secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.44/35/159/25. no vent changes noc. will continue full support.
"
1246,"resp: [**name (ni) 97**] pt on psv 10/5/40% (mmv back up rate) bs auscultated reveal bilateral crackles. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. vt's 400-480, rr 18-22.am abg 7.40/59/97/30. no further changes noted. will continue to follow.
"
1247,"admission
pt is a 77 year old female admitted from cath lab, s/p stenting of left cx and rca. presented to er this am ~0600 from nh due to pt being lethargic,code stemi done after ekg done, intubated in er due ? responsiveness. on dopamine as high as 15mcg/kg/min in cath lab, at present time dopamine at 5mcg/kg/min.

neuro: pt tracks rn when being spoken to, does not follow commands, perrla. no indication of pain.

cv: hr 60-80s sr. arterial sheath [**name6 (md) **] by md [**last name (titles) 7625**], act 160. right groin cdi, no bleeding, no hematoma venous sheath kept in. dopamine at 5mcg/kg/min. sbp labile, 70-110s. fluid bolus 500cc given as ordered, improving sbp. hct for 23.9, transfused 1 unit of prbcs, no adverse reactions/ ekg done on arrival as ordered, elevated st, slightly improved per ccu team. +dopplerable right dp/pt, +dopplerable left dp, absent pt on left. ccu team aware, no new orders. next ck due 1900. bp on left arm only per ccu team, right has old fistula that does not work.

resp: ls clear. orally intubated, weaned vent to cpap [**5-10**] fio2 40%. ccu team aware of abgs (md [**doctor last name **]). see flowsheet for details. unable to get sats at times, ccu team and md [**doctor last name **] aware. sats when showing 100%. sputum culture sent.

gi/gu: abd soft hypoactive bs. ogt +placement. clamped at present [**doctor first name **], ok to hook up to lcs [**name8 (md) 9**] md [**last name (titles) 7626**]. foley draining 0-10cc/hr of amber color urine. left subclavian hd cath [**last name (titles) 240**]. ua and uc sent.

endo: per sliding scale.

plan: wean vent. assess neuro (pt with hx of dementia). ck due 1900. hct pending. blood cultures when aline placed. ?aline placement. wean dopamine. full code.
"
1248,"resp: [**name (ni) 97**] pt on psv 12/5/40%. alarms on and functioning. ambu/syringe @ hob. 7.5 ett taped and secured @ 23 lip. cp 23 cmh20. bs auscultated reveal bilateral crackles. suctioned for scant to small amounts of thick white secretions. mdi's administered q 4 hrs with no adverse reactions. vent changes to decrease ps to 10. am abg's 7.36/56/94/33. rsbi=63. no further changes noted.
"
1249,"resp: [**name (ni) 97**] pt on ac 12/600/+5/50%. ett #7.5 24@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick tannish secretions. mdi's administered q4 alb/alb with no adverse reactions. am abg 7.40/32/140/21. rsbi=125. pt is scheduled for trach/peg in or today.
"
1250,"resp: [**name (ni) 97**] pt on a/c 18/650/+10/50%. ett#7.0, 24 @ lip. bs are slightly coarse. suctioned for small amounts of tannish secretions. mdi's administered q 4 hrs. alb/atr with no adverse reactions. am abg's 7.47/32/207/24. no vent changes noc. will continue full vent support.
"
1251,"resp: pt rec'd on 18/650/+12/50%.  bs are clear. mdi' administered alb/atr with no adverse reactions. vent changes to decrease peep +10. abg's 7.43/34/169/23. no further changes noted. will continue with full vent support.
"
1252,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/550/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral slight coarse sounds with crackles in bases. suctioned small amounts of white/yellowish secretions.  mdi's administered q4 atr/alb with no adverse reactions. placed pt on psv and didn't tolerate.  rsbi=155.  am abg's 7.33/44/101/24.  will continue to wean as tolerated.
"
1253,"resp: [**name (ni) 97**] pt on a/c 14/500/+5/40%. ett 7.0, 22 @ lip. bs are coarse to clear and suctioning small to moderate amounts of thick yellow secretions. mdi of atr administered as ordered with no adverse reactions. no abg's or changes noc. will continue present support.
"
1254,"0700-1900 npn
alert, oriented, coperative with care.  mae.  pain not well controlled this am, c/o sharp stabing pain with cramps, [**10-21**] pain.  neurotin dose started with minimal effect. pca increased and ativan iv given with limited effect.  aps into consult and epidural placed and started on bupivicane/dilaudid epidural with good effect.  able to titrate up without adverse reactions. given valium and ativan for breakthrough.  tmax 99.9, hr 60-60 nsr 4 beat run vtach x1, asymptomatic.  bp stable 130-140's.  pp palpable, sm amt generalized edema.  lungs clear, using is with encouragment.  abd tender, greatly improved with epidural, hypoactive bowel sounds.  ngt lcs.  urine adveraging 30cc/hr.  dsg intact, jp sites intact, no breakdown.  stoma pink, sm amt serosang output.  plan to increase activity as tolerated, monitor pain and medicate prn, monitor hemodynamics, provide emotional support to patient and family.
"
1255,"resp: pt on hi-flow mask @ 40%. nebs administered as ordered alb/atr with no adverse reactions. bs are coarse bilaterally with no change following tx. will continue to follow and monitor.
"
1256,"neuro: pt. is a&ox3, cooperative, followign commands, +mae, +perrla, intact gag/cough. had 1 episode of anxiety attack after tee, treated with ativan 1mg ivp. pt. is on clonopin [**hospital1 26**].
resp: ls diminished bilat, in am sats 80s-90s on 40%fio2 oft. encouraged to cough and deep breath with sats up to 90s immediately after. cxr showed emphysematous changes, lll atelectasis, no chf. at 1200 pt preped for tee by cardiology, medicated with 50mcg of fentanyl, 2mg of versed ivp per orders, cardiology administered hurricane spray for the procedure, during the procedure pt became cyanotic with face and extremities turning purple-[**doctor last name 797**], sats droped to 70s, pt developed hurricane induced methenoglobulemia treated with methylene blue iv (total of 38ml ivp per orders). serial blood gases obtained via periph. stick with improvement (see careview for results). fio2 increased to 100%, pt. diaphoretic right after procedure, but with stable bp, denied sob or breathing discomfort. at 1600 sats up to 80s, pt. verbalizing, appeares more comfortable. at 1700 pt. taking a nap with sats in high 70s-80s.
cv: hr 70s-90s, nsr, no ectopy, bp 100-130s/50s-60s.remains on captopril, lopressor po. tee done to r/o endocarditis, revealed ef of 55%, mild mitral regurge, no signs of infection. hct 26, started on iron po
gi/gu: abd. soft, distended, +bs, no bm today. npo for tee, started on ice chips and sips of clears, maintain free h2o restrictions [**2-3**] na 130. foley patent, clear yellow urine out, turned green after methylene blue administration, to be expected per team.
skin: lt. foot dsg changed, cultures obtained by podiatry, multipodis boots applied bilat. per orders.
id: t max 101, remains on iv piperacillin, vanco.
access: a-line discontinued due to call out status which was changed after hurricane induced adverse reaction.
social: son with wife visited, updated by md and nursing on events of the day, plan of care.
"
1257,"resp: pt rec'd on mmv (see carview for psv back up settings). bs are coarse bilaterally and suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. am abg 7.37/36/143/22. rsbi=78. plan to wean psv to possible extubation today.
"
1258,"resp:  [**name (ni) 97**] pt on 7200 ps 20/+15/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that clear with suctioning.  suctioned small to moderate thick yellowish/whitish secretions, and also out of oral cavity.  mdi's administered q 4hr alb/atr with no adverse reactions. eet retaped, moved and secured.  vent changes as follows; a/c 18/650/+15/40%.  02 sats remain in ^90's over noc with no additional changes noted.
"
1259,"resp: [**name (ni) 97**] pt on a/c 10/450/+5/45%. bs are coarse bilaterally. suctioned for small to moderate amounts of white secretions as well as oral secretions. mdi's administered alb as ordered with no adverse reactions. rsbi=127. pt more awake. plan to wean to ps as tolerated. no abg's no a=line
"
1260,"resp: [**name (ni) 97**] pt on a/c 20/500/+5/40%. bs reveal bilateral aeration. no wheeze noted. suctioned for small amounts of yellow secretions and bloody secretions x1, rn/md aware. mdi's administered q4 hrs combivent with no adverse reactions. rsbi attempted=no resps. no changes noc.  will continue full vent support.
"
1261,"resp: [**name (ni) 97**] pt on [**last name (un) **] simv 15/600/10/14+/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished bases with aeration noted in apecies. mdi's administered combivent 2 p with no adverse reactions.  suctioned for small amounts of white/yellow secretions. am abg's 7.38/44/98/27.  vent changes reflect abg's (see careview) no rsbi due to ^ peep. no further change ntoed.
"
1262,"resp:  [**name (ni) 97**] pt on 7200 a/c 18/650/50%/+20.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies,with some coarse bs in bases which clear with suctioning.  suctioned x2 small amounts of thick yellow secretions.  mdi's administered alb/atr q4h with no adverse reactions noted.  no rsbi performed due to ^peep.  no further changes noted.
"
1263,"npn shift 1900-0700:

neuro unchanged. very anxious, inappropiate behavior. yelling, crying, whining, flailing extremities. comfort measures and emotional support given w/ little effect. verbalizes wnats to drink. explained reason why npo, unreceptive to teaching. swabbed mouth, magic mouth wash as needed. other times refuses to verbalize whats wrong at times. medicated w/. ativan 0.5ng iv w/ good effect. humi air 35% for dry oral airway. satting 97-100%. no s/sof distress. pulm toileting. cough prod.  nsr-st, rare ectopy. no s/s of cardiac distress. sbp wnl. hct=26.0. tx rprbc x2 u w/ good effect, no s/ sof an adverse reaction. am hct=31.2. k+=3.4, mg+=1.9. repleted w/ kcl 20meq iv x1, mg+ 2amps x1. need add'l kcl 20meq iv. ho aware and in to assess pt throughout the night aware of inapprop behavior. [**month (only) **] order psych consult.
"
1264,"nursing update
   abdomen drained 250cc sanguenous fluid overnoc. transfused with 5-pack platelets, no adverse reaction. post transfusion plts 92, 95 this am. hct stable @ 31 this am. bp stable, nipride utilized x 1h only for brief episode of hypertension with sbp 140-150's. blood sugar stabilized on insulin gtts 0.5u/h. ativan, dilaudid and cisatracurium gtts cont -> ativan and cisat gtts increased slightly to resolve tachypnea and facilitate ventilation.
"
1265,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/650/+20/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned small to moderate amounts of thick bloody tinged secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats remain in^ 90's 96-98% with no distress noted during the noc.  current vent settings remain and recent abg noted as 7.33,44,94,24,-2.  no further changes noted.
"
1266,"resp: [**name (ni) 52**] pt on a/c 22/600/+5/40%. ett # 8 @ 21 lip. bs reveal bilateral aeration with diminished bases, no wheezes noted. alarms on and functioning. ambu/syringe @ hob. suctioned for small amounts of tanish secretions. mdi's administered  q 4 alb/atr with no adverse reactions. abg (venous) 7.39/40/39/25. 02 sats @ 100%. attempted rsbi although pt not awake enough. will attempt again this am. plan is to wean as tolerated to ps with possible extubation.
"
1267,"resp care note

pt given 300 mg pentamadine in 6 cc sterile water via respraguard neb and mouth piece. no adverse reaction noted
"
1268,"resp: [**name (ni) 52**] pt on simv 7/450/5/+5/40%. pt has #7 [**last name (un) **] trach. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. [**last name (un) 1017**]=113. no abg's or changes this shift.
"
1269,"resp: [**name (ni) 52**] pt on simv 7/450/5/+5/40%. trach #7 [**last name (un) **] [**last name (un) 1999**]. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs of alb/atr with no adverse reactions. abg's 7.36/71/71/41. md aware and satisfied with results. will continue to maintain current vent settings.
"
1270,"resp: pt rec'd on a/c 14/500/+5/60%. bs auscultated reveal bilateral aeration in apecies with diminished bases. mdi's administered q 4 comb/[**last name (un) **] [**hospital1 **] with no adverse reactions. am abg's 7.44/38/93/27. suctioned for small amounts of thick bloody tinged secretions. proceeded to initiate wean decreasing fio2 to 50%. will continue to wean appropriately.
"
1271,"npn: s/p cabg

neuro: drowsy and lethargic at times. easily arouses. oriented to self,hospital,or family. occ sl confused to day/time. mae with equal strength. knees sl buckling with oob to chair. perrl. visited with husband and [**name2 (ni) 2585**]. [**name (ni) 2586**] hopes to be back to work in 4 weeks.
cv: 100-70's sr-st with occ to freq pac's-rare pvc's seen-triplet x2. on/off neo to .75 to keep map>60. ci>2.5. swan dc'd.  k repleted. lytes wnl. pacer set a s a demand at 60. pedal pulses by doppler. hct stable 32.6.
id: tmax 99. wbc 9. cont on postop vanco.
resp: lungs diminished in bases. cough prod of bloody to blood tinged secretions early. requiring 4l nc and 40% ftneb especially when dozing. ct/mt to sxn-no airleak-serosang dng decreasing. sats > 95%. gu: foley to gd with initially good uo-now trending low0500cc ns given. cr .5.
gi: abd obese,soft, nt, nd. periods of nausea especially with movement which pt states happens r/t her meniere's. reglan given x1. tol small amt clears.
endo: on insulin gtt per cts protocol-gl to 71-gtt now off.
comfort: dilaudid .5 mg iv q 2-3 hrs for pain with effect. pt cont to state multiple allergies to everything you try to give her. no adverse reactions seen. to have vicodin ordered for po pain med.
activity: oob to ch with 2 assists-tol well but very slow-c/o knees buckling and very tired.
incisions: sternum and ct with original dsd-old staining on sternum-d/i. l leg ace wrapped d/i.
a: stable -still requiring volume and +/- neo
p: wean neo as tol, 500cc ns bolus, monitor uo-? lasix later if needed. po pain med, replete lytes.
"
1272,"nsicu npn 0700-1500
see carevue for subjective/objective data.  neuro:  pupils 2mm, sluggish most of shift however at 1430 pupils 3mm, brisk.  does move all extremities on bed when propofol lightened, does withdraw to pain. purposeful movement-->consistently lifts left hand toward ett when un-
restrained.  icp drain in place, icp 12-22, drng blood tinged sec 11-24ml/hr.  spec obtained by md and sent to lab.  poor waveform--md aware.  icp flushed by md with minimal improvement in waveform.  +gag, +cough, +corneals.  dsg-->icp drain d+i.  one suture on icp drain out; again, md aware (not new).  to ct at 0800 for ct of head; results pending.

cv/pulm:  initially on neo--gradually weaned, turned to off at 1400 with bp 120's.  goal is to keep bp 120's-140's.  ekg done.  started on sq heparin.  hct=25; one unit prbc's hung at 1430 with no adverse reactions thus far.  mp=nsr, no vea noted.  maintenance iv kvo'd while prbc's infusing.  remains vented on ac10x600x50%x5peep.  peep was 10, decreased to 5, abg's pending.  suct for mod amts thick yel sec via ett and thick clear orally.  bs coarse bil.  no other vent changes made this shift.  ett rotated to l side mouth, [**name8 (md) 76**] md pulled back to 21cm lip line.  no rpt cxr done.

gi/gu:  ogt-->lcs drng 75ml coffee ground material.  tf started at 1430 fs promote with fiber at 10ml/hr.  goal=60ml/hr.  no bm, +flatus. hypoactive bs.  u/o qs q1h via foley.

integ:  no open areas noted.  changed to air mattress with 5assists tol well.  turned s/s but consistently left in supine position.

id:  tmax=100.1 po.  no change in abx.

psychosocial:  fam in to visit.  emotional support given to pt and fam.  per fam they will return this pm to visit again.
"
1273,"resp: pt rec'd intubated via or placed on [**last name (un) **] a/c 14/500/+5/60%.ett 7.5, taped @ 19 lip.  bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick bloody secretions with occasional plug. mdi initiated and administered q4 alb/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see careview) am abg's 7.38/42/86/26.  will continue full vent support.
"
1274,"ccu nursing progress note
neuro:  pt a&o tpp, pt able to follow all commands, and move all extremeties well.  pt had difficulty sleeping overnight, pt unablet o receive aids, pt had adverse reaction to ambian and ativan.

cardiac:  pt in af rate 100-120, bp 110-130/60-70.  pt has swan pa 36-42/16-22, no co drawn, cvp not [**location (un) **] appropriately.  pt on dilt at 15 mg/hr, heparin 1000 u/hr, ptt 53.3 inr 1.5; and ntg 20 mcg/min.  will go to cabg today.

resp:  pt on 2l via nc, with o2 sats, ranging 92-96%.  pts resp pattern [**last name (un) **]-[**doctor last name **] breathing, o2 sats will drop to low 90's during apenic period.  bs are exp wheezes on r, clear in lul, and decreased in lll.  ? of influtrate.

gi:  pt npo since midnight, +bs, -bm.  abd soft distended nt.

gu:  pt has f/c producing >30 cc/hr, urine is pink, blood tinged.

id:  pt had one bottle of blood cultures grow out g+ cocci in pairs and clusters.  pt afebrile.  pt currently on levo.
"
1275,"ccu nursing progress note
s""i want to go home""
o: pt s/p right carotid stenting. pt alert, oriented x2. answers questions and speaking w/o aphasia. no difficulty swallowing liq.  follows commands. pt was not able to  sleep   frequently disoriented with escalating agitation. med w/ xanax w some effect.  daughters stayed w/ pt throughout the noc.
cv:mhr vp, no vea, sbp 120-130, +mur, dp palp bilat. r groin dsg d+i.
resp:lungs clear, sats 98% on ra.
gi:+bs, sm stool, guiac neg
gu: u/o 80-100cc/hr.
a/p: pt hemodynamically stable post stent. evidence of sundowning/acute delirium vs pt psychosis neurosis. this is the second night the pt has not slept according to family. family not wishing to try other sedatives or zyprexa due to adverse reactions to these meds in the past.
"
1276,"resp:  [**name (ni) 97**] pt on 40% cam (t/c).  bs auscultated revealed bilateral i/e wheeze. placed pt back on [**last name (un) **] mmv 12/500/+5/5/30% noc.  mdi's administered of comvbivent q4 hrs with no adverse reactions.  suctioned x3 small amounts of white thick secretions.  trach care performed, stitches removed, trach collar placed.  cuff pressure @ 20 cmh20.  02 sats ^ 90's 98%.  no rsbi performed since pt is being placed on t/c during the day.  no further changes noted.
"
1277,"resp: [**name (ni) 97**] pt on psv 10/10/50%. alarms on and functioning. ambu/syringe @ hob. ett #8.0 @ 21 lip. bs are coarse bilaterally. suctioned for small amounts of white secretions. sample obtained and sent. mid's administered as ordered alb/atr with no adverse reactions. am abg's 7.43/41/137/28. no rsbi due to ^ peep.
"
1278,"resp: [**name (ni) 97**] pt on 40% t/c. ambu @ hob. bs are coarse bilaterally with diminished ls in base. mdi's administered q6 hrs of alb with no adverse reactions. pt able to expectorate with spc. rusty thick secretions. 02 sats @ 100%. will continue to follow as per trach protocol.
"
1279,"resp:  [**name (ni) 97**] pt on 7200 psv 18/40% +5.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that clear with suctioning. suctioned several times during the night for thick yellow/greenish secretions. pt tends to accumulate moderate amounts of whitish secretions also in oral cavity.  mdi's administered q4 hr, 6 p combivent with no adverse reactions.  pt was place on a/c 10/400/+5/40% at noc to rest.  rsbi=108 this morning so no sbt initiated.  returned pt to psv 18/5/40 this am and tolerating settings well.  no further changes noted.
"
1280,"data/action: afebrile, hr 80's w/o ect. sb/p<160. heparin 200u/hr gtt.
o2sats 97% on room air. doing incentive spirocare well q4hrs. coughing
not raising. c/o abd. pain-relief w/ pca ms04 1mg-has used 30mg over 12 hrs.  bs q1hr ranging 77-133->ins. gtt off since 2100 last evening w/ bs's remaining <150. jp draining sm. amt sero-sang. atg infused over 6hrs w/o no adverse reaction. ngt-mod. watery drainage-no bowel sounds heard. abd. dsg d&i abd. soft.
"
1281,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 10/500/+12/50%. alarms on and functioning. ambu/syringe @ [**last name (un) **]. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of bloody tinged secretions with noted plugs.  mdi's administered q 4 hrs combivent with no adverse reactions.  no rsbi's performed due to ^ peep. am abg's 7.52/45/109/38. attempted to wean on psv, maintaining tv's/ve's appropriate although pt had periods of apnea. suggest possibly mmv to wean.  no further changes noted.
"
1282,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 20/400/40%/+8.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.   suctioned x3 moderate amount of thick bloody tinged secrections.  mdi's administered q4hr alb/atr with no adverse reactions.  o2 sats remain in ^90's.  no further changes noted.

"
1283,"resp: pt remains on psv 10/10/50%. bs are coarse bilaterally. suctioned for moderate amounts of tannish thick secretions with some bloody tinged. mdi's given q4 hrs combivent with no adverse reactions. abg's (see careview) am abg pending. no rsbi due to ^ peep. will continue to wean appropriately.
"
1284,"resp: [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small to moderate thick yellow secretions.  pt is able to self suction oral cavity.  mdi's administered alb/atr with no adverse reactions.  02 sats remain between 98-100%, maintaining adequate tv during the noc @ 350-400. pt does continue to have periods of apnea during noc, but in no distress.  no [**name6 (md) 239**] performed rn suggests let pt rest.  will advise day therpist to perform when pt is more awake.  no further changes noted.
"
1285,"resp: pt remains on psv 12.5.50%. vt's 600-700/ve 10/r 19, bs are slightly coarse suctioning small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.41/50/118/33. rsbi=166. no vent changes noc.
"
1286,"npn 1900-0700:

events: pt has required low-dose levo for bp management. crrt/uf resumed without complication.

ros:
neuro: pt remains on fentanyl 150mcg/hr and versed 1mg/hr with good effect. she is generally comfortable at rest and requires [** **] for turning. moving l arm only, weakly and without purpose. perrl, sluggish. did not appear to respond to her son.
resp: [**name2 (ni) **] vent changes made; most recent abg 7.33/43/121 on cmv .4/550/14/5. minimal thick tan, [**name2 (ni) **] blood-tinged secretions. although she has minimal secretions, her pp's increase significantly when she needs to be suctioned at all. ls: e wheezes, diminished lower. sats consistently 99-100%.
c-v: hypotensive at start of shift, requiring initiation of low-dose levo, which she has remained on. hr mostly 70's-90's, afib, with [**name2 (ni) **] pvc's. during the evening she had period of time during which she had intermittent slowing of hr with different-appearing qrs complex, representing a different conduction pathway. beats were well-perfused, with no significant drop in bp. she has been in her usual rhythm for the past several hours. ck's 218. 280, mb flat. troponin slightly elevated at .09, but pt has renal failure. cvp 20-21; lytes wnl.
gi: tf's continue at goal; belly obese but benign, no significant stool past several days.
gu: ampho bladder irrigation changed to continuous infusion; uo difficult to measure exactly, but seems to be running 10-30cc/hr. crrt/uf resumed at 0030, with current goal of -100cc/hr, which we are meeting without difficulty. please note that fluid balance on flow sheet is off by ~42cc/hr d/t ampho irrigant not accounted for in intake. ca gtt per sliding scale. bun/creat stable at 71/1.6.
id: afebrile, no need for bair hugger. wbc up to 18.8 (15.4). single dose of vanco given over 4 hours after pre-medication with benadryl. dose was well-tolerated with no evidence of adverse reaction.
heme: ptt therapeutic at 49.1; plt's wnl, hct stable at 30.3. no evidence of further bleeding.
endo: insulin gtt titrated prn.
skin: skin folds under breasts and in groin remain cracked/bleeding slightly. areas cleaned gently, double [**last name (un) **] and gauze applied. coccyx/perianal areas unchanged. upper l thigh blistering and draining now. l breast erythematous; both lower legs more red and blistering. ? if she has cellulitis in legs and breast.
access: r ij hd cath, r radial a-line, l sc mlc.
social: son [**name (ni) **] in to visit; he was updated on events of the day.

a: more stable night; tolerating crrt/uf once again.

p: current plan is to continue to remove fluid with goal of 3-4l/day off. would favor supporting bp as needed to facilitate this goal, as it appears to be about the only thing we can offer that might make a difference. per renal notes, plan to reassess when we have removed ~25kg (pt is ~55l positive for los, though this is improved from 59l a couple of days ago). otherwise, continue current management, ensuring pt comfort as a primary goal.
"
1287,"7a-7p
neuro: pt a+ox3,mae,perrla. dilaudid sc 2mg for pain.

cv: hr 80-100s sr no ectopy. sbp labile, on and off neo throughout day, see carevue for details. received one unit of prbcs, no adverse reactions. received lasix 20mg ivp after transfusion. +palpable pulses. generalized edema. at present to keep map >60, [**name8 (md) 9**] md [**last name (titles) 822**].

resp: ls wheezing throughout, audible at times especially w/ exertion. nebs q4 hours as scheduled. sats >97% on 4lnc.

gi/gu: abd soft,+bs,+flatus per pt. foley draining adequate amts of yellow urine-> light yellow after iv lasix.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. keep in unit overnoc, ? transfer to floor if remains off neo.
"
1288,"blood transfusion: 1 unit prbc started as per protocol. vss throughout. pt tolerating transfusion displaying no s/s of an adverse reaction. will monitor.
"
1289,"7p-7a
neuro: pt chinese speaking. pt alert granddaughter at bedside at beginning of shift translating, pt answering appropriately, follows commands,perrla, mae. granddaughter told pt in chinese not to touch ngt. medicated w/ dilaudid 2mg ivp q2 hours for incisional right ct pain, pt points to area and states ""pain"" or ""hurt"". at 0430, c/o left neck pain near jp and left shoulder, md [**doctor last name 896**] aware no new orders.

cv: hr at beginning of shift 110s, sbp 170 while intubated, md [**name6 (md) 1081**] and md [**doctor last name 896**] aware, additional lopressor iv given + hydralazine 10mg ivp. at 2100, hr again to 110s (after lopressor hr dips to 90 sr), md [**doctor last name 896**] aware additional lopressor iv 10mg given bringing hr down to 90s for approx 45min-1 hour. md [**doctor last name 896**] aware, labs ordered and sent. troponin 0.11 ck 488 md [**doctor last name 896**] aware, ekg done and reviewed by nd [**doctor last name 896**]. 1 unit of prbcs ordered and lopressor increased to 15mg iv q6hours. prbcs infused w/ no adverse reactions, md [**doctor last name 896**] aware of temp prior to transfusion, ok to give [**name6 (md) **] [**name8 (md) 9**] md [**last name (titles) 896**]. sbp 100-130s, see carevue. + palpable pulses.

resp: ls clear diminished. pt extubated at [**2109**], see carevue for post abg. sats >98% on 35% fio2 face tent, face tent kept on to keep pt's mouth and throat moist. sats on ra 94%-94%. see carevue for ct amts 2 right 1 left ct. jp to left neck draining serosang to bulb suction.

gi/gu: abd soft, tender to touch. multi abd dsgs from minimally invasive procedure, scant amt of serosang to dsgs. absent bs. j tube to gravity w/ scant amt of bile drainage. ngt to lwcs draining scant amt of thick [**name8 (md) **], md [**name6 (md) 896**] and md [**doctor last name 1081**] aware. continues at 3 [**11-26**] line as ordered, ngt not manipulated. foley draining clear yellow urine 30-80cc/hr. see carevue.

endo: per pt's scale. am glucose 69, 1 hour later 91.

plan: monitor hemodynamics. pain control. pulmonary toilet. increase activity. follow labs and treat as appropriate.



"
1290,"resp: pt rec'd on psv 5/5/30%. ett #7.5/22 lip. bs are coarse bilaterally. suctioned for copious to moderate amounts of thick bloody secretions iin beginning of shift then tapered off towards end. mdi
s alb/atr administered q4 with no adverse reactions. pt does have coughing episodes. rsbi=84. no changes this shift
"
1291,"shift note:  1900-0700
please see careview for all objective data:

neuro:  pt a+ox3, sleeping well t/o most of shift.  received percocet 2 tabs po as ordered x 1 for c/o [**7-28**] sharp, non-radiating, substernal cp as pt has been having.  pt denies changes in pain quality or increased sob. multiple ekg's w/ cp have been negative for acute changes and per report team feels pain is likely r/t pulmonary hypertension.  pt reporting pain free after percocet and has since been sleeping well.  pt remains free of diaphoresis or distress t/o shift.  pt able to reposition self in bed.  pt continues on seroquel as ordered for ptsd w/ good effect.  per report pt w/ adverse reaction to ativan.

resp:  pox remains stable 88-93% on 95% fio2 via t-peice w/ 10l via nc.  bbs remain cta to diminished at bases. snx w/ lavage x1 by rt for mucus plug.

cv:  hr 70's to 90's wap to afib/flutter w/ bbb w/ occasional pvc's.  bp remains stable.  trace ble edema continues, though improved from 3+ pitting edema on admission.  inr has been sub-therapeutic s/p vitamin k for picc placement.  no inr was checked on [**2-8**] and dr. [**first name (stitle) **] reports aware and orders coumadin 6mg po to be given as ordered w/ inr to be rechecked this am.  compression sleeves remain in place for dvt prophylaxis.  picc difficult to flush per report and alteplase had been ordered though able to flush slowly by this rn.  alteplase held and ns at kvo infusing through port to maintain patency.

id:  pt remains afebrile.  pt continues cefepime for pseudomonas pna.

fen:  pt tolerating diet well.  fsbs at 2200: 71mg/dl.  120ml apple juice and [**last name (un) 3612**] crackers were given.  fsbs up to 141 at 2230.  am labs to be checked though hct and lytes have been stable.  bun and creatanine continue to improve nearing baseline creat. of 1.2 to 1.3.  foley catheter d/c'd last shift per pt request.  pt has been voiding clear yellow urine in urinal, qs.  fluid status <2.3l> los.

social:  no contact from family this shift.

plan:  continue to wean fio2 and increase activity as pt tolerates.  pt has been oob to chair during day.  continue to monitor vs and labs.  continue abx as ordered. paper pg. ii started and placed in chart in anticipation of d/c to rehab facility when bed available.
"
1292,"pt came to micu6 from [**wardname 1699**] for merepenem desensitization because of multiple allergy.pt got here around [**2089**].completed desensitization without any complication.? c/o.

neuro: ox3.calm and cooperative.

id: frequent uti,now with e-coli. no signs of adverse reactions to merepanam.

cardio: nsr.vss.am lab pending.heparin drip per protocol.ptt qd.

resp: ls cta.

gi; abd soft. bowel sounds present.fsbs as noted.

gu: voids.minimal pain upon urination.clear yellow urine.

pain: severe left flank pain pain mgmt improved after multiple pain med adjustments as noted.

pain: ?c/o to floor today.

"
1293,"nurse progress note 0700-1900

events: po vanco started @1800[**name8 (md) 3097**] md order to uptitrate dose with goal 125mg po q6hrs.  no adverse reaction with starting doses- anaphylaxis kit @ bedside. hd @ bedside. see carevue for details.

neuro/pain: alert, oriented, dosing @ times. pain when cleaning from frequent stooling-denies further pain/discomfort.

resp: resp rate regular nonlabored, rr 19-26, ls clear bilat upper lobes, deminished bilat lower lobes-known right pleural eeffusion. trace scattered crackles on r-is encourage and at bedside. sat 93% resting in bed, placed on 1l nc currently 96-98%. cough/deep breath encouraged.

cv: hr 88-109 sr/st with rare pac, occ pvc's. hx labile bp, bp goal 130-170/ per pt am po meds held [**2-16**] hx hypotension during hd. hd- bp brief 105/60 ""i feel dissy and my vision is poor"" recieved 200cc back via dialysis. bp 132-191/57-89 map 73-112. no edema noted. riopathy, hx vascular dz, r bka. + weak pulses, thin dry skin.

gi: tolerating po's,  poor/changin appitie, wife bringing in food. has fd and riss-see [**month (only) **] for pt specific dosing. fs 204-286 -hx labile fs. inc frequent sm, green loose bm- cdiff +.

gu: anuric. hd @ bedside-started 1550-goal 3hrs. pos 1260 past 24hrs, pos 1860 los.

fen/endo: no ivf. heart healthy/consistant carb diet. iddm, dm 1 x 45yrs.

id: t max 98.6 po, cont iv flagyl, starting po vanco - recent cdiff and pna. blood cultures drawn during hd, thoracentesis results pending. vre/mrsa/cdiff precautions.

skin: excoriated peri area-no open sites, covered with barrier cream.  general thin dry.  no further breakdown in skin integrity noted.  sitting on side of bed.  heal elevated on pillows.

social: wife [**name (ni) **] @ bedside-updated on poc, medications.

poc
1. vanco desentitization- cont vanco per order, anaphylaxis kit @ bedside- monitor s/s given hx allergy to iv vanco
2. cont monitor resp status, encourage is
3. cont emotional support of pt and family
4. ? hd in am for ultrafiltration-renal following
4. cont all routine icu care, maintain bp goals
"
1294,"[**2204**]-0700

neuro: received pt from or awake, alert, oriented. follows commands well. maes. rigors noted. pt cooperative and exhausted. partner to visit at bedside.

resp: pt tachypnic resp 20-28 thru the night. c/o of sob with exertion. not tolerating activity well. o2sat remain stable. lungs clear/ex wheezing to bases bilaterally. nc 3l. no am abg done.

cv: s.tachycardia without ectopy noted. max temp 102.4-tylenol given. hr 110-130, sbp 90-130, complains of generalized discomfort. full body rash noted. ?adverse reaction to bactrim or transfusion reaction when on floor. piv x2. nss with 40 kcl bolus given. nss/20kcl@ 50cc/hr. + pulses to ext. no edema noted. porta cath removed and cultured-dsg changed this am. posterior neck dsg d+i. mg-1.5, k-3.8.

gu/gi: abd soft + bs, copious liquid stool-fecal incontinent bag intact draining liquid green stool. foley placed draining clear yellow urine.

plan: continue monitor cvp/fluid status due to not tolerating pd.
"
1295,"admission note
   this 75yr old woman was admitted at 2130, c/o dr [**first name (stitle) **], following a 13hour surgery - biorbital-frontal craniotomy for resection of 5cm meningioma.
   anesthsia was reversed and pt was extubated in or prior to admission to nsicu.  slow to wake up, but startled easily when arousing for neuro exam. s/b dr [**last name (stitle) **] @ 0130 and neuro exam done.  at this time, pt moving all extremites, speaking a few words clearly but tires easily after effort. following commands of opening eyes, hand squeezing and toe wiggling inconsistently.  c/o headache @ 0300, mso4 2mg ivp with good effect.  pupils equal in size and reactivity, but pupillary exam causes pt increased distress making exam difficult.  craniotomy incision draining mod amount sanguinous drainage, original dressing intact.
   nipride gtts continued to maintain sbp<140, dose increased slightly as bp elevated with waking up.  post-op hct 26.6, transfused with 2u prbc's without adverse reaction. ica of 1.04 repleted with ca gluc 2g iv.
"
1296,"resp:  [**name (ni) 97**] pt on psv 15/5/40%. alarms on and functioning.  ambu and syringe @ hob.  bs auscultated reveal diminished bilateral bases, aeration noted in apecies. mdi's administered of alb q 4hrs with no adverse reactions.  suctioned x2 moderate amounts of thick yellow secretions. pt has episodes of ^rr and decrease in tv with suctioning.  pt was placed on a/c in order to stabilize and decrease the wob. bp decreased then pt again returned to psv at above settings where she remains. rsbi=135 with no further changes noted.
"
1297,"resp: [**name (ni) 52**] pt on a/c 14/450/5/50%. ett 8.0, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and suctioning moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. no vent changes noc. am abg 7.45/39/97/28. pt scheduled for cabg x4 today with mv. rsbi=72.
"
1298,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/500/+5/50% alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clears sounds with diminished bases. suctioned for scant amounts of white secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions. am abg's 7.39/45/179/28.  decreased fio2 to 40%. no further changes noted. will continue to wean appropriately.
"
1299,"ccu nursing note 0700-1900

s/p r groin av fistual repair under conscious sedation; return to ccu @ 1130

neuro: pt neurologically intact, ao x3, speech clear, maew with equal strength, follows commands, denies pain, lightheadedness, sob or cp.  bedrest till 5 pm today.

cv: hr 60-80s nsr with rare pvcs.  sbp 120-140 map > 60.  new peripheral iv 18g placed in l fa by or staff.  no ivf ordered. old r ac iv dc'd with cathereting intact; drsg [**name5 (ptitle) **].  hct 24.3 this am; 1 unit rbc ordered and transfused; no adverse reactions noted.  repeat hct 27.3.  peripheral pulses palpable. r groin ecchymotic, or drsg [**name5 (ptitle) 819**].  l groin drsg [**name5 (ptitle) 819**].

pulm:  received pt from or on facemask.  o2 weaned to off; spo2 94%; resps even and unlabored; no acute distress noted.  lungs clear bilaterally. no cough.

gi:  pt tolerating ice chips without difficulty. abdomen benign; bs present.

gu: voids clear yellow urine per bedpan.

skin:  skin grossly intact; no breakdown noted;

social:  numerous family members have telephone and spoken with the patient following the procedures.  all family members updated on pt status and plan of care.

plan: transfer to floor today (?[**hospital ward name **] 9) and d/c home tomorrow.
"
1300,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 12/550/+5/60%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's given q2 hrs alb. with no adverse reactions. am abg's 7.37/52/92/31.  expect to wean to psv today and if tolerated, then possibly extubate
"
1301,"nsicu nsg adm note
ms. [**known lastname 6616**] is a 79yo female admitted to nsicu post op axillo [**hospital1 **]-fem bypass grafts to both legs.  pta she had abd, back and leg pain for 24hrs at home.  pain became severe and she presented to [**hospital1 95**] [**2191-2-8**]. pmh significant for mi, cabg [**2188**], htn, hypercholesterolemia, diabetic, ef 20% and depression.  she had been hospitalized 3days prior to this adm for r/o mi (neg for mi at that time).  she speaks [**year (4 digits) 413**], minimal english.  contacts are [**name2 (ni) 2905**]--phone [**telephone/fax (1) 11317**] and [**doctor first name **]--phone [**telephone/fax (1) 11318**].  [**doctor first name **] speaks english and [**doctor first name 413**]; [**doctor first name 2905**] is primarily [**doctor first name 413**] speaking.  in the or she rec'd a total of 1875ml prbc's and 6l cryst followed by lasix with a fair response.  in the icu she has rec'd additional 2units prbc's, 3units ffp, one 6pack platelets and numerous fluid boluses (goal is to keep pre-load high--cvp of 15 or greater).  she is currently on dobutamine at 5mcg, propofol at 30mcg, levo at 0.07mcg/kg/min and a bicarb gtt.

review of systems

neuro:  off propofol pt squeezes hands to command, opens eyes to command.  no attempts to speak around ett.  moving arms ad lib; no movements legs noted.  last assessment off propofol done at 0600.

cv/pulm:  dobutamine titrated up to maintain cvp>15 and ci>2.0.  blood products given as noted above; all transfused without adverse reactions.  levo remains at 0.07mcg/kg/min with map consistently>60.  dobutamine currently at 5mcg/kg/min.  fluid boluses per carevue in addition to blood products.  cvp trending down to 11-12--dr. [**last name (stitle) **] notified, additional ffp given.  remains vented with abg's improving--see carevue for vent settings and abg's.

gi/gu:  ogt placed, clamped.  no fluids given as ?bowel function.  hypoactive bowel sounds.  abd distended, soft.  mucous/bloody [**last name (un) 1366**] from rectum noted x3, foul smelling.  u/o qns--dr. [**last name (stitle) 11319**] notified, additional fluid and blood products given per carevue with little effect.  u/o now decreased to 5-8ml/hr.

integ:  l leg doppler pulses both dp and pt q1h.  l leg warm to touch with cap refill <3sec.  r leg pulses absent, leg increasingly mottled from toes to upper thigh, cold to touch.  r groin staples intact, dsg d+i.  l groin dsg d+i.  r side of buttocks white with ecchymosis, cold to touch.  r flank with ecchymotic area.  increasing edema throughout shift to hands and face.  no open areas noted.

id:  temp initially cool--bair hugger on, gradually warmed to current temp of 100.8 core temp.  bair hugger off when temp 99 range.  remains on kefzol.

psychosocial:  no fam contact [**name (ni) 23**].  [**name6 (md) 413**] speaking rn spoke to pt when lightened off propofol, briefly explained ett, restraints and that ""had an operation""; pt seemed to comprehend information.

"
1302,"resp:  [**name (ni) 97**] pt on 7200 a/c 20/500/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with improve some with suctioning. suctioned x3 small to moderate amounts of thick yellow secretions. mdi's administered q4hr of alb with no adverse reactions. rsbi=135, pt not initiating any breaths.  02 sats @ 100%. no further changes noted
"
1303,"npn shift 1900-0700:

neuro: attempted to wean fentanyl as per ho because of hypotension. wean to 400mcg/hr was unsucessful. pt exhibited s/s of discomfort. ho aware. fentanyl increased back to 500mcq/hr. nimbex titrated secondary to increased resp efforts. infusing at 0.75mg/kg/hr. ho aware. train of four remains at 4/4 on 8ma of energy. b/l pupils 4mm, r sluggish, l brisk. +corneals. pt remains unresponsive w/ no spon nor purposeful mobility.

resp: b/l bs diminished, coarse w/ rales throughout. oett, vent settings at start of shift;  a/c/ 34/ .70/ 350/ 14. i:e at 1:1, abg improved. pip 50-60's, periods of desaturation; nmb titrated w/ some improvement, pip in 40's. 0200 abg; 7.18/80/63/31. pt satting at 90. i:e reverted back to 1:1.5, rate increased to 36. 0430 abg; 7.20/78/64/32. abg w/ miniscule effect. pt remains hypercarbic and hypoxic. fio2 increased to 80% satting at 98% pulminary toileting q2hr. suctioned small-mod amt of thick yellow. chest pt via bed. tongue edematous. oral airway inserted to prevent injury to tongue and to facilitate oral suctioning.

cv: pt in st for most of the shift, rate 100-120. afebrile. qrs 0.08 pr 0.18 qt. 0.38. hypotensive at start of shift resolved w/ ns 1l bolus total. neo started temporarily during this time and d/c'd. cvp 12-14. 0200 hct=22.9. tx 1u prbc, tolerated well, no s/s of an adverse reaction. pt anasarcic throughout. i&o approx 3l positive for shift.  all pulses via dopper. skin warm, pale. am k+=4.0, mg+=2.0.

gi: abd more distended, possibly sec to third spacing. trouble shooting implemented; no residuals, no gastric build-up via ogt, bladder pressures wnl, no urinary retention. passing large amts of green, liquid [** **]. lft this am wnl. hypoactive bs to blq. tpn at target. tol peptamen tf at 20cc/hr via peditube; increasing slowly as per ho.  insulin gtt at 19u/hr to maintain bs 80-100.

gu: foley c/d/i, good urine output, patent.


"
1304,"resp: [**name (ni) 52**] pt on a/c 22/650/+7/100%. ett #9, taped @ 27 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of frothy bloody secretions. mdi's ordered and administered 2p atr q4-6h prn/alb 2p q6h prn with no adverse reactions. pt remains on 100% fio2, with sats @ 96%. peep ^ to 10, bp is stable on such. last abg 7.34/47/96/26 with am abg pending following changes in peep. will continue full vent support.
"
1305,"resp: [**name (ni) 52**] pt on a/c 22/650/70%/+13. ett#9, taped @ 28 lip. alarms on and functioning. ambu/syringe @  hob. bs are diminished bilaterally wish some coarseness noted. suctioning for small amounts of tan/bloody thick secretions. sputum sample obtain and sent. mdi's administered 6p alb/atr with no adverse reactions. last abg 7.40/39/77/25. 02 sats @ 97%, additional abg pending. plan to wean fio2 accordingly. continue full vent support.
"
1306,"resp: [**name (ni) 52**] pt on a/c 22/600/20+/60%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases, improvement noted from previous days.  suctioned for small amounts of thick yellow/white secretions. mdi' administered as ordered combivent/flovent with no adverse reactions. several abg's (see careview) vent changes to decrease fio2 to 50%, and ^ peep to 22 following esophogeal ballon numbers.  no further changes noted. will continue to wean off fio2 as tolerated. no rsbi due to ^ peep.
"
1307,"resp: [**name (ni) 52**] pt trach/vented via sicu on psv 10/5/40%. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick tan secretions. mdi's administered q4 hr alb with no adverse reactions. abg 7.35/59/181/34. rsbi=48. t/c trials to continue today as tolerated.
"
1308,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds. no wheeze noted. mdi's administered of alb/atr with frequency changed to q4 hrs. adverse reactions of ^ hr. suctioned for small amounts of thick white secretions. rsbi initiated and terminated due to ^ hr to 160's. vent changes to decrease ps to 10. abg's pending. will continue to wean appropriately.
"
1309,"resp: pt trached #7 portex on [**last name (un) **] psv 10/5+/35%. vt's 300's, ve 7l 02 sats@100%. bs auscultated reveal rs clear with ls coarse. lavaged and suctioned for moderate amounts of thick tan secretions. mdi's administered q4 alb with no adverse reactions. pt becomes anxious at times and continues to be tachy. am abg's 7.51/40/156/33, rsbi=73. decreased ps to 10. plan is to continue to wean and possible t/c trials today as tolerated.
"
1310,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/10+7/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with some rhonchi in apecies.  suctioned for thick amounts of yellow/tannish secretions. mdi's administered q4 hrs combivent with no adverse reactions.  am abg's 7.42/42/93/28. rsbi=147
"
1311,"resp: [**name (ni) 52**] pt on a/c 22/550/15+/60%. ett 7.5 taped @ 23 lip. bs are  diminished bilaterally with aeration noted. suctioned for large amounts of oral secretions with scant from ett. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. vent changes to decrease fio2 to 50%. am abg 7.34/38/92/21. no rsbi due to ^ peep. will continue to wean as tolerated.
"
1312,"resp:  [**name (ni) 52**] pt intubated from osh. eet #7 taped and secured 22@lip and placed on [**last name (un) **] a/c 10/500/+8/60%.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of charcoal tinged secretions.  mdi's administered q 4 combivent with no adverse reactions.  vent changes to decrease tv to 450/^ peep to 10. am abg's 7.35/37/83/21. no rsbi.  no further changes noted.
"
1313,"7a-11a
see carevue for details of assessment and vs. 1 unit of prbcs infusing no adverse reactions. lopressor and lasix given per pa [**doctor last name **]. pa [**doctor last name **] aware of hypotension when pt sleeping, continue w/ po meds as ordered per pa [**doctor last name **]. pa [**doctor last name **] aware of ct drained 100cc w/ getting oob. continue to monitor.
"
1314,"resp: [**name (ni) 52**] pt on a/c 22/550/25+/60%. ett 7.5 23 @ lip. bs are diminished bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q6 combivent/[**last name (un) **] with no adverse reactions. vent changes to decrease fio2 to 50%, peep to 20, ^ tv to 600. am abg 7.31/34/172/18. plan to wean as tolerated. bicarb to be administered.
"
1315,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/500/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small - moderated amounts of thick yellow secretions.  mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.45/44/149/32.  rsbi=73. no further changes noted.
"
1316,"resp: pt rec'd on psv 5/5/40%.  ett#8, [**e-mail address 9512**] are coarse bilaterally. sucitoned for copious amounts of brown thick secretions frequently. mdi's administered as ordered with no adverse reactions. no changes [**e-mail address **]. am abg 7.32/35/78/19 with [**e-mail address 239**]=84. plan to trach @ bedside this am.
"
1317,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #8 portex. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4 hrs combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. [**hospital1 239**]=43. am abg pending. plan to wean to t/c trials today.
"
1318,"resp: [**name (ni) 97**] pt on psv 5/5/40%. pt has #8 portex.  bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered as ordered combivent/flovent with no adverse reactions. am abg 7.32/46/120/25. [**name (ni) 239**]=24. plan to continue with t/c trials as tolerated today.
"
1319,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 12/15/50%. alarms on and functioning.
ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds, slightly coarse in apecies.  suctioned for small amounts of thick white secretions.  mdi's administered q4hrs alb with no adverse reactions.  no rsbi due to ^ peep. am abg's 7.36/48/94/28.  plan to continue to wean as tolerated. no further changes noted.
"
1320,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/12/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned small amounts of thick white secretions. mdi's administered q4 hrs alb with no adverse reactions. periods of agitation when suctioning.  am abg's 7.35/39/99/22.  will continue to wean appropriately.
"
1321,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds.  mdi's administered q4hrs [**doctor last name **]/alb/atr with no adverse reactions.  02 sats remain in^ 90's @ 98%.  rsbi=40, although no sbt initiated.  pt is scheduled for trach/peg this friday.  no further changes noted.
"
1322,"nsg admission note
ms. [**known lastname 341**] is a 75 yo female admitted to [**hospital1 95**] from ed for ? gi bleeding, hct drop.  see fhp for complete history.  this am pt was walking, felt weak, bystanders called 911, transported to ed via ambulance.  in ed found to have hct 23.0.  treated with fluid, trans to micu a for serial hcts (q4h), prbc and close observation.

current status
neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  mp=nsr, no ectopy.  vss.  hct at 1800 21.7; one unit prbc hung at 1850; no adverse reactions noted thus far.  breath sounds clear bil.  no sob or doe noted, pt on room air.

gi/gu:  abd soft, non-tender, bowel sounds present.  no flatus, no bm. no evidence of gi bleeding thus far.  u/o qs ad lib.

id/endo/integ:  afebrile.  endo--no issues.  skin intact.

psychosocial/plan:  emotional support given to pt.  no visitors this shift.  pt had many valuables with her (credit cards, money, id cards)--all sent to security--pink receipt in front of chart.  plan: q4h hct checks, transfuse prbc as ordered (started), cont to monitor i+o, cont with current nursing/medical regime.  to be scoped in am.
"
1323,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 20/500/10/+12/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of yellow thick secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.38/49/92/30. no rsbi due to ^ peep. no further changes noted.
"
1324,"resp:  pt rec'd on [**last name (un) 993**] simv 18/650/ps 8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear after sux.  sux x's 3 for some small to mod amount of yellow/greenish thk secretions.  mdi's administered through in line alb/atr [**3-12**] p q4hrs with no adverse reactions.  pt 02 sats remain in ^90's 95-97% during the night/rr 20-23 with no distress noted.  pt appears comfortable with no further changes noted.
"
1325,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 18/650/60%/ps8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  mdi's administered q4 hrs alb/atr with no adverse reactions.  vent changes to rr as per abg's. decrease to rr @ 12:00 to 16, @ 2:00 to 14, and @ 5:00 to a rate of 12 with no further changes, pending additional abg.  pt is awake and alert, follows commands.  no further changes are noted.
"
1326,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/60%/ps8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with clear with suctioning. sux x 3 for small to moderate yellowish thick secretions.  mdi;s administered alb/atro q4hrs with no adverse reactions.  no further changes noted.  pt resting comfortably.
"
1327,"resp: pt rec'd on psv 16/10/40%. ett #7.5, 22 @ lip.  ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amount of white thick secretions, rn suctioned for copious tan. mdi's administered as ordered of alb with no adverse reactions. am abg 7.44/31/131/22. no rsbi=^ peep. will continue present support.
"
1328,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/ps 8/+15/60%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sound which clear with suctioning.  suctioned small amounts of white thick secretions.  mdi's administered q4 alb/atr with no adverse reactions.  vent changes with a decrease in fio2 to 50%.  no further changes noted.
"
1329,"resp: pt rec'd on psv 12/10/40%. ett #8, retaped and secured @ 22 lip. bs reveal bilateral crackles with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered alb as ordered with no adverse reactions. no changes this shift. am abg 7.46/35/146/26. no rsbi due to ^ peep. will continue to wean as tolerated.
"
1330,"resp: [**name (ni) 52**] pt on psv 18/5/40%. ett 7.0 19@ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases.mdi's administered as ordered with no adverse reactions. pt continues with low vt's and apnea @ times. vent changes to place on mmv with back up rates of vt 350/18/10+5/40% during night. am abg 7.51/35/115/29. rsbi=109+. placed pt on psv 5/5/40%.  will attempt sbt this am with possible extubation.
"
1331,"resp: [**name (ni) 52**] pt on psv 15/5.40% following trip to mri. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with diminished bases. suctioned for small amount of light tanish secretions. mdi""s administed alb/atr as ordered with no adverse reactions. changes to decrease ps to 5. rsbi=98.am abg 7.36/48/108/28. sbt initiated @ 5:45.
"
1332,"resp: [**name (ni) 52**] pt on psv 5/5/40%. ett 7.5, 18@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. vt's 600. ve's [**6-22**]. rr 16. rsbi=34. no changes noc. am abg 7.34/35/121/20. plan to monitor metabolic status and treat accordingly.
"
1333,"resp: [**name (ni) 52**] pt on psv 10/8/40%.  ett 8.0 retaped and secured 23 lip, not rotated due to sore on r side of mouth. bs are coarse bilaterally. suctioned for moderate amountsof thick brown/plugs. mdi's administered as ordered of alb with no adverse reactions. am abg 7.44/39/100/27. rsbi=101. no changes this shift, will continue to wean as tolerated
"
1334,"resp: pt remains intubated ett 7.5, 22 @ lip on psv 10/8/40%. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered alb as ordered with no adverse reactions. no abgs this shift. rsbi=54. pt remains on cvvhd. will continue to wean as tolerated.
"
1335,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 15/10/60%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions, and from oral cavity.  mdi's administered q4h alb with no adverse reactions.  pt ^ rr to 40, place back on ac 12/ 450/ 10+/ 60% where the settings remain. 02 sats between 92-97% during noc.  no [**last name (un) 1017**] performed due to ^ peep/^ fio2.  no further changes noted.
"
1336,"resp: rec'd on a/c 20/500/12+/30%. ett #7.5, 25 lip.bs are coarse bilaterally. suctioned for moderate to copious amounts of thick bloody tinged secretions. mdi's administered q4 hrs. alb/atr with no adverse reactions and some improvement noted. am abg 7.43/42/126/29. open abdomen. no rsbi. will continue full vent support.
"
1337,"resp: [**name (ni) 52**] pt on mmv switched to psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished sounds. suctioned for small amounts of thick bloody tinged secretions. mdi's administerd q4 hrs combivent with no adverse reactions. am abg's 7.38/49/115/30. rsbi=30. plan to extubate today.

"
1338,"resp:  [**name (ni) 52**] pt on [**last name (un) **] cpap 5/+0/40%. ambu/syringe @ hob.  bs auscultated reveal sl coarse sounds which clear with suctioning. suctioned x3 small amount of thick whitish secretions. mdi's administered q4 hrs with no adverse reactions. rsbi=48.  no further changes noted.
"
1339,"resp: [**name (ni) 52**] pt on a/c 14/550/+5/40%. ett #8, taped and secured @ 23 lip. bs auscultated reveal bilateral diminished bases with slight coarse sounds in middle lobes. suctioned for small amounts of bloody thick secretions, copious amounts from oral cavity. mdi's administered q4 alb with no adverse reactions. no abg's today, pt scheduled today for trach in or @ 9:00. no vent changes noc.
"
1340,"resp: pt rec'd on psv 10/10/50%. pt has #8 [**last name (un) **] trach, secured @ 12.5 flange. bs are clear bilaerally and suctioned small amount of [**last name (un) 4953**] yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats @ 100%. no abg's or changes this shift. no rsbi due to ^ peep. plan: wean as tolerated.
"
1341,"resp: pt remains on psv 14/10 noc. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow (greenish) secretions. sending sputum sample this am. mdi's administered q4 hrs combivent with no adverse reactions. pt more alert today following commands. am abg pending. will continue to wean appropriately.
"
1342,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 24/550/+10/60%. alarms on and functioning. ambu/syinge @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick white secretions. [**last name (un) **]'s administered q4 alb/atr/[**last name (un) **] [**hospital1 **] with no adverse reactions. am abg's 7.45/43/95/31. no vent changes noc.
"
1343,"resp: [**name (ni) 52**] pt on a/c 15/550/5+/40%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are clear bilaterally. suctioned for moderate amounts of thick yellow secretons. mdi's administered alb/atr with no adverse reactions. no abg's this shift or changes. rsbi= no resps. will continue with present settings.
"
1344,"ccu nursing progress note 7p-7a
s: "" i am just really tired""

o: please see careview for complete vs/ additional data

ms: aaox3. pleasant and cooperative. pt very tired and declining pm care and repositioning. denies any pain or discomfort. pt dozing in naps [** 100**] following 5mg po [** **] dose.

cv: vss. pt remains vpaced w/ hr 60-66. very rare pvc noted. transvenous pacer site cdi. abp via right radial arterial line 92-124/37-54. initial assessment found maps to be in the 50s. received pt with bld transfusion in progress. following bld transfusion abp improved w/ sbp>100. maps ^ 60-70s (^50s). posttransfusion hct 31.1(29.7). heparin gtt remains at 1350u/hr. + distal pulses. am labs stillen

resp: ls cta posteriorly. pt denies sob. rr 16-24. o2 sats 95-98%. while asleep sat 95% on 2l nc. increased supplemental o2 to 4l nc while pt asleep. good cough.

gi/gu: abd soft. +bs. no stool. pt denies any episodes of nausea [** 100**]. pt standing at bedside voiding via urinal in marginal amts q 6-8hrs. pt approx -300cc [** 100**] and remains -2l los. despite bld transfusion and improved maps bun/cr remained elevated 28/2.3. urine lytes sent on prior shift to r/o atn.

id: afebrile. tmax 98.1 po. wbc is currently11.9(12.5). pt is currently on day 10 zosyn for vent assoc pna. pt is on vanco for ? line infection. per id zosyn and vanco are to be continued until surgery.

skin: intact. no breakdown.  encouraged repositioning, yet pt is quite resistant at times. reiterated importance of changing positioning to maintain skin integrity.

social: wife called at bedtime. no other calls or visitors [**name (ni) 100**].

a/p: very pleasant 60 yo male w/ significant pmhx including phtn, afib, r-sided chf, sob and ^cr. decreased fx at home initially admitted for chf managment. hospital course c/b brady arrests x2. pt noted to have severe mr. [**first name (titles) **] [**last name (titles) **] consulting. mvr/maze on hold until cr returns to baseline. pt had adverse reaction to natrecor gtt today which was turned off. bld transfusion improved vss. cont on abx until surgery which is currently planned for monday. follow vanc levels qday. follow i/os and cont to follow cr. support pt and family and keep them aware of [**last name (titles) 637**].
"
1345,"resp: pt rec'd on a/c 14/500/+8/40%. ett #8, retaped and secured @ 20 lip. bs are coarse bilaterally with occasional exp wheeze. suctioned for moderate amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's this shift (no aline). rsbi attempted with no spont resps. will continue full vent support.
"
1346,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 24/550/60%/10+. alarms on and functioniong. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with some coarse sounds noted. suctioned for copious amounts of bloody thick secretions. circuit changed to heated. [**last name (un) **]'s administered q4 alb/atr and [**last name (un) **] [**hospital1 **] with no adverse reactions.  am abg's 7.45/43/120/31.  no vent changes as noted by md. plan to continue to wean as tolerated.
"
1347,"resp: [**name (ni) 52**] pt on a/c 15/550/+5/40%. ett #7.5 retaped and secured @ 21 lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. see careview for rsbi, plan to continue full vent support.
"
1348,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick bloody secretions.  mdi's administered q4 alb/atr with no adverse reactions.  rsbi=155.  no further changes noted
"
1349,"resp:  [**name (ni) **] pt on [**name (ni) **] ps15/+5/50% alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning. suctioned x 3 small to moderate amount of  thick bloody/yellow tinged secretions.mdi's administered q4 hrs with no adverse reactions.  [**name (ni) 1017**]=85, sbt initiated.  not further changes noted.
"
1350,"resp: [**name (ni) 52**] pt on ac 550/15/5+/40%. ett retaped and rotated. bs are clear with diminished bases. suctioned for small amount of thick yellow to tan secretions. mdi's administed as ordered with no adverse reactions alb/atr. rsbi=136. plan to continue with present settings. family still to discuss cmo status.
"
1351,"resp: [**name (ni) 52**] pt on psv 10/10/50%. pt has air filled [**last name (un) **] trach secured @ 12.5 flange. 02 sats @ 100%. bs are clear with diminshed bases. suctioned for scant amount of white secretions mdi's administered alb/atr as ordered with no adverse reactions. vent changes to decrease fio2 to 40% and peep to 8. 02 sats remain @ 100%. plan: continue to wean as tolerated. no a-line.
"
1352,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 26/450/+10/50%.   alarms on and functioning. bs auscultated reveal bilateral diminished with some scattered rhonchi. suctioned for small amounts of  thick white secretions.  [**last name (un) **]'s administered q 4 hrs alb/atr with no adverse reactions. [**last name (un) **] given [**hospital1 **].  abg's drawn with notable vent changes (see careview) am abg's 7.41/45/104/30. present vent settings; a/c 20/45/10+/50%.  bedside abdominal ultrasound scheduled for today.
"
1353,"resp: pt rec'd on a/c 450/12/+8/40%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral coarseness in upper lobes with diminished bases. suctioned for small amounts of thick yellow. mdi's ordered and administered q6 hrs atr with no adverse reactions. rsbi=170. placed on psv 15/8/40% obtaining vt's 500's.  will continue to wean as tolerated.
"
1354,"resp: pt rec'd on psv 12/5/40%. pt has #8 portex trach. bs are clear and suction for small amounts of white secretions. mdi's administered alb/atr with out any adverse reactions. rsbi=60. pt has daily nif performed and t/c trials initiated and to continue today. pt has tendency to be anxious although with coaxing settles out. will continue to wean as tolerated.
"
1355,"1900-0700

   pt admitted from home for elective asa desenseitization to be followed by cardiac cath with stent placement. pt has significant hx: cad, mi [**67**], s/p rcs/pda, htn, hyperlipidemia, hypercholerolemia, menieres disease, ?copd, etoh, cocaine hx, + smoker.

neuro: pt awake,alert, oriented, follows all commands well. limited weight bearing and unsteady gait on r knee. dos not use assistive devices at home. pt non compliant with cardiac regiment at home ex-diet, lifestyle.

resp: nc 2l on, resp easy and regular with clear bs/diminished at bases. no cough noted. o2sat stable.

cv: nsr without ectopy, alarms on. hr 90-60, sbp 100-165, restarted on po meds. afebrile. asa desensitization completed without adverse reactions. nahco3^@75cc/hr. pt c/o of cp at 2315, ho at bedside 3 sl nitro q 5 minutes given with no relief, pain 7 out of 10, radiating to neck and back. denies sob/skin warm/dry. ekg completed showing st elevation in v1,v2,v3.  cardiac fellow to examine pt. nitroglycerine drip ^ titrating prn, heparin drip @ 750 units^ ptt 48.3. integrilin started at 0130. morphine givenx 3. pt finally became cp free. cpk:43.0. skin dry/intact, palpable pulses noted. pt awaiting cath this am. pt kept on bedrest.

gi/gu: abd round soft + bs, voids clear yellow urine via urinal.

iv: piv x2.

plan: cardiac cath, supportive cardiac care.
"
1356,"resp: pt on 2 lpm n/c and maintaining good sats @ 98%. bs reveal occasional wheeze. nebs adminisered q6 hrs alb/atr with no adverse reaction. will continue to monitor and treat.
"
1357,"resp: pt remains on psv 15/5/60%. placed on 50% t/c for nearly 4 hrs and tolerated well. periods of desaturation with ^ fio2. on psv 15/5/60 noc. bs auscultated to reveal bilateral coarse sounds. suctioned for small amounts of tan thick secretions. pt is [** 554**] and awake. no abg's rsbi=>200. mdi's administered q4hr alb with no adverse reactions. will continue t/c trials as tolerated.
"
1358,"resp: [**name (ni) 52**] pt on a/c 14/500/10+/40%. suctioned for scant amount of thin white secretions. mdi's administered as ordered with no adverse reactions. no changes noc or rsbi due to ^ peep. plan to wean as tolerated. abg 7.42/34/77/23
"
1359,"resp: [**name (ni) 52**] pt on psv 12/8/40%. ett 7.5, 23 @ lip.  bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. this am secretions appear to be slightly green. mdi's ordered alb q6 hrsprn and administed with no adverse reactions. pt had anxiety episodes noc and antivan administered. rsbi=54. pt weaned to psv 8/5/40%. vt's 350/ve's [**6-20**],rr 22 with additional abg pending. will continue to wean with mechanic's in am.
"
1360,"resp: [**name (ni) 52**] pt on a/c/14/500/10+/70%. ett 7.5, 20 @ teeth. bs are clear with diminished bases. mdi's ordered 4p alb and administered with no adverse reactions. suctioned for scant clear thin secretions. vent changes/abg's (see careview) am abg 7.35/38/101/22 on  a/c 14/500/10/70%. no rsbi due to ^ peep. will continue with present vent settings.
"
1361,"resp: pt rec'd on a/c 14/450/+8/40%. ett #7, retaped and secured 20 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small to moderate amounts of thick white secretions. mdi's administered q 4hrs alb/atr with no adverse reactions. no a line/abg's. rsbi=110.
"
1362,"resp: pt ordered for nebs of alb/atr. bs are diminished bilaterally. no adverse reactions following neb. will continue to follow.
"
1363,"nursing admission note:
   this 28 year old female was admitted from pacu @ 2045 c/o dr [**last name (stitle) 513**]. s/p craniotomy for clipping of opthalmic artery aneurysm.  patient had been extubated in pacu just prior to transfer to sicu and had stable respiratory status through noc on 4l o2 via n/c.
   neuro checks done q1h, pt not displaying any neuro deficit on exam, see neuro assessment flow sheet, also no evidence of drift or facial droop. c/o headache, neck incision pain and general discomfort x2, fentanyl 25mcg ivp given with good effect and no adverse reaction. craniotomy incision dressing dry and intact. left femoral artery sheath remains in place and transduced.
   taking sips of h20 and ice chips po, tolerating well with no nausea. diuresing well.
"
1364,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv10/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  cuff pressure@ 21cmh20.  ett taped and secured.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for small to moderate thick yellow secretions.  improvement noted after suctioning.  mdi's administered q4 hrs of albuterol with no adverse reactions.  rsbi=21, although no sbt initiated.  pt is scheduled for trach today. 02 sats remain in ^ 90's. no further changes noted.
"
1365,"respiratory care
pt remains intubated (#7.5 ett 23@lip) and on vent support. vent changes were simv to psv due to spont breathing and increase in ps from 5 to 8 due to rr >35. lung sounds were course t/o. suctioned for scant amounts of thk yellow secretions. mdi's given with no adverse reactions. last abg was borderline normal. care plan is to continue to wean and ? of extubation tomorrow or friday. will continue to follow pt.
"
1366,"resp: [**name (ni) 52**] pt on a/c 12/450/+8/50%. ett #7.5 21 @ lip. bs are slightly coarse with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered atr as ordered with no adverse reactions. no abg's, attempted rsbi=no spont resps. pt becomes aggitated with decrease in sedation. will re attempt rsbi with plans of possible extubation this am.
"
1367,"resp: [**name (ni) 52**] pt on a/c 12/450/+8/60%. bs are slightly coarse suctioning for small amounts of thick light yellow secretions. mdi's administered atr with no adverse reactions. pt desaturates when sedation is light. abg 7.41/40/59/26. fio2 ^ 70%, peep 12 to maintain sats of 96%. rsbi >150.
"
1368,"resp: [**name (ni) 52**] pt on a/c 15/600/15+/50%. ett #8. bs are coarse bilaterally. suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt has frequent coughing episodes when awake. no rsbi due to ^ peep. am abg 7.44/42/76/29. plan to wean as tolerated.
"
1369,"resp: [**name (ni) 52**] pt on a/c 10/600/10+/40%. pt has #8 shiley trach. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. no abg's this shift. 02 sats @ 97%. mdi's administered as ordered with no adverse reactions. rsbi=^peep. will continue with present vent settings.
"
1370,"resp: [**name (ni) 52**] pt on a/c 14/450/50%/10+. ett #7.5 taped @ 20 teeth. bs reveal bilateral crackles, and suctioning for small to moderate amounts of yellow (bile looking) secetions. bloody secretions from oral cavity. mdi's ordered and administered alb/atr with no adverse reactions. no abg's this shift (no a-line) or rsbi performed due to ^ peep. will continue with present settings.
"
1371,"resp: [**name (ni) 52**] pt on psv 15/10/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. changed out heated wire circuit, and inner cannula. suctioning copious amounts of bloody secretions. [**name (ni) **]'s administerd q4 hrs alb/atr no adverse reactions. vt's 400-500, rr 15-18. no vent changes noc.
"
1372,"resp:  [**name (ni) 52**] pt on psv 15/10/50%. alarms on and functioning. ambu/syringe @ hob. spare inner cannula in rm. 8.0 shiley trach. vt's 400-500, rr 17-24. trach care done, inner cannula changed. changed out heated wire vent circuit due to excessive blood (fluid) in tubing. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of old (brown) blood. slight improvement from yesterday. [**name (ni) **]'s administered q 4 alb/atr with no adverse reactions. no vent changes noc, no abg's. will continue vent support.
"
1373,"resp: [**name (ni) 52**] pt on a/c 10/600/10+/40%. pt is trached with #8 shiley. bs are coarse bilaterally and suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. no rsbi=^peep. no changes or abg's this shift. plans for rehab.continue with present settings.
"
1374,"resp: [**name (ni) 52**] pt on psv 16/6/40%. ett #7.5, 21 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned moderate amounts of thick yellow secretions. mdi's administered q4 hrs with no adverse reactions. no abg's this shift. rsbi=108. weaned to psv 12/5/40%. plan to continue to wean as tolerated.
"
1375,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 16/10+/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  attempted to wean ps to 14 and pt did not tolerate ^rr. difficult wean, becomes aggitated with lighten sedation. will continue to wean as appropriate. no further changes noted.
"
1376,"resp: [**name (ni) 52**] pt on pcv 27/dp22/+5/50%. ett 8, taped @ 25 and pulled out to 23 as [**name8 (md) 76**] md/xray. bs are slighly coarse/occasional exp. wheeze. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=155. am abg 7.42/47/74/32. pt will be scheduled for trach when condition improves. plan: wean vent as tolerated.
"
1377,"resp: [**name (ni) 52**] pt on pcv. bs are coarse to clear and suctioning for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=145. am abg 7.36/47/90/28. plan: wean to a/c as tolerated.
"
1378,"resp: pt rec'd on a/c 500/20/+12/30%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. ett #7.5, retaped and secured @ 25 lip. no changes this shift. am abg 7.45/37/141/27. will continue full vent support.

"
1379,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 12/10/40%. alarms on and functioning. ambu/syringe @ hob.  bs ausculatated reveal bilateral aeration with diminished bases.  mdi's administered q4 hrs alb/[**last name (lf) **], [**first name3 (lf) **] [**hospital1 **] with no adverse reactions. suctioned for moderate to copious amounts of thick yellow secretions. continue to wean as tolerated. am abg's 7.46/46/134/34.  no further changes noted.
"
1380,"[**2130-5-14**] ""b"" nsg progress note:

cvs:  tmax 102.7-tylenol given, down to 99.4 po. hr=92-114 sr with rare pvc's and pac's noted. iv mgso4 4gm given, kcl 20meq iv given. iv ns + 20meq kcl at 75cc/h. pulses present.

neuro:  a&ox3. mae. no deficits noted.

pain:  using pca mso4 appropriately with good pain relief noted. pain is in sternum when turning or coughing and deep breathing [**5-7**] reduced to [**2-6**] with pain med. no adverse reactions noted.

resp:  o2 4l nc. sats=95-98%, doing is 500-700. coughing and deep breathing well, small amts white sputum noted. lung sounds clear.

gu:  u/o=25-50cc/h given 2 boluses of 500cc iv lr per resident.

gi:  taking ice chips and sips of milk shakes.  water still causing some coughing.  +bs.

skin:  dsg on sternum intact with no drainage noted. 3 jp's draining serosanguinous. left heel red and sore,up on pillow.

plan:  antibx as ordered. increase diet today. continue weaning iv levophed.  encourage is, and deep breathing and coughing. tylenol for temp as needed.
"
1381,"7p-7a
neuro: alert, oriented x3. speech clear. mae with equal strength, follows commands.

cv: remains sr 60-70 with occasional pac's. sbp 110-130. a-wires capture and pace, set at a-demand 60; v-wires do not work, polarity changed. palpable distal pulses to extremities. svo2 >65; ci> 2.19. no gtts. started po metoprolol with good effect, no adverse reactions.

resp : ls clear, diminished at bases. 02sats>96% /2l nc. uses is to 750-800, coughs and deep breathes.

gi/gu: abd soft, not distended. +bowel sounds. tolerating po well. indwelling cath draining clear yellow urine to gravity, sufficient amts.

endo: riss continues as well as metformin.

plan: continue to monitor cv, continue pulmonary toilet. continue to advance diet and activity as tolerated. ?transfer to [**hospital ward name **] 2.
"
1382,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 12/500/40%/+8/ps20. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal coarse bs which improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rotated/taped and secured ett tube @ 21 lip.  rsbi= 120, no sbt initiated. no vent changes noted
.
"
1383,"resp:  [**name (ni) 52**] pt on [**last name (un) **] on a/c 14/500/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal clear apecies, with slight coarse bs in bases.  suctioned x2 for small-moderate amounts of thick yellow secretions.  mdi's administered q4 hrs with no adverse reactions.  rsbi=52.  no further changes noted.
"
1384,"7am-7pm update
neuro: pt alert and orienated x 3. cooperative. mae and able to follow commands. pt continues on respiradone.

cv: pt remains in nsr/st, rare pvc noted this am. hr 110-90's. sbp 150-100's. map 60-80. lopressor increased to 50 mg [**hospital1 **] -> tolerating. epicaridal wires dc'd this afternoon. k, inonized cal and mg replaced frequently. pt recieved 5 mg coumadin this evening (inr 1.1 this am) and started on heparin gtt at 500 u/hr (no bolus) due to clot in atrium (per dr. [**last name (stitle) **]).

resp: ls coarse. pt cotinues on 5 l nc. o2 sats 93-96%. pt with strong non productive cough. pt using is 500-750. cpt done. pt slighly wheezing afternoon after chair -> bed -> treated with med neb

gi/gu: pt with + bs. no stool. + flatus. tolerting cardiac diet. able to swallow pills without difficulty. foley to gravity draining clear yellow urine -> pt with large uo (autodiuresing) pt stated on lasix this afternoon-> diuresing well -> -> -> chasing lytes.

comofort/activity: pt oob to chair x 2 today with 2 person assist. pt receiving percocts for pain

plan: pulm toliet, monitor lytes, contines on heparin gtt, monitor coags, monitor qtc (d/t adverse reaction of resperidone -> pronlonged qt)
"
1385,"resp: [**name (ni) 52**] pt on [**last name (un) **] psv 10/8/50%. alarms on and functioning. ambu/syringe @ hob. transferred from ccu.  bs auscultated reveal bilateral ins/exp wheeze. mdi's administered q6 alb/atr with no adverse reactions. improvement noticed. rsbi=73. no abg's.
"
1386,"update
o: resp status: attempts to wean sedation to extubate unsuccessful d/t pt agitation/biting ett. propofol changed to precedex by 1700 & pt although tremulous & anxious calmer than while on propofol. suctioned q3-4h for sm amts tan secretions.lavaged w no appreciable change in amt of secretions.

cv status: hemodynamics stable subseq to iab dc.plan pa line dc subseq to vent wean.distal pulses dp's palp bilat and pt's+ w doppler.

skin: hives noted over trunk and thigh area after vancomycin nearly finished, ho notified-> benadryl given w rash receding w/in 20-30 mins. antibx changed to kefzol and pharm notified of pt drug allergy.
temp ^ w adverse reaction to vanco& ho notified. tylenol 1300mg pr given.

neuro status: as noted above pt poorly tol propofol wean,req versed and reinstituting propofol gtt until precedex cleared by pharmacy. pt opens eyes intermittently to voice, shaking arms intermittently. reinforced to pt the need for soft restraint until ett out,pt nodding but continues to have freq hand movement and tremors.pt denies pain upon questioning


endocrine: remains on low dose insulin gtt for glucose control.
a/p: attempt wean to extubate-> cpap w ps as tol while on precedex.cont to monitor glucoses and titrate per protocol.
"
1387,"resp: [**name (ni) 52**] pt on [**last name (un) **] psb 10/10/50%.  ambu/syringe @ hob.  bs ausculatated reveal bilateral coarse bs which clear with suctioning. suctioned moderage to large amounts of thick whitish/yellowish secretions for oral and ett.  mdi's administered alb/atr/ser/[**hospital1 **] with no adverse reactions. pt tends to drop sats, 02 probe better positioned on pts forehead.  no distress is noted noc, with no changes.
"
1388,"resp: [**name (ni) 52**] pt on a/c 26/470/12/40%. ett #7 taped @ 24 lip. bs are clear bilaterally. suctioned for scant amount of white secretions. mdi's administered as ordred alb/atr with no adverse reactions. vent changes (see careview) rsbi=41. am abg 7.40/35/71/22. will continue to wean as tolerated.
"
1389,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/+5/40%.  alarms on and functioning.
ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases.  suctioned x2 scant to small amounts of whitish secretions.  mdi's administered q4 of albuterol with no adverse reactions.  rsbi=42 02 sats remain @ 100% with no further changes noted.
"
1390,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 14/600/50/+10.  ambu/syringe @ hob.  bs auscultated reveal bilaterl coarse sounds with clear with suctioning.  suctioned x3 small to moderate thick yellowish secretions.  mdi's administered q4hr combivent/servent/flovent [**hospital1 **] with no adverse reactions.  vent changes as follows:  rate ^ to 16, peep ^ 12, fio2 ^ 60% resulting in improved abg. no further changes noted.  rsbi performed this morning results equal 47, rr 20.
"
1391,"resp: [**name (ni) 52**] pt on a/c 26/470/+8/40%. ett #7.0 taped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered atr as ordered with no adverse reactions. rsbi=61 with am abg's pending (see carview for results) plan to continue on present settings.
"
1392,"resp0: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/450/1.0/5+.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished bases. suctioned for small amounts of thick yellow secretions. mdi's 2p [**last name (un) **] [**hospital1 **]/4p combivent q4 hrs with no adverse reactions. vent changes reflect abg's (see careview). present settings a/c 20/350/50%/5+. am abg's 7.41/37/211/24. no further changes noted.
"
1393,"7p-7a: full assessment in flow sheet.

neuro: alert to person. pt was more confuse, mumble words, very tired earlier in evening. slept most of night. pt is  ""feeling better, more alert, clearer words, no pain"". mae - strong bilaterally. perl - [** **]. follow all commands. restraints hands - pt attempt to remove nc and ng tube. explain to pt the importand of medical equipments and why restraints need to be on.

cv: st 116-27 without ectopy. lopressor 10 mg pt tid - no adverse reaction, no change in bp. bp 110-130/56-62. warm, dry, no edema. heparin drip on, continue to monitor ptt, pulses, and bleeding precaution.

resp: clear in upper lobes then progress to coarse throughout - nasotracheal suction, chest pt and deep breathing and cough was done to assist pt (q 4 hr and prn). pt rr increase to 40-50 for short period of time then return to 20-40 after respiratory toileting. sao2- 98-100 at 5 l nc. thick/tenacious yellow sputum was suction.

gu/gi: soft distended abd. slight tender on left side. +bs x4 normal to hyper active. large amount of gas and stool. brown, loose, negative guiac. rectal bag intact. ng - tolerate tf (goal 60), +placement, minimal residual.

int: skin intact.

plan: respiratory toileting, bleeding precaution, gu/gi monitor.
"
1394,"resp: [**name (ni) 52**] pt on psv 5/5/40%. alarms on and functioning.  ett#8.0, taped @ 22 lip. ambu/syringe @ hob.  bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb/atr as ordered with no adverse reactions. vent changes to ^ ps to 10 due to ^ rr. am abg 7.41/53/104/35. rsbi=173.
"
1395,"resp: [**name (ni) 52**] pt po intubated ett 7.0 23 2 lip on a/c 18/500/5+/50%. bs are clear bilaterally. suctioned for small amount of brownish thin secretions. mdi's administered as ordered alb with no adverse reactions. intubation attempted fiberopticly but unsuccessful then intubated by direct larygoscopy and aspirated. abg 7.45/35/85/26. decreased fio2 to 40%. plan to extubate this am under direct supervision by anesthesia.
"
1396,"resp: [**name (ni) 52**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. am abg 7.23/42/229/25 with rsbi=28. pt continues on cvvhd. plan:continue to wean as tolerated.

"
1397,"pt update:

neuro: pt sedated. arouses to voice. mae on the bed. withdraws to painful stimuli. propofol weaned once precedex started @1300, and pt at comfortable level of sedation. pupils 3mm and reactive bilaterally. pt denies pain. ivig started @ 1400. no adverse reactions. rate advanced to 240cc/hr.

cv: hr 70-90s. nsr. no ectopy. sbp hypertensive in 190-200's in am. sbp max 210 @ 1200. treated with 10mg lasix and 15mg total hydralzine. htn continued until precedex given @ 0.7mcg/kg/hr. sbp came down to 120-140s where it remained through out rest of shift. ppp.

resp: attempt at ac early in shift. failed due to level of wob and increasing hr and bp. pt put back on cpap c/ ps. fio2 40, 5 and 5, 785 at 19. ls coarse with slight i/e wheeze. sxn'd for thick tan secretions.

gi: tf @ 20 via og tube. +bs. no bm.

gu: foley draining adequate amounts clear, yellow urine.

endo: iss.

plan: monitor for sbp htn. monitor infusion of ivig for fever, signs of adverse effect, etc.
"
1398,"resp: [**name (ni) 52**] pt on a/c 12/500/+5/40%. ett 7.5 rotated, retaped and secured @ 21 lip. bs are coarse to clear with suctioning. suctioned for small amounts of bloody/tinged secretions to tan by morning. mdi's administered as ordered alb/atr with no adverse reactions. no fever noc or changes. am abg 7.54/44/180/39. rsbi=86. plan: wean to psv as tolerated.
"
1399,"resp: pt rec'd on a/c 10/500/+5/50%. pt has #8 portex trach. bs are clear bilaterally with a few scattered crackles in bases. mdi's administered as ordered alb/atr/qvar with no adverse reactions. multiple abg's (see careview) with vent changes to ^ rr to 18, then 20 presently. cvvhd initiated noc and remains in am. am abg 7.34/42/104/24. no rsbi due to hemodyamic/no resps. plan: continue present mode of support.
"
1400,"resp: [**name (ni) 52**] pt on a/c 24/500/5+/50%. pt has #8 portex trach. bs are coarse to clear and suctioning small to moderate amounts of tan/bloody tinged secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. am abg 7.36/46/114/27. no changes noc. pt remains on cvvhd. no rsbi due to hemodynamic issues/no resps. plan: continue to wean as tolerated
"
1401,"resp: [**name (ni) 52**] pt on a/c 14/550/+5/40%. ett #8.0, rotated, retaped, and secured.  bs are coarse bilaterally and suctioned for small to moderate amounts of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. [**name (ni) 1017**]=82. no abg's or changes this shift. 02 sats @ 100%.  possible family meeting today to discuss cmo status?
"
1402,"resp:  [**name (ni) 52**] pt on a/c 16/600/10+/60%. bs are coarse bilaterally. suctioned for thick amounts of tan to yellow secretions. mdi's administered as ordered with no adverse reactions. weaned fio2 to 50%. am abg 7.42/25/125/17. no rsbi due to ^ peep. will continue to wean as tolerated.
"
1403,"addendum
back from or 1615. s/p exploration of mediastinum, drainage of pericardial effusion, and washout. received pt on propofol and vasopressin, levo added, and epi started [**name8 (md) 76**] md [**last name (titles) 10381**]. levo and vasopressin weaned to off [**name8 (md) 76**] md [**last name (titles) 10381**]. hct 21.9, 2 units of prbcs ordered and given, no adverse reactions noted. k 5.8, treated with 10units regular iv and 1 amp of d50 [**name8 (md) 76**] md [**last name (titles) 10381**], repeat 5.6, md [**doctor last name 10381**] aware, no new orders. pa 50s/30s. cvp 20. svo2 56-65. ci >2 via thermodilution. insulin gtt restarted for bs 214. see flowsheet for assessments and further details.

plan: hold heparin. hold vanco, level in am. wean epi as pt tolerates. monitor labs every 6 hours [**name8 (md) 76**] md [**name6 (md) 10381**] and md [**last name (titles) **].
"
1404,"resp: [**name (ni) 52**] pt on psv 12/14/50%. pt has #8 portex trach. bs are diminished with noted aeration. suctioned for small amounts of white secretions. mdi's administered of alb with no adverse reactions. pt had episode of desaturation then placed on a/c with fio2 @ 100% then titrated down. am abg 7.46/45/141/33 then weaned to psv 12/14/50%. plan to wean as tolerated. no rsbi=^ peep
"
1405,"resp: [**name (ni) 52**] pt on psv 22/10/70%. pt has #8 [**last name (un) **] air filled cuff, secured @ 12 flange. bs are coarse bilaterally and suctioned small amounts of greenish secretions. copious secretions of bile suctioned from nares/oral cavity. mdi's administered alb/atr with no adverse reactions. following rotation of pt in prone position, ett migrated to 8 with notable cuff leak. tube advanced to 12 with immediate improvement and no cuff leak. am abg 7.44/38/79/27 (following prone positioning). no changes noc. plan to continue present settings/wean when appropriate.
"
1406,"resp: [**name (ni) 52**] pt on psv 18.5/40%. pt has #8 trach with occasional positional leak. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's. o2 sats @ 98%. [**name (ni) 1017**]=141. plan to wean as tolerated.

"
1407,"resp: rec;d pt on a/c 22/500/10+/40%. ett #8, taped @ 24 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow to white secretions. insp ^ to .9/i:e 1:2.0 am abg 7.40/45/74/29. mdi's administered alb/atr with no adverse reactions.  no rsbi due to ^ peep. no further changes noted. pt remains on rotating bed. plan: wean as tolerated.
"
1408,"7a-7p
neuro: propofol decreased, pt able to mae on commnds, lower extremeties weaker than upper. pt nodded head yes/no to questions. perrla. medicated prn w/ dilaudid iv for incisional pain.

cv: hr 80-90s sr w/ occasional pacs and rare pvcs. in and of afib, at 0815 pt in afib, md [**doctor last name **] aware, amio bolus 150mg iv, converted to sr w/ pacs. again at 1345 pt in afib, md [**doctor last name **] aware, amio 150mg iv bolus and gtt increased to 1mg/min. at present time pt in sr w/ rare pac. see flowsheet. pt transfused w/ 1 unit of prbcs no adverse reactions, repeat hct 27-26, md [**doctor last name **] aware, no new orders. sbp 90-100s/. milrinone weaned to off as [**name8 (md) 76**] md [**last name (titles) **]. svo2 >60s. ci>2 by fick. levophed weaned to 0.06mcg/kg/min. epi gtt continues at 0.02mcg/kg/min, vasopressin continues at 3units/hr. pa 30/20s. cvp 14-18. see flowheet for details. k taken at 1500 as [**name8 (md) 76**] md order, k 5.8, md [**doctor last name **] aware, kayexeleate given as per order. repeat k due at 1900 [**name8 (md) 76**] md [**last name (titles) **]. dopplerable bilat at/pt.

resp: ls clear/diminished. cpap [**5-22**] w/ acceptable abg ~3 hours. after 3 hours pt rr >35, pt placed back on cmv rate 12, 5 peep, fio2 40%, see flowsheet. sats 100%. ct no airleak, draining dark serosang small amts. see flowsheet for further details.

gi/gu: abd obese soft, hypoactive bs. ogt +placement draining bilious drainage. no tf today per team, ? to start tomorrow. foley draining clear yellow 15-30cc/hr. no crrt today per renal. most likely tomorrow per renal. lasix 40mg ivp tid given as ordered.

endo: insulin gtt per protocol.

skin: see flowsheet.

social: [**name (ni) 1976**] (wife) visited pt today ~ 2hous. updated w/ poc.

plan: monitor henodynamics. monitor resp. status. wean levophed as pttolerates. pain control. ? crrt tomorrow. monitor k.
"
1409,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are clear to coarse and suctioned for small amount of bloody tinged thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.34/44/156/25. rsbi=57. plan; possible trip to or today, although nothing confirmed.
"
1410,"resp: pt rec'd on a/c 15/500/+5/40%. ett 8 taped @ 22 lip. bs are coarse and suctioned for moderate amounts of thick tan to yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. am abg 7.50/39/120/31. rsbi=166. plan: wean as tolerated
"
1411,"resp: [**name (ni) 52**] pt on psv 5/5/40%. ett 7.5 taped @ 21 lip. bs are clear with scant amount of suctioning. mdis administered as ordered alb/atr with no adverse reactions. no abg's this shift. rsbi=52. plan is to extubate this am following [**name (ni) **].
"
1412,"resp: [**name (ni) 52**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no abg's this shift. pt had episode of desating to 88, then increased fio2 to 50%. 02 sats this am @ 98%, then decreased fio2 back to 40%. rsbi=26. plan to continue to wean as tolerated.cvvhd discontinued noc.
"
1413,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett 7.5, taped @ 23 lip. bs are coarse bilaterally and suctioning small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift 02 sats @ 100 %. rsbi=43. plan to trach/peg today.
"
1414,"resp: pt rec'd on mmv 10/500/10/5+/40%. ett 7.5. taped @ 21 lip. bs are coarse to clear with diminished bases. suctioned for small amounts of bloody tinged/tan thick secretions. mdi's administered alb/atr with no adverse reactions. pt remains to become aggitated when not sedated with ^ bpto 190. no vent changes noc. am abg 7.48/50/137/38. rsbi=52. plan to wean as tolerated.
"
1415,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.44/56/142/39. rsbi=107. no change noc. [**name (ni) **] trip pending. family in discussing transfer to [**hospital1 1771**] & women today.
"
1416,"resp: [**name (ni) 52**] pt on a/c 14/600/+5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for copious amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=127. no abg's 02 sats remain @ 100%. plan to continue to wean as tolerated on psv.
"
1417,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett #7.5, taped @ 23 lip. bs are coarse to clear and suctioned for moderate amounts of thick tan/yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. am abg 7.50/36/122/29. rsbi=71. plan is to trach/peg today.
"
1418,"resp: pt rec'd on a/c 15/600/+5/40%. pt has #8 portex trach is vent dependent. bs are coarse bilaterally and suctioned for moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. attempted to wean to psv and pt did not tolerated became tachy with ^ wob immediately. rsbi=110. no aline or abgs. 02 sats @ 100%. plan to continue to wean to psv as tolerated.
"
1419,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett 7.5, taped  @ 23 lip. bs are coarse bilaterally and suctioning for moderate to copious thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes this shift. am abg 7.49/34/81/27 with a rsbi of 65. plan: family meeting today to discuss cmo status?
"
1420,"resp: [**name (ni) 52**] pt on 35% t/c t/c with humidification. bs are coarse to clear with spc. suctioned x1 for thick white secretions. mdi's administered alb/atr with no adverse reactions. inner cannula changed. 02 sats @ 100%. will continue to follow.
"
1421,"resp: rec'd on psv 10/5/40%. ett #8.0 taped @ 26 lip. bs are coarse to clear and suctioned for small amounts of thick bloody tinged secretions. mdi's administered as ordered alb/(atr d/c'd)with no adverse reactions. no changes noc or abg's. rsbi=38. family meeting to discuss trach? will continue to wean ps as tolerated.
"
1422,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 12/8/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with some coarse sounds noted throughout.  suctioned x3 for small amounts of white thick secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=70, no sbt initiated with ^ rr to ^ 30's and decrease in mean to 2.  02 sats remain @ 98% noc with no further changes noted.
"
1423,"day shift update
neuro: pt not moving extremeties at beginning of shift, pt on fentanyl gtt at 100mcg/hr. pa [**last name (un) 9952**] aware. fentanyl gtt turned off, approximately 1 hour after turning off fentanyl pt mae, not following commands. pt grimacing w/ any touch abd. team aware, general surgery consulted. see gi part of note for details. left pupil slightly larger than right, though both react briskly to light.

cv: hr 90-110s afib rare pvcs. mg 2gm iv for ectopy. sbp labile, hypotensive, pa [**doctor last name **] aware, neo gtt started as per pa. pt received 3 units of prbcs, no adverse reactions. see flowsheet for details of extremeties and pulses.

resp: ls coarse. unable to get pleth at times. acceptable abgs on cmv rate 24, 5 peep. fio2 40%. suctioned for thick pale yellow. see flowsheet.

gi/gu: abd slightly round, soft, grimacing w/ any type of touching abd. +visible blood w/ loose bm, pa [**doctor last name **] aware. +hemmorroids, surgery team aware. at present time pt in or, for exploratory lap. urine output dropped w/ hypotension, pa [**doctor last name **] aware. see flowsheet for details.

skin: see flowsheet. draining serous fluid out of open areas.

endo: riss.

social: daughter updated w/ poc.

plan: ?mri once abd. issues resolved. pt in or at present time. monitor hemodynamics. monitor resp. status.
"
1424,"7p-7a
neuro: pt lightly sedated on propofol 10-15mcg/kg/[** **]. moves all extremeties weakly, followed commands (wiggled toes on command), perrla. morphine 2mg ivp prn for pain shown by grimace scale and by pt nodding head when asked if in pain.

cv: hr 80-90s 1st degree avb pr 0.25. rare pac noted. mg 2.5, k 4.6, no repletion needed. sbp labile 86-130s (130 while turning in bed), neo gtt as high as 2.0mcg/kg/[**name8 (md) **], md [**doctor last name 1118**] aware at [**2173**] of sbp 86/ while on 2.0mcg/kg/[**year (4 digits) **] of neo, 1 unit of prbcs ordered and given as ordered, followed by 20mg of ivp lasix. md [**doctor last name 1118**] aware of increased temp, ok to transfuse [**name8 (md) 76**] md. tylenol 650mg pr given, see carevue for details. no adverse reactions. [**md number(3) 7143**]/20s. cvp 13-16. ci>2.2 thermodilution see carevue for details. svo2 60-69, see carevue. sternal and medistinal dsgs cdi. right groin iabp site cdi, no hematoma. + dopplerable pedal pulses.

resp: ls diminished. improved oxygenation after pt placed on simv [**name8 (md) 76**] md [**last name (titles) 1118**] (to rest overnoc). presently, on simv rate 14 (breathing [**2-3**] over rate at rest) tv 600 fio2 60% ps 8 peep 12, see carevue for details of abgs and vent settings.

gi/gu: abd softly distended. hypoactive bs. foley draining 33-280cc/hr, increased u/o after lasix given at 2230, see carevue for details. creatinine 1.4 this am.

id: receiving post-op vanco doses. wbc 12.2. temp 101-100.3, bc and uc sent on day day shift. no secretions via ett yet to send a sputum cx. tylenol 650mg pr prn.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. closely monitor urine output. wean vent as pt tolerates.
"
1425,"resp: pt rec'd on 35% t/c. pt has ""#7 portex fen. trach. inner cannula changed. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow/bloody tinged secretions. pt has a strong cough and is able to expectorate secretions. mdi's administered alb/atr with no adverse reactions. no changes. 02 sats @ 100%. will continue to monitor
"
1426,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are coarse to clear and suctioning for small amounts of bloody tinged thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/65/131/41.pt following commands.  rsbi=54. family meeting to discuss possibility of trach? will continue to wean as tolerated.
"
1427,"resp: pt on 50% cam. bs auscultated reveal bilateral i/e wheeze which improve following tx administered of sd hhn of 2.5 mg albuterol/ns. no adverse reactions noted. pt is on droplet precautions pending results of pcp/tb tests.
"
1428,"1500-2300 npn
see carevue for subjective/objective data.
neuro:  intermittently making eye contact, intermittently squeezing l hand to command.  no movement r arm/hand noted.  no attempts to speak around ett.

cv/pulm:  mp=afib, isolated pvc noted.  remains on neo currently at 0.15mcg/kg/min to maintain map>75.  attempted to wean neo however map dropped to 60.  l rad a-line intact with sharp waveform.  l multi-lumen central line intact.  prbc's infused without evidence of adverse reaction; rpt hct due between 2400-0100.  hands, feet edematous--elevated on pillows as much as possible.  remains vented on ps12 (increased to 12 from 10 for rr 40's), 5peep, 40%.  suctioned q4h for sm amts thick yel sec via ett.  bs clear, diminished bil.

gi/gu:  abd drain in place.  stat lock applied by radiology rn; site cleaned with ns and dsd applied by writer.  abd round, soft, bowel sounds present.  anuric (receives hemodialysis).

id/endo/integ:  tmax 99.2 r.  lactate cont to rise (md aware). sliding scale insulin coverage for fingersticks.  waffle boots r+r'd q2h.  multiple ecchymotic areas noted, unchanged.  skin care rn in, aquacell applied to coccyx, adaptic to r leg.

psychosocial/plan:  wife in to visit.  emotional support given to pt and fam.  plan is for ct of head/torso in am with contract followed by hemodialysis after ct due to contrast.  rpt hct.  maintain vent support.  cont with current nursing, medical regime.
"
1429,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  remains sedated with fentanyl at 15mcg/hr and versed at 1mg/hr.  spontaneous movement of arms noted, no movements of legs noted.  no attempts to speak or communicate; does not open eyes.

cv/pulm:  mp=afib, isolated pvc noted.  remained on vasopressin until 1530 when vasopressin off.  remained off until 1700 when bp dropping  to 68/41, remainins 68-72/42.  vasopressin restarted, dr. [**first name (stitle) **] notified.  prbc' infusing at this time; will re-try to dc vasopressin once prbc's have infused.  prbc's infusing without evidence of adverse reactions thus far.  l tlc, l a-line unchanged.  remains vented on ps was on [**4-5**] until traveled to ct scan then placed on a rate for ct.  upon return placed back on [**4-5**] but pt not tolerating [**4-5**], rr increased to 40's-->placed on [**11-5**] with rr improved to 20's.  bs coarse, diminished bil.  ct of chest and abdomen done; results pending.

gi/gu:  abd soft, non-tender, bowel sounds hypoactive.  tol tf at goal rate of 60ml/hr via ogt.  tol baricat pre-ct; now stooling liquid golden stool via mushroom catheter and occasionally oozing around mushroom.  u/o 20-40ml/hr.

id/endo/integ:  afebrile.  sliding scale coverage for fingersticks.  skin continues to weep requiring soft-sorb changes q2h-->arms, legs, back and buttocks.  multiple open areas noted, multiple skin tears noted--see carevue.

psychosocial/plan:  fam in to visit.  no decisions made by family re: re-intubation of pt if she is extubated.  encouraged fam to make these decisions at this time/prior to extubation planned for am.  emotional support given to pt and fam.  plan is [**month/day (1) **]'d vent support, npo after mn for ? extubation in am.  complete prbc's and re-check hct.  monitor vs, i+o, breath sounds.  [**month/day (1) **] with q2h skin care, current nursing/medical regime.  pt is dnr at this time.
"
1430,"resp: pt rec'd on psv 15/5/30%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of bloody tinged thick secretions. mdi's administered q 4 alb with no adverse reactions. pt had ^ in rr to 38 due to anxiety, ativan administered with good affect. rsbi=143, no abg's. attempted to wean psv but did not tolerate. will continue to wean appropriately.

"
1431,"nursing update:
   2nd unit of prbc's tranfused without adverse reaction.  hypertensive early noc >180, not responding to lopressor, lasix, capoten and atenolol.  pt c/o pain not relieved by mos4. dilaudid 1mg ivp given with good effect on comfort status and bp.
   placed on air mattress. large amount of serosang dng from left groin and abdominal incision.
pt remains alert and oriented when roused, though sleeping more comfortably on dilaudid.
"
1432,"2200-0700

received pt from [**hospital ward name 54**] 7 for meropenem desensitization. pt has bc x2 with gram negative rods and requiring meropenem for iv abx coverage.  pt awake, alert, orientedx3. follows commands well. moves upper ext well, lower ext bka bilaterally. speech clear and pt appropriate. no confusion noted. no neuro deficits.

resp: resp easy and regular without difficulty. no sob noted. o2 sat remain stable. lungs clear/diminished at the bases bilaterally.

cv:nsr without ectopy noted. hr 70-80s, sbp 130-150, low grade temps noted. denies pain at this time. meropenem desensitization started at 0245am. pt tolerating well. no adverse reactions. piv x1 to larm 20g intact.

gi/gu: pt on [**doctor first name 602**] diet. abd flat soft + bs, no bm noted. denies nausea. [**name (ni) **] pt. r arm av fistula not yet matured for use, +thrill/bruit. pt last received hd [**12-4**].

endo: riss.

plan: pt to finish meropenem desensitization and transfer back to [**wardname 1699**]-bed being held for pt.
"
1433,"resp: pt remains on psv 10/5/40%. bs are diminished bilaterally. suctioned for small amounts of thick tan secretions. mdi's administered q4 alb with no adverse reactions. am abg's 7.45/43/111/31. rsbi=148. no changes noc.
"
1434,"resp: [**name (ni) **] pt on [**name (ni) **] psv 5/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal noted aeration with slight i/wheeze on ls. suctioned for small amounts of thick yellow secretions mdi's administered q4 hrs alb/atr with no adverse reactions. abg's 7.41/55/136/36 rsbi=23.
"
1435,"resp: [**name (ni) 52**] pt on simv 10/600/5/+5/40%.  ambu/syringe @ hob.  pt has lg cuff leak, although tv's remain in 500's.  also noted secretions around trach site.  pt 02 sats decreased a few times during the noc.  bs auscultated reveal coarse bs bilateral with clear with suctioning.  suctioned x 4/5 times for bloody tinged thick secretions.  pt appears uncomfortable, rn aware.  mdi's administered q4 alb with no adverse reactions.  vent changes as follows:  rr ^ from 10, to 12, then 14, peep ^ 7, fio2^ 50%.  no further changes noted.
"
1436,"resp: [**name (ni) 52**] pt on a/c 12/400/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse to diminished.suctioning small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes or abg's this shift. plan to continue full vent support.
"
1437,"respiratory care note:
     patient remains trached with a #8.0 portex and on full vent support.  no changes have been made this shift.  bs are coarse throughout.  sx for small amounts of tan thick secretions via trach.  no rsbi this am due to fio2 of 60%.  patient remained afebrile.  mdi's administered as ordered, including 300mg of tobramycin at ~0200.  no adverse reactions noted.  spo2 remains 95-98%.  plan is to continue with current course of therapy.
"
1438,"resp: pt rec'd on psv 12/12/40%. bs are coarse with occasional wheeze noted. mdi's administered q4 hrs alb/atr with no adverse reactions. suctioned for small amounts of thick secretions. no vent changes this shift. am abg 7.49/37/122/25. will contine to wean appropriately.
"
1439,"resp: [**name (ni) 52**] pt on a/c 16/500/10+/40%. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered alb.atr with no adverse reactions. am abg 7.47/42/143/31. no rsbi due to ^ peep. noted occasional [**name (ni) 1999**] leak which is positional. will continue full vent support.
"
1440,"resp: [**name (ni) 52**] pt on a/c 12/400/10+/60%. alarms on and functioning. ambu/syringe @ hob. pt has #8portex trach. bs are relatively clear with some occasional wheeze noted. suctioned for small thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/59/115/41 then decreased fio2 to 59%. no rsbi due to ^ peep. will continue full vent support.
"
1441,"resp: pt administered 300 mg tobramycin @ 2:00 with no adverse reactions.
"
1442,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/+5 40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small amounts of thick whitish secretions.  pt became tachy once during the noc, lavaged, ambu, suctioned for small thk whitish amount, but no further episodes during the noc.  mdi's administered q4 of alb with no adverse reactions.  rsbi=38.  no further changes noted.
"
1443,"resp: [**name (ni) 516**] pt on psv 10/5/40%. pt has #7 portex trach. inner cannula changed. bs reveal noted aeration with diminished bases.suctioned for small amounts of thick tan/yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/30/104/19. rsbi=96. plan: wean as tolerated, initiate dialysis?
"
1444,"resp: pt rec'd on psv 16/10/50%. ett 8.0 19 @ lip. bs are coarse bilaterally and suctioning for moderate to copious thick yellow secretions. mdi's administered q4 alb with no adverse reactions. no changes noc. am abg 7.41/41/123/27. no rsbi due to ^ peep and procedure today. pt is being trached in am.
"
1445,"admission
pt admitted from or at 1305 s/p avr tissue and mv repair. uneventful or per anesthesia. ozzy from ct upon arrival from or. np [**name6 (md) **] and md [**doctor last name 816**] aware, protamine 50mg iv given as ordered. peep increased as [**name8 (md) **] np see fowsheet for details. 1 unit of prbcs given as ordered, no adverse reactions. pt requiring multi fluid boluses for svos 48-50s.epi gtt started as ordered. going by fick for co/ci, see flowsheet, pt w/ hx of tricuspid regurgitation.

neuro: pt sedated, perrla. no indication of pain. body temp 34.9-35 on arrival, bair hugger applied.

cv: hr 80. apacing. underlying 40s sb. sbp labile. goal sbp 90-110. see flowsheet for details, on and off neo and ntg gtts. [**md number(3) 1227**]/15-20s. cvp 5-11. requiring multi fluid boluses for low pad and cvp. np [**doctor last name 307**] aware. +dopplerable pedal pulses.

resp: ls clear diminished bases. sats >96%. presently orally intubated on simv mode rate 12, not breathing over, 5 peep, 5ps. plan to wake and wean as tolerates.

gi/gu: abd obese soft, absent bs. ogt +placement, draining bilious drainage.foley draining clear yellow urine 45-100cc/hr.

endo: gtt started per protocol, see flowsheet.

plan:monitor hemodynamics. monitor resp. status. follow fick q2 hours. allegy to latex. monitor ct drainage.
"
1446,"resp: pt rec'd on psv 5/10+/40%. ett 7.5, rotated, taped and secured @ 23 lip. bs are clear bilaterally. suctioned for small amounts of yellow thick secretions. mdi's administered as ordered atrovent with no adverse reactions. no abg's this shift. rsbi=47. weaned peep to 5. plan to continue wean with possible extubation in am.
"
1447,"resp: [**name (ni) 516**] pt on psv 10/5/40%. pt has #7 portex trach. bs are clear with diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.32/36/120/19. rsbi=43. plan: continue wean as tolerated with possible t/c trials.


"
1448,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #7 portex trach. bs are slightly coarse which clear with suctioning/diminished bases. suctioned for small amounts of bloody secretions due to recent trach. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/31/123/19. rsbi=97. plan: continue to wean as tolerated.
"
1449,"resp: pt on 3 lpm n/c and ordered for nebs alb/atr q6 hrs prn. administered alb/atr with no adverse reactions. will continue to follow.
"
1450,"resp: [**name (ni) 516**] pt on a/c 25/400/12+/60%. bs are diminished with crackles in bases bilaterally. suctioning for small to moderate amounts of thick tan/yellow secretions. mdi's administered alb with no adverse reactions. no changes noc. am abg 7.21/47/75/20. no rsbi due to ^ peep. plan: wean as tolerated.
"
1451,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #7 portex trach. bs are slightly coarse to clear. suctioned for small amounts of bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt wob ^ with declining abg's and ^ bp then placed on a/c (see careview for settings)with improved am abg 7.38/32/111/20. rsbi=97 but d/c due to ^bp to 180. plan:wean back to psv as tolerated.
"
1452,"resp: [**name (ni) 52**] pt on psv 10/5/40%. ett#8 retaped and secured @ 26 lip. bs are coarse to clear and suctioned for small amoutns of blood thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt had noted ^ in wob then increased ps to 15. vt's 400-500/ve 11/rr 25. rsbi=83. pt remains on ps 15. plan to wean ps as tolerated.
"
1453,"resp:  [**name (ni) 52**] pt on a/c 12/500/+8/50%. ett 7.0 taped @ 22 lip. bs are clear with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered of combivent with no adverse reactions.  abg 7.36/75/84/44.no rsbi due to or procedure today. no changes noc pt scheduled for trach/peg today?
"
1454,"resp: [**name (ni) 52**] pt on a/c 12/500/40%/+8. pt has #8 [**last name (un) **] air filled cuff which is secured @ 14 flange. bs are coarse to clear and suctioning for moderate amounts of thick bloody secretions which lighten in am. sputum sample obtained and sent. mdi's administered of combivent/ovar as ordered with no adverse reactions. rsbi=147. pt has coughing episodes causing desaturation at times. attempted psv but pt did not tolerate. plan maintain present settings.
"
1455,"resp: pt rec'd on a/c 14/450/+5/40%. pt has #8 portex trach. bs reveal ls clear with rs noted sub-q/crackles. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.50/51/92/41. rsbi=200. plan to wean as tolerated.
"
1456,"addendum
back from or at 1345 s/p exploratory of right axillary artery and repair dissection bovine patch. right hand cool, +palpable right radial, +ulnar and brachial via doppler. see flowsheet. svo2 dropped to 48, np [**doctor last name 330**] aware, 1 unit of prbcs given as ordered, no adverse reactions. ok for sbp 120s [**name8 (md) 76**] np [**doctor last name 330**]. fluid bolus for low urine output and low svo2, improving svo2 to 55-60. also epi gtt increased to 0.03mcg/kg/[**name6 (md) **] [**name8 (md) 76**] np. [**name (ni) **] (hcp) spoke to rn and updated w/ poc. mg 2gm given for ventricular ectopy. epicardial wires attached, not checked due to ectopy and tachycardia.  ptt >150, np [**doctor last name 330**] aware, no new orders. np[**md number(3) 732**] of act 170, no new orders. continues on epi, insulin, propofol, on and off ntg. see flowsheet for details.
"
1457,"resp: [**name (ni) 52**] pt on psv 10/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for copious amounts of thick bloody secretions/plugs. mdi' administered alb/atr with no adverse reactions. rsbi=58. pt is to be discharged today, although possibility of bronch this am.
"
1458,"condition update
d: see carevue flowsheet for specifics
 patient afebrile. dose of 2 million pcn g given this am at 0900 without any adverse reactions. pt was then bronched at 1015. second dose of 4 million pcn given at 1400 also given without any adverse reaction. thoracic team aware and transfer orders written. awaiting bed on floor.
 patient is a/ox3 and restarted on po diet.
 medicated with dilaudid 4mg po x2 with good effect.
 2 ct and 1 [**last name (un) **] remain intact. without any leaks. left lung with diminished breathsounds. 2l nc with o2 sats 98-100%.
plan:
 transfer out to floor when bed avail.
 notify h.o. with any changes
"
1459,"pt update

n: pt sedated on propofol. will open eyes and respond to stimuli. mae on bed. perla. fentanyl gtt for pain control.

cv: nsr, no ectopy. hr 90s. sbp 120s/80s. can get tachy to 130s and hypertensive to 200/90s when receiving treatment/vent changes/etc. repleted with 40kcl. pt received 1 unit prcs at 1700 with no adverse reaction.

resp: pt intubated. unable to wean from cpap ps fio2 .40, ps 18, peep 5. ls clear bilaterally.

gi: +bs. tf increase to goal of 40cc/hr. no stool.

gu: foley draining clear, amber urine. lasix gtt discontinued. uo ~50cc/hr.

endo: iss for control of blood sugars.

plan: attempt to wean from vent. monitor hemodynamics. replete electrolytes prn. monitor for s/s bleeding.
"
1460,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex trach, some ozzing form trach site. bs are coarse/diminished bases bilaterally. suctioned for copious amounts of thick yellow secretions until this am then became bloody. rn aware. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. rsbi=52. plan:wean as tolerated.
"
1461,"respiratory care note
pt received on ac as noted. bs essentially clear with good aeration. mdi's given q4 with no adverse reaction. ett repostioned and retaped without incident. bronchoscopy done - pt suctioned for large amts thick, yellow secretions. bal of rul sent to lab. plan to continue on current settings at this time.
"
1462,"micu npn 7a-3p

52 y.o. female s/p pcn desensitization for treatment of neurosyphillis.

neuro: alert and oriented x3. independent with adls.
resp: ls clear on room air.
cardiac: bp 100's/60's hr 80's nsr. no cardiac complaints offered.
gi: abd soft, nt, +bs. tolerating house diet.
gu: voiding clear yellow urine.
id: afebrile. tolerating oiv pcn q4hrs without s/s adverse reaction.
access: single lumen picc placed in left antecub. cxr confirmed; picc working well. pt to receive iv pcn for 2 weeks.

pt is called out to floor awaiting bed.
"
1463,"resp: pt rec'd on 35% t/c with humidification. pt has #7 portex. bs are coarse to clear and suctioned for small to moderate amounts of thick white to yellow secretions more towards morning. mdi's administered via trach alb/atr with no adverse reactions. pt has spc and is able to expectorate sputum.
"
1464,"npn
pt recieved from the er s/p 2 week history of headache, nausea, vomiting found [**5-29**] at home by friend lethargic. pt's daughter called by pt's friend and decided to call 911. pt taken to [**hospital 4223**] [**hospital 506**] hospital where a cxr and cat scan showed lung mass (l upper chest opacity) and ct head with l frontal mass with 5mml to r shift and hemnmorhagic l cerebellar mass causing tonsillar herniation. pt medflighted to [**hospital1 3**] for further eval/rx.
neuro deficit/pt disoriented to year will often respond ""[**2161**]"".
otherwise perrla 3mm each, mae with equal strength, no hand drift noted. tongue midline, smile symmetrical, no seizure activity. neuro sx = headache initially [**7-1**]. mri with and w/o contrast done. loading dose of dilantin 1000mg ordered in ew was given in icu. pt states allergy to steroids is increased hr, decadron given in ew without any adverse reaction and repeated x 1 in icu per dr [**last name (stitle) **]. pharmacy aware.
pain/as above [**7-1**] generalized h/a treated with dilaudid 0.5 mg ivp which decreased h/a pain to 3 then down to 1.
fluid deficit/pt c/o being thirsty, urine concentrated yellow, oral mucosa dry. pt recieved ns with kcl 40 meq at 250 cc/hr in the ew (1 liter). then iv changed to d5ns with 20meq kcl at 80ml/hr. pt is npo with exception of taking meds.
hypokalemic/k repleted in the ew as added to main iv for k 3.1. serum k level pending.
o2 sat 93%. at 12mn pt's o2 sat was 93% added 02 at 3lnp and sats improved to 97-98%.
icu prophylactics/h2blocker started, compression boots applied, sc heparin started.
psychosocial/pt,s sister [**name (ni) 2168**] in to see pt and with pt signed on as [**hospital **] healthcare proxy, form in chart. [**name (ni) 29**] brother has his phd and works with oncology research. pt has 2 young adult children who were in to visit. pt's family very concerned with recent developments in pt's health and decided to stay in hotel in [**location (un) 496**]. pt has hx of bipolar disease, anxiety disorder and depression. see [**month (only) **] for psych meds. pt is pleasant, calm and cooperative. she did ask for her xanax but neurosurg resident dr [**last name (stitle) **] did not want pt to take xanax. pain med as documented above has made pt comfortable and no further c/o anxiety after pain med given.
plan:nvs q1hr, notify neurosurg with changes.
emotional support for pt and her family.
monitor serum k's and replete as needed.
needs social work consult.


"
1465,"resp: [**name (ni) 52**] pt on psv 15/5/40%. ett #8.0 retaped @ 26 lip. bs are clear in apecies with diminshed bases/crackles. suctioned for small amount of thin bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. no vent changes noc. vt's 500's/ve 10. rsbi=66. rec'g rbc unit. plan remain on present settings and to wean as tolerated.
"
1466,"resp: [**name (ni) 52**] pt on a/c 16/500/5+/40%. ett 8.0, rotated, retaped and secured @ 22 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged/yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no-aline/no abg's this shift. no rsbi-or procedure this am.
"
1467,"resp: [**name (ni) 52**] pt on psv 12/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered combivent with no adverse reactions. no abg's 02 sats @ 99%. [**name (ni) 1017**]=124. plan to d/c today to rehab.
"
1468,"resp: pt rec'd on a/c 16/500/+5/40%. ett 8/0 rotated, retaped and secured @ 22 lip. bs are clear to coarse and suctioned for small to moderate amounts of thick bloody tinged/yellow secretions. mdi's administered combivent/alb as ordered with no adverse reactions. vent changes to ^ rr to 18. rsbi attempted but no spont resps. am abg 7.42/54/112/36. plan to wean as tolerated.
"
1469,"resp: pt rec'd on psv 5/5/40%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are coarse bilaterally and suctioned for small to moderate amounts of thick bloody tinged secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt placed on a/c (see abg's in careview) a/c 18/500/+5/40%. am abg 7.37/33/138/20/-4. no further changes. rsbi=190. plan: wean as tolerated.
"
1470,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are basically clear bilaterally. suctioned for scant to small amounts of bloody tinged thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes noc. am abg 7.35/38/131/22. rsbi=61. pt to or today for hip surgery.
"
1471,"resp: [**name (ni) 52**] pt on a/c 16/500/+5/40%. ett 7.5 taped @ 21 lip. bs are basically clear and suctioned for small amount of bloody tinged secretions. sample obtained and sent with results pending. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.44/37/154/26. rsbi=>200. weaned to psv 15/5/40% and pt tolerating. will continue to wean as tolerates.
"
1472,"resp: [**name (ni) 52**] pt on psv 10/12/60%. pt has #8 portex trach. inner cannula changed. bs are coarse bilaterally with diminished bases. suctioning for moderate to copious amounts of thick tan/yellow secretions, sample sent. mdi's administered as ordered alb/atr/qvar with no adverse reactions. abg's (see careview) no rsbi due to ^ peep.  am abg 7.42/58/68/39. plan: continue with t/c trials as tolerates.
"
1473,"resp: [**name (ni) 52**] pt on 40% cam, then ^ to 60% due to decreasing sat's. nebs ordered and administered q6 hrs alb/atr with no adverse reactions. will continue to treat.
"
1474,"nursing progress note

events: pt to [**hospital ward name **] for ercp, procedure performed under    anesthesia supervision, tolerated well, no adverse reaction. per gi team, no stones in cbd, + presence of sludge. sphincterotomy performed, pt doing well at present. febrile this morning, tmax 102.8, given tylenol for comfort, temp slowly improved, currently down to 99.1.

neuro: a+ox3, mae, normal strength. c/o diffuse achiness d/t being in bed, occas c/o ha and mild epigastric/ruq pain. given dilaudid prn w/ good effect.

resp: ls clear, dimin w/ intermittent fine crackles to r base posteriorly. pt given i/s instruction, o2 sats low 90-91% on room air, 2l nc o2 intact, sats 95-100%.

cv: bp stable, extrem warm, pulses intact. for most of shift hr nsr, rate 80s; note few episodes lasting anywhere from 5-10 minutes of sinus tachycardia w/ rate holding in the 120s. does not appear to correlate w/ any stimulation, increased pain, etc.  all episodes self limiting, hr returning to baseline w/ no intervention.  pt's home dose lopressor po restarted this am.

gi: belly soft/mildly distended. bs present. +flatus. denies nausea. remains npo post procedure.

gu: foley patent clear amber/icteric urine, qs.

endo: maintenance ivf per orders, glucose levels stable.

social: daughter [**name (ni) **] in for visit, updated on pt's status.

a/p: 54 yo female w/ known gall stones s/p ercp today. procedure uneventful, see report for findings.  abd pain minimal, remains npo. febrile this am, much improved this aft.  remains in icu for close obs, likely will require cholecystectomy in near future.
"
1475,"resp: pt has #8 portex trach with pmv in place. pt is on 50% t/[**hospital1 **] are diminished bilaterally and suctioned for small amounts of white thick secretions. mdi's administered via trach/ambu with no adverse reactions. will continue to monitor.
"
1476,"readmit
pt readmitted at 0645 from [**hospital ward name 54**] 6, unresponsive, intubuted, left pleural ct placed on [**hospital ward name 54**] 6. bs 30s at 0600, treated on [**hospital ward name 54**] 6. to cvicu hypotensive on 3mcg of neo. levophed gtt added, also vasopressin added as ordered. see flowsheet for details. neo gtt weaned to off as per team. echo done at bedside at 0730. fem aline placed at 0715. pa catheter inserted at 0915. see flowsheet for details.

neuro: pt mae on arrival, though not following commands, sedated on propofol gtt. pupils 6mm, left sluggish, right nr. np [**doctor last name **] aware. propofol off at 1100 to assess abd [**name8 (md) 76**] np [**doctor last name **]. at 1130, pt restless, mae, not following commands, grimacing at baseline, hard to assess abd d/t baseline grimacing. np [**doctor last name **] at bedside, ok to restart propofol [**name8 (md) 76**] np.

cv: hr 50-70s sr rare pvc noted. hypotensive on arrival. sbp 80s on neo gtt at 3mcg/kg/min. levophed gtt added as ordered. also pitressin started as ordered. see flowsheet for details. pa catheter placed at bedside. wedge pressure 22. svo2 70s-80s. [**md number(3) 10822**]/15-20s. cvp 8-14. ci>2 via thermodilution. co 4.2-4.8. 2 units ffp given as ordered and 2 units of prbcs given as ordered. no adverse reactions noted. multi-lumen rij dc'd and tip sent for culture,dc'd without incident. sternum uneven, team aware. pt in or at present time for ? sternal washout/ ? explor. lap.

resp: ls coarse throughout. bronch done at bedside, scant amt of secretions. lactate [**10-30**]. csurg team aware. see flowsheet for abg results, ph 7.22 on arrival, 2 amps of bicarb iv given as ordered. repeat ph 7.35. np [**doctor last name **] updated throughout shift of abgs and lactate. fluid boluses given as [**name8 (md) 76**] np, total of 1.5lns.

gi/gu: abd soft, no bs. ogt draining bilious brown scant amts. bmx2 large liquid brown, c.diff sent. + ob stool. general surgery consulted. lfts elevated. coag elevated. foley inserted, amber clear urine sent. ua and uc sent as ordered.

endo: 1/2amp of d50 at 0800 for decreasing bs. followed bs q1 hr. see flowsheet.

id: bc from fem aline and [**location (un) **] left subclavian. hypothermic. temp 92.2-93.4, see flowsheet. np [**doctor last name **] aware. uc sent. bronch specimen sent. zosyn and flagyl given before or. vanco given to anesthesia, to be given in or.

social: family updated by md.

plan: pt in or (at present time) for sternal washout and ? exploratory laparotomy to assess abd. monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. full code.
"
1477,"resp: [**name (ni) 52**] pt on psv 10/5/50%. pt has #8 portex trach. bs are coarse to clear with diminished bases. suctioned for moderate amounts of thick yellow secretions. inner cannula clear. mdi's administered as ordered alb/atr/qvar with no adverse reactions. vt's 500/rr 27 with 02 sats in 90's. a-line removed this am. rsbi=51. plan: continue with t/c trails as tolerated.
"
1478,"resp: [**name (ni) 52**] pt on t/c with hi-flow @ 60%. 02 sats @ 95%. bs are coarse bilaterally and suctioning for copious amounts of thick yellow secretions frequently. mdi's administered alb/atr/ovar as ordered with no adverse reactions. pt remained on t/c until 02:00. no distress was noted, 02 sats in 90's rr 18-20, although pt was noticably more lethargic. abg revealed ^ co2 with ph7.2 then placed on vent psv 10/8/50%. improvement noted pt more awake. co2 @ 62. ph 7.39. rsbi=52. plan: continue with frequent suctioning and t/c trials.
"
1479,"resp: [**name (ni) 52**] pt on a/c 14/500/5+/40%. bs are coarse to clear with suctioning. secretions initially bloody tinged then more white towards morning. mdi's administered alb/atr as ordered with no adverse reactions. abg's (see careview) within normal range on a/c. weaned to psv 10/5/40% in am with abg's pending. rsbi=123. still remains tachy
"
1480,"resp: [**name (ni) 52**] pt on a/c 35/450/16+/60%. ett 7.5 taped @ 23 lip. bs are clear and suctioned for none/white secretions. mdi's administered alb/atr with no adverse reactions. abg 7.15/48/74/18. [**name (ni) **] changes to ^ peep to 18. bicarb initiated again. plan: meeting to discuss cmo status. continue full [**name (ni) **] support.
"
1481,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 16/600/+5/10/40%. alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned copious bloody secretions. mdi's administered q4 of combivent with no adverse reactions.  rsbi=90.  no futher changes noted.
"
1482,"11p-0700
pt admitted from or at 2145 [**2186-8-24**], ( s/p aicd/ddd permanent pacer placed [**2186-8-24**] am, hypotension while on floor, back to or). see admission history for details.

neuro: pt sedated first on propofol, propofol weaned off and fentanyl 50mcg/hr and versed 1mg/hr gtts started d/t hypotension 88-90s/. opens eyes on verbal command, moves extremeties with hands on care, hx of right arm w/ steel rod placement. perrla. no facial grimacing noted.

cv: ddd permanent pacer hr 80-120s (120s while dopamine infusing). v paced, varying w/ own intrinsic and a paced beats. dopamine changed, secondary to hr, to neo gtt for sbp 90-100s. labile bp. goal 90-100s sbp. see carevue for details. cvp 5-8. + palpable pedal pulses. received 1 unit of prbcs, no adverse reactions. post hct 27. hct from ct 17.2, pa [**doctor last name 739**] aware. trauma line to left groin bleeding when received from or, pa [**doctor last name 739**] at bedside, stitched, no further bleeding. k repleted, order to replete k <4.0.

resp:ls clear. orally intubated, suctioned for scant blood tinged. sats >96% on fio2 40% rte 14 simv, see carevue for details.  left ct intact, no air leak, no crepitus, draining sang. minimal amts, see carevue.

gi/gu: abd soft, +bs. ogt + placement to intermittent wall suction, scant amt of blood via ogt after suctioning pt, pa [**name (ni) 739**] aware, no new orders at present. once bp stabilized, lasix 40mg ivp given. foley draining clear yellow urine adequate amts. see carevue.

endo: insulin gtt started for fs 150s, see carevue.

social: no contact from family this shift.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent as pt tolerates. monitor ct drainage. keep pt comfortable.
"
1483,"resp: [**name (ni) 52**] pt on h/f @ 50%. bs auscultated reveal bilateral coarse sounds. nasal trumpet in place. hhn alb/atr administered q 4 hrs with no adverse reactions. pt on cpap 16 with 2 lpm 02 bleed in noc.
"
1484,"resp:  [**name (ni) 52**] pt on [**last name (un) 993**] a/c 10/500/40%/+10.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral diminished breath sounds.  suctioned x3 small to moderate amounts of thick yellowish secretions.  mdi's administered q4 combivent with no adverse reactions.  no rsbi performed due to ^peep.  02 sats remain in ^ 90's @ 97-99%.  no further changes noted.
"
1485,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett 8.0 rotated, retaped @ 27 lip. bs are clear with diminished bases. scant amounts suctioned. mdi's administered as ordered alb/atr with no adverse reactions. [**name (ni) 520**] changes to decrease peep x1 increments and presently @ 14. am abg 7.47/43/79/28. no rsbi due to ^ peep. plan:continue to wean peep as tolerated/appropriate. presently on full [**name (ni) **] support.
"
1486,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett #8, rotated, retaped @ 27 lip. bite block in place. bs are coarse bilaterally and suctioning for copious amounts of thick yellow /brownish plugs. mdi's administered as ordered alb/atr with no adverse reactions. no rsbi due to^ peep. am. abg 7.34/43/103/24. plan: maintain full [**name (ni) **] support.
"
1487,"7a-7p
neuro: received pt sedated on fentanyl and versed gtts. weaned versed gtts to off. pt mae on command (spoken in french by translator), nodding appropriately to questions. fentanyl gtt wean to off to attempt cpap ps on ventilator. perrla. sleepy at present time.

cv: hr 80-90s sr rare pvc. sbp labile. aline overshooting/fling in aline waveform. nibp ~20-30points lower [**name6 (md) **] aline, md [**name6 (md) 859**] and md [**doctor last name 1357**] aware, go by nibp to titrate gtts [**name8 (md) **] md [**name6 (md) 859**] and md [**last name (titles) 1357**]. at present time on ntg to keep goal sbp 120-140. hct 25 this am, 1 unit of prbcs infused w/out adverse reactions, repeat hct 28, md [**doctor last name 859**] aware. ci [**2-20**] via thermodilution. [**md number(3) 5420**]/15-20. cvp 9-12. see flowsheet for details. 3+ generalized anasarca. +palpable pedal pulses.

resp: ls coarse, diminished bases. sats 100%. cxr done this am. attempted cpap/ps x2 unsuccessful d/t pt sleepy. will attempt when pt more awake. see flowsheet for abg/vent settings. ct to water seal, draining serosang. drainage, no airleak, no crepitus.

gi/gu: abd softly distended. hypoactive bs. ngt to suction draining bilious drainage. foley draining 80-400cc/hr of clear yellow urine. received 20mg of lasix ivp as ordered after blood transfusion. another dose of lasix 20mg x1 on hold for now [**name8 (md) **] md [**doctor last name 859**] since pt already 2.6 liters negative since midnoc. will need more lasix on pt's u/o starts to decrease [**name8 (md) **] md [**last name (titles) 859**].

endo: no coverage needed 90-100s.

social: friends into visit.

plan: monitor hemodynamics. monitor resp.status. monitor output. bp control by following cuff pressure. diurese. wean vent to cpap/ps.




"
1488,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett #8 rotated, retaped @ 27 lip. bs are clear/diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. new a-line inserted. am abg 7.36/45/78/26. plan was to decrease peep slowly, although with pao2 @ 78 peep remains @ 16. no rsbi=^ peep. plan: maintain full [**name (ni) **] support.
"
1489,"resp: [**name (ni) 516**] pt on a/c 34/380/12+/70%. ett 7.0 retaped, rotated and secured @ 20 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. fio2 weaned to 60%. am abg pending.no rsbi due to ^ peep/fio2. plan: wean as tolerated.
"
1490,"resp: [**name (ni) 516**] pt intubated ett 7.0 taped @26 lip transfer from sicu via or. vent settings a/c 26/600/10/40%.  bs are clear bilaterally with diminished bases. sputum sample obtained and sent. suctioned for small amounts of thick yellow/tan secretions. cvvhd initiated.  mdi""s administered as ordered alb with no adverse reactions. am abg 7.33/37/119/20. pt had episode of desaturation following arrival from or, vent changes to ^peep/fio2 to 60%,then titrated back down to present settings. no rsbi due to ^ peep. no further changes noted. plan: wean as tolerated.
"
1491,"resp: pt rec'd on psv 8/5+/25%. pt has a #7 portex trach. bs are coarse bileratally and suctioned for small amounts of white secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt had episodes of aggitation, trying to get oob at times, with rr to 40's. placed on a/c 14/450/+5/25% in morning to control/reduce rr with immediate improvement.  will wean back to psv when pt calms. rsbi=72. no abg's this shift, 02 sats @ 99%.
"
1492,"resp: [**name (ni) 516**] pt on a/c 22/600/12+/40%. bs are clear with dminished bases and suctioned for small amount of white thick secretions. mdi's administered as ordered alb with no adverse reactions. no changes this shift. am abg 7.42/40/103/27. no rsbi due to ^ peep.  plan: maintain full vent support. or on monday.
"
1493,"resp: [**name (ni) 516**] pt on psv 8/5/35%. pt has #7 portex trach. bs are coarse to clear and suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. titrated fio2 down to 25% and ps to 6. 02 sats @ 99%. pt tolerated presents noc with no distress noted. rsbi=90. continue to wean with t/c trials as tolerated.
"
1494,"resp: [**name (ni) 516**] pt on a/c 20/700/17+100%. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered with no adverse reactions. pt having episodes of desats with ^ bp, ^ hr. pt is dnr. pt expired @ 2:34 this am.
"
1495,"resp: [**name (ni) 516**] pt on psv 8/5/25%. pt has #8 portex. bs are coarse with decrease in aeration on ls. mucomyst/alb instilled as well as mdi's administered alb/atr with no adverse reactions. some green secretions oozing around trach site. bs reveal end exp. wheezing following administration of mucomyst. suctioned for small amounts of thick white/yellow secretions. episode of desaturation with ^ in ps & peep. weaned back to present settings in am. 02 sats @ 97% with adequate tv's. plan continue wean and attempt t/c trials if tolerates.
"
1496,"resp: pt rec'd on 40% f/t. alb/atr ud administered q6 hr with no adverse reactions. bs are coarse to clear. will continue to follow.
"
1497,"resp:  [**name (ni) **] pt on psv 12/5/40%. pt has #7 portex trach. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered atr as ordered with not adverse reactions.  rsbi=52. plan: pt is being screened for rehab. continue to wean as tolerated.
"
1498,"0700-1900  micu progress note


77 yo male admitted on [**6-28**] from home w/ 2 day history of confusion.  pt was intially admitted to cc-7 but acutely became more lethargic.  lp was done at that time on the floor which showed wbc >2300.  pt was treated for probable viral menigitis.  pt was intubated yesterday briefly for mri.  mri showed no acute bleed or mass.  pt had eeg today, results pending. pmh per care-vue.  pt started on ivig at 5pm, no adverse reaction

allergy: antihistamines

[**name (ni) 57**]  pt remains sleepy and lethargic, but arrousable to gentle stimulation.  pt unable to follow commands, and can be very impulsive and attempts to climb oob.  pt is at risk for falls and needs close monitoring.   grasps strong.  pt appears to be having pain when attmpting to [**last name (lf) **], [**first name3 (lf) 93**] monitor.  speech garbled and pt refuses to answer questions at times.  pt knows his wife and son, but unaware who his daughter was when she was visiting.

c/v-  remains in afib, rate controlled 80-120 with occas pvc's.  pt has no edema.  b/p 130-140/60-80.

resp-  respiratory pattern irregular at time, w/ short periods of apnea <5secs noted.  pt has weak and ineffective cough noted.  sat's have remained 94-96% on ra.  rr 12-24.  lungs coarse and diminshed.  mouth is very dry secondary to mouth breathing, mouth care provided.

g/[**name (ni) **]  pt on po lactulose for increased [**last name (un) **] level, no bm noted today.  remains npo, ngt in place for meds.  abd soft, +bs.

g/u-foley patent..u/o 50-250cc/hr  clear yellow.

endocrine-  remains on insullin gtt, fs q1hr..see care vue

[**name (ni) **]  pt's wife, son and daughter into visit and updated by pcp.  [**name10 (nameis) **] also provide update on poc.  family appropriate with queations.

i/[**name (ni) **]  pt will need labs drawn on tues [**7-4**] to be sent to the state lab for eee,and [**location 3989**].

plan-
continue to monitor mental status
state labs to be sent out tues am
? start tf in am

"
1499,"resp: [**name (ni) 516**] pt on psv 15/10/50%. ett #8, rotated, and retaped @ 26 lip. bs are clear/diminished bases bilaterally. sucioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.50/32/118/26. vent changes to decrease ps to 12, peep to 8. plan: wean as tolerated. rsbi to be done in am following pt tolerating decrease in peep
"
1500,"resp: pt rec'd on psv 5/5/40%. ett 8.0 taped @ 26 lip. bs are coarse to clear and suctioned for small to moderate white/yellow thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/43/148/30. rsbi=47. plan:trach/peg
"
1501,"resp: transferred from micu with incident, intubated with #7.5 ett, taped @ 21 lip. bs are clear on rs, diminished bases on ls. suctioned for small to moderate thick tan secretions. a-line in place. mdi's administered alb/atr with no adverse reactions. pt scheduled for radiation tx this am. plan to continue on present settings.
"
1502,"resp: pt rec'd on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear and suctioning for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.50/30/176/24. rsbi=55. possible t/c trials today?
"
1503,"resp: [**name (ni) 516**] pt on a/c 26/350/5+/50%. ett 7.5 taped @ 24 lip. bs are coarse and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. pt had episode of desaturation then peep ^ to 10. am abg  7.36/38/66/22. fio2 ^ to 60%. radiation treatment today. no further changes notes. no rsbi=peep
"
1504,"resp: [**name (ni) 516**] pt on psv 8/5/40%. ett 7.5, retaped and secured @ 21 lip. bs are coarse to clear and suctioning small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no abg's 02 sats @ 100%. vt 300's ve 7. rsbi=76. plan to continue diuresing with extubation on [**12-28**].
"
1505,"resp: mdi's administered of combivent as ordered without any adverse reactions.
"
1506,"resp: pt rec;d on psv 10/5/40%. ett 7.5, rotated, retaped and secured @ 25 lip. bs are clear with occasional coarse sounds. suctioned for small amount of tan secretions. mdi administered as ordered atr with no adverse reactions. am abg 7.37/46/135/28. rsbi=22. pt remains on cvvhd. plan to maintain present settings.
"
1507,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett #7.5, 21 @ lip. bs are coarse to clear and suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. pt had episode of ^ wob, then increased ps/peep temporarialy (see careview) and weaned to psv 5/5 this am. rsbi=90. plan is to extubate in am.
"
1508,"npn 0700-1900
events: weaned ntg to off, no c/o sob. weaned o2 to 2lnc. chemo regime started in [**hospital unit name 142**]. plt tx w/bump 16->39
neuro: afebrile, oob, amb in room, gait steady. med for back pain w/relief w/2-4mg dilaudid iv.
resp: ls:poor aeration t/o, exp wheezes t/o. denies sob. pre chemo hydration begun w/bicarb gtt @ 75cc/hr and mesna @42cc/hr, monitoring for sob, desaturation, may need lasix prn.
cv: b/p 160s/80s, cont w/2+edema. double lumen picc for access and 1perpheral 20guage iv added for chemo administration. plt transfusiom
gi: abd soft, distended, no bm today. refused lactulose as stated he moved bowels yesterday. pt w/fair appetite,eating most of food from trays.
gu: voiding clr yellow urine in urinal, now on chemo precautions.
plan: cytoxan administration tonight by oncology rn, monitor for s/s chf, adverse reactions.

"
1509,"11p-7a
neuro: pt alert and oriented, mae, follows commands, perrla. medicated w/ toradol, tylenol po, and dilaudid 0.25mg ivp prn for c/o incisional pain.

cv: apacing most of shift, d/t sbp 80s w/ intrinsic rate of 60s. hr at present 65 sr, no ectopy, sbp 96/44 w/neo gtt at 1.25mcg/kg/min. [**md number(3) 2282**]/10s, cvp 5-8, ci > 2 by thermodilution. epicardial wires attached and intact, see carevue. right radial aline dampened, going by femoral aline for bp readings. received 1 unit of prbcs for hct 25 as ordered,no adverse reactions, repeat hct 30. +palpable pulses.

resp: ls clear diminished. sats >94% on 2lnc. rr wnl. encouraged coughing and deep breathing.

gi/gu: abd soft, hypoactive bs. foley draining adequate amts of clear light yellow urine, see carevue.

endo: received pt w/ fs 48, 1/2amp of d50 given iv. gtt restarted for fs>200, see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean neo as pt tolerates. follow intake and output, treat as appropriate.
"
1510,"code status;dnr/dni

allergies;nkda

access;two piv one on each hand

cvs;a-fib on coumadin hr 80-110 frequent pvc's nbp 110-130/50-70 extremities are edematous pedal pulses are palpable.iv fluid d/cd at am.transfused one unit of prbc today without any adverse reactions.lytes and crit repeated,please see careview for results.metoprolol was d/cd after am dose.

resp;breathing efforts are normal rr 16-28 ls are clear spo2 100% on room air.

neuro;alert and oriented x 3 follows all commands moves all extrimities.medicated with versed 0.5 mg/iv and fentanyl 25 mg/iv for procedure at 1600 and pt is sleeping now.

gi;upper endoscopy done verbally reported as no active bleeding.still has active [**last name (un) **] emptied 150 ml from bag since am.ng tube to be pulled out and feed can be started as [**name8 (md) 21**] md.abdomen soft distended with positive bs.on pantoprozole iv.

gu; diuresed with 20 mg lasix prior and 20 mg/iv after blood transfusion.

skin;redness at back and haematoma on lt side of his thighs positioned q4h.

id;afebrile not on any antibiotics

endo;fs 270,s fixed dose d/cd and updated the sliding scale

social;daughter called and updated

plan;?to restart metoprolol
monitor vital signs
repeat crit /transfusions if remains low
n/g to pull out and restart feed when pt is awake
? call out
"
1511,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett 7.5, taped @ 24 lip. bs are coarse to clear and suctioning moderate to copious thick yellow/greenish secretions. mdi's administered as ordered combivent with no adverse reactions. am abg 7.48/40/99/31. rsbi=46. no changes noc. plan to wean as tolerated.
"
1512,"resp: [**name (ni) 516**] pt on psv 10/8/50%. ett #8, taped @ 20 lip. bs are coarse to clear and suctioned for small to moderate yellow/tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.45/49/93/35. vent changes to decrease peep to 5. rsbi=92. plan to continue wean as tolerated.
"
1513,"resp: [**name (ni) 516**] pt on a/c 26/550/+8/40%. ett 8.0 rotated and retaped @ 23 lip. bs are coarse to clear and suctioning moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt remains with ^ temp. attempted rsbi=132. no aline. 02 sats @ 94%. plan: wean as tolerated.
"
1514,"11p-7a
neuro: received pt on propofol, weaned to off, mae, follows commands, perrla. see carevue for details. nodded yes when asked if in pain, medicated w/ morphine 2mg ivp prn.

cv: hr 80-90s sr rare pacs, mg 2gm repleted. epicardial wires turned off d/t inappropriate spiking. following cuff pressures, aline waveform inaccurate, see carevue. sbp 100s-130s, after propofol weaned to off, sbp by cuff increasing 140-150s ntg restarted, see carevue. [**md number(3) 1227**]/17-20s, cvp 8-15, ci>2, see carevue for filling pressures. + dopplerable bilat pt, absent right dp unchanged from previous shift.

resp: ls clear. orally intubated, weaned from cpap 10/5-> [**6-16**] at 0600 w/ acceptable abgs, though still sleepy. see carevue for abgs and vent changes. sats 99-100%. rr 20s. tv 300s.

gi/gu: abd soft, absent bs. +placement of ogt, draining bilious drainage scant amts. low u/o 5-15cc/hr, pa [**doctor last name **] aware, albumin 500ccx2, additional 1l fluid bolus w/ no improvement. 1 unit of prbcs given, no adverse reactions, lasix 20mg ivp after blood increasing u/o >100cc/hr, see carevue.

endo: gtt per protocol.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. plan to extubate this morning. ?deline.

"
1515,"respiratory care:

pt remain orally intubated & sedated on spontaneous ventilation. we weaned ips this morning after early am abg. rsbi done ~89. bs are dim bil. mdi's adm as ordered with no adverse reactions. we are sxtn for small amt of thick whitish secretions, some orally, cough present. plan: wan as tolerate, ?sbt and continue present icu monitoring. will follow.

"
1516,"resp: [**name (ni) 516**] pt on psv 10/8/50%. ett #8 retaped, rotated and secured @ 22 lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no abg's noc. 02 sats @ 96%. rsbi=175. plan to continue to wean as tolerated.
"
1517,"resp: [**name (ni) 516**] pt on a/c 22/550/+10/40%. bs are clear with diminished rs base. suctioned for small amount of thick secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. pt remains on fentanyl/midaz. am abg 7.47/36/119/27. rsbi=no resps. plan: pending ip assessment, possible or for sent placement?
"
1518,"resp: [**name (ni) 516**] pt on psv 12/10/60%. bs are coarse to clear and suctioning for copious thick bloody/rusty plugs/secretions. sample sent. several vent changes due to pt aggitation and desaturation/^ wob (see careview for changes) mdi's administered (see carview for dosage/drug) with no adverse reactions. present settings;psv 20/12/50% with am abg 7.45/52/82/37.  no rsbi due to ^ peep/or procedure. plan: or for trach today.
"
1519,"resp: [**name (ni) 516**] pt on psv 12/10/50%. ett 8.0 taped @ 20 lip. bs are coarse to clear. suctioned for small to moderate tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt desating to 80's then increased peep to 14, weaned to 12. am abg 7.43/38/78/26. no rsbi due to ^ peep.  will continue to wean as tolerated.
"
1520,"resp: pt rec'd on a/c 12/450/5+/75%. bs are clear bilaterally. suctioned for small amounts of tan secretions and moderate amount x1 bloody clots from oral cavity. mdi's administered alb/atr with no adverse reactions. colistin neb tx given. pt continues to have ^ hr, ^ wob with rr to 40's. peep ^ to 15 with ^ sedation for noted improvement.no rsbi=^fio2/peep. fio2 weaned to 60%. plan to continue wean as tolerated.
"
1521,"resp: [**name (ni) 516**] pt on psv 12/14+/50%. ett 8.0 taped @ 20 lip.  bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.42/38/73/25. rsbi=^peep. will continue to wean as tolerated.
"
1522,"resp: [**name (ni) 516**] pt on a/c 28/500/+8/40%. ett # 8.0 retaped @ 23 lip. bs are clear/diminished bilaterally with poor chest rise. suctioned for small amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.29/47/121/24. rsbi=178. plan: maintain present support.
"
1523,"resp: [**name (ni) 516**] pt on 50% t/c and tolerated well this shift. bs are coarse to clear with suctioning. suctioned for small amounts of thick yellow secretions. mdi's administered via t/c with spacer alb/atr with no adverse reactions. pt remains anxious at times. will continue with t/c trials as toelrated.
"
1524,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, retaped and secured @ 20 lip. bs are clear with diminished bases. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered of atrovent with no adverse reactions. vent changes to decrease ps to [**10-17**]/and presently on 5 which reflect abg's (see careview) presently on ps [**2124-5-14**] %. am abg 7.44/37/113/26. will attempt [**month/day/year **] in am. plan is to wean to extubate today.
"
1525,"resp: [**name (ni) 516**] pt on a/c 22/550/14+/50%. pt has #8 portex trach with some bloody oozing from trach site. suctioned for minimal secrections. bs are clear with diminished bases. mdi's administered alb/atr with no adverse reactions.  am abg 7.49/39/91/31, no rsbi due to ^ peep. plan: wean as tolerated.
"
1526,"resp: [**name (ni) 516**] pt on psv 14/12+/50%. bs are coarse to clear and suctioned for small amount of secretions. pt has #8 portex trach. mdi's administered alb/atr/qvar with no adverse reactions. periods of desaturation to 80's and fio2 ^ to 60%. abg's (see careview). am abg on 50% 7.46/43/69/32. fio2 ^ back to 60%. no rsbi due to ^ peep. plan to continue to wean as tolerated.
"
1527,"resp: [**name (ni) 516**] pt on psv 10/5/50%. pt has #8 portex trach. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered combivent/alb prn as ordered with no adverse reactions. pt has episodes of anxiousness with ^ wob to 30's. rsbi=91. plan to wean as tolerate and initiate t/c trials.
"
1528,"resp: [**name (ni) 516**] pt on mmv 500/6/10/5/40%. ett 7.5, taped @ 25 lip. bs are coarse to clear. suctioned for moderate amounts of secretions. mdi's administered alb/atr with no adverse reactions. vt's 500-600 with ve's [**5-31**]. c02^ then placed on a/c 18/500/+5/40%. am abg 7.45/52/67/37. fio2 ^ to 50%. additional abg pending. plan to wean to psv as tolerated.
"
1529,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett #7.5, 25 lip. bs are coarse to clear and suctioned for small to moderate amounts of thin/frothy white secretions. mdi's administered as ordered alb/atr with no adverse reactions. vt's 400-500, ve's 6. 02 sats @ 100. abg 7.36/60/125/35. rsbi=31. plan to continue to wean as tolerated.
"
1530,"admission
pt admitted from or at 1600, s/p thrombectomy aortobifem limb thrombectomy and stent, vein graft thrombectomy, fasciotomy to right leg, see fhp for details of or and pmh.

neuro: received sedated on propofol. pupils equal sluggish.

cv: hr 80s. fluid bolus for hypotension w/ results. received 2 unit prbcs for hct 21.7. no adverse reaction noted. sbp labile 80s-110s. cvp 7-11. +dopplerable right pt, +dopplerable right popliteal. see flowsheet for details. left aka dsg cdi.

resp: ls coarse. peep increased to 8 [**name8 (md) **] np for sat abg 89%, rate decreased to 12. hard to obtain sats at times (poor wavefrom). see flowsheet for vent changes and abgs.

gi/gu: abd soft hypoactive bs. ogt +placement, not draining any secretions. foley draining [**location (un) **] urine, 20-45cc/hr, see flowsheet. np [**doctor last name **] aware.

endo: fs 120 no coverage.

plan: monitor hemodyanamics. monitor resp. status. start fentanyl gtt when bp improves. bicarb gtt x 1 liter for kidney protection as ordered. keep sedated. ? to go back to or tomorrow.
"
1531,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5 taped @ 23 lip. bs are clear bilaterally and suctioned for scant amount of secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no changes noc. pt is awake and alert and only remains intubated noc due to difficult airway/stent procedure po. rsbi=25. plan"": extubate this am with anesthesia present.
"
1532,"resp: pt has #8 portex trach and is on 50% t/c. bs are coarse to clear and suctioning moderate amounts of thick yellow to white secretions. mdi's administered via trach of combivent with no adverse reactions. no abg's this shift. 02 sats @ 98%.
"
1533,"7a-7p
neuro: received pt on propofol and fentanyl gtts. daily wake- up done per csurg team. with propofol off x 1/2 hour, pt awoke moving upper extremeties, agitated, not following commands, resedated. csurg and vascular teams aware. perrla. medicated w/ fentanyl gtt for pain, propofol weaned off, midaz gtt started as ordered.

cv: hr 80-90s sr w/ bbb, w/ occasional-> freq. ventricular bigeminy, np [**doctor last name 307**] aware. lytes checked q 4-6hours. i ca++ repleted as ordered. sbp 100s-120s. left radial aline sharp and intact. right ac arterial sheath transduced and w/ sharp waveform. sheath to stay in today per vascular. cvp 8-14. plavix and asa given as ordered for recent stent placements. see flowsheet for assessment of pulses. + dopplerable right pt/dt. right leg warm to touch. left amp dsg changed, staples intact, oozing small amts of serosang, to keep dry sterile dsg over, not to constrict left amp per vascualar. staples from right leg fasciotomy sites removed by vascular, large amts of sang. drainage, np [**doctor last name **] aware, hct sent. hct resulted to be 20. np [**doctor last name **] aware, 2 units of prbcs given as ordered, no adverse reactions. repeat hct 24.8, np [**doctor last name 307**] aware, no new orders at present time.  see flowsheet for details.

resp: ls coarse diminished at bases. sats >94%. tolerating cpap 10 peep, 12ps. rr 12-18. acceptable abgs. see flowsheet for details of vent changes and abgs.

gi/gu: abd soft absent to hypoactive bs. ogt +placement, draining greesnish clear. foley draining amber to clear yellow dark urine. on bicarb gtt for protection of kidneys and ck >30,000. np [**doctor last name 307**] aware of all labs throughout day. bicarb gtt off at 1745 [**name8 (md) **] np. continue maintenance fluid ns 250cc/hr as [**name8 (md) **] np. pt received lasix 20mg ivp btw blood, increasing u/o >100cc/hr.

endo: insulin gtt per protocol.

skin: see flowsheet.

plan: monitor hemodynamics. monitor resp. status. goal cvp ~12. next labs due [**2096**] [**name8 (md) **] np [**doctor last name 307**]. follow ck. monitor u/o.


"
1534,"resp: [**name (ni) 516**] pt on a/c 12/500/+8/50%. bs are coarse bilaterally and suctioning for moderate amounts of thick bloody tinged yellow secretions. hr remains tachy with increased close to 140 and rr in ^ 30's. combivent administered as ordered with no adverse reactions. no changes noc.am abg 7.37/35/89/21. plan: continue full vent support
"
1535,"resp: pt remains on a/c on 18/550/+5/50%. bs are coarse to clear and suctioning for moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reaction. no changes or [** **]'s this shift. rsbi=136. plan to wean to psv as tolerated.
"
1536,"resp: [**name (ni) 516**] pt on psv 5/5/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift 02 sats @ 100%. rsbi=82. plan to wean as tolerated, trach discussion?
"
1537,"resp: pt on 2 lpm nc. nebs alb/atr given with no adverse reactions. will continue to follow.
"
1538,"npn 7a-7p
events: pt was acutely agitated and combative this am. pt climbing oob and swinging fists at this rn. pt was unable to re-orient and calm down. dr. [**last name (stitle) 3215**] to bedside. pt medicated with 2.5mg iv haldol with good effect. pt nnoted to have ?able previous reaction to haldol, but family does not know what this reaction was. there was no adverse reaction today when this dose was given and it actuallly had a good effect. later this afternoon pt appeared to be more wheezy and with labored breaths. abg wnl, atrovent nebs given w/o effect. pt given 10mg iv lasix with good effect.

neuro: pt has slept in naps since this mornings events, but remains only oriented to person and his family. when told that he is the hospital he states ""i know"". no c/o pain. pt remains in bilateral soft wrist restraints for safety.

cv: dilt gtt weaned off. hr 60s-80s in afib. bp 100s-130s/60s-80s. pt has difficult to palpate pulses. pt on standing po loressor.

resp: sats> 96% on 4.0l nc. abg wnl. ls with exp wheezes in bilateral upper lobes, crackles over right base. pt on standing nebs. rr 16-20s.

gi/gu: abd is softly distended, +bs. pt is ordered heart healthy diet, but has refused all meals today. pt takes his pills well. u/o adequate, foley draining clear yellow urine.

skin: rue more swollen than left with small bruised area below armpit. dr. [**last name (stitle) 3216**] made aware and will cont to monitor. r arm elevated with pillows.

id: pt has been afebrile. pt covered on ceftaz and vacno, also tamiflu.

social: [**name (ni) 4**] wife and three daughters int to visit today and updated by dr [**last name (stitle) 3216**] and this rn.

plan: cont to monitor resp status, prn lasix/nebs.
      monitor ms, prn haldol for acute confusion and pt now on standing olanzapine at night.


"
1539,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett #7.5 retaped and secured @ 22 lip. bs are clear with diminished bases. suctioned for small amounts white thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.52/30/146/25. rsbi=75. no changes noc. will continue with present settings.
"
1540,"resp:  [**name (ni) 516**] pt on a/c 22/600/10+/60%. pt has #8 portex trach. bs are clear with diminished bases. suctioned for small amounts of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. weaned vent settings to present psv 10/5/50% (see careview for changes) rsbi=55. am abg 7.48/44/98/34 on psv. plan: continue to wean with possible t/c trials today.
"
1541,"resp: [**name (ni) 516**] pt on a/c 12/500/+5/40%. ett 7.5, 21 @ lip. bs are clear bilaterally. suctioned for no/scant clear secretions. mdi's atrovent administered with no adverse reactions. am abg 7.45/34/189/24. rsbi=34 plan: wean as tolerated.
"
1542,"resp: pt rec'd on psv 15/5/50%.  pt has #8 portex trach. bs are coarse bilaterally with decreased bs in l base. suctioned for large amounts of white frothy thick secretions. mdi's administered alb/atr with no adverse reactions. pt had large bm with immediate episodes of desaturation to low 80's and ^ wob with rr to 40's and hr >120. placed on a/c (md aware) with positive results then weaned back to psv. rn repositoned pt around 5:30 and pt once again had episodes of desats to 80's along with ^ wob to 40's and remains tachy.requiring to be placed back on a/c to rest. no rsbi due to above issues. pt is extremely sensitive to any movement/repositioning. plan is to wean back to psv when pt recovers.
"
1543,"resp: [**name (ni) 516**] pt on psv 10/5/40%/ ett #7.5, taped @ 23 lip. bs are coarse bilaterally and suctioning moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/45/80/32. rsbi=82. plan to extubate this am following cuff leak.
"
1544,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, 23 @ lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered of alb with no adverse reactions. vent changes to decrease ps to 10. vt'd 400's, ve's 10. no abg's this shift with rsbi=116. bal negative. will continue to wean as tolerated.
"
1545,"resp:  rec'dpt on a/c14/600/+5/40%. ett 8.0, rotated, retaped and secured @ 26 lip. bs are coarse bilaterally and suctioning for copious amounts of thick yellow secretions qhr. mdi's administered alb/atr as ordered with no adverse reactions.  abg's 7.48/40/104/31. rsbi=hemodynamic unstability. hr continues to be tachy with ^ bp. pt has no gag. no changes this shift. plan is to wean to psv, although questionable with 6 hr & bp.
"
1546,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett #7, rotated and retaped @ 20 lip. bs are coarse to clear and suctioning for moderate amounts of thick yellow secretions. mdi's administed as ordered alb/atr wtih no adverse reactions. pt had ^ wob with declining abgs then placed on a/c 18/400/+5/50% with immediate improvement noted. rsbi attempted for 184 although pt reacted with ^ bp to 180. am abg 7.38/48/95/29. plan: attempt to wean back to psv as tolerated.
"
1547,"resp:  pt has #8 portex trach and is on 40% t/c with humidification. bs are coarse bilaerally and pt able to expectorate secretions.  ud of tobramycin administered in line trach (door is to be closed while treatment is being administered and masks worn up to 1 hr following tx) with no adverse reactions. water bottle filled and drain placed in line. will continue to follow.
"
1548,"resp care
pt given neb tx. bs course with diffuse exp. wheezes that clear after neb tx and with producitive coughs. no adverse reactions.
"
1549,"resp: [**name (ni) 516**] pt on a/c 16/500/+5/40%. bs are clear bilaterally. suctioned for scant amounts of white secretions. mdi's administered atr as ordered with no adverse reactions. am abg 7.44/30/185/21. decreased rate to 12. rsbi=75. no further changes noted. continue on present settings.
"
1550,"resp: [**name (ni) 516**] pt [**name (ni) **] #8 ett @ 24 lip. xray confirmed placement. bs are clear with diminished bs. suctioned for small amounts of thick yellow/white secretion (large amounts of oral secretions) mdi's administered as ordered alb/atr with no adverse reactions. multiple abg's see careview. pt had vats left attempted;left open thoracotomy with decortication with a bronch. settings a/c 22/600/12/100% post op and weaned fio2 to 60%, peep to 10. no rsbi due to ^ peep.  am abg 7.50/43/105/35. plan to continue to wean.
"
1551,"resp: [**name (ni) 516**] pt on a/c 18/400/+5/50%. ett 7.0. taped @ 20 lip. bs reveal bilateral exp wheeze with improvement following mdi's. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. no changes noc. am abg 7.37/49/92/29. rsbi=177. plan: continue full vent support. trach expected next week.
"
1552,"nursing progress note 1900-0700
*full code

*access: 22g r wrist piv

*nkda

** please see admit note/fhp for admit info and hx.

neuro: pt had difficulty sleeping, given 2.5mg ambien x2 w/ little effect.  no c/o pain or discomfort overnight.  moves self in bed, turning on own.  may require assist to ambulate to commode when she eventually has to go.

cardiac:  sb w/o ectopy, hr 42-57, sbp 92-134, remains off dopamine.  cardiac consult w/ interpreter assist, stated they don't feel this is a cardiac issue.  hr of 50's is her baseline per patient.  cardiac feels she may have dropped pressure d/t vagal stimulation caused by pain from diverticulitis.  lactate last evening was 2.2 from 2.6.  awaiting am labs for hct and lytes.

resp:  o2sat 93-97 on ra, rr 12-21, ls clear, no c/o difficulty breathing or sob.

gi/gu:  tolerating reg heart healthy diet, +bs, no stool this shift, started on bowel regimen (has commode @ bedside, c.diff cx if pt stools), abd soft/non-tender.  urine out foley yellow/clear, 20-100cc/hr.

id:  afebrile. flagyl and cipro for diverticulitis w/ no signs of adverse reactions.  iv site wnl, skin intact.

psychosocial:  had friend visit in evening, received a few phone calls as well.  is looking forward to getting out of icu and getting disconnected from monitor.  request that foley be taken out, but this nurse explained that we need to closely monitor her urine output in the event that her bp drops.

dispo:  cont to monitor bp (restart dopamine gtt if required), awaiting am labs, assist pt to commode when bowel regimen begins to work, cont med regimen and abx, cont icu care @ this time.  possibly a call out to floor today.
"
1553,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 24 lip. bs are coarse bilaerally and suctioning for moderate amounts of thick yellow/greenish looking secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg 7.48/49/141/38. rsbi=46. no changes noc. plan: or/trach/peg vs cmo. family still undecisive.
"
1554,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 23 lip. bs are coarse bilaterally and suctioning for moderate amounts of thick tan/yellow and occasional plug.  mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. 02 sats @ 98%. rsbi=64. plan: family still unable to make decision on code status/or/trach/peg. family meeting again scheduled for today to discuss.
"
1555,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 19 lip. bs are coarse and suctioning thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.50/32/186/26. rsbi=75. maintain support.
"
1556,"resp: [**name (ni) 516**] pt on psv 5/5/40%.  ett 7.0 taped @ 24 lip. bs are coarse to clear and suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt has periods of anxiousness and lifting head off pillow. sedation administered. rsbi=162.  no changes noc. plan: family meeting to discuss trach/or?
"
1557,"resp: [**name (ni) 516**] pt on a/c 20/500/+5/50%. bs are coarse to clear and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.34/38/187/21. rsbi=30. weaned to psv 10/5/50% tolerating well with adequate tv's/ve's. cvvhd discontinued. plan: continue to wean as tolerated.
"
1558,"resp: [**name (ni) 516**] pt on a/c 14/400/+5/40%. pt has #7 portex trach. bs are clear bilaterally and suctioned for some bloody tinged due to new trach. scant white secretions in am. mdi's administered alb/atr with no adverse reactions. abg's (see careview) rsbi=52. weaned to psv 8/5/30% with additional abg's pending. plan: continue with wean to possbile t/c trials if tolerates
"
1559,"resp: [**name (ni) 516**] pt on a/c 22/500/10+/40%. ett 8.0 taped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for thick tan/yellow secretions. large amounts of oral secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift or vent changes. no rsbi due to ^ peep and or procedure today. pt expected to transfer to sicu following or.
"
1560,"resp: [**name (ni) 516**] pt on psv 18/5/45%. pt has #8 portext trach. bs are clear with occasional crackle and suctioned for small amounts of white thick secretions. mdi's administered alb/atr with no adverse reactions. no changes noc or abg's. rsbi=100. plan is possible d/c to rehab this am.
"
1561,"respiratory care note
pt received on psv 18/5 as noted. bs clear bilaterally and diminished in the bases. pt suctioned for small amts thick, tan secretions. ps weaned throughout the morning from 18 to 14. pt tolerated well with vt ranges 405-431 and rr 28-31. mdi's given a/o without any adverse reactions. plan to transfer pt to [**hospital **] rehab at [**hospital1 1589**] this afternoon.
"
1562,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett 7.5, taped @ 21 lip. bs are coarse bilaterally and suctioning for small amounts of white/yellow thick secretions. mdi's admimistered as ordered with no adverse reactions. no changes noc or rsbi performed due to or procedure today (trach). am abg pending, see carevue.
"
1563,"resp: pt rec'd on a/c 22/500/+5/50%. ett 7.5 taped @ 22 lip. bs are clear with diminished bases. suctioned for basically none. mdi's administered of alb/atr with no adverse reactions. pt remains on cvvhd=no rsbi. am abg 7.38/31/173/19. vent changes to decrease rr to 20. plan: wean as tolerated.
"
1564,"resp: pt rec'd on psv 11/5/50%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate to copious amounts of bloody thick secretions. mdi's administered alb/atr with no adverse reactions. pt has episodes of ^ wob with rr to 40. ps ^ to 15 and sedation administered with noted improvement. abg 7.41/35/112/23. rsbi=64. pt weaned back to psv 11. plan: continue to wean as tolerated.
"
1565,"resp: [**name (ni) 516**] pt on a/c 22/500/+5/40%.  ett 8.0 taped @ 24 lip. bs are diminished bilaerally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=51. weaned to psv 5/5/40%. vt's 400-500, rr 26, 02 sats @ 99%. plan: additional abg/sbt with extubation expected today.
"
1566,"resp: [**name (ni) 516**] pt on psv 8/5/40%. ett 8.0 taped @ 24 lip. bs are clear to diminished. suctioned for small/mod tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. weaned ps to 5/peep 5. rsbi=73. plan: wean to extubated this am. niv possible if pt begins to fail.
"
1567,"resp: [**name (ni) 516**] pt on a/c 24/400/+10/60%. ett 7.5, taped @ 20 lip. bs reveal bilateral clear apecies with diminished bases.suctioned for small amounts of yellow to tan thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes noc.  noted improvement in am abg's 7.45/66/73/47. no rsbi due to ^ peep/^fio2. plan: maintain present support.
"
1568,"resp: [**name (ni) 516**] pt on psv 5/10+/40%.  ett 7.0 taped @ 24 lip. bs are diminished bilaterally and suctioned for small to moderate [**name (ni) 1444**] tinged/plugs/secretions. mdi's administered alb/atr as orderd with no adverse reactions. no abg's this shift 02 sats @ 98%. no rsbu due to ^ peep. plan: family meeting to discuss cmo/trach/peg/or?
"
1569,"resp:  [**name (ni) 516**] pt on a/c 14/550/+5/40%. pt has #8 portex trach. suctioned for small to moderate amounts of tan to white thick secretions. mdi's administered as ordered of atr with no adverse reactions. no abg's or changes this shift. rsbi=no resps but will attempt again in am. plan to wean as tolerated.
"
1570,"resp: pt rec'd on a/c 10/550/+5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioned for small amounts of thick bloody secretions. mdi's administered as ordered atrovent with no adverse reactions. multiple vent changes (see careview) am abg 7.42/33/181/22. rr decreased to 14. no rsbi due to or procedure today. pt to be peg.
"
1571,"resp: pt rec'd on a/c 14/550/+5/40%. pt has #8 portex trach. inner cannula changed.  bs are coarse to clear. suctioned for scant to small amounts of thick tan secretions. mdi's administered as ordered of atrovent with no adverse reactions. no vent changes noc or abg's. rsbi=121. continue plans for placement in rehab. plan to wean to psv as tolerated.
"
1572,"resp: [**name (ni) 516**] pt on psv 12/10/60%. pt has #8 portex trach. bs are coarse to clear. suctioning for copious bloody secretions, pt developed epitaxis noc and subsided this am. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.46/35/112/26. vent changes to decrease ps to 10/peep to 8/fio2 to 50%. rsbi=61. plan to continue to wean as tolerated.
"
1573,"resp: [**name (ni) 516**] pt on 50% t/c. pt has #8 portex trach. pt began to desat then ambu/suctioned [**name (ni) 2160**] amounts of thick brown plugs. 02 sats 90-91%. nebs of albuterol administered x1, then mdi's combivent with no adverse reactions. pt is begin d/c to rehab this am.
"
1574,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has # 8 portex trach. bs are coarse and suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. pt placed on t/c trial around 3:00 @ 50% with humidification. cuff inflated. 02 sats @ 96%, rr 28 and tolerating well. will continue to monitor/assess.
"
1575,"resp: [**name (ni) 516**] pt on a/c 22/500/+14/40%.  ett #8, taped a@ 25 lip. bs are coarese bilaerally and suctioned moderate amounts of thick yellow/tan secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg pending. plan: pt scheduled for or for trach/peg this am. no rsbi=^peep.
"
1576,"resp: [**name (ni) 516**] pt on psv 12/10/50%. bs are basically clear with some scattered crackles with diminished bases. suctioned for scant amount of clear secretions. mdi's administered alb as ordered with no adverse reactions. am abg 7.41/42/102/28. no rsbi due to amount of peep. check leak is noted today. pt remains positive,and may continue with lasix today. no further changes noted. maintain present settings.
"
1577,"cvs;hr 80-100 a-fib no ectopy abp 100-120/40-70 on vasopressin 1.2 u/hr anasarca pedal pulses are doppled,extrimities are warm,left toes are dusky.hct 27.5 @ 2100 one unit prbc transfused without any any adverse reactions.for access a-line and pa line remains intact.recieving regular dose of albumin q6h.

neuro;sedated with fentanyl 50 mcg/hr,pt is comfortable,nodding head and appropriate with answering.not moving extrimities.

resp;recieved on cmv 40/400/20/5 no vent changes over night,saturation probe is not sensing well frequent abg was done to confirm o2 sats,po2 >130.ls are coarse throughout,required occasional suction for thin whitish secretions.

gi;abdominal dressing was done by surgen yesterday with jp in place,connected to wall suction draining serous drain please carevue for details,getting tpn for nutrition.no bowel movement at this shift.

gu;draining adequate amounts of amber color urine via foley catheter.

skin;anasarca,multiple skin breakdown and oozing from extrimities.sacral dressing intact,positioned and back care given as needed.lower extrimities are warm positive pedal pulses.

id;core temperature 38.2,on antibiotics vanco/flagyl/levaquin

social;no contact from family at this shift.

plan;abdominal wound closure--add on, consent taken over phone by surgen and filed.
type and screen send yesterday
pain management,monitor lytes,replete lytes as needed
continue albumin
update with pt and family.
"
1578,"resp: pt rec'd on 40% cam. nebs administered of mucomyst 3 cc's and albuterol with no adverse reactions. also ns nebulizer x1. bs are coarse bilaterally. will continue to follow.
"
1579,"resp: [**name (ni) 516**] pt on psv 10/5/40% @ start of shift then pt ^ wob and ^ rr and bp. increased ps back to 15 and pt tolerated well. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow secretions. mdi's administered alb with no adverse reactions. am abg 7.50/37/124/30. rsbi=87. plan: wean ps as tolerated.
"
1580,"resp: [**name (ni) 516**] pt on a/c 24/450/5+/50%. bs are basically clear with some occasional coarseness. suctioned for small amounts of thick yellow/tan secretions. mdi's administered as ordered alb/[**name (ni) **] with no adverse reactions. no changes noc or abg's. pt had some episodes of ^ wob when [**name (ni) **] light. rsbi=173. plan: continue present mode of support.

"
1581,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett 8.0 retaped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. rsbi=62. no abg's this shift. plan: pt scheduled for trach today.
"
1582,"resp: [**name (ni) 516**] pt on a/c 24/450/+8/50%. ett #7.5, rotated, retaped and secured @ 23 lip. bs are coarse to clear with exp wheeze noted at start of shift and suctioning for moderate to copious amounts of thick yellow secretions. mdi's administered as ordered alb/[**name (ni) **] with no adverse reactions. no abg's this shift/no a-line. 02 sats @ 99%. rsbi=134. plan: wean as tolerated.
"
1583,"resp: [**name (ni) 516**] pt on 24/450/+8/50%. ett 7.5 taped @ 23 lip. bs are coarse to clear bilaterally. suctioned for moderate amounts of thick yellow secretions which seems to be an improvement over yesterday, although continues to have fever.mdi's administered alb/[**name (ni) **] with no adverse reactions. no changes noc. am abg 7.44/40/97/28. rsbi=152. plan;wean as tolerated.
"
1584,"pt came to micu from [**wardname 665**] for merepenem desensitization  because of multiple allergy around [**2090**].completed desensitization without any complication. c/o ?

neuro:ox3. calm &cooperative

id: frequent uti now with e-coli. no signs of adverse reactions to merepenem.

cardio: nsr,vss.am lab pending. heparin drip per protocol. ptt qd.

resp: ls cta.

gi: abd soft. bowel sounds present. fsbs as noted.

gu:voids,minimal pain upon urination.clear yellow urine.

pain: severe left flank pain. pain mgt improved after multiple pain med adustments as noted.

plan ? c/o to floor today.
"
1585,"nursing progress note.
pls see carevue for specifics.
care of pt 1500-1900hrs.

resp:
trache 8.0 patent.  vent settings pressure support 18/10 50%.  tolerating well.  chest occasionally coarse.  few secretions.  trache care attended.

neuro:
awake and alert.  sat up in chair.  interactive with family.  denying pain.  answering questions by nodding.  in good spirits.  minimal movement left hand persists.  purposful with right hand.

cv:
afib continues.  pt pink, warm.  gross edema to legs.  diuresing well with lasix administered on prior shift.  weaning phenylephrine.  goal map >65mmhg sbp 100mmhg per csru pa.  1 unit prbc complete without adverse reaction.  repeat hct sent.

gigu:
abdomen large, soft.  minimal stool.  foley patent.

id:
antibiotics commenced.  tmax 100.1f this afternoon.

psychsoc:
multiple visitors.  questions addressed.

plan:
continue to monitor.  wean phenylephrine as able within given parameters.
follow hct.
continue discharge planning.


"
1586,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has #7 portex trach. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats maintained @ 98% with adequate tv's. rsbi=20. plan: continue wean/sbt with possible t/c trials.
"
1587,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #8 portex trach. bs are slightly coarse/diminished ls. suctioned for small/moderate amounts of white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's noc. rsbi=68. plan: wean as tolerated with possible t/c trials.
"
1588,"resp: pt rec'd on psv 15/5/40%. ett 7.5 taped @ 21 lip. bs are clear in apecies with diminished bases. suctioned for small amounts of white/pale yellow secretions. mdi's administered of alb with no adverse reactions no changes noc. am abg 7.48/35/104/27. rsbi=102. plan: wean as tolerated.
"
1589,"resp: [**name (ni) 516**] pt on psv 15/10+/60%. pt has #8 portex trach. bs are coarse to clear and suctioning small to moderate amounts of thick brown/plugs secretions.mdi's administered as ordered combivent/alb prn with no adverse reactions. no rsbi due to ^ peep. am abg 7.50/37/182/30. vent changes to decrease ps to 10, fio2 to 50%. plan to continue to wean as tolerated.
"
1590,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are clear to coarse bilaterally. suctioned for small amount of tan thick secretions. mdi's administered combivent q4 hrs with no adverse reactions. rr ^ to 30's then ^ psv to 10. tv's 500-600. no abg's this shift. rsbi=44. plan to wean as tolerated.
"
1591,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear. suctioned small amounts of thick yellow secretions. mdi's administered q4 hrs combiven with no adverse reactions. pt became ^ wob with rr to 30's then increased psv to 10. am abg 7.46/41/153/30
rsbi=49. plan to wean ps as tolerated.
"
1592,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, taped @ 20 lip. bs are clear with diminished bases. suctioned for small amount of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. rsbi=51. am abg pending. plan: continue to wean ps as tolerated.
"
1593,"resp: pt rec'd on psv 5/5/70%. pt has #8 portex trach. bs are clear with slight coarse bases which clear with suctioning. suctioned for small amounts of thick bloody tinged, then tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt fio2 wean to 50%. am abg 7.48/29/78 with 02 sats of 99%. rsbi=38. continue to wean as tolerated/possible t/c trials?
"
1594,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear and suctioned for clear to yellow thick secretions. mdi's administered as order alb/atr with tobramycin nebs. no adverse reactions noted. pt has episodes of desaturations to 80's then increased fio2 back to 50% resulting in saturations >94%.  am abt 7.44/31/83/22. rsbi=19. plan to continue to wean as tolerated and attempt t/c trials again today.
"
1595,"resp: [**name (ni) 516**] pt on psv 8/10+/60%.  ett 8.0 retaped @ 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions as well as large amounts of oral secretions. mdi's administered alb/atr as ordered with no adverse reactions. trip to ct scheduled for this am. no rsbi due to ^ peep. 02 sats @ 97%. plan to trach/peg this tuesday. plan: maintain present settings.
"
1596,"resp: pt rec'd on simv 14/500/14/+5/40%.  pt has #8 [**last name (un) **] air filled cuff trach, secured @ 14cm flange. bs are coarse bilaterally and [**last name (un) 7273**] thick white to yellow secretions. some improvement following suctioning. mdi's of combivent administered as ordered with no adverse reactions. no changes noc. rsbi=86. plan to continue with t/c trials as tolerated.
"
1597,"resp: pt rec'd on a/c 16/500/+5/40%. bs are coarse bilaterally and suctioned for small amount of tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's or aline. 02 sats @ 100%. rsbi=no resps. plan to continue to wean to psv as tolerated.
"
1598,"resp: [**name (ni) 516**] pt on a/c 24/300/10+/40%. bs are coarse and suctioned for small to moderate amounts of bloody tinged thick secretions to tan. no changes noc. mdi's administered alb with no adverse reactions. 02 sats @ 98% tonight. am abg 7.45/43/83/31. no rsbi due to ^ peep. will continue full vent support.
"
1599,"resp: [**name (ni) 516**] pt on a/c 16/500/10+/60%. bs are coarse to clear. suctioned for moderate amounts of thick bloody to tannish secretions. mdi's administered of alb with no adverse reactions. 02 sats continue to fluctuate with turning and light sedation. weaned to psv 16/10/60%. placed on 100% temporarily when pt turned. am abg 7.45/42/84/30. plan to wean as tolerated. discussion of trach?
"
1600,"resp: [**name (ni) 516**] pt on a/c 24/650/+14/60%. ett 7.5 taped @ 22 lip. bs are diminished bilaterally with minimal suctioning. mdi's administered as ordered comb/[**last name (un) **] with no adverse reactions. abg 7.36/42/80/25. no rsbi due to ^ peep. plan to wean as tolerates.
"
1601,"npn 7a-7p


#2 remains on nasal prongs cpap 5, 28-32%. rr 60-80's. ls =
and clear, sx'd x 1 for small yellow from nares. receiving
28cc prbc's in 2 aliquots today for fio2 requirement, sao2
drifting, paleness, and hct 27 (retic 1.9). is infusing w/o
adverse reaction. to receive lasix between infusions.
monitor.

#3 tf at 150cc/k/d, tolerating gavage feeds w/o spits, girth
steady, + bowel sounds, is voiding. gaining wt on 30cal pe.
monitor.

#5 maintaining temp in air isolette while swaddled. is very
alert with cares, settling well. skin intact. is pale-pink.
likes to suck on pacifier. con't present interventions.

#8 mom called and was updated on infat's status as well as
plans to transfuse. mom will call again for update later on.
visits every other day and held for 1hr yesterday. con't to
teach/support.


"
1602,"resp: [**name (ni) 516**] pt on psv 8/12/60%. pt has #8 portex trach. bs are coarse to clear and suctioning moderate amounts of thick bloody tinged to tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. cuff pressures @ 22 cmh20. vent changes to decrease ps to 10, then 8, fio2 to 50%, then 40%. rsbi=38. am abg 7.39/43/169/27. icp's continue to fluctuate noc. no further changes noted. plan:continue to wean as tolerates.
"
1603,"resp: pt rec'd on a/c 16/500/40%/5+. bs are coarse bilaterally.suctioned for small to moderate amounts of thick tan secreitons, sample sent.  mdi's administered alb/atr with no adverse reactions. no abg's 02 sats remain at 100%. vent circut changed to heated. rsbi=150. plan to wean to psv as tolerated.
"
1604,"resp: [**name (ni) 516**] pt on a/c 20/600/+15/70%. ett 7.0, taped @ 23 lip. bs reveal bilateral clear apecies with diminished ls base. suctioned moderate amounts of thick bloody tinged secretions. mdi's administered as ordered alb/ovar with no adverse reactions. pt continues to demonstrate abdominal desynchronous breathing. improved abg's oxygenation then weaned fio2 to 50%. am abg 7.34/35/91/20. no rsbi due to ^ peep. plan: continue wean as tolerated.
"
1605,"resp: [**name (ni) 516**] pt on psv 10/10/60%. ett 7.5 rotated, retaped and secured @ 22 lip. **note** ett was cut back.  bs are coarse bilaterally and suctioned for moderate-copious amounts of thick yellow/white secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. no changes noc. am abg 7.24/47/76/26. no rsbi due to ^ peep. plan: continue to wean as tolerated
"
1606,"resp: [**name (ni) 516**] pt on simv 18/550/5/+5/40%. ett # 7.5 taped @ 21 lip. bs are clear with diminished bases. suctioned for scant amount of clear thin secretions. mdi's administered combivent/alb with no adverse reactions. abg 7.42/37/97/25. no changes noc. rsbi=no resps. plan: wean as tolerated.
"
1607,"resp: [**name (ni) 516**] pt on simv 14/550/5/5/50%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are clear with diminished bases. suctioned minimal to no secretions. mdi's administered combivent/alb as ordered with no adverse reactions. am abg 7.30/50/137/26. vent changes to ^ r to 18, decrease fio2 to 40%. no rsbi due to hemndynamic instability. plan is to wean as tolerated.
"
1608,"7a-7p
neuro: pt sedated and paralyzed on fentanyl,midaz,and fentanyl gtts. pupils 3mm sluggish, equal.

cv: hr 60s sr w/ rare pvcs. as day progressed, hr 56-58 junctional pa [**doctor last name 87**] aware, no new orders. pt has epicardial wires v wires only, pacer not checked d/t ventricular ectopy. 1 episode of 25 beat run of vt self limiting, mg 2gm given. sbp 90s-100s. levophed gtt weaned to off. epi gtt continues at 0.02mcg/kg/min. vasopressin continues at 2.4units/hr. [**md number(3) 7566**]/30s. cvp 15-20. ci>2 by fick, team aware. at beginning of shift svo2 58-59, md [**doctor last name 859**] aware, 1 unit of prbcs infused as ordered, no adverse reactions. svo2 >60 after 1 unit of prbc. chest remains open w/ wound vac in place, draining serosang small amts. 4+ pitting edema. +dopplerable pedal pulses.

resp: ls clear diminished. sats 100%. continues on cmv mode rate 16, not breathing over vent, fio2 40% peep5. see carevue for abgs and vent settings. pa [**doctor last name 87**] aware of abg at~ 1700, no new orders.

gi/gu: abd softly distended. tf on hold at present time d/t high residuals, [**name8 (md) **] md [**last name (titles) 859**]. hypoactive faint bs. ogt to lcs/g tube to gravity draining bilious drainage, pa [**doctor last name 87**] aware. foley draining 5-10cc/hr of clear yellow urine. cvvhdf clotted x1, renal fellow aware and increased replacement fluid to 2000cc/hr. pt negative 1100cc since midnoc thus far. goal -100cc/hr as pt tolerates.see flowsheet for details.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. cvvhdf goal -100cc/hr as pt tolerates. monitor hr.


"
1609,"7a-7p
neuro: pt able to respond to stimuli throughout shift with responses to voice at times. goal to keep pt sedated.  pt thrashing arms and legs at times. pt currently on midaz and fentanyl with periods of midaz boluses in between [**name8 (md) **] np [**doctor last name 307**].  perrla sluggish in am and more brisk in afternoon.  pt able to mae's when more awake. no temp at this time and pt continuing on iv vanco.

cv: hr- sr/st with frequent pac's/pvc's 90's-120's at beginning of shift. at 1200, hr 80's with pac's. amiodarone drip contiuing at 1mg/min as ordered. placed on asynch 96 via epicardial wires in order keep pt out of a-fib [**name8 (md) **] np [**doctor last name 307**]. right radial a-line dampened and bleeding at site at 0900. np at bedside with several attempts to place a-line at another site. at 1030, left fem placed with positive fling. weaning drips (neo, levophed, vasopressin) according to fem map >60 [**name8 (md) **] np. electrolytes monitored and wnl throughout shift. see flow sheet for pulses. svo2 50's-60's with co [**4-8**]. ci above 2 per thermodilution. see flow sheet. np [**doctor last name 307**] aware. pt given multi-fluid boluses and hespan given as ordered. pa's 30's/20's and cvp 16-20. pt with hct of 21 at 1400. np [**doctor last name 307**] aware and pt transfused 2 units of prbc's with no adverse reactions. repeat hct pending.

resp: ls-coarse in am. cta/dim at bases in afternoon. pt given mdi's per respiratory. pt suctioned as needed with small amounts of thick white sputum. pt on cmv mode, rate 16, 5 peep, 650 tidal volume, and 60 fio2. abg's drawn in am with respiratory acidosis. resolved with settings on vent increased to 20 and peep increased to 8. abg rechecked and vent rate increased to rate of 24. resolving respiratoy acidosis. lactic acid 2.4 but resolving and 1.6 when rechecked after fluid given.  see flow sheet for abg's and flow sheet changes. np[**md number(3) 94**] throughout the shift. sats 93-96%. chest tube draining minimal amounts of serosang with no air leak.

gi/gu: abd soft with absent/hypoactive bs. pt with ng tube draining bilious/clear.  foley intact draining minimal amounts of urine 10-40cc/hr. np [**doctor last name **] aware. after fluid and blood given, pt given 20mg iv lasix with still minimal amount of urine output.

endo: pt continuing on insulin drip per protocol.

skin: see flow sheet. skin intact.

plan: keep pt hemodynamically stable with goal bp map >60 and titrate drips. pain control. monitor blood sugars and insulin protocol. monitor abg's. monitor urine output.
"
1610,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett 38.0 retaped, rotated and secured @ 24 lip. bs are diminished in bases with noted aeration in apecies. suctioned for small amount of white/tannish secretions.circuit changed to heated wire circuit. mdi's administered alb/atr with no adverse reactions. noted ^ in wob, then placed back on a/c 18/550/5+/40%. am abg 7.41/41/145/27. plan to continue to wean to psv as tolerated.
"
1611,"resp: [**name (ni) 516**] pt on psv 15/5/35%. ett #8, retaped, rotated and secured @ 24 lip.  bs are coarse bilaterally and suctioned for moderate amounts of thick yellow to tannish secretions. pt placed on a/c 12/400/5+/35% to rest noc. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=116. plan to continue to wean to psv.  no plans for pt to have trach, although may consider?
"
1612,"resp: [**name (ni) 516**] pt on psv 8/15+/50%. bs are diminished and suctioning for small to moderate amounts of thick bloody tinged to yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt continues to be desychronous with vent and had ^ wob episode then placed on a/c to rest noc. noticeable improvement noted and weand back to psv this am. pending abg to follow. plan: continue to wean as tolerated, possible dialysis? following renal consult.
"
1613,"resp: [**name (ni) 516**] pt on psv 12/8/50%. ett 7.4 taped @ 24 lip. bs are coarse to clear bilaerally and suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered comb/alb with no adverse reactions. abg 7.45/47/86/34. rsbi=62. weaned psv to [**11-11**]+ plan to continue wean as tolerated, extubate?
"
1614,"resp: [**name (ni) 516**] pt on psv 5/5/40%. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow/greenish secretions. changed to heated wire circuit. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. rsbi=53. am abg 7.45/42/85/30. family meeting today to cmo?
"
1615,"npn 7p-7a (please also see carevue flownotes for objective data)

dx: neutropenia; fuo

49f admitted for neutropenia, fevers; pt went to clinic, received injection, initally felt her s/s were adverse reaction (per family...);
pt became hypotensive, started on levophed; started on several iv abx, required several electrolyte iv replacements; also received 1 unit prbc's;

at approx 12a, went to ct for abd/chest, drank bari-cat w/out difficulty; at end of ct pt c/o not being able to breath; icu resident paged to come down, also to bring lasix; pt returned to [**wardname **]4 w/out event; continued develop resp distress w/ audible rales, lasix/morphine/ativan received, pt finally became more comfortable w/ respirations, especially after mask ventilation applied;

pt received bedside u/s at approx 04:00, team looking to see if pt had perf'd gallbladder, found to be intact; (at approx. c/w md stated pt had pna and untreated strip recently; [**8-4**] bld cx's grew [**4-19**] bacteria in chains:)

team/ w. c/s input decided since pt's lactate now 3+, up from 1+ in er, that pt needed vigorous fluid resucuitation, and that pt would need to be intubated to prevent pulm edema/resp distress;

pt intubated at approx 05:00, started on versed/fent gtt for sedation, started on [**2-/2095**], not adequate, as of 07:00, on [**3-/2110**];
iv hydration restarted; a-line attemped left wrist, not accessed;

plan:
1) iv abx as ordered (likely to be consolidated at rounds)
2) iv hydration
3) update family prn
4) levophed to maintain b/p
5) pt states we can give information to her mother, as well as husband
"
1616,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5 found @ 27 then retaped and pulled back to 24 as per xray. bs are coarse to clear and suctioning moderate amounts to small thick yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.45/40/144/29. rsbi=82. family mmeeting today for cmo status.
"
1617,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5, rotated, retaped and secured @ 24 lip. bs reveal ls clear with rs noted exp wheezes. suctioned for moderate amounts of thick greenish secretions. mdi's initiated and administered alb/atr as ordered with no adverse reactions.  bs in am noted exp wheezes on rs and diminished ls. am abg 7.45/40/104/29. rsbi 50. no changes noc. pt has cooling blanket/temp 101. plan: continue wean as tolerates
"
1618,"resp: [**name (ni) 516**] pt on psv 10/5/50%.  ett 6.5, taped @ 20 lip. bs are coarse bilaterally. suctioned for moderate to copious yellow to green plugs this am. mdi's administered alb/atr with no adverse reactions. 02 sats @ 98%. vt's 400. rsbi=70. pt spiking temp of 102. sbt scheduled for this am, question extubation with onset of temp and ^ hr to 120's. am abg pending.
"
1619,"resp: [**name (ni) 516**] pt on a/c 20/450/+8/40%. ett 7.5 taped @ 24 lip. bs are diminished bilaterally and suctioned for small amount of white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. plan: pt is to be trach/peg today.
"
1620,"7p-7a
neuro: pt attempts to open eyes w/ stimuli, perrla, random movements of hands and toes, not to command. medicated prn w/ morphine for pain noted by pt's grimacing.

cv: hr 100-110s. st. sbp >90 while on levo gtt. weaning levo gtt as pt tolerates, goal map>65 per vascular team, see carevue. cvp 12-14. lopressor held d/t levophed and hypotension, md bridges aware. k 5.4-5.3, md bridges aware, k gtt stopped from cvvhd.  received 2 units of prbcs, no adverse reactions. fingers and toes dusky. + palpable pulses.

resp: ls coarse. orally intubated, ps decreased to 18, w/ acceptable abgs, see carevue. rr 20s. tv 500-600 on cpap [**6-22**], fio2 50%. see carevue for further details. sats 94-100%, poor waveform at times. ct w/ no-> scant serosang drainage, flushed as ordered.

gi/gu: abd firmly distended, hypoactive bs. tf nutren renal at goal of 10cc/hr, w/ minimal residuals. flexiseal intact, draining loose brown stool. foley draining 8-15cc/hr of clear yellow urine. cvvhdf running pt even as pt's bp tolerates. see carevue for details.

endo: per pt's scale.

social: wife and son into visit at beginning of shift. vascular md [**doctor last name 2261**] spoke to son [**name (ni) 351**] re: pt and ct results.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean levophed to off, then start to remove fluid via cvvhdf slowly. skin care. keep pt comfortable.
"
1621,"resp: [**name (ni) 516**] pt on psv 10/5/40%. bs are coarse to clear. suctioned for moderate amount of thick yellow/tan secretions in am. pt is nasally intubated in r nare. noted audible cuff leak. pt has episodes of decreased ve and placed on mmv then returned to psv in am. mdi's administered alb with no adverse reactions. no further changes noted. rsbi=48. plan to monitor and extubate when appropriate.
"
1622,"resp:  [**name (ni) 516**] pt on psv 10/5/40%. ett 7.5, rotated, retaped and secured @ 23 lip. bs are coarse bilaterally. changed circuit out to heated wire which improved secretions, although still suctioning a moderate amount of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.46/39/115/29.  rsbi=99. plan to continue on present settings.
"
1623,"resp> pt rec'd on psv 10/5/40%. pt has #8 portex trach. bs are coarse and suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes or abg's this shift. 02 [** **] @ 100%. rsbi=43. plan to continue to wean as tolerated.
"
1624,"7a-7p
neuro: received pt on nimbex/fentanyl/midaz gtts. nimbex gtt dc'd as per csurg team this am. continuing fentanyl/midaz gtts for sedation while intubated. pt opens eyes to name, perrla, mae, follows commands.

cv: hr 70-90s sr no ectopy. sbp labile. weaned levo gtt to off, see flowsheet. received 1 unit of prbcs as ordered, no adverse reactions. repeat hct 29.9. cvp 9-12. new tlc placed to left subclavian. old right subclavian tip sent for culture. +[** **] left pt/ absent left dp, md [**doctor last name 420**] aware, not new. +[**doctor last name **] right pedal pulses.

resp: ls clear / coarse at bases. sats 94-98%. pt orally intubated on cmv rate 27, breathing 0-5 over set rate, peep weaned from 12 to 10. fio2 increased to 50% w/ pao2 70s, after right ct placement, repeat abgs showing pao2 120s, fio2 weaned back to 40%, md [**doctor last name **] aware. see flowsheet for abgs/vent changes. nasal tampon to right nare intact. suctioning small amts of blood tinged secretions from back of throat. new right pneumo, ct placed by md [**doctor last name **], scant amt of serosang drainage, no air leak, no crepitus. bronch done this am, large mucus plugs seen to left bronchus, suctioned and specimens sent [**name8 (md) **] md [**last name (titles) **].

gi/gu: abd soft, hypoactive bs. no bm. +placement of ogt, draining brownish/bilious. tpn as ordered. foley draining 30-100cc/hr of clear yellow.

endo: no gtt started d/t bs 90s-120s.

skin: see flowsheet.

id: fungal cultures sent. tmax 99.3 po. antibiotics as ordered.

plan: monitor hemodynamics. monitor resp. status. wean vent as pt tolerates. comfort/pain control.
"
1625,"nicu npn addendum:
prbc transfusion started but after 15 min site leaking, enough to redden band-aid. was removed and iv restarted in left foot. is infusing well, no complications at site or adverse reactions observed during transfusion so far.
"
1626,"npn


34 [**4-24**] week infant admitted to nicu warmer. infant pale but
active and responsive. vs stable. bp mean 40; sat 97%
d-stick 73. cbc and bx sent. crit 17.5->received 15cc's/kg
of prbc's over 4 hours without adverse reactions. will
recheck crit in 6 hours. infant very active, resting
comfortably between cares, sucks well on binki, vital signs
unchanged. blood culture pending. no antibiotics given.
erythromicin and vitamin k given as ordered. parents in and
spoke with nnp at bedside. infant currently resting
comfortably in room air with sat of 100%. nnp placed dluvc
infusing d10w at 60cc's/kg. piv heplocked.

see flowseet for further details.


"
1627,"npn:


2. infant remains on nco2 200cc flow, 30% fio2. rrs-40s-60s.
ls clear and equal, ic/sc rtxns noted upon exam. infant
remains on [** **] as ordered, no spells thus far. cont
towean fio2 as tolerated.

3. wgt-2070g, up 20g. tf remain @ 150cc/kg/d of bm30 with
promod. infant tolerating ng feeds well over 1hr. no attempt
to po feed made. abd benign, no spits, min aspirates. vdg
and stooling adaquate amts, stool heme neg. cont to monitor
wgt gain and feeding tolerance.

4. [**known lastname **] remains swaddled in an oac, temps remain stable.
alert and active with cares. bringing hands to face,
fontanels remain soft and flat. hep b vaccine administered
to infant this pm, no adverse reactions noted. consent
prsent in chart. cont to [**doctor last name 730**] dev needs.

5. mom and [**name (ni) 3809**] in tonight, updated @ bedside on infants
condition. mom independently participating in cares, held
infant x 1hr. asking appropriate questions. cont to update
and educate as needed.


"
1628,"nursing note days

7 hyperbilirubinemia
11 infant with potential sepsis

#1 resp: hfov, map 14, dp 19. no vent changes today, 2 abgs
done, see flowsheet. fio2 60-75%. baby gram done at 1530,
see [** 96**] note, keeping baby positioned w/ right side up. ls
course, large airleak. suctioned for mod cloudy secretions
in ett, and large tan and blood tinged from mouth and nose.
con't to monitor, check next abg at 2100.

#2 fen: tf 100cc/k/d, no basing fluids on current weight of
812g. recieving tpn d30, il, and dopamine in d12.5 by picc.
1/2 ns w/ hep running in radial art line. piv in right arm
hep locked. ds 60&56. uo: 1.7cc/k/hr for 12hrs. no stool.
abd full, soft, no bs (?hypoactive). ng repogle to low
intermittent suction, draining ~2cc of dark green bilious
aspirate per 12hrs. con't to monitor closely.

#4 g&d/pain&stress: alert and active, agitated easily w/
noise and bright lights. recieved fentanyl ~q3hrs, responded
well. maintaining stable temps nested in sheepsking w/ tight
boundries on servo controlled warmer. under tent for noise
controll. con't to support dev needs. due for 30day hus
thurs.

#5 family: mom in to visit today for ~1hr. asking
appropriate questions, talked to and touched baby. very
[**name2 (ni) **]. con't to support and update as needed. planning to
come in for family meeting at 3pm tomorrow and to kangaroo
sibling.

#8 cv: no murmor heard this shift. infant pale, pink, hr
140-190s. cbc checked at 0900. plt count 98, hct 33.6.
transfused 1st alequot of 20cc/k [**name2 (ni) 4103**]; 8cc over 4hrs,
completed at 1900. no adverse reactions, vitals checked per
protocol. due for next 8cc tonight. infant on dopamine drip
(60mg/50cc d12.5); required 6-7mcg/k/m this shift to keep
maps 32-36. con't to monitor and support.

#11 sepsis: cbc and cx sent at 0900. culture pending. see
flowsheet for cbc results. infant started on vanco and gent
iv, first doses given this am. con't to monitor for signs of
infection and administer meds per orders, check levels w/
3rd doses.

revisions to pathway:

  7 hyperbilirubinemia; d/c'd
  11 infant with potential sepsis; added
    start date: [**2149-3-4**]

"
1629,"7am-7pm


2. received infant in nasal cannula 200cc flow in room air.
resp rate stable as per flow sheet. breath sounds clear and
equal. o2 sats 92-100%. infant currently receiving
transfusion of prbc's for symptomatic anemia. tol procedure
well. no adverse reactions noted at this time.
14.intermittent murmur audible. color pale, mottled at
times. mild to mod intercostal/subcostal retractions noted.
stable at this time receiving prbc's.
cont to monitor per protocol.
3. no contact with [**name2 (ni) 26**] this shift. md spoke with [**name2 (ni) 26**]
re: transfusion procedure.
4. tf 140cc/kg/day. pe26 with promod. tol well. small spits,
min aspirates. abd full, active bowel sounds. voiding qs see
flow sheet. no stool x2 days. abd girth stable.
tol full feeds.
cont per plan.
6. in open crib cobedding with sibling. maintaining temp.
swaddled with boundries. sucks on pacifier
intermittently.wakes for feeds.
tol handling and minor stress with current stress
precautions.
cont plan.




"
1630,"respiratory care note
pt remains on imv 22/5 x 20 .21-.35fio2.  bbs ess clear with audible leak.  sx'd for scant pale yellow secretions.  2nd dose of 4.4cc survanta administered per protocol with subsequent wean of fio2 from .35 to .24fio2.  well tolerated with no adverse reaction.  comfortable rr 40-60s.  post intubation cxr this morning c/w rds and slightly high tube.  will continue to follow and wean as tolerated.
"
1631,"respiratory care note
pt remains on simv 27/7 x 28 .57-.70 fio2.  bbs coarse and diminished throughout.  sx'g for mod amts of cloudy secretions.  2puffs combivent given via mdi at 8a and 4p  - no adverse reaction.  rr 28-40s.  vts around [**9-20**] (spont [**1-10**]).  occ [**month/day (3) 182**] req increased fio2.  will cont to follow.
"
1632,"respiratory care note
pt remains on imv 23/6 x 18 .40-.55.  bbs coarse w/crackles and positional leak around the tube.  sx'd for mod amt of cloudy thick white secretions.  1pm [** **] held due to tachycardia, given at 5pm.  pt started on dornase alpha (pulmozyme via minineb) 1.25mg [**hospital1 **], given at 5pm, well tolerated w/no adverse reaction.  oral ett resecured ~8.5 @ lip. 5pm cbg (drawn prior to [**hospital1 **]/neb):  7.38/62/25/38/+7, no [**hospital1 **] changes made.  continues on caffeine.  occ [**hospital1 182**], usually self resolved.  comfortable rr 35-50s.  nard.  will continue to follow and wean as tolerated.
                                  [**first name4 (namepattern1) 2693**] [**last name (namepattern1) 2694**], rrt
"
1633,"pca progress note 3-11p


fen: feeding plan changed by order of feeding team consult.
tf: min 80cc/kg/d of neosure22 q3 hours. pt [**name (ni) 2563**] full
bottles+ at both feeds this shift. pt remains on reflux
percautions. pt mottles throughout with cares. abd is
benign; soft w/ +bs. v/s qs. infant is active to eat feeding
time, appears to stress and tire toward end of feeds,
becoming tachypnic and arching frequently, often until
bottle is removed. please refer to pt's chart for additional
fen data. continue to monitor and support feeding plan,
while encouraging all po feeds as tolerated.

dev:
  pt's temp remains stable while swaddled in [**name (ni) 133**]. axillary
temps have been inacurate due to pt sitting in swing with
arms uncovered. rectal temps are stable. pt woke for 1st
feed, and needed to be woken for 2nd. she is [**name (ni) **] and very
active with cares. activly sucks on pacifier for comfort
when waking. loves to be cuddled and held. continue to
encourage and support developmental milestones.

par: no  contact with [**name2 (ni) **] by this pca so far this shift.

sepsis:
  day 30 of 42 of oxicillin. no temp noted.  broviac line is
patent. no issues. plan to continue meds as ordered and
monitor for s&sx of toxicity or adverse reactions.


"
1634,"nursing status/progress note 7a-7p


#2 infant now under double photo tx w/yeye and genital
protection in place. to check a bili later this afternoon
along with cbc and lytes (last k 3.1). rec'd 2nd of 3 doses
immunoglobulin this am w/o adverse reactions, 3rd dose to be
given again in am. infant is jaundiced with pink mucosa.
further plan as per bili/lab results this afternoon. con't
to monitor.

#3 piv hl'd this am, and is bottling enf 20 well on a
""demand"" schedule. is voiding, and has been stooling
frequently. monitor intake on oral feeds.

#4 no parental contact so far this shift, but reportedly
parents are very involved. family meeting planned for 4pm
this afternoon. will con't to update and support.

#5 infant remains under photo tx on ""off"" warmer and is
maintaining temp well. is on all enteral feeds, bili level
has been decreasing and are con't to monitor. is very active
and alert with cares, is waking for feeds and settling well
afterward. will con't present interventions at this time.




"
1635,"npn 7a-7p


#1 tf at 140cc/k/d, bottling ~[**1-30**] volume but sometimes takes
all. has some head-bobbing and retractions when bottling and
when getting tired during feed. ngt in place. increased cals
to 34 of bm/neosure. voiding and [**month/day (2) **], circ site w/o
bleeding/oozing. on nitrofurantoin for hydronephrosis. no
adverse reactions noted so far. con't to monitor wt, check
lytes in am.

#2 [**month/day (2) **] took care plan (for play-time/positioning) home
with some discharge info. has been sleeping comfortably b/t
activities, wakes for feeds, bottles eagerly but gets a bit
tired. likes to suck on pacifier and sit in swing. will
receive eip when discharged.

#3 [**month/day (2) **] disappointed that [**month/day (2) **] would not be discharged,
but today they completed most of discharge teaching and
[**month/day (2) **] will have renal u/s and vcug at tch tomorrow prior to
discharge so out-patient app'ts have been cancelled. will
try to arrange for urology (dr. [**last name (stitle) 5004**] to see [**last name (stitle) **] on
friday when [**last name (stitle) 26**] bring [**last name (stitle) **] in to tch for cardiology
app't with dr. [**last name (stitle) 4998**]. vna will visit home tomorrow at 3pm,
as [**last name (stitle) **] will be discharge as early as possible in am.
([**location (un) **] home infusion will drop off equipment at house
today). mom states she is comfortable with passing ngt (and
she demonstrated on friday). discharge medication dosing and
administration was reviewed and return demonstrated
(needless syringes given).
-circ done, passed hearing screen, passed car seat test, and
synagis given. con't to support/review teaching.

#4 [**location (un) 345**] has murmur, hr 140-160's, is pale-pink (mottled at
times). hct 44/retic 2.7. observing for s&s of chf. is on
lasix, kcl, and digoxin. will be followed by dr. [**last name (stitle) 4998**] at
tch (app't fri [**2-25**] 10:30 am). con't to monitor.



"
1636,"nursing notes:


#1fen:tf-[**month (only) **]to 140cc/k/d. npo throughout this shift r/t
bilious asp. 1-2cc dark green asp. w/each care thus far this
shift. dr.[**first name (stitle) 612**] aware. kub this am w/o no neumotosis noted.
?malrotation,blockage? infant going to tch this pm for upper
gi series. abd.soft,mottled, hypoactive bs. voiding,no stool
noted thus far this shift. no spits today. ivf tpn d14w@
4.7cc/hr and lipids @.6cc/hr. dstick-108.g19-19.5. sepsis
eval.sent w/lytes this pm. results pending.a;?malrotation,
nec watch?mec.blockage?p;continue npo and closely monitor.
tx.to tch at this time for upper gi.
#2g/d;[**first name (stitle) **],active,and irritable throughout shift. comfort
measures given w/good response noted- positioning on abd,
pacificer,containment w/iv bag.nested in lambswool
w/bendybumper for boundaries. maew. mild temp.instability
97.5 this pm-?sepsis. remains in isolette and temp.adjusted.
[**first name (stitle) **]'s eod, no [**first name (stitle) **] today r/t current gi issues.
a;irritable r/t npo?sepsis?p;continue to monitor sepsis w/u
results. continue temp.monitoring and assess and support g/d
milestones. [**first name (stitle) **] tomorrow if stable.
#3parenting;[**first name (stitle) **]/grandparents at [**first name (stitle) **] this pm. asking
many appropriate questions. appropriately concerned r/[**initials (namepattern4) **]
[**known lastname 827**] and gi issues. update given and plan discussed
w/family by md. [**last name (titles) 190**],ot at [**last name (titles) **] coaching [**last name (titles) **] on ways
to get involved w/cares. [**last name (titles) 143**] demonstrated good hands on
skills with infants. a;involved,very loving towards infants.
mom continues to be slightly hands off with babies.
encourage soft speaking. support and encouragement of cares
given to mom.p;continue to support and educate. facilitate
touch of babies with moms comfort level. [**last name (titles) 8**] to [**first name9 (namepattern2) **]
[**known lastname 827**] tomorrow if stable.
#4cv;hr150-170's. pale,mottled. tx.today w/1alloquate-10cc
prbc. no adverse reaction noted. second alloquate due tonite
post gi procedure at tch.hx. of intermittant murmur. cbc
sent tonite r/t r/o sepsis.results pending. b/p stable means
30-40's(see flow sheet).a;anemia,sepsis?p;continue to
closely monitor. f/u cbc result


"
1637,"respiratory care note
pt continues on imv 24/6 x 21 .21-.33fio2.  rate had been weaned from 23 secondary to early am cbg.  pt had major desat to 20s requiring manual bagging to get sats up.  pip increased at this time to 24 with good effect.  fio2 weaned as low as r/a -continued labile sats despite increased pip, however now mostly self resolved and has dipped as low as 50bpm, and come back up on her own.  cxr, which was unremarkable had a sltly high ett but [**name8 (md) 90**] rn some tension was applied during cxr.  bbs coarse, but clearer after sxn.  sx'd frequently for small to mod cloudy white secretions.  1 puff combivent given at noon via mdi/spacer with no adverse reaction.  rr 30-50.  will monitor closely and will repeat a blood gas if worsening desats continue.
"
1638,"npn 1900-0700

16 heme

fen:  cw 2245g (down 60g).  infant npo for pneumotosis by
kub & bloody stools.  tf 140cc/kg/day via [**known lastname **]: pnd10 +
il.  prn piv hl l hand.  abd remains distended, firm, occ
soft loops, active bs.  ag= 29-30cm.  kubs done 2200 & 0300;
[**name8 (md) 90**] [**name8 (md) 1**] somewhat unchanged, bowel somewhat less distended at
0300 film.  repogle to cont lws.  scant amt cloudy/bilious
secretions in [**last name (un) **] trap (~1cc).  voiding qs, lg stools with
each diaper change.  stools rusty in color, mucousy, with
some blood streaks present; heme positive.  [**last name (un) 1**] aware.  ds=
96, 84.  lytes sent: 138/3.2/99/31.

dev:  temps stable while nested on open warmer.
active/lethargic with cares.  occ wakes crying btwn.
settles with pacifier. [**last name (un) 383**].  mae.

par:  mom in to visit at [**2148**].  updated at bedside by this
rn.  asking approp questions, approp concerned.  discussed
possibility of transfer to tch for study.  consents to be
obtained if needed, with interpreter.  [**year (4 digits) 143**] called at 2400
for update.  continue to support and update [**year (4 digits) **] as
needed.

bili:  recent bili 11.8/7.9.  infant with hx of elevated
direct bili.  actigal d/c'd yesterday due to npo status.  pt
may be transfered to tch for omega study, [**name8 (md) 90**] [**name8 (md) 1**].  continue
to monitor.

a/b's:  rec'd infant in ra.  infant placed in nc at 2400 for
freq drifts/spells; nc 100%, 60cc.  infant able to wean to
20cc at end of shift.  rr 30-50s, ls c/=, mild ic/sc
retractions.  2 spells thus far this shift.  required stim
and bbo2 for resolvement.  total of 4 spells in 24hrs.
continue to monitor.

id:  infant on zosyn tid for nec.  med admin as ordered.
cbc repeated at 0400; results pending.  temps stable.
infant active/lethargic with cares.  continue to monitor for
s/s sepsis.

heme:  infant transfused total 2 alloquots prbcs overnoc
(10cc/kg x2) for hct 25.7.  consent signed in chart.  no
adverse reactions noted.  soft murmur auscultated.  hr
150-160s, infant pink, mod gen edema.  bp stable 78/40 (53).


revisions to pathway:

  16 heme; added
    start date: [**2156-3-30**]

"
1639,"npn 1900-0700


resp:  infant in nasal [**doctor last name **] cpap 5, fio2 37-49%.  ls
clear/=, mild sc retractions.  rr 20-40s.  sxn'd mouth x1
for moderate amt clear secretions.  occ drifts, no spells
thus far this shift.  pt on iv [**doctor last name 775**] [**hospital1 **].  continue to
monitor.

fen:  cw 2185g (up 85g).  pt remains npo.  tf 130cc/k/day.
picc l ac patent and infusing pn d10 + il.  piv r hand
hep-locked.  repogle to cont lws.  4.2cc clear secretions
aspirated at 2100; discarded.  tube irrigated with 2cc
sterile h20 (asp entire volume back).  suction canister
changed at 2100 due to not maintaining proper suction.
repogle now appears to be draining secretions adequately.
abd soft, [**hospital1 **], round.  no loops, active bs.  ag stable,
27cm.  8hr uo= 3.0cc/k/hr, no stool thus far this shift, pt
is passing gas.  surgery fellow from tch in to consult.  no
plans for repeat kub as yet.  2 aloquots prbcs transfused
overnoc (20cc/k) for hct of 28.4.  consent present in chart.
 tolerated transfusion well, no adverse reactions.

par:  dad called x1 thus far this shift.  updated by this
rn.  asking [**hospital1 **] questions.  provided much support by this
rn.  continue to update and support as needed.

dev:  temps remain boarderline low; 97.8ax swaddled with
t-shirt, 2top blankets, hat.  [**hospital1 1**] aware.  a/a, irritable
with cares.  settles well with sucrose pacifier.  slept well
tonight in btwn cares.  moves hands to face.  [**last name (lf) 383**], [**first name3 (lf) 57**].

sepsis:  pt now day 3 of 14 with abx clinda and zosyn.  meds
admin as ordered.  temps boarderline low, will monitor
closely.  bc negative.  stool cultures: fecal culture
negative, campylobacter culture negative, prelim results of
viral culture negative.  will monitor for s/s sepsis
closely.


"
1640,"nicu nursing note 7p-7a


2.resp= o/remains intubated on hfov map 9, amp 15.  fio2
30-38%.  bscoarse, diminished bilaterally.  occas drifts in
o2sats to low- mid 80's. sxn'd small cloudy secretions via
ett.  orally sxn'd for mod thick cloudy secretions.  cbg
obtained 7.25, 44, 35, 20, -8.  no changes made.  cont on
vit a.  a/stable on hfov with current settings.  p/cont to
monitor for resp distress.

3.fen= o/bw= 717g current wgt= 711g (+34).  cont on tf=
160cc/kg/d.  enteral feeds @ 70cc/kg/d of bm 20 gavaged q3h
over 30min.  ivf @ 90cc/kg/d of pnd12 + lipids via central
picc in rarm.  received prbs via lfootpiv, infused without
difficulty.  no adverse reaction noted. abd benign, soft.
no loops.  + bowel sounds.  ag= stable.  uo= 4.8cc/kg/h x
12h.  having liquid yellow stools, heme(-).  a/tol feeds.
p/cont to monitor fen status.  plan to check lytes in with
next cares.

4.g&d= o/temp stable nested in servo isolette.  alert and
active. maew. afof.  a/aga. p/cont to support g&d needs.

5.[** **]= o/mom and dad visited for 2100 cares.  updated by
this rn and [** 7**].  p/cont to support and educate.


"
1641,"nursing progress note


#1. o: infant remains on hifi ventalation on unchanged
settings of map 7, delta p 14. fio2 overnight has been
29-32%. brief o2 sat drifts noted overnight. no bradycardia
noted thus far. ett suctioned for sm/mod white. breath
sounds are coarse and equal. ic/sc retractions noted. cbg
7.25-50-44-23--5. no changes made. last dose of indocin
given tonight.  a: stable on current settings. p: continue
to monitor resp status.

#2. o: infant transfused 2nd aloquot of 20cc/k transfusion
of prbc's tonight. no adverse reactions noted. last dose of
indocin given. no murmur heard tonight. infant [** 211**] and well
perfused. bp stable. a: s/p transfusion and indocin
treatment. p: continue to monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d of d6.5pn and
il's infusing well via dluvc line. infant npo. abd soft and
flat with active bowel sounds. no loops. no meconium thus
far. infant voiding 3.8cc/k/hr today. d/s 219-226. wgt is up
41gms tonight to 450gms. a: npo. p: continue to monitor fen
status. check elec's on sunday morning.

#5. o: infant remains in heated isolette with stable temp.
he is alert and active with cares. maew. sucking on fingers
intermittently. a: aga. p: continue to assess and support
developmental needs.

#6. o: mom called x1 for brief update. apologized for not
showing up at 1600. she stated she will be in today. a:
involved mother. p: continue to inform and support.

#8. o: infant remains under single phototherapy. eye shieds
in place. a: hyperbili. p: continue to inform and support.


"
1642,"nursing progress note


#1. o: infant remains on ampicillin and gentamicin for
sepsis. today is day [**10-30**]. cultures remain negative. a:
sepsis. p: continue with treatment.

#2. o: infant remains on prong cpap 5. fio2 has been 27-26%.
(27-30% while prone position). rr 40's-50's. breath sounds
are clear and equal. mild/mod ic/sc retractions noted. no
spells. remains on caffiene. a: stable. p: continue to
monitor resp status.

#3. o: infant completed 2nd aloquot of prbc's this evening.
lasix given. infant received total of 20cc/k of prbc's. no
adverse reactions noted during transfusion. infant pink and
well perfused. soft murmur heard. a: low hct. p: continue to
monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d. currently d9pn
and il's infusing well via picc at 120cc/k/d. feeds of bm
are at 30cc/k/d. no spits or aspirates. ag stable. abd
remains full and soft. no loops. active bowel sounds. d/ss
125. no stools. voiding 5.9cc/k/hr. wgt is up 10gms tonight
to 1025gms. a: advancing on feeds. p: continue to advance
feeds 10cc/k/[**hospital1 **] as tolerated. a.m. elec's pending.

#6. o: infant remains in servo control isolette with stable
temp. he is alert and active with cares. maew. otherwise
sleeping well. hc remains unchanged at 24cm's. a: aga. p:
continue to assess and support developmental needs. ?hus
today.

#7. no contact from [**name2 (ni) 4**] this shift.

#9. o: rebound bili sent this a.m. awaiting results.


"
1643,"social work
met with mother during her visit to the nicu [**4-15**]. states that she is slowly beginning to feel better after her c/section and subsequent adverse reaction to a blood transfusion. mom thrilled with the health of her newborn twins. asking appropriate questions re: visiting etc. mom has good support from her [**month/day (4) 4**] with whom she lives and she is currently uncertain about and open to fob's involvement with babies. mom had some ins. questions and requested [**first name4 (namepattern1) 330**] [**last name (namepattern1) 331**]-[**doctor last name 156**], lsw, community resource specialist speak with her. ms. [**doctor last name 332**] planned to do so this am. also provided info re: reduced parking.
mom aware that she will feel teary and emotional about her planned d/c today. encouraged her to call unit to maintain sense of connection. denied other questions/concerns at this time. overall mother appears to be slowly adjusting to her premature delivery and nicu environment. mom aware that i will continue to follow. please call with questions/cocnerns. thank-you.
"
1644,"nursing notes:


#2resp;
  o:[**known lastname 932**] remains in nc 30-40%fio2, 200ccflow to maintain
02sat's>92%. rr40-60's. lungs cta. sc/ic retx. 4bradys
w/apnea noted thus far this shift. 2requiring bb02!
dr.[**last name (stitle) 962**] aware. remains on caffiene, diuril,kcl. cbc
w/diff and blood cx. done this am r/t bradys. no shift in
cbc noted. blood cx.results pending. hct-23.6! [**known lastname 932**]
currently w/blood transfusion in progress. (see flow sheet).
no adverse reactions noted thus far. vss. 35cc to infuse of
prbc over 4hrs. [**known lastname **] aware per dr.[**last name (stitle) 962**]. a;inc. resp
effort, inc. apnea/bradys r/t anemia? no sepsis noted today.
p:monitor. observe transfusion.
#2fen;
  o:tf=140cc/k/d. bm26w/pm. 54ccq4hrs. po feeding qshift, bf
when mom at bedside. [**known lastname 932**] [**last name (namepattern1) 62**]. 45 cc w/nuk nipple this
pm. occasional periods of discoordination noted. active and
interested when po feeding. all other feeds gavaged over
40min. no spits, no evidence of reflux noted thus far this
shift. remains on reglan/zantac and reflux precautions
maintained. abd.soft,[**last name (namepattern1) 211**],no loops. voiding, no stool this
shift. last stool, noted last nite.a;stable, working on po
feeding.p;continue current feeding plan.
#3g/d;
  o:[**last name (namepattern1) 3**],active,and appropriate w/cares. occasionally
waking for feeds. stable temps in open crib.dressed,
swaddled,and positioned with [**last name (un) 58**] bumper. maew w/mild
hypertonia noted. ot involved. [**last name (un) **].sucks on pacificer at
times.a;agap;continue to assess and support g/d milestones.
#4parents:
  o:dr.[**last name (stitle) 328**] called mom this am w/update. no furthur
contact noted this shift.p;continue to educate and support.



"
1645,"npn 0700-1900
heme: infant born with known rh-isoimmunization. ivig given at 1230 today. infusion given over 4hrs and completed at 1630. no adverse reactions. vitals signs done as ordered, see flowsheet. no plan for further ivig infusion at this time. plan to check q4hr biliirubin levels. see attending note for further details.

bili: infant continues on triple phototherapy since 0800 today with eye shields in place. bili levels checked q4hrs this shift. bili presently 5.5/0.3, down from 6.5/0.3.
p: continue to monitor closely for hyperbilirubinemia.


**please refer to attending's notes above for details.
"
1646,"npn 0700-1900
heme: infant born with known rh-isoimmunization. ivig given at 1230 today. infusion given over 4hrs and completed at 1630. no adverse reactions. vitals signs done as ordered, see flowsheet. no plan for further ivig infusion at this time. plan to check q4hr biliirubin levels. see attending note for further details.

bili: infant continues on triple phototherapy since 0800 today with eye shields in place. bili levels checked q4hrs this shift. bili presently 5.5/0.3, down from 6.5/0.3.
p: continue to monitor closely for hyperbilirubinemia.


**please refer to attending's notes above for details.
"
1647,"npn 7a-7p


resp: infant in ra. lscl/=. mild scr. rr=30's-50's. 02 sats
>95%. no spells. continue to monitor resp status.

cv: infant is pink and well perfused. no murmur noted.
hr=130's-150's. bp is stable. continue to monitor cv.

fen: bw1835. new wt=1730gms -105gms. tf 80cc/kg/d ivf of d10
infusing via piv. site patent. rh hl. alos patent to flush.
abd is soft, flat with +bs. no stool yet. ag is 22cm. no
loops. ds=70. uop for 8hrs=4.9cc/kg/hr. conitnue to monitor
fen.

sepsis: infant continues on amp/gent for 48hr r/o. bc pndg.
continue to monitor for s/sx of infx.

g/d: infant is nested on sheepskin on radient warmer. temps
stable. a/a with cares. brings hands to face. sleeps well
inbetween. afsf. maew. continue to monitor dev.

[** 2**]: dad in with family member x1. updated at bedside.
mom resting in house. continue to update and support
[** **].

hyperbilirubinemia: infant is under triple phototherapy, eye
shields in place. high bili levels from previuous. sent bili
level at 2400 results pending. are now checking levels q6hrs
not q4hrs. may change with results. infant was treated today
for ivig, no adverse reaction occurred. continue to monitor
for s/sx of hyperbili.


"
1648,"progress note 7p-7a


fen: tf [** 145**] 120cc/k enfamil ar all po. waking to eat q/ 4
hrs. intake over last 24 hrs=175cc/k. abdomen soft and
benign. voiding/no stools so far this shift. no spit noted.
will continue to monitor feeding tolerance and progression.

dev: temps stable swaddled in [** 13**]. active and [** 29**] w/
cares. comforted by pacifer. will continue to support
developemental needs.

a's and b's: day [**1-3**]. no spells noted so far this shift.
will continue to monitor closely.

tachy: hr and bp wnl. continues on propanilol q. 8hrs.
tolerating well with no adverse reactions noted so far. will
continue to monitor closely.


"
1649,"respiratory care note
pt continues on simv 23/6 x 22 .50fio2.  bbs slightly coarse.  sx'd ett tube for small amts of cloudy white secretions. nares sx'd for thick yellow secretions.  comfortable rr 30-50s.  good vts;  5-7ccs.  2p combivent given as ordered w/no adverse reaction. no spells and nard.  will continue to follow - wean fio2 as tolerated.
"
1650,"nursing note 1900-0700


resp: recieved in simv 26/6 x29bpm. abg at 0200 was
7.45/44/54/32/5. breath rate weened to 27. fio2 55-70%,
increased slightly w/ [** **] ween. ls course/crackly but has
good aeration. sats v. [**known lastname **]. rr 27-50, rides [**known lastname **] often.
lasix given x1. stable on current settings, con't to
monitor. check [**known lastname 1380**] gas this am.

fen: weight 936, up 1gram. tf 100cc/k/d of pn d18 w/hep and
il. npo. ds109. abd soft and full, no loops. girth up 3cm to
20.5. bs active. uo: 4.7cc/k/hr x12hrs. no stools. con't w/
current plan.

cv: soft murmor heard w/ all cares. pulses normal, brisk cap
refil, hyperactive precordium. hr 150-180s. recieved
dopamine drip at 5mcg throughout night, turned off at 6am.
keeping maps 32-38. given 10cc/k prbc transfusion w/ lasix
x1 at 8pm for hct of 34 yesterday. also given 15cc/k
platelet transfusion at 6am after plt count dropped from 88
to 66 o/n. no adverse reactions noted, vitals assessed per
protocol. [**known lastname **] out currently 0.8cc. stable at this time, bp
means 30-36. con't to monitor closely and check bps q 15min.


parenting: no contact w/ [**name2 (ni) **] so far this shift. [**name2 (ni) 18**]
spoke w/ [**name2 (ni) **] yesterday evening to give update on
[**name2 (ni) 168**]'s condition. con't to support and update as needed.

bili: [**name2 (ni) **] pink. last bili level checked on [**2152-4-25**].
recieving phenobarbitol for increased direct bili. con't to
monitor for jaundice and check bili levels per orders.

r/o sepsis: [**date range **] remains w/out signs of infection at this
time.  temps stable, alert and active. continues on gent and
oxacillin iv. con't to monitor closely.


"
1651,"npn 1900-0700


resp/heme:  infant on nasal prong cpap 7, fio2 29-35%, incr
with cares.  ls c/=, ic/sc retractions.  rr 20-50s.  sxn po
x1 thus far this shift, no secretions noted.  2 spells noted
thus far this shift.  total of 11 spells in 24hrs.  infant
transfused 1 alloquot directed donor prbcs; 12.5ml over
4hrs.  no adverse reactions noted.  consent signed in chart.
 lasix given x1 after transfusion complete.  pt on caffeine
and vit a.  continue to monitor.

fen:  cw 830g (down 5g).  tf 140cc/kg/day.  ef currently at
60cc/kg/day bm/sc20.  non-cent picc patent and infusing
pnd10 + il at 80cc/kg/day.  prn piv rl; hl.  appears to be
tolerating pg feeds well.  no spits, max asp 1.2cc; benign,
refed.  abd full, soft, soft loops noted x1, hyperactive to
active bs.  ag= 20-21cm.  8hr uo= 5cc/kg/hr, trace mec
stools noted qdiaper change.

dev:  temps stable while nested in servo isolette.  a/a with
cares, sleeps well btwn.  likes pacifier, moves hands to
face.  [**last name (lf) 457**], [**first name3 (lf) 83**].  pt planned for repeat hus today; hx of
nml hus.

par:  mom called x1 thus far this shift.  updated by this
rn.  asking approp questions.  plans to be in to visit
today.  continue to update and support parents as needed.


"
1652,"npn 1900-0700

8 potential for sepsis

resp:  [**name (ni) **] pt on conv vent settings 21/6, r 19.  0200 abg
was 7.24/40/42/18/-9, therefore decreased pip by 1 to
current settings 20/6, r 19.  0600 cbg 7.25/43/36/20/-9.
fio2 21-38%, mostly in 30s since last setting change.  rr
30-50s, sc/ic retractions.  ls wheezy/sl diminished.  air
leak noted thru ett.  sxn x1 sm amt cloudy via ett/oral.  1
spell tonight.  hr to 68, o2 sat 81% after cares.  mild stim
and incr o2 required to resolve.  cont to monitor resp
status.

fen:  cw 965g (up 3g).  pt remains npo.  tf 120cc/kg/d.
dluvc infusing pn d12.5.  repogle to gravity; 0.1cc clear
asp.  abd soft, hypoactive bs, no loops.  ag 21-22cm.  12hr
uo= 4.5cc/k/hr, no stool this shift.  lytes drawn:
143/4.0/117/15.  triglycerides: 165.  glucose=140.

dev:  maintaining temps nested in servo isolette.  pt is
a/a.  irritable with cares; settles with hand containment
and decr stim.  moves hands to face, sucks on thumb.  r & l
feet edematous/bruised (r>l).  excoriated area on abdomen
improved; bacitracin applied.  repeat hus today.

social: mom in most of noc tonight (2200-0100; 0400-0630).
updated at bedside by this rn and nnp.  asking appropriate
questions.  appeared loving/affectionate to nb.  plans to be
in later today to participate in cares.

bili:  single phototx restarted at 0600 for rebound bili
5.3/0.2 (up from 3.4/0.2).  eye mask in place.  pt ruddy, no
stool this shift.  cont to monitor.

cv:  infant transfused tonight.  9cc prbcs transfused over
4hrs.  pt tol well; no adverse reactions.  bp means 30-50s.
hr 130-150s.  no murmur auscultated; s/p 1 course indocin.
palmar pulses absent.  pt ruddy.  total blood out since
transfusion tonight: 1.2cc.





revisions to pathway:

  8 potential for sepsis; resolved

"
1653,"npn 1900-0700


resp:  infant remains on conv [** **] settings 18/5, r 18.  abg
2200: 7.23/46/105/20/-8; no changes made.  fio2 27-35%, incr
with cares.  ls coarse, sxn'd q3-4h thick cloudy secretions
via ett, small po and nares.  no bradys thus far this shift.
 caffeine held tonight for tachycardia.  pt continues on vit
a.  continue to monitor.

fen:  cw 852g (up 92g).  feeds restarted at 0100 at
100cc/k/day pe24.  picc infusing d10 ns + 0.5u hep/cc at
1.5cc/hr.  no spits, min asp.  abd full, soft.  ag noted to
be incr at 2200 (20.5cm with soft loops).  [** 41**] aware.  ag
now back to baseline at 18cm without loops.  uo improving.
8hr uo= 9.2cc/k/hr.  no stool thus far this shift.  lytes
sent 2200: 123/5.1/96/18.  na improving (up from 118 on
days).  lytes to be resent at 0500.  ds= 89.

par:  mom called x2 thus far this shift and in to visit with
dad at 2300.  updated at bedside by this rn, [** 41**] [**doctor last name **], and
md [**last name (titles) **].   mom expressed her concerns to this rn.  very
emotional and worried about her daughter.  much support
provided.  anxious to hear hus results this am.  continue to
support and update as needed.

dev:  temps stable while nested in servo isolette.  a/a with
cares, irritable at times btwn.  settles with hand
containment and pacifier.  moves hands to face.  anterior
font appears slightly full.  [**last name (titles) 41**] aware.  hus to be done in
am.  continue to monitor.

cv:  loud murmur auscultated.  pt tachycardic this shift,
170-190s (occ to 200s).  team aware.  caffeine therefore
held at 2100.  bp means stable (37-56).  most recent cuff
74/44 (56).  pt transfused 2nd aloquot (8cc) prbcs at 2330
over 4hrs.  consent signed in chart.  no adverse reactions
noted.  post-hct to be sent later today.  continue to
monitor cv status.


"
1654,"nicu admit: pls see dr.[**name (ni) 179**] detailed note reviewing both mom and [**name2 (ni) 700**] history. to nicu for ivig transfusion s/p platelet count of 29 last eve.  1cc of whole blood collected for platelet antigen genotyping. hl placed in infants r foot. 30cc of ivig infused over 4hrs as ordered. frequent vs monitoring done. infant without any evidence of an adverse reaction. fed 1-2oz of similac20 q 4hrs with ease. wet diapers x 2, no stool passed. mom and dad in to visit. reviewed plan for son. platelet count to be resent ~ 0700.
"
1655,"npn 1900-0700


sepsis:  infant now day 4 of minimum 7 day course iv abx amp
and gent.  meds to be admin as ordered.  infant continues to
have foul odor.  repeat cbc dol 1 with left shift; bc
negative.  cbc to be repeated later today.  lp planned.
continue to monitor for s/s sepsis.

resp:  intubated on hifi settings map 6, delta p 14.  delta
p weaned x2 overnoc according to abgs.  most recent abg
0300: 7.34/44/56/25/-2 (decr from amp 16 to 14 at this
time).  fio2 23-33%.  ls coarse bilat.  sxn'd mod-lg white
via ett & po.  ic/sc retractions.  no bradys thus far this
shift, occ drifts.  pt is on vit a.  continue to monitor.

fen:  bw 605g  cw 555g (up 5g).  pt npo.  tf 170cc/kg/day:
uac: sterile h20 + 7.7meq naace + 0.5uhep/cc; dluvc: pnd10
(70cc/kg/day) + d10w + 0.5uhep/cc.  ds stable, 63, 92.  abd
soft, flat, bs unappreciated.  ag= 14.5cm.  ngt pulled by
pt, not replaced at this time due to npo status.  12hr uo=
5.9cc/kg/hr, no stool this shift.  q6h lytes, most recent
0400: 145/3.2/112/22/14.  bun: 35, creat: 0.8, mg: 3.2.

dev:  infant nested on servo warmer with water pillow,
sheepskin, tent.  ear muffs provided for comfort with noise.
 fentanyl given prn x1 thus far this shift for unsettled
aggitation, with good effect.  infant can become aggitated
at times, usually settles well with hand containment or decr
stim.  aquaphor applied [**hospital1 56**] as ordered, skin intact.  eyes
fused bilat, rt eye appears to be opening slightly.

par:  parents in to visit for early part of shift
(~[**2171**]-2400).  updated at bedside by this rn.  asking approp
questions.  dad participated in temp taking and diaper
change.  continue to update and support parents as needed.

cv:  loud murmur ausculated.  pda by echo.  1st course
indocin started yesterday.  2nd dose given at 2330.  [**location (un) **]
pulses absent, good cap refill.  ruddy, wp.  hr 140-170s,
uac means 28-41.  cuff 72/44 (50).  infant transfused
overnoc prbcs (20cc/kg total).  consent signed in chart.  no
adverse reactions noted with 1st alloquot.


"
1656,"nsg note 0700-[**2041**]


resp:infant received in nasal prong cpap-6, 21% fio2. cpap
decreased to 5 at 0930, infant tolerated well. placed in
room air at 1430. bilateral lung sounds clear and equal with
good aeration. respiratory rate 20-50's. saturations
99-100%. mild subcostal retractions. no spells. p:continue
to assess and support respiratory status.

c/v:infant's heart rate 120-140's, nsr. no murmur
auscultated. pink and well perfused. received second aliquot
of prbc's, 14 ml, over four hours. tolerated tranfusion
well, no adverse reactions. bp's stable 60/29 (40).
p:continue to assess and support cardiovascular status.
repeat hct lab.

f/n:infant on total fluids of 80cc/kg/day. npo. tpn @
80cc/kg/day via double lumen uvl, primary port @4.8cc/hr.
d/s stable-76. abdomen benign, +bowel sounds. girth stable
at 22.5cm. voiding, small mec smear. p:continue to assess
and support nutritional status.

dev:infant maintaining temperatures, nested on servo warmer.
appropriate for gestational age. alert and active for care
times, sleeping well between. comforts with boundaries.
sucking on pacifier well. p:continue to assess and support
growth and development.

par:mom called this morning. dad in for a visit. asking
appropriate questions. discussed respiratory status and plan
for second aliquot of prbc's. very loving with [**known lastname **].
p:continue to support and update parents.

id:infant continues on ampicillin and gentamycin for a 48
hour rule out. blood cultures pending. no signs/symptoms of
sepsis. temperature's stable, active and alert, stable
respiratory status. p:continue to monitor for signs of
infection.


"
1657,"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**]
"
1658,"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



"
1659,"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**]

"
1660,"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**]



"
1661,"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**]"
1662,"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**]

"
1663,"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.



"
1664,"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**]"
1665,"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**]"
1666,"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**]
"
1667,"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.



"
1668,"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



"
1669,"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**]

"
1670,"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**]"
1671,"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**]
"
1672,"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**]



"
1673,"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**]

"
1674,"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**]
"
1675,"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**]

"
1676,"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**]"
1677,"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**]"
1678,"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.


"
1679,"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**]



"
1680,"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**]"
1681,"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**]"
1682,"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**]"
1683,"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**]"
1684,"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**]

"
1685,"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**]
"
1686,"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



"
1687,"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**]
"
1688,"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



"
1689,"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**]

"
1690,"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**]"
1691,"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**]

"
1692,"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**]"
1693,"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.



"
1694,"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



"
1695,"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**]"
1696,"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**]
"
1697,"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**]"
1698,"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**]"
1699,"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**]
"
1700,"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**]
"
1701,"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**]
"
1702,"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**]"
1703,"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**]"
1704,"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**]"
1705,"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



"
1706,"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 **]
"
1707,"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**]

"
1708,"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**]"
1709,"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**]
"
1710,"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**]"
1711,"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**]

"
1712,"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**]"
1713,"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**]"
1714,"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**]"
1715,"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**]"
1716,"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**]"
1717,"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**]"
1718,"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.



"
1719,"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**]

"
1720,"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**]"
1721,"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.



"
1722,"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**]"
1723,"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.



"
1724,"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**]"
1725,"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.



"
1726,"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 **]
"
1727,"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.



"
1728,"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).



"
1729,"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**]"
1730,"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**]"
1731,"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**]
"
1732,"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**]
"
1733,"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



"
1734,"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**].



"
1735,"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**]"
1736,"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**]"
1737,"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**]

"
1738,"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



"
1739,"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**]
"
1740,"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**]



"
1741,"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**]"
1742,"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**]

"
1743,"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 **].



"
1744,"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**]"
1745,"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**].



"
1746,"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**]"
1747,"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**]

"
1748,"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**]



"
1749,"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**]"
1750,"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



"
1751,"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**]

"
1752,"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**]"
1753,"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**]"
1754,"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



"
1755,"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**]"
1756,"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 **]
"
1757,"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.



"
1758,"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**]"
1759,"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**]



"
1760,"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**]
"
1761,"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) **]"
1762,"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

"
1763,"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**]"
1764,"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**]"
1765,"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



"
1766,"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**]
"
1767,"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**]"
1768,"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**]"
1769,"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



"
1770,"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**]"
1771,"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**]
"
1772,"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**]
"
1773,"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:
.


"
1774,"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.


"
1775,"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) **].



"
1776,"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



"
1777,"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**]"
1778,"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



"
1779,"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) **].



"
1780,"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.


"
1781,"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**]"
1782,"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



"
1783,"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



"
1784,"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**]
"
1785,"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**]
"
1786,"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**]

"
1787,"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**]"
1788,"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 **]
"
1789,"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**]
"
1790,"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



"
1791,"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**]
"
1792,"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**]"
1793,"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**]"
1794,"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.
"
1795,"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.
"
1796,"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.
"
1797,"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.
"
1798,"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.
"
1799,"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.
"
1800,"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.
"
1801,"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.
"
1802,"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.
"
1803,"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.
"
1804,"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.
"
1805,"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.
"
1806,"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:
"
1807,"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
"
1808,"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:
"
1809,"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
"
1810,"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.
"
1811,"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.
"
1812,"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.
"
1813,"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 ------
"
1814,"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 adverse reactions.
   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.
"
1815,"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.
"
1816,"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.
"
1817,"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.
"
1818,"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.
"
1819,"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:
"
1820,"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.
"
1821,"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.
"
1822,"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.
"
1823,"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.
"
1824,"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.
"
1825,"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.
"
1826,"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.
"
1827,"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.
"
1828,"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.
"
1829,"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.
"
1830,"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
"
1831,"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:
"
1832,"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**]
"
1833,"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 ------
"
1834,"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.
"
1835,"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.
"
1836,"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.
"
1837,"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.
"
1838,"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
"
1839,"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 ------
"
1840,"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:
"
1841,"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:
"
1842,"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:
"
1843,"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:
"
1844,"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
"
1845,"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 ------
"
1846,"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:
"
1847,"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
"
1848,"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
"
1849,"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
"
1850,"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 ------
"
1851,"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
"
1852,"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 ------
"
1853,"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.
"
1854,"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:
"
1855,"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:
"
1856,"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:
"
1857,"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:
"
1858,"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
"
1859,"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
"
1860,"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
"
1861,"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.
"
1862,"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.
"
1863,"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.
"
1864,"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.
"
1865,"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
"
1866,"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
"
1867,"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.
"
1868,"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.
"
1869,"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:
"
1870,"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
"
1871,"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.
"
1872,"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
"
1873,"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:
"
1874,"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
"
1875,"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 ------
"
1876,"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:
"
1877,"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 ------
"
1878,"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:
"
1879,"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:
"
1880,"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:
"
1881,"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:
"
1882,"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 ------
"
1883,"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:
"
1884,"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 ------
"
1885,"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:
"
1886,"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.
"
1887,"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:
"
1888,"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:
"
1889,"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.
"
1890,"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 ------
"
1891,"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:
"
1892,"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
"
1893,"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:
"
1894,"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
"
1895,"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 ------
"
1896,"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.
"
1897,"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 ------
"
1898,"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:
"
1899,"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:
"
1900,"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.
"
1901,"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
"
1902,"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
"
1903,"title:
   respiratory care: atrovent nebs administered  @ 4:00 . bs are clear
   bilaterally in apecies with diminished bases. no adverse reactions
   following tx.
"
1904,"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:
"
1905,"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 ------
"
1906,"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:
"
1907,"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 ------
"
1908,"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:
"
1909,"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:
"
1910,"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:
"
1911,"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 ------
"
1912,"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 ------
"
1913,"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.
"
1914,"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
"
1915,"[**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.
"
1916,"[**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.
"
1917,"[**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
"
1918,"[**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
"
1919,"[**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
"
1920,"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 ------
"
1921,"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 ------
"
1922,"[**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.
"
1923,"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.
"
1924,"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.
"
1925,"[**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.
"
1926,"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
"
1927,"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:
"
1928,"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
"
1929,"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
"
1930,"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.
"
1931,"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.
"
1932,"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.
"
1933,"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.
"
1934,"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 ------
"
1935,"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.
"
1936,"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
"
1937,"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
"
1938,"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
"
1939,"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
"
1940,"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:
"
1941,"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
"
1942,"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
"
1943,"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.
"
1944,"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.
"
1945,"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.
"
1946,"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:
"
1947,"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.
"
1948,"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:
"
1949,"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
"
1950,"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
"
1951,"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
"
1952,"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
"
1953,"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.
"
1954,"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
"
1955,"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
"
1956,"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.
"
1957,"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.
"
1958,"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.
"
1959,"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.
"
1960,"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.
"
1961,"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:
"
1962,"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
"
1963,"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
"
1964,"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.
"
1965,"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.
"
1966,"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
"
1967,"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 ------
"
1968,"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 ------
"
1969,"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:
"
1970,"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.
"
1971,"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
"
1972,"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
"
1973,"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
"
1974,"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
"
1975,"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
"
1976,"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.
"
1977,"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
"
1978,"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
"
1979,"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
"
1980,"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
"
1981,"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:
"
1982,"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
"
1983,"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:
"
1984,"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
"
1985,"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
"
1986,"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
"
1987,"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 ------
"
1988,"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:
"
1989,"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:
"
1990,"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.
"
1991,"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:
"
1992,"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:
"
1993,"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
"
1994,"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.
"
1995,"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.
"
1996,"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
"
1997,"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
"
1998,"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.
"
1999,"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.
"
2000,"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
"
2001,"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
"
2002,"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
"
2003,"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
"
2004,"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
"
2005,"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.
"
2006,"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.
"
2007,"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.
"
2008,":
   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.
"
2009,"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:
"
2010,"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:
"
2011,"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:
"
2012,"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
"
2013,"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.
"
2014,"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.
"
2015,"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
"
2016,"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:
"
2017,"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 ------
"
2018,"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:
"
2019,"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:
"
2020,"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:
"
2021,"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
"
2022,"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
"
2023,"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:
"
2024,"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 ------
"
2025,"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 ------
"
2026,"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 ------
"
2027,"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
"
2028,"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:
"
2029,"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
"
2030,"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
"
2031,"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
"
2032,"title:
   respiratory care: alb/atr nebs administered as ordered q 6hrs with no
   adverse reactions. bs are coarse bilaterally.
"
2033,"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
"
2034,"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
"
2035,"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 ------
"
2036,"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 ------
"
2037,"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.
"
2038,"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
"
2039,"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
"
2040,"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.
"
2041,"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 ------
"
2042,"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:
"
2043,"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
"
2044,"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
"
2045,"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
"
2046,"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.
"
2047,"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.
"
2048,"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.
"
2049,"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:
"
2050,"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:
"
2051,"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:
"
2052,"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.
"
2053,"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.
"
2054,"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.
"
2055,"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:
"
2056,"[**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.

"
2057,"[**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.


"
2058,"[**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.

"
2059,"[**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.

"
2060,"[**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.




"
2061,"[**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.

"
2062,"[**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.



"
2063,"[**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.

"
2064,"[**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.



"
2065,"[**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)

"
2066,"[**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.




"
2067,"[**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)

"
2068,"[**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)

"
2069,"[**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)

"
2070,"[**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.



"
2071,"[**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.


"
2072,"[**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.


"
2073,"[**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)

"
2074,"[**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.

"
2075,"[**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.



"
2076,"[**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)

"
2077,"[**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.



"
2078,"[**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.



"
2079,"[**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.


"
2080,"[**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)

"
2081,"[**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)

"
2082,"[**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)

"
2083,"[**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.

"
2084,"[**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)

"
2085,"[**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.

"
2086,"[**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.


"
2087,"[**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.

"
2088,"[**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.






"
2089,"[**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)

"
2090,"[**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.

"
2091,"[**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.

"
2092,"[**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.


"
2093,"[**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.


"
2094,"[**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)

"
2095,"[**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.









"
2096,"[**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.

"
2097,"[**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.

"
2098,"[**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)

"
2099,"[**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.


"
2100,"[**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.

"
2101,"[**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.

"
2102,"[**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)

"
2103,"[**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.

"
2104,"[**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)


"
2105,"[**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.


"
2106,"[**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.


"
2107,"[**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.

"
2108,"[**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.

"
2109,"[**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.



"
2110,"[**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.



"
2111,"[**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.


"
2112,"[**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.


"
2113,"[**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.


"
2114,"[**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.



"
2115,"[**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)

"
2116,"[**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.

"
2117,"[**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**].


"
2118,"[**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.



"
2119,"[**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)

"
2120,"[**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**].


"
2121,"[**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)


"
2122,"[**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.


"
2123,"[**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**].


"
2124,"[**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.



"
2125,"[**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.



"
2126,"[**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.



"
2127,"[**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)

"
2128,"[**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.



"
2129,"[**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


"
2130,"[**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.


"
2131,"[**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.

"
2132,"[**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.


"
2133,"[**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)

"
2134,"[**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.



"
2135,"[**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  21 year old man with
 reason for this examination:
  r/o inj
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: eez sat [**2185-1-29**] 12:58 am
  aorta ok. tiny, non-linear focus of decreased attenuation in posterior spleen,
  less than 1cm deep, too small to characterize by ct, but cannot exclude a
  small laceration. no perisplenic hematoma is present. no free fluid in abdomen
  or pelvis. no free air.
 ______________________________________________________________________________
                                 final report *abnormal!
 indication:    motor vehicle accident.

 technique: helically acquired axial images were obtained of the abdomen and
 pelvis from the lung bases to the pubic symphysis with 150 cc of optiray
 contrast.  there were no adverse reactions to contrast administration.
 multiplanar reformations were made.

 ct chest with contrast: the aorta is well opacified demonstrating no
 extravasation or contour abnormality. there is no aortic dissection or para
 aortic hematoma. age appropriate thymus tissue and a small pretracheal lymph
 node are present. evaluation of the lung parenchyma is limited due to
 respiratory motion but there are no gross consolidations or pulmonary
 contusions.  there is no pneumothorax. no rib fractures are seen.  there are
 no pleural or pericardial effusions.

 ct abdomen with contrast:  no hepatic lacerations or parahepatic hematoma is
 present.  there is no hematoma adjacent to the spleen but there is a tiny
 focal area of decreased attenuation along the posterior splenic border. no rib
 fractures are seen in this region.  there is no perisplenic hematoma. the area
 of decreased attenuation is too small to accurately characterize by ct, but
 overall depth is less than 1 cm.  the kidneys enhance symmetrically without
 evidence of obstruction or injury.  the adrenal glands, duodenum, pancreas and
 gallbladder are unremarkable.  intra abdominal loops are normal. there is no
 free air or free fluid within the abdomen or pelvis.

 ct pelvis with contrast: distal ureters are unremarkable. the bladder contains
 a foley catheter but is otherwise unremarkable. there is no free fluid in the
 pelvis or pelvic or inguinal lymphadenopathy.

 no fractures are seen.

 multiplanar reconstructions: coronal and sagittal reformats show no evidence
 of traumatic aortic injury.

                                                             (over)

 [**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report *abnormal!
 (cont)
 impression:
 1) no evidence of aortic injury.
 2) tiny focus of decreased attenuation in the posterior spleen, too small to
 characterize on ct.  there is no adjacent hematoma. overall depth of the area
 of decreased attenuation is less than 1 cm. a tiny laceration cannot be
 excluded.


"
2136,"[**2198-2-14**] 8:31 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8085**]
 ct 150cc nonionic contrast
 reason: s/p fall, trauma, r/o internal injuries, abdominal distension
 field of view: 36 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with s/p fall
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  status post 20 foot fall.

 ct abdomen and pelvis with contrast:

 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 abdomen with iv contrast: there is no basilar pneumothorax. there is a
 small left lower lobe contusion vs atelectasis. no pleural or pericardial
 effusions are present. no hepatic or splenic lacerations are seen. the
 kidneys, pancreas, gallbladder, and stomach are unremarkable. there  is motion
 throughout portions of the scan, limiting evaluation somewhat. there is no
 free fluid in the abdomen or evidence of free intra- abdoimnal air. the bowel
 is unremarkable.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable. there is no free fluid in the pelvis.subcutaneous contusion
 is see in the right buttock region

 osseous structures:  bilateral nonunionized apophyses are present adjacent to
 the posterior acetabular rim. no acute fractures are seen.

 impression:   no evidence of acute intra-abdominal injury.  no fractures seen.


"
2137,"[**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  59 year old man with
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications: trauma.

 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.  there were no adverse reactions to contrast administration.
 additional delay sequences of the superior mediastium and liver/spleen were
 acquired.

 ct of the chest with iv contrast: on the initial sequence, there is fluid
 density anterior to the distal ascending aorta.  on the delayed scan with a
 breath hold, this is not seen.  there is a small retrosternal hematoma, but
 the fat adjacent to the aorta is unremarkable. there is no evidence of
 extravasation of iv contrast from the aorta. on the reconstructed images, the
 aortic contours are smooth. there is no evidence of disssection.  there are
 areas of calcification in the aortic arch, and in the left subclavian artery.
 no pneumothorax is seen.  no focal pulmonary consolidations or contusions are
 seen.  there are no pleural or pericardial effusions.  no pathologically
 enlarged axillary, hilar, or mediastinal lymph nodes are seen.  no rib
 fractures are seen.  visualized portions of the clavicles and scapula appear
 intact.

 ct of the abdomen with iv contrast:  the liver and spleen are intact without
 focal laceration or adjacent hematoma.  the adrenal glands, pancreas, and
 kidneys show no evidence of acute traumatic injury.  there is no free
 intraabdominal air.  there is no free fluid within the abdomen or in the
 mesentery.  bowel loops are all normal in course and caliber.  the abdominal
 aorta is unremarkable.

 ct of the pelvis with iv contrast: the bladder contains a foley catheter with
 internal air.  there is no free fluid in the pelvis.  distal bowel is normal.

 bone windows: there is a comminuted fracture of the proximal right femur.
 within the proximal femoral diaphysis, there are three major fragments, one of
 which is anterior, the other lateral, and the final one is medial.  the
 lateral fragment is contiguous with the greater trochanter, femoral neck, and
 head. the anterior fragment is small and extends superiorly to the level of
 the femoral neck, where there is a small anterior cortical defect within the
 femoral neck, but no full thickness femoral neck fracture.  the smallest
 fragment is the medial fragment, which is highly comminuted, and it consists
 mostly of an avulsed lesser trochanter.  the left proximal femur is intact.
                                                             (over)

 [**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 osseous structures of the pelvis appear intact.  no spinal fractures are seen.
 note is made of a likely healed left 11th rib fracture laterally. there is
 extensive costal cartilage calcinosis.

 ct reconstructions:  coronal and sagittal reformations show a normal aortic
 contour.

 impression:
 1.  no aortic extravasation, periaortic hematoma, or dissection.
 2.  no evidence of acute traumatic intraabdominal injury.
 3.  comminuted fracture of the proximal right femur as described above.


"
2138,"[**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  68 year old man pod#3 s/p r colectomy now with increasing o2 requirement,
  hypoxia, and tachycardia
 reason for this examination:
  evaluate for pulmonary embolism
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: oxygen requirement.  evaluate for pulmonary embolism.

 technique: axial images of the chest were aquired helically from the lung
 bases through 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 angiography of the pulmonary vessels.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:

 ct chest with iv contrast:  the pulmonary vasculature is well opacified and
 demonstrates no intraluminal filling defects suggestive of pulmonary emboli.
 there is extensive collapse/consolidation in both lower lobes. small bilateral
 pleural effusions are present. portions of the right lower lobe consolidation
 are more patchy, raising suspicion for pneumonia.  there is an additional
 dense consolidation in the dependent portion of the right upper lobe which is
 suspicious for aspiration or pneumonia.  there is fluid within the esophagus.
 numerous small mediastinal lymph nodes are seen which do not meet size
 criteria for pathological enlargement by ct scan. no pathologically enlarged
 axillar or hilar nodes are seen.  osseous structures are unremarkable. limited
 evaluation of upper abdominal structures shows possible fluid adjacent to the
 liver and a cystic structure immediately under the left hemidiaphragm which is
 not fully evaluated.

 ct reconstructions: multiplanar reformations show no evidence of pulmonary
 embolism.

 impression:
 1) no evidence of pulmonary embolism.

 2) bilateral pleural effusions with extensive consolidation in both lower
 lobes and the right upper lobe from aspiration or pneumonia.

 3) fluid filled esophagus. further evaluation with barium esophagram may be
 performed to evaluate for achalasia, stricture, or possible reflux.

 results were discussed with the surgical team at the time of interpretation.

                                                             (over)

 [**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)










"
2139,"[**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
     66 year old man with persistent fevers, increasing abdominal pain, s/p
  ex-lap. also decreasing hematocrit.
 reason for this examination:
  evaluate for abscess/intra-abdominal infection, as well as source of bleeding.
  with po and iv contrast.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  fevers, increasing abdominal pain after exploratory laparotomy,
 decreasing hematocrit.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 findings:  comparison is made to the prior torso ct from [**12-28**] and the
 gallbladder ultrasound from [**2119-1-6**].

 ct of the abdomen with iv contrast:  there are moderate-sized bilateral
 pleural effusions with associated bibasilar atelectasis.  again identified is
 a likely cyst within the right posterior hepatic lobe inferiorly (segment vi).
 there is stable intrahepatic biliary ductal dilatation.  the gallbladder
 contains calcified stones and asymmetrical areas of wall thickening consistent
 with the previously seen adenomyomatosis.  the common bile duct remains
 prominent extending into the duodenum.  there is no stranding around the
 gallbladder.  the pancreas is unremarkable.  the adrenal glands and kidneys
 are unchanged.  within the posterior aspect of the spleen is a wedge-shaped
 focal area of decreased attenuation, which likely reprents an infarct.  the
 spleen has progressively enlarged over the past two ct scans, now measuring
 over 13 cm. the appearance of the stomach is unchanged. there is no evidence
 of bowel obstruction.

 ct of the pelvis with iv contrast:  again, there is a small amount of fluid in
 the pelvis, but no loculated pockets with enhancing rims or internal air to
 indicate an abscess.  multiple cecal diverticula are seen.  the appendix is
 visualized, and is filled with oral contrast, and normal.  again, there is a
 suggestion of cecal, and transverse colonic wall thickening.  again, these
 segments are not fully distended, limiting evaluation.  there is some ascites
 in the right inguinal fat-containing hernia.

 osseous structures:  no suspicious lytic or sclerotic lesions are present.

 impression:
                                                             (over)

 [**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 1) no definite intraabdominal abscess.  moderate bilateral pleural effusions
 with associated bibasilar atelectasis.
 2) progressive splenic enlargment compared to [**2118-12-28**] and [**2118-12-16**]. the spleen
 now measures over 13cm. findings are suspicous for possible lymphoma in the
 absence of other etiologies for splenic enlargement.

 results were discussed with dr. [**last name (stitle) 4478**] at 9:55 pm on [**2119-1-8**].

"
2140,"[**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old woman with s/p intramural hemmorage in sigmoid
 reason for this examination:
  s/p intramural hemmorage in sigmoid-?resolved
 ______________________________________________________________________________
                                 final report
 indications:  status post intramural hemorrhage in sigmoid colon.  evaluate
 for resolution.

 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.  non-ionic contrast was used secondary to the patient's
 asthma history.  there were no adverse reactions to contrast administration.

 findings:  comparison is made with the study from [**2158-12-7**].

 ct of the abdomen with iv contrast:  no focal lung lesions are identified.
 there are no pleural or pericardial effusions.  no focal liver lesions are
 identified.  the spleen contains several punctate calcifications, likely
 calcified granulomas.  the adrenal glands, pancreas, stomach, and
 intraabdominal loops of small bowel are unremarkable.  there is a single focus
 of decreased attenuation in the lower pole of the left kidney which likely
 represents a simple cyst, and is unchanged in appearance since the prior
 study.  the kidneys otherwise enhance symmetrically without evidence of focal
 mass or obstruction.  there is no ascites or pathological mesenteric or
 retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast:  there has been marked reduction in the
 previously seen sigmoidal wall thickening.  extensive diverticular disease and
 likely muscular hypertrophy in the sigmoid colon, but there is no evidence of
 surrounding stranding to indicate acute diverticulitis.  the previously seen
 small amount of free fluid in the pelvis has also resolved. distal ureters and
 bladder are unremarkable.  there is no pathological pelvic lymphadenopathy.

 a small sclerotic focus is seen in the superior pubic ramus, which is likely a
 bone island.  additional sclerotic foci are seen in lower-thoracic vertebral
 bodies, which are also likely bone islands.  no suspicious lytic lesions are
 identified.

 impression:
 1) marked improvement in the previously seen sigmoidal wall thickening, and
 resolution of free fluid in the pelvis.  extensive diverticular disease is
 present, but there is no evidence of acute diverticulitis.

 2) tiny left renal cyst.

 3) multiple splenic granulomas.
                                                             (over)

 [**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)



"
2141,"[**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  66 year old man with h/o gallstone/necrotizing pancreatitis and multiple
  drainage procedures
 reason for this examination:
  pancreatic protocol - renewed pancreatitis?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  history of necrotizing/gallstone pancreatitis.  evaluate for
 acute pancreatitis.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 comparison:  [**2107-2-10**] abdominal ct scan.

 findings:

 ct of the abdomen with iv contrast:  there are small bilateral pleural
 effusions, left greater than right, with associated compressive atelectasis of
 both lower lobes.  no focal liver lesions are identified.  the spleen, adrenal
 glands, kidneys, and stomach are unremarkable.  again seen are two drainage
 catheters in the region of the pancreas and a jejunostomy tube.  located
 immediately below the catheters are fluid pockets with internal air.  these
 appear slightly smaller than on the previous study.  only the head of the
 pancreas enhances. the degree of inflammatory change surrounding the pancreas
 has not changed appreciably. the fluid pocket adjacent to the tip of the
 pancreas extending inferiorly is unchanged.  the degree of abdominal
 stranding/fluid is unchanged.

 ct of the pelvis with iv contrast:  the distal ureters and bladder are
 unremarkable.  the bladder contains a foley catheter and internal air.  no
 sigmoid bowel wall thickening.  no pathologically enlarged inguinal or pelvic
 lymph nodes are seen.

 osseous structures are unchanged, again showing diffuse degenerative changes.

 impression:
 peripancreatic fluid collections with internal air slightly smaller adjacent
 to the two drainage catheters.  the degree of inflammatory stranding around
 the pancreas and in the abdomen has not changed significantly. only the
 pancreatic head enhances.

                                                             (over)

 [**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)


"
2142,"[**2146-12-28**] 7:12 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8484**]
 ct 100cc non ionic contrast
 reason: trauma
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with mva
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  trauma.

 technique:  axial images of the abdomen and pelvis were acquired helically
 from the lung bases through the pubic symphysis with 150 cc optiray contrast.
 there were no adverse reactions to contrast administration.

 findings:

 ct of the abdomen w/iv contrast:  there is a small focal area of consolidation
 in the right lower lobe, medial basal segment.  no pleural or pericardial
 effusions are seen.  there is periportal edema, consistent with vigorous fluid
 resuscitation.  the liver is intact without evidence of laceration.  the
 spleen appears intact.  the adrenal glands, kidneys, pancreas, and duodenum
 are all unremarkable.  the gallbladder is normal.  there is a general lack of
 intra-abdominal fat, limiting sensitivity for mesenteric injury.  there is no
 free fluid in the abdomen.  no free air is seen.

 ct of the pelvis w/iv contrast:  the bladder contains a foley catheter and
 air.  sigmoid colon and rectum are unremarkable.  there is no free fluid in
 the pelvis.

 no pelvic fractures are seen.  note is made of a densely sclerotic area in the
 left femoral neck, which likely represents a bone island.  there is a
 diminutive first right lumbar rib.  no rib fractures are seen.

 impression:

 1. no evidence of acute traumatic intra-abdominal injury.
 2. likely diminutive right first lumbar rib. no acute fracture.


"
2143,"[**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  62 year old woman with hx of bladder cancer with resection of tumor and
  retroperitoneal disection as well as chemotherapy.
 reason for this examination:
  pt with hx of bladder cancer with resection of right kidney and ureter as well
  as retroperitoneal dissection and has received chemotherapy now needs  ct of
  torso for staging.
 ______________________________________________________________________________
                                 final report
 indication:  renal cancer, status post resection of right kidney, ureter, and
 retroperitoneal dissection.

 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.

 comparison:  comparison is only able to be made to the study from [**2171-10-28**].  the more recent torso ct from [**2171-12-9**] is not available
 secondary to pacs malfunction.

 ct of the chest with iv contrast:  there are no pathologically enlarged
 axillary, hilar, or mediastinal lymph nodes.  there are no pleural or
 pericardial effusions.  again identified are multiple bilateral pulmonary
 nodules.  one previously seen nodule in the right lung base laterally is not
 visualized on the current study, but the largest nodule, in the left lung
 base, has increased in size.  the bronchi remain patent to the subsegmental
 levels.  the heart and great vessels is unremarkable.

 ct of the abdomen with iv contrast:  there has been marked progression of the
 patient's multiple hepatic masses.  there is some local biliary ductal
 dilatation adjacent to one of the masses in the right lobe.  surgical clips
 are seen in the right renal fossa from prior nephrectomy.  no soft tissue
 density suggestive of disease recurrence is present in this area.  there is a
 slight prominence of the first and second portion of the duodenum, but the
 bowel is not fully opacified, limiting evaluation.  the pancreas and adrenal
 glands, along with the spleen, and stomach are unremarkable.  the left kidney
 enhances uniformly.  there is no filling defect in the left renal pelvis or
 ureter.  no pathologically enlarged mesenteric or retroperitoneal lymph nodes
 are seen.  the descending aorta is calcified.  there is no ascites.

 ct of the pelvis with iv contrast:  the appearance of the cystic structure in
 the right adnexa is unchanged.  again seen is stranding in the presacral fat,
 likely post operative in nature, which is unchanged since [**2171-10-28**].
 the distal left ureter is unremarkable, with a normal appearing left ureteral
 jet.  the bladder is within normal limits.  there is no free fluid in the
 pelvis or pathological inguinal or pelvic lymphadenopathy, although multiple
                                                             (over)

 [**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 small pelvic nodes are seen which do not meet size criteria for pathological
 enlargement by ct scan.  the sigmoid colon and rectum are unremarkable.

 no new suspicious lytic or sclerotic osseous lesions are identified.

 impression:  progression of multiple intrahepatic masses, some of which are
 associated with localized biliary ductal dilatation.  no ascites.  enlargement
 of pulmonary nodule in left lung base.  findings all consistent with
 progression of disease.

"
2144,"[**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   42 year old man with pod#10 s/p ex-lap, small bowel resection x4, found to
  have celiac sprue, t-cell lymphoma on path, now w/ temps post-op, and new pus
  draining from ex-lap wound.
 reason for this examination:
  evaluate for perforations, fluid collections, wound infection.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: celiac  sprue, multiple small bowel resections, now with post
 operative fevers, pus draining from exploratory laparotomy wound.  evaluate
 for intraabdominal abscess or perforation.

 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 contrast.  there were no adverse reactions to contrast
 administration.

 findings:  comparison is made to the study from [**2150-3-2**].

 ct abdomen with iv contrast: again seen is a rounded 4 mm nodule in the right
 lower lobe which is unchanged in appearance.  there is bibasilar atelectasis.
 no focal consolidations suggestive of pneumonia are present.  no focal hepatic
 lesions or splenic lesions are seen.  the pancreas and gallbladder are normal
 in appearance.  both adrenal glands and kidneys are unremarkable.  multiple
 surgical suture lines are seen throughout the small bowel.  there are multiple
 dilated small bowel loops, and enlarged mesenteric lymph nodes.  the
 appearance is unchanged since [**2150-3-2**]. there is no free intraperitoneal
 air. again seen is a heterogeneous area of attenuation in the anterior
 abdominal wall in between the rectus muscles, which measures 13 x 22 mm on
 today's study.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable.  again seen is a small amount of fluid adjacent to the
 sigmoid mesocolon which is slightly smaller than on the previous study.  no
 new intrapelvic abscess is present.  there is no pathologic inguinal or pelvic
 lymphadenopathy.

 impression: no new focal intraabdominal abscess.  stable appearance of
 multiple small bowel resections, with dilated small bowel loops and mesenteric
 lymphadenopathy.

                                                             (over)

 [**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

"
2145,"[**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  32 year old woman with ard and pancreatitis s/p multiple medication overdose
 reason for this examination:
  please check pancreas for necorsis by pancreatitis protocol and evaluate lungs
  for ards
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  multiple medication overdose, with pancreatitis and acute
 respiratory distress.

 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 patient's debility.  there were no adverse reactions to
 contrast administration.

 findings:  reference is made to the portable ap chest x-ray from [**2167-2-16**].

 ct of the chest with iv contrast:  again seen are sternal wires.  the
 orogastric and post-pyloric feeding tubes in appropriate positions.  the
 endotracheal tube is present in satisfactory position.  there are extensive
 bilateral areas of ground-glass opacity and consolidation consistent with
 ards.  there are small bilateral pleural effusions.  no pericardial effusion
 is seen.  oral contrast is seen within the thoracic esophagus, suggestive of
 possible aspiration. there are multiple prominent mediastinal lymph nodes,
 which are likely reactive.

 ct of the abdomen with iv contrast:  no focal hepatic lesions are identified.
 the spleen, adrenal glands, kidneys, stomach, and intra-abdominal loops of
 small and large bowel are unremarkable.  the gallbladder is mildly distended,
 but there is no adjacent stranding to suggest acute cholecystitis.  the
 pancreas enhances symmetrically without adjacent fluid collection.  there is
 minimal stranding adjacent to the pancreatic tail, consistent with the
 patient's known pancreatitis.  there is no ascites or pathological mesenteric
 or retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast: the appendix, distal ureters, sigmoid
 colon, and rectum are within normal limits.  there is a small amount of free
 fluid within the pouch of [**location (un) **].  the bladder contains a foley catheter.
 there is no pathological inguinal or pelvic lymphadenopathy.

 no suspicious lytic or sclerotic osseous lesions are identified.

 impression:
                                                             (over)

 [**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 1)  stranding adjacent to the tail of the pancreas consistent with patient's
 known pancreatitis.  no peripancreatic fluid collection or hematoma or
 abnormal pancreatic perfusion.

 2)  ards.


"
2146,"[**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  44 year old man with all s/p allo-bmt with likely cmv colitis here with new,
  diffuse abdominal tenderness.
 reason for this examination:
  eval for evidence of perforation, other pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 history:  all s/p bone marrow transplant. diffuse abdominal tenderness, likely
 cmv colitis.

 comparison:  no prior ct studies.

 technique:  helically acquired contiguous axial images of the abdomen and
 pelvis were obtained with intravenous optiray per cte  protocol.  however,
 oral contrast was not administered secondary to the patient's inability to
 tolerate po intake or an ng tube, due to esophageal ulcers.  coronal
 reconstructions were performed.

 contrast: 122 cc  of intravenous optray were administered through a right
 antecubital iv catheter. during the initial injection, a few cc's of optiray
 squirted out between the external portion of the iv catheter and the power
 injector tubing. there was no subcutaneous infiltration of optiray. the
 intravenous line remained patent, allowing for normal drawing back of blood
 and flushing with saline.  the power injector was reconnected to the iv
 catheter, and injection of optiray was continued without further
 complications. the intravenous line was removed immediately after the study to
 reduce the risk of infection.  there was no adverse reaction to optiray during
 or immediately following the study.

 abdomen ct with intravenous contrast:  several subcentimeter nodular opacities
 are present at the visualized lung bases.  the largest opacity in the right
 lower lobe measures 8 mm, and the largest opacity in the left lower lobe
 measures  5 mm.  there are no pleural effusions.

 there is diffuse wall thickening in the proximal small bowel, with associated
 stranding and small lymph nodes in the proximal mesentery.  both the proximal
 and distal small bowel is distended with fluid.  however, there is no wall
 thickening in the distal small bowel, including the terminal ileum.  this
 appearance is consistent with enteritis, which may be due to graft-vs-host
 disease or infection.

 there is a 2 mm appendicolith within the appendix.  the appendix does not
 contain any air.  it measures 8 mm in cross-section diameter at the level of
 the appendicolith, but appears smaller distal to the stone. the cecal tip
 appears mildly thickened. there is some periappendiceal stranding, which is
                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)
 less advanced than the stranding in the proximal small bowel mesentery. there
 is no periappendiceal free air or fluid collection. these findings are
 equivocal regarding the presence of appendicitis. there may be mild typhlitis
 at the cecal tip , consistent with graft-vs-host disease. serial clinical
 exams are suggested. if clinically indicated, repeat imaging of the appendix
 may be helpful.

 the remainder of the ascending colon and the transverse colon are distended
 with fluid, without wall thickening.  the descending and sigmoid colon are
 collapsed. there is no free air or free fluid. in addition to the previously
 described proximal mesenteric stranding and small mesenteric lymph nodes,
 there is stranding and small lymph nodes in the para-aortic retroperitoneum.
 the liver, gallbladder, spleen, pancreas, kidneys, adrenal glands and ureters
 are unremarkable.

 pelvis ct with intravenous contrast:  calcifications are seen within the
 prostate gland.  the bladder, seminal vesicles and rectum are unremarkable.
 there is no pelvic or inguinal lymphadenopathy. there is no free fluid.

 bone windows:  there are no suspicious lytic or sclerotic lesions within the
 visualized osseous structures.

 ct reconstructions:  coronal reconstructions confirm the presence of wall
 thickening in the proximal small  bowel, with adjacent mesenteric stranding.

 the findings were discussed with dr. [**last name (stitle) 104418**] at 11:40 pm on [**2140-4-5**].

 impression:

 1)  proximal enteritis, which may represent graft-vs-host disease or
 infection.

 2)  appendicolith.  the appearance of the appendix is equivocal for
 appendicitis.  there may be mild typhlitis. serial abdominal exams are
 suggested. if clinically indicated, repeated imaging of the appendix may be
 helpful.

 3) subcentimeter peripheral nodular opacities at both lung bases, which are
 nonspecific. follow-up is suggested.





                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)




"
2147,"[**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  60 year old man with
 reason for this examination:
  fu aortic dissection and last week 4 d sx sob, chest pain radiating to back
 ______________________________________________________________________________
                                 final report
 indications: followup of aortic dissection. chest pain radiating to back.

 technique: contiguous axial images of the chest and abdomen were acquired
 helically from the lung apices through the proximal common iliac vessels,
 before and after administration of 150 cc of optiray contrast, secondary to
 the rapid bolus injection rate required for ct angiography of the aorta. there
 were no adverse reactions to contrast administration. coronal reformations
 were made.

 findings: comparison is made to the chest cta from [**2178-11-3**].

 ct chest with iv contrast:  again seen are changes from repair of a prior
 aortic dissection, with graft material extending from the aortic root to the
 proximal aortic arch. no extravasation is seen.  previously seen small amount
 of contrast in the false lumen and aortic arch is no longer present. the
 origins of the brachiocephalic, left common carotid, and subclavian arteries
 are all patent. no contrast is seen in the false lumen, until the dome of the
 right hemidiaphragm. there is a tiny circular area of contrast present which
 is not continuous with either the true lumen or the more inferiorly mixing
 contrast within the false lumen. there is symmetrical opacification of the
 true and false lumens by the level of the aortic hiatus in the diaphragm. the
 true lumen perfuses the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left renal artery is fed by both
 the true and false lumens.  the dissection flap extends into both common iliac
 vessels for a longer extent into the left than into the right. there is no
 peri-aortic hematoma or evidence of active extravasation. there are no pleural
 or pericardial effusions. emphysematous changes are seen in the lungs. again
 identified is a small, ill defined right middle lobe nodule which is unchanged
 in appearance. bibasilar atelectasis is seen.  no pathologically enlarged,
 axillary, hilar, or mediastinal lymph nodes are seen.

 ct abdomen with iv contrast: limited evaluation with only one phase of
 contrast shows no focal hepatic or splenic lesions. multiple bilateral renal
 cysts are present which are unchanged in appearance. visualized portions of
 intra-abdominal bowel loops are unremarkable.  the adrenal glands are normal.
 ct reconstructions: coronal reformats show a stable appearance of the aortic
 disection, without definite evidence of leak.

 impression:

 1. status post surgical repair of prior type a dissection. overall, appearance
                                                             (over)

 [**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 is unchanged compared to [**2178-11-3**].  the previously seen small amount of
 contrast in the false lumen in the aortic arch is no longer present.  the true
 lumen supplies the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left kidney is supplied from
 both the false and true lumen. there is a small rounded contrast pocket within
 the false lumen located slightly above the site of mixing, but this is not
 definitely connectable to either the true lumen, or to the mixing contrast.



"
2148,"[**2129-10-30**] 1:23 pm
 cta head w&w/o c & recons; ct 150cc nonionic contrast           clip # [**clip number (radiology) 85922**]
 reason: ? bleed and emboli
 admitting diagnosis: pulmonary edema,dm
  contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   74 year old man with history of somnolence, now w/ acute delta ma, lethargy

 reason for this examination:
  ? bleed and emboli
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 indication:  acute mental status changes.  history of endocarditis.  evaluate
 for embolus or stroke.

 technique:  axial images of the brain were acquired before and after
 administration of 150 cc of optiray contrast.  nonionic contrast was used
 secondary to the rapid bolus infusion rate required for ct angiography.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:  comparison is made to the study from [**2129-10-16**].  again
 identified is an old left frontal lobe infarct.  there is no acute intra- or
 extra-axial hemorrhage, hydrocephalus, or shift of normally midline
 structures.  no areas of abnormal enhancement are present to suggest septic
 emboli.  there is no evidence of impending herniation.

 both internal carotid arteries are visualized.  there is moderate stenosis of
 the distal cervical portion of the right internal carotid artery, likely due
 to atherosclerotic disease, albeit this is a somewhat unusual locale.
 atherosclerosis seems more likely than dissection, as the vessel shows mural
 calcifications, and there is a history of diabetes as well. note is made of
 moderately stenotic left cavernous carotid artery.  the middle cerebral
 arteries to the level of the bifurcation, anterior communicating artery, and
 anterior cerebral arteries are unremarkable.  both vertebral arteries are
 patent.  the basilar artery is slightly small, but demonstrates good flow, and
 fills both posterior cerebral arteries, the proximal portions of which are
 normal.

 impression:  remote infarct of left frontal lobe.  atherosclerotic stenoses
 as noted above.


"
2149,"[**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  55 year old woman with
 reason for this examination:
  55 yo female.  change in bowel habits.  unable to do colonoscopy secondary to
  adverse reactions to sedations.  request ct colonography to screen for colon
  ca.
 ______________________________________________________________________________
                                 final report
 indication:  recent change in bowel habits, unable to tolerate conventional
 colonoscopy secondary to adverse reaction to conscious sedation.  assess for
 colon cancer.

 technique:  contiguous axial images were obtained from the lung bases to the
 pubic symphysis after insufflation of intrarectal air in the prone and supine
 positions.  iv contrast was not administered.

 comparison:  ct abdomen/pelvis of [**2180-9-28**].

 ct colonography:  no suspicious lesions are seen.  there is no evidence of
 polyps, masses, strictures, or inflammatory disease.  there is a small amount
 of fluid within the cecum, descending colon and sigmoid which displaces with
 repositioning.  there is minimal retained fecal matter.

 ct of abdomen w/o iv contrast:  the imaged portions of the lung bases again
 show a 1-2 mm noncalcified nodule of the peripheral right lower lobe.  the
 liver, spleen, pancreas, adrenal glands, kidneys, and unopacified loops of
 small bowel are unremarkable.  there is no free air, free fluid, or
 lymphadenopathy.  the patient has had a previous cholecystectomy.

 ct of pelvis w/o iv contrast:  the rectum, urinary bladder and adnexal regions
 are unremarkable.  there is no free air, free fluid, or lymphadenopathy.

 bone windows:  there are no suspicious osseous lesions.

 multiplanar reformatted images and full endoluminal navigation performed in
 the antegrade and retrograde direction confirm and aid in the above findings.

 conclusion:
 1)  no significant polyp or mass identified (greater than 1 cm).  please note
 that the sensitivity of ct colonography for polyps greater than 1 cm is
 85-90%.  the sensitivity for polyps 6-9 mm is about 60-70%.  flat lesions may
 be missed with ct colonography.

 2)  stable 1-2 mm noncalcified nodule within the right lower lobe, likely
 representing a benign granuloma.  in the absence of any known primary
 malignancies, no further follow up is needed.

                                                             (over)

 [**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
                                 final report
 (cont)

"
2150,"[**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  36 year old man with cerebral palsy, epilepsy and history of recurrent
  aspiration pneumonias now with fever, rll cavitation
 reason for this examination:
  please assess for lung abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  cerebral palsy, epilepsy, and history of recurrent aspiration
 pneumonia.  now with fever, and right lower lobe cavitation on chest x-ray.
 please assess for lung abscess.

 comparison:  no prior chest ct.  chest radiograph of [**2191-11-7**] is
 available for comparison.

 technique:  axial multidetector ct images were obtained from the thoracic
 inlet through the adrenal glands without intravenous contrast.

 chest ct without contrast:  there is extensive consolidation in the right
 middle and lower lobes.  evaluation of these areas is somewhat limited by the
 patient's body habitus, lack of intravenous contrast enhancement, and streak
 artifact from surgical hardware in the spine.  there is a large rounded cavity
 with irregular margins and a fluid level in the right lower lobe, which
 appears most consistent with an abscess.  there are necrotizing areas in the
 adjacent lung in the right lower and middle lobes.  no definite pleural
 disease is seen in this area or in the remainder of the thorax.  there are
 patchy peribronchiolar ground-glass opacities in the dependent portions of the
 left lung, suggestive of aspiration.  paraseptal emphysema is noted in the
 medial left lower lobe.

 the airways appear patent to the level of segmental bronchi.  there is no
 mediastinal or axillary lymphadenopathy.  the heart and great vessels appear
 unremarkable.

 there is high-density material layering within the gallbladder, suggestive of
 previously administered intravenous contrast.  the patient did not have any
 radiology studies with intravenous contrast at our institution. alternatively,
 this finding may represent unusually dense sludge or stones. clinical
 correlation is suggested. there is a hiatal hernia.  there are gas-distended
 bowel loops in the upper abdomen.  clinical correlation is suggested.
 evaluation of the visualized portions of the liver, spleen, pancreas, adrenal
 glands, and kidneys is limited by streak artifact from the [**location (un) 1354**] rod in
 the spine. no abnormalities are detected.  marked scoliosis is noted.

 the findings were discussed with dr. [**last name (stitle) 25949**] at 10:50 a.m. on [**2191-11-8**].

 impression:
                                                             (over)

 [**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
                                 final report
 (cont)

 1.  necrotizing right middle and lower lobe pneumonia with a large abscess in
 the right lower lobe.

 2.  patchy ground-glass opacities in the left lung, with appearance suggestive
 of aspiration.

 3.  dense material in the gallbladder, which may represent intravenous
 contrast or unusually dense sludge or stones.  contrast in the gallbladder
 could represent an adverse reaction to intravenous contrast, or it may be seen
 in renal failure.

 4.  gas-distented bowel loops, incompletely assessed. consider dedicated
 abdominal radiograph series.

 5.  hiatal hernia.


"
2151,"[**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  72 year old woman pod4 from r. colectomy for cecal mass, now with fevers,
  tachycardia, incr abd distention, tenderness
 reason for this examination:
  assess for leak, collections
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  72-year-old female with abdominal distention.

 comparisons:  comparison is made to ct of the abdomen from [**2126-11-19**] and ct
 of the abdomen from [**2126-11-14**].

 technique:  ct of the abdomen and pelvis with oral and iv contrast.  150 cc of
 optiray 350 were administered without adverse reaction.

 coronal reconstructions were performed.

 ct of the abdomen with oral and iv contrast:  there are mild atelectatic
 changes in the right base.  there are no pleural effusions.  there is a small
 hiatal hernia.  there is no pericardial effusion.  the liver is slightly
 fatty.  however, there are no focal lesions.  there are two gallstones within
 the gallbladder.  there is no evidence of cholecystitis.  the spleen, adrenal
 glands are unremarkable.  there is a small hypodense area in the mid pole of
 the right kidney that was not completely evaluated in this study.  although
 statistically, it most likely represents a simple cyst, ultrasound could be
 performed to further evaluate this.

 there is a large transverse incision in the right aspect of the abdomen. there
 is fluid and air in the subcutaneous tissues, which could be postoperative.
 however, infection cannot be excluded on the basis of the ct scan.

 the proximal small bowel loops contain contrast and are dilated.  the distal
 small bowel loops are slightly decompressed.  however, there is contrast in
 the distal small bowel loops and the appearance most likely represents an
 ileus.  there are staples in the splenic flexure of the colon from prior right
 colectomy.  there are several slightly thickened small bowel loops, however,
 this appearance could be postoperative.  there is no evidence of free air or
 fluid collections within the abdomen.

 ct of the pelvis with oral and iv contrast:  there are multiple diverticula
 within the colon without evidence of diverticulitis.  as described above, the
 same postoperative changes are present in the pelvis.  there are also multiple
 mesenteric lymph nodes that are small and do not meet ct criteria for
 pathology.  there is no significant free fluid in the pelvis.  there is a
 foley catheter within the urinary bladder, which contains air.  the rectum is
                                                             (over)

 [**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
                                 final report
 (cont)
 unremarkable.

 bone windows:  there are no suspicious lytic or blastic lesions.

 impression:

 1.  postoperative changes as described above.  fluid and air in subcutaneous
 tissues could be postoperative, but infection cannot be excluded by ct scan.

 2.  mildly dilated loops of small bowel likely representing ileus.

 3.  multiple small mesenteric lymph nodes as described above.  they do not
 meet ct criteria for pathology and attention at followup is recommended.

 4.  multiple gallstones.

 5.  fatty liver without focal lesions in the liver.

 6.  diverticular disease without evidence of diverticulitis.

 7.  small hypodense area in the mid pole of the right kidney was not
 completely evaluated in this study.  although statistically, it most likely
 represents a simple cyst, ultrasound could be performed to further evaluate
 this.

"
2152,"[**2113-7-18**] 7:48 am
 lumbar puncture                                                 clip # [**clip number (radiology) 42757**]
 reason: please do lumbar puncture, not cervical - ? cns infection
 admitting diagnosis: weakness
 ********************************* cpt codes ********************************
 * [**numeric identifier 2678**] lumbar spinal puncture          [**numeric identifier 2679**] fluoro guid for spine diag/the   *
 ****************************************************************************
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  78 year old man with waxing/[**doctor last name 561**] mental status - ? cns infection, unable to
  obtain lp.
 reason for this examination:
  please do lumbar puncture, not cervical - ? cns infection; please also note the
  patient should receive no benzos for sedation given prior adverse reactions.
 ______________________________________________________________________________
                                 final report
 indication:  78-year-old male patient with waxing and [**doctor last name 561**] mental status
 changes.  evaluate for cns infection.  referring service unable to obtain
 bedside lumbar puncture.

 radiologist:  drs. [**first name8 (namepattern2) 4228**] [**last name (namepattern1) 33771**] and [**first name8 (namepattern2) **] [**last name (namepattern1) 722**], the attending
 neuroradiologist, was present and supervising throughout the procedure.

 procedure and findings:  the risks and benefits of the procedure were
 discussed with the patient through a portuguese interpreter.  written informed
 consent was obtained.  a preprocedure timeout was performed using two patient
 identifiers.

 the patient was brought to the fluoroscopy suite and placed on the
 angiographic table in prone position.  the lower back was prepped and draped
 in the usual sterile fashion.  using fluoroscopic guidance in ap and lateral
 planes, a suitable location for lumbar puncture was identified at the l2-3
 level.  approximately 10 cc of 1% lidocaine was used for local anesthesia.
 using fluoroscopic guidance, a 22 gauge spinal needle was used to access the
 lumbar subarachnoid space at the l2-3 level.  approximately 12 cc (four tubes,
 2 cc, 3 cc, 3 cc and 4 cc) of clear cerebrospinal fluid was removed and
 submitted to the laboratory for requested diagnostic test.  the patient
 tolerated the procedure well without immediate complications.

 impression:  technically successful fluoroscopic guided lumbar puncture.  csf
 samples sent for laboratory analysis.

"
2153,"[**2137-6-1**] 10:51 am
 mr hip w&w/o contrast left; mr 3d rendering w/post processing on independent wsclip # [**telephone/fax (1) 89222**]
 reason: preop planning - eval neurovascular structures, response to
  contrast: magnevist amt: 13
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  42 year old man with left posterior hip chondrosarcoma soft tissue recurrence
  s/p xrt/chemo
 reason for this examination:
  preop planning - eval neurovascular structures, response to tx
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  left posterior hip chondrosarcoma with soft tissue recurrence status
 post radiation therapy and chemotherapy.  preoperative evaluation.

 comparison:  mr thigh, [**2136-1-30**], and ct pelvis [**2137-4-29**].

 technique:  the following sequences of the pelvis and superior thighs were
 obtained on a 1.5 tesla magnet:  axial t1, axial t2, axial stir, coronal t1,
 axial 3d spgr pre- and post-contrast, coronal 3d spgr post-contrast, axial t1
 post-contrast with fat suppression.  gadolinium-dtpa was administered without
 adverse reaction.

 findings:

 the patient is status post left hip bipolar arthroplasty, and susceptibility
 artifact from the hardware slightly limits evaluation of the adjacent
 structures.

 again demonstrated centered within the gluteus muscles, especially the gluteus
 maximus, is a lobulated, multiseptated lesion which measures 14.0 x 7.2 x 18.2
 cm.  this lesion is predominantly hypointense on t1-weighted imaging with
 respect to the surrounding musculature and hyperintense on t2- weighted
 imaging.  post-contrast administration, there is predominantly peripheral rim
 enhancement with minimal internal enhancement of the septations.  given the
 lack of internal enhancement and predominantly fluid signal of the lesion, a
 large amount of necrosis is likely present in this mass.  no nodular
 enhancement is seen within the lesion.  this lesion drapes around the
 posterior aspect of the left ischial tuberosity, and extends along the course
 of the left sciatic nerve, which appears expanded and demonstrates
 heterogeneous high signal on t2-weighted imaging.  additionally, it appears
 that there is perineural extension of the tumor to involve the left s1, s2,
 and s3 nerve roots as they exit the neural foramina, as these nerve roots
 appear enlarged.  the extent of this mass overall appears grossly unchanged
 from the previous ct.

 subcutaneous edema is demonstrated within the scar in the left lateral
 proximal thigh.  edema is also seen along the superior fascial planes of the
 left hamstring muscles.  presacral edema is also present which crosses the
 midline and involves the right pelvis.

 there also appears to be abnormal signal involving the left piriformis and
                                                             (over)

 [**2137-6-1**] 10:51 am
 mr hip w&w/o contrast left; mr 3d rendering w/post processing on independent wsclip # [**telephone/fax (1) 89222**]
 reason: preop planning - eval neurovascular structures, response to
  contrast: magnevist amt: 13
 ______________________________________________________________________________
                                 final report
 (cont)
 obturator internus muscles, similar to the prior ct.

 visualized intrapelvic parenchymal structures appear grossly unchanged.  no
 pelvic or inguinal lymphadenopathy is demonstrated.

 the remaining bone marrow signal appears within normal limits.

 impression:

 1.  soft tissue recurrence involving the left pelvis and hip which appears
 predominantly necrotic in nature.  there is extension of tumor into the pelvis
 along the left s1 through s3 nerve roots to the left neural foramina, as well
 as along the entire course of the left sciatic nerve.

 2.  presacral edema extends to the right of midline.

"
2154,"[**2104-8-26**] 12:26 am
 mr head w & w/o contrast                                        clip # [**clip number (radiology) 45621**]
 reason: 41 year old man with left thalamic brain mass
 admitting diagnosis: brain mass
  contrast: magnevist amt: 12
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  41 year old man with left thalamic brain mass
 reason for this examination:
  41 year old man with left thalamic brain mass
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jrci [**name2 (ni) 2384**] [**2104-8-26**] 5:44 pm
  mass centered within the left thalamus with extension into the brainstem most
  consistent with a glioblastoma multiforme.  metastasis, lymphoma and pnet also
  in the differential.
 ______________________________________________________________________________
                                 final report
 study:  mri head with and without contrast.

 indication:  41-year-old male with left thalamic brain mass.

 comparison:  ct head without contrast, [**2104-8-25**].

 technique:  sagittal short tr, a short te spin echo images were obtained
 through the brain.  axial imaging was performed with long tr, long te, fast
 spin echo, flair, gradient echo, and diffusion technique.

 contrast: 12 ml magnevist gallium base contrast material was administered
 without adverse reaction.

 findings:  a lesion centered within the left thalamus demonstrates thick-
 walled nodular enhancement with patchy enhancement centrally with predominant
 non- enhancement centrally.  the lesion measures 3.6 (cc) x 3.3 (ap) x 3 cm
 (tr). there is approximately 8 mm of rightward shift of midline of the massa
 intermedia at this level.  superior and rightward mass effect is demonstrated
 upon the ipsilateral lateral ventricle.  a relatively large region of high
 signal flair abnormality is detected associated with this lesion extending
 throughout the entire ipsilateral basal ganglia and into the surrounding
 corona radiata.  there is inferior extension of a predominantly nonenhancing
 portion of the lesion inferiorly into the mid brain and pons.  flair high
 signal abnormality is seen extending into the ipsilateral middle cerebellar
 peduncle.

 diffusion-weighted imaging demonstrates slow diffusion within the enhancing
 portion of the lesion which may suggest a component of high cellularity.
 within the nonenhancing portion, there is a predominant component of fast
 diffusion which is suggestive of necrosis.

 impression:
 1.  irregular rim-enhancing mass centered within the left thalamus with
 inferior extension into the brainstem.  the imaging characteristics including
 inferior extension favor a glioblastoma multiforme.  less likely in the
                                                             (over)

 [**2104-8-26**] 12:26 am
 mr head w & w/o contrast                                        clip # [**clip number (radiology) 45621**]
 reason: 41 year old man with left thalamic brain mass
 admitting diagnosis: brain mass
  contrast: magnevist amt: 12
 ______________________________________________________________________________
                                 final report
 (cont)
 differential are metastasis, lymphoma and pnet.

 of note, it has been shown that slow diffusion within the enhancing portion of
 a glioblastoma multiforme, as in this case, is associated with an aggressive
 behavior.




"
2155,"[**2117-10-26**] 8:54 pm
 mr head w & w/o contrast; mr orbit w &w/o contrast              clip # [**clip number (radiology) 45362**]
 reason: evaluate for stroke, stenosis
 admitting diagnosis: stroke;telemetry;transient ischemic attack
  contrast: magnevist amt: 12
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  76 year old woman with sudden onset of right eye pain and visual blurring
 reason for this examination:
  evaluate for stroke, stenosis
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jrci wed [**2117-10-27**] 7:22 pm
  no evidence of infarction or orbital abnormality.
 ______________________________________________________________________________
                                 final report
 study:  mri brain and orbit.

 indication:  76-year-old female with sudden onset of right eye pain and visual
 blurring.

 comparison:  concurrent cta of the head and neck.

 technique:  sagittal short tr, short te spin echo images were obtained through
 the brain.  axial imaging was performed with long tr, long te, fast spin echo,
 flair, gradient echo, and diffusion technique.  short tr, short te spin echo
 imaging was repeated after intravenous administration of gadolinium-based
 contrast.  mri of the orbits was performed with coronal stir, axial and
 coronal precontrast t1w, and postcontrast fat-suppressed axial and coronal t1w
 images.

 contrast:  12 ml magnevist gadolinium based contrast material was administered
 without adverse reaction.

 mri head:  there is no evidence of hemorrhage, edema, masses, mass effect or
 infarction.  no diffusion abnormalities are detected. mild prominence of the
 sulci and ventricles is consistent with cerebral atrophy.  there is no flow
 void in the right internal carotid artery, corresponding to the occlusion
 demonstrated on the concurrent cta. a right frontal developmental venous
 anomaly is noted.  foci of high t2 signal in the subcortical, deep and
 periventricular white matter of the cerebral hemispheres, and in the right
 pons, likely correspond to chronic microvascular ischemic disease in a patient
 of this age.

 fluid and aerosolized secretions are present in the left maxillary sinus.

 mri orbits: coronal postcontrast images are limited by motion, but axial
 postcontrast images are diagnostic in quality. no abnormalities are detected
 in the orbits or cavernous sinuses. the optic nerves are normal in morphology
 and signal intensity.

 impression:

                                                             (over)

 [**2117-10-26**] 8:54 pm
 mr head w & w/o contrast; mr orbit w &w/o contrast              clip # [**clip number (radiology) 45362**]
 reason: evaluate for stroke, stenosis
 admitting diagnosis: stroke;telemetry;transient ischemic attack
  contrast: magnevist amt: 12
 ______________________________________________________________________________
                                 final report
 (cont)
 1.  occlusion of the right internal carotid artery, better demonstrated on the
 concurrent cta. no evidence of acute infarction.

 2.  chronic small vessel ischemic disease.

 3.  right frontal lobe developmental venous anomaly.

 4.  fluid and aerosolized secretions in the left maxillary sinus, which may
 indicate acute sinusitis.

 5.  normal appearance of the orbits.

"
2156,"[**2100-8-24**] 11:19 am
 ct t-spine w/ contrast                                          clip # [**clip number (radiology) 31907**]
 reason: pls perform with and without contrast to r/o infection/abces
 admitting diagnosis: pancoast tumor/sda
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  60 year old man with t1-3 lami and removal of pancoast tumor w/ chest wall
  reconstruction.
 reason for this examination:
  pls perform with and without contrast to r/o infection/abcess include cervical
  spine c6 thru t6 s/p t1-3 lami pod#8
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 study:  ct c-spine with contrast and reconstructions.

 indication:  60-year-old male with t1 through t3 laminectomy and removal of
 pancoast tumor with chest wall reconstruction.  please evaluate for infectious
 process, fever.

 comparison:  ct thoracic spine without contrast [**2100-8-17**], mri
 thoracic spine [**2100-8-4**].

 technique:  multidetector ct axially acquired images were obtained of the
 thoracic spine after the uneventful intravenous administration of contrast
 material.  multiplanar reformatted images were obtained.

 contrast:  100 cc optiray 350 is administered without adverse reaction.

 findings:  soft tissue with minimal enhancement is present within the
 postoperative bed status post right partial laminectomies from t1 through t3.
 the soft tissue findings obliterate the right paraspinal musculature, however,
 not appreciably changed since comparison study from [**8-17**].

 two new right apically oriented chest tubes are present.  an endotracheal tube
 is present in standard position approximately 5 cm from the [**month (only) 5381**].  ng tube
 courses through the mediastinum into the stomach and out of the field of view.
 a surgical drain is noted in the right mediastinum in between the azygos vein
 and right pulmonary artery.  the medial aspect of the right pleural effusion
 demonstrates a new loculated appearance (2a:51).  overall, the right
 pleural effusion is slightly larger with little change to a tiny effusion on
 the left. there is a mild increase in the degree of atelectasis on the left.

 impression:

 1.  no appreciable change in soft tissue appearance within the post-surgical
 bed. findings are difficult to distinguish between purely postoperative change
 versus superimposed infection; however, no findings specific to infection are
 detected. mri with gadolinium versus labled white blood cell nuclear medicine
 scan may be of use as necessary.

 2.  right pleural effusion is slightly larger with appearance of new medial
                                                             (over)

 [**2100-8-24**] 11:19 am
 ct t-spine w/ contrast                                          clip # [**clip number (radiology) 31907**]
 reason: pls perform with and without contrast to r/o infection/abces
 admitting diagnosis: pancoast tumor/sda
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 loculated component.



"
2157,"[**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  81 year old man with s/p mvc, ct without contrast showing ? hemothorax osh
 reason for this examination:
  please eval r/o intra thoracic injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: ipf [**doctor first name 137**] [**2161-10-15**] 8:48 pm
  right hemothorax with active extravasation from a branch of interal mammary
  artery.
  stranding in the mediastinum.
 ______________________________________________________________________________
                                 final report
 ct of the chest with contrast, ct of the abdomen with contrast, ct of the
 pelvis with contrast, [**2161-10-15**] at [**2086**] hours

 history:  post-trauma from motor vehicle collision with outside hospital
 non-contrast ct demonstrating a large hemothorax.  assess for thoracic
 vascular injury.  the patient is now hypotensive with hematocrit drop.

 technique:  serial transverse images were acquired sequentially during the
 arterial phase administration of 80 ml of optiray 350.  no adverse reaction
 was encountered.  multiplanar reformatted images were generated.

 comparison:  non-contrast torso ct obtained earlier same day from outside
 hospital and uploaded to local pacs.

 findings:  similar to the prior study performed without contrast, there is a
 large anterior extrapleural collection in the right hemithorax.  with the
 benefit of contrast, it is markedly heterogeneous with large areas of fluid
 attenuation, a high-attenuation fluid-fluid level, surrounding rim
 enhancement, and multiple foci of active extravasation of vessels.  one of the
 larger foci of active extravasation is seen on series 2 image #74.  this is at
 the level of a non-displaced transverse fracture of the distal sternal body.
 foci of active extravasation are also seen at slightly more cephalad levels
 including at the inferior margin of the second sternocostal junction and at
 the inferior margin of the first sternocostal margin all along the course of
 the right internal mammary artery.  these are presumed extravasations off
 direct branches from that vessel, likely the proximal aspects of the
 corresponding intercostal vessels.  a component of this large extrapleural
 hematoma extends along the retrosternal space anterior to the mediastinum and
 heart.  a corresponding anterior mediastinal hematoma is also present.  no
 aortic injury is identified.  there is mass effect on the heart, specifically
 the anterior aspect of the heart, principally the right ventricle.

 in addition to the large extrapleural anterior hematoma, there is a relative
 large free-flowing dependent hemothorax with a hematocrit level layering
 posteriorly in the right hemithorax.  the combination of both of these
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)
 hematomas, results in significant mass effect on the underlying lobes of the
 right lung with compressive atelectasis seen both in the right upper, right
 middle and right lower lobes.  a small effusion is identified on the left.
 there is calcification over the apex of the right lung, presumably along the
 visceral pleura.  no pneumothorax is present.  there are no focal
 consolidations or areas of pulmonary contusion identified.

 the study was acquired predominantly in expiratory phase with inward bowing of
 the posterior membrane of the trachea and the major bronchi.  however,
 otherwise the major airways are widely patent.  incidental note is made of an
 aortic origin of the left vertebral artery, an anatomic variant.  the aorta
 otherwise is intact with normal contour, caliber and course.  there is
 scattered calcified plaque seen at multiple levels.  there is no apparent
 aortic injury.  there is fullness in the supraclavicular space on the right.
 this is incompletely evaluated on this chest ct protocol.

 timing was not optimized for solid organ evaluation given the concern for
 vascular injury.  however, grossly there are no discrete traumatic lesions of
 the solid abdominal organs of the upper abdomen.  a focal curvilinear
 calcification in the right hepatic lobe likely is reflective of prior
 granulomatous insult.  there is a high-attenuation focus in the most inferior
 tip of the right hepatic lobe.  this is most reminiscent of a flash-filling
 hemangioma although focal nodular hyperplasia or adenoma may also be
 considered.  gallbladder is present but otherwise unremarkable.  bilateral
 kidneys enhance symmetrically.  there are small cortical scars on both kidneys
 presumably due to prior infection.  conceivably, these may reflect prior small
 infarcts as well.  a 10 mm x 30 mm hypoattenuated lesion is identified
 anteriorly in the pancreatic body.  this is incidental and not related to
 trauma.  no pancreatic ductal dilatation is evident.

 the stomach and small bowel are largely collapsed.  no wall thickening or
 dilatation is evident.  a normal appendix is identified.  there is scattered
 stool throughout the colon.

 similar to the chest, there is scattered calcified and non-calcified plaque of
 the abdominal aorta and major branch vessels.  eccentric irregular plaque is
 identified at the bifurcation of the right common iliac artery.  no pathologic
 lymphadenopathy is seen within the abdomen or pelvis.  there is no free
 intraperitoneal fluid or air.

 the urinary bladder is markedly distended.  there is an enlarged prostate.
 the enlargement of the prostate is relatively non-uniform with an irregular
 focus of enlargement centered at left of midline causing mass effect on the
 base of the bladder.  there is no apparent invasion.  however, given the
 relative morphology of the enlarged prostate, an underlying mass lesion such
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)
 as prostate cancer cannot be excluded.  seminal vesicles image normally.

 osseous structures:  aside from the non-displaced horizontal fracture through
 the distal sternal body described above, no further fracture of the chest,
 abdomen, or pelvis is identified.  there are no suspicious osseous lesions.
 multilevel degenerative disease is seen principally in the upper lumbar spine
 and in the mid lower thoracic spine.

 impression:

 1.  there is active extravasation of the medial branches of the right internal
 mammary artery into a large presumed extrapleural anterior right hemithorax
 hematoma.  there is some element of tamponade of this hematoma and a portion
 of it does extend along the retrosternal space.  there is minimal at this
 point mass effect on the underlying heart.

 2.  no apparent aortic injury.  no obvious cardiac injury; however, the
 evaluation for such is limited on ct.

 3.  large layering hemothorax posteriorly in the right chest as well.  small
 pleural effusion on the left.

 4.  as above, a non-displaced transverse distal sternal body fracture.  this
 coincidentally occurs at the site of the largest focus of extravasation
 detailed above.

 5.  no evidence of acute solid organ injury in the abdomen or pelvis.  there
 may have been prior infections or infarcts of the kidneys as detailed above.

 6.  enlarged and irregularly shaped prostate.  underlying prostate cancer
 cannot be excluded.  appropriate workup after acute presentation is resolved,
 may be pursued.

 7.  hypoattenuated lesion of the pancreas, nontraumatic in etiology.  further
 evaluation after emergent conditon is addressed should be pursued with
 referral to pancreas center and likely abdominal mri (without
 contraindication).

 the emergent results of the study were immediately placed on the ed dashboard
 as a wet read.  the study was also reviewed in person with surgical consult,
 dr. [**first name4 (namepattern1) 1688**] [**last name (namepattern1) 2723**], of the trauma surgery team at approximately 9 p.m.
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)

"
2158,"[**2165-10-27**] 2:52 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 50239**]
 reason: pe?
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  83 year old man with pleuritic chest pain and dyspnea, positive d-dimer.
  creatinine 1.6, baseline. hydrating.
 reason for this examination:
  pe?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sun [**2165-10-27**] 3:42 pm
  1. no pe or acute aortic syndrome.
  2. small (7-8 mm thick) pericardial effusion; may represent pericarditis in
  the setting of pleuritic chest pain; no compression of heart [**doctor last name 4473**] to
  suggest tamponade at this time.
  3. trace r and small l pleural effusions w/ associated atelectasis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with pleuritic chest pain and dyspnea.

 study:  chest cta.

 mdct images were generated through the chest without iv contrast.  subsequent
 mdct images were generated through the chest after administration of 100 cc of
 optiray intravenous contrast in the pulmonary arterial phase.  there is no
 adverse reaction or complication.  coronal, sagittal, and right and left
 oblique reformatted images were also generated.

 comparison:  v/q scan from [**2165-10-3**].

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.

 the aorta is of a normal caliber along its course without evidence of
 intramural hematoma or dissection.  minimal calcified atherosclerotic disease
 is seen in the aortic arch.  the pulmonary artery is of a normal caliber at
 its origin and there are no filling defects to the subsegmental level.
 coronary artery calcifications are seen bilaterally.  a small pericardial
 effusion is present, measuring up to 7 mm in thickness in the axial plane.
 subtle stranding is seen in the adjacent mediastinal fat.  the heart [**doctor last name 4473**]
 do not yet show evidence of compression.  bilateral pleural effusions are
 seen, trace on the right and small on the left, with associated atelectasis.
 otherwise, the lungs are clear.

 visualized portion of the upper abdomen shows no gross abnormality.  the
 previously described opacity in the posterior base of the lung still may
 represent an eventration versus a diaphragmatic hernia.

 the visualized bones demonstrate moderate degenerative changes of the thoracic
 spine, but there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2165-10-27**] 2:52 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 50239**]
 reason: pe?
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 1.  no pe or acute aortic syndrome.
 2.  pericardial effusion with surrounding inflammation, compatible with
 pericarditis.
 3.  small left and trace right pleural effusions with associated atelectasis.

"
2159,"[**2144-9-7**] 10:05 am
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 25226**]
 reason: r/o pe
 admitting diagnosis: pancreatitis
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  60 year old man with asthma, factor v leiden p/w etoh vs stone pancreatitis,
  transferred from osh with hypoxia, tachycardia
 reason for this examination:
  r/o pe
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2144-9-7**] 12:55 pm
  1.  pe involving the right lower lobe branch of the pulmonary artery without
  evidence right heart strain.  this finding was communicated to [**first name8 (namepattern2) 490**] [**last name (namepattern1) 1021**]
  at 12:27 p.m. on [**2144-9-7**] but [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
  2.  bilateral moderate pleural effusions with compressive atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with asthma, factor v leiden deficiency, now with
 pancreatitis; now with hypoxia and tachycardia.

 study:  chest cta; mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after the
 administration of 100 ml of intravenous contrast without complication or
 adverse reaction.  coronal, sagittal as well as right and left oblique
 reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.

 the pulmonary arterial trunk is of a normal caliber at its origin.  the
 pulmonary artery is of a normal caliber at its origin.  filling defect is
 noted at the right lower lobe branch of the pulmonary artery, which extends
 into the posterior basal, lateral basal, and anterior basal segments.

 the aorta is of a normal caliber along its course and shows no evidence of
 dissection or intramural hematoma.  there is no pericardial effusion. there is
 no inward bowing of the intraventricular septum into the left ventricle to
 suggest right heart strain.

 the visualized portion of the right lower lobe lung parenchyma shows no
 evidence of infarct.  a small area of ground-glass opacity is seen in the
 right upper lobe.  moderate bilateral simple pleural effusions are seen with
 associated compressive atelectasis.

 the visualized portion of the upper abdomen shows no overt abnormality.

 the visualized portion of the bones show no aggressive-appearing lytic or
 sclerotic lesions.
                                                             (over)

 [**2144-9-7**] 10:05 am
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 25226**]
 reason: r/o pe
 admitting diagnosis: pancreatitis
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 1.  pe involving the right lower lobe branch of the pulmonary artery without
 evidence right heart strain.  this finding was communicated to [**first name8 (namepattern2) 490**] [**last name (namepattern1) 1021**]
 at 12:27 p.m. on [**2144-9-7**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
 2.  bilateral moderate pleural effusions with compressive atelectasis.
 3.  small right upper lobe opacity - inflammatory versus infectious etiologies
 may be considered.

"
2160,"[**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old man with group g strep sepsis and unknown source
 reason for this examination:
  abscess?  gi pathology which might cause bacteremia?
 contraindications for iv contrast:
  esrd, gets hd on mondays, needs to have hd after scan;esrd, hd on mondays
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2186-7-31**] 11:56 pm
  1. no acute intra-abdominal process.
  2. ragged appearance of l4-l5 intervertebral disc endplates - this can be seen
  in discitis - correlate with patient's clinical condition.
 pfi version #1 jekh mon [**2186-7-31**] 12:59 pm
  no acute intra-abdominal process; specifically no evidence of a bacteremic
  source.
 ______________________________________________________________________________
                                 final report
 history:  45-year-old male with group g strep sepsis, an unknown source.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was given without complication or adverse reaction.
 coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  visualized portion of the lung bases appears unremarkable.

 the liver shows no focal lesion or biliary duct dilation.  the gallbladder is
 decompressed.  the spleen is normal in size and appearance.  pancreas shows no
 surrounding fluid collection.  the adrenal glands are normal appearing
 bilaterally.

 the kidneys enhance with and excrete contrast symmetrically without evidence
 of hydronephrosis or perinephric fluid collection.  in the inferior pole of
 the right kidney is a hypodensity that is too small to characterize but likely
 represents a simple cyst.

 the small and large intestine show no evidence of obstruction or wall edema.
 the appendix is visualized and is normal.  there is no free air, free fluid,
 or lymphadenopathy.

 pelvis:  the bladder, prostate, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.

 bones:  there are no aggressive appearing lytic or sclerotic lesions.
 moderate degenerative changes are seen throughout the lumbar spine.  anterior
                                                             (over)

 [**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 osteophytes are also noted throughout the lumbar spine.  at the l4-l5 level,
 there is enplate sclerosis, likely degenerative, however there is ragged or an
 erosive/destructive appearance to the adjacent endplates with mild soft tissue
 prominence anteriorly.

 impression:
 1. no acute intra-abdominal or intra-pelvic process.
 2. abnormal appearance of l4-l5 level, as described above, concerning for
 discitis/ostemyelitis - correlate with patient's clinical condition.

 findings discussed with [**first name8 (namepattern2) **] [**last name (un) 29352**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone at 8:49 am
 on [**2186-8-1**].

"
2161,"[**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old man with fall from roof, unequal bps
 reason for this examination:
  pls evaluate aortic arch
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2189-8-17**] 4:50 pm
  chest:
  1. 50% r anterior ptx w/ mediastinal shift and compressive effects on both
  lungs; r chest tube enters low and is oriented in posterior pleural space
  (away from ptx).
  2. no l ptx.
  3. no aortic or injury.
  4. extensive r chest wall emphysema.
  5. r posterolateral rib fx [**3-24**]; l posterolateral rib fx [**8-24**]; r clavicle fx.

  abdomen/pelvis:
  1. worsening hepatic and splenic lacerations w/ growing perihepatic and
  perisplenic hematomas - active extrav around spleen; small amt blood tracking
  along b paracolic gutters.
  2. prominent r adrenal gland - ? hematoma.
  3. no free intraabdominal air.
  4. extensive r abd/flank wall emphysema extending into r groin; early r flank
  hematoma.
  5. no spine or pelvic fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  75-year-old male with fall off roof of rv.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was given without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  torso ct from [**2189-8-17**], from an outside hospital at
 1304.

 findings:

 chest:  the patient is intubated with the tube terminating in the mid trachea.
 there is a pneumothorax involving 50% of the right hemithorax and is situated
 mostly anteriorly.  a chest tube placed on the right exists in the posterior
 pleural space, but does not come in contact with this pneumothorax.  there is
 severe mass effect on the right lung, mediastinum and left lung, consistent
 with tension pneumothorax.  additionally, extensive pneumomediastinum and
 pneumopericardium is noted.  both lungs demonstrate extensive atelectasis
 primarily in their lower lobes.  the heart shows no pericardial effusion.
 there is no mediastinal hematoma.  the aorta demonstrates no evidence of
                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 dissection.  there is no contrast extravasation.  extensive chest wall
 emphysema is demonstrated.

 abdomen:  multiple liver lacerations are demonstrated in segments v, vi, vii
 and viii with surrounding dense fluid around the liver and tracking along the
 right paracolic gutter.  a single focus of peripheral contrast blush is
 demonstrated in segment viii (2; 41), concerning for active extravasation.
 this appearance appears worse and has progressed from prior ct.

 multiple splenic lacerations are demonstrated with a growing surrounding
 splenic hematoma.  additionally, multiple areas of contrast blush are noted,
 concerning for active extravasation.  this fluid tracks along the left
 paracolic gutter.  this too represents an increase from prior study.

 thickening of the head of the right adrenal gland is compatible with hematoma.

 the kidneys enhance with and excrete contrast symmetrically.  there are no
 perinephric fluid collections.  pancreas appears unremarkable.  the small and
 large intestine show no evidence of obstruction or wall thickening.  there is
 no free air.  the abdominal aorta is intact.

 continued subcutaneous emphysema and a developing right flank hematoma are
 demonstrated along the right abdominal wall.

 pelvis:  the bladder contains locules of gas and a foley balloon.  the
 prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.  gas tracking along the right abdominal wall tracks down into
 the right groin.

 bones:  multiple segmental fractures are demonstrated in the right
 posterolateral ribs from the third rib through the twelfth rib; there is
 additionally a fracture of the right clavicle.  multiple posterolateral rib
 fracture is also noted in the left ribs 9 through 12 although they appear to
 be older in age.  no acute left rib fracture is seen.  no spinal fracture is
 demonstrated.  the sternum is intact.  the pelvis is intact.  a total hip
 arthroplasty on the left is in place without evidence of periprosthetic
 fracture or loosening.

 impression:
 1.  right tension pneumothorax; right chest tube and posterior pleural space,
 not evacuating this pneumothorax; mediastinal deviation and compression of the
 right and left lungs are concerning for tension pneumothorax.
 pneumomediastinum and pneumopericardium is also present along with extensive
 right chest and abdominal wall subcutaneous emphysema extending into the
 groin.

                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  extensive hepatic and splenic lacerations with growing perihepatic and
 perisplenic hematomas with areas concerning for active extravasation.

 points 1 and 2 were called to or 15 at the time of dictation to make the
 operating team aware.

 3.  multiple segmental rib fractures on the right; the potential for flail
 chest exists.  right clavicular fracture.

 4.  right adrenal hematoma.

"
2162,"[**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  36 year old woman with hemorrhagic pancreatitis s/p ercp for choledochal cyst
  s/p ex-laps/washouts, perc drain drain removed on [**2129-10-10**].
 reason for this examination:
  please do a ct scan of the abdomen and pelvis w/ oral and iv contrast to assess
  for recurrent collection. patientis having ongoing pain. please page dr. [**first name8 (namepattern2) **]
  [**last name (namepattern1) 1350**] w/ a wet read, thanks.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  36-year-old female with choledochal cyst status post ercp,
 complicated by hemorrhage pancreatitis and persistent fluid collection, now
 with percutaneous drain removed with recurrent abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; optiray 350 intravenous
 contrast was administered without complication or adverse reaction.  coronal
 and sagittal reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis with contrast from [**2129-8-26**].

 findings:

 abdomen:  the visualized portion of the lungs appears unremarkable.

 the liver demonstrates no defined hypodensity measuring 15 x 9 mm in the axial
 plane (4; 15), which is incompletely characterized but similar appearance to
 prior study.  again is seen fusiform aneurysmal dilatation of the cbd
 measuring 39 x 20 mm in the axial plane, compatible with a type 1 choledochal
 cyst.  the gallbladder is decompressed.  the spleen, pancreas and adrenal
 glands appear unremarkable.

 multiple fluid collections are seen in the abdomen.  two fluid collections
 just beneath the hepatic flexure of the colon are seen measuring 22 x 15 and
 44 x 11 mm in the axial plane (4; 33).  these are slightly decreased in size
 when compared to prior study.  further down in the right mid to lower abdomen
 is a larger fluid collection measuring 44 x 25 mm in the axial plane; two
 smaller fluid collections are seen lateral to it measuring 16 x 14 mm (4; 43)
 and 18 x 13 mm (4; 45).  these fluid collections are thick rimmed and
 peripherally enhancing.  there is extensive inflammatory fat stranding around
 them.  there is extensive right colonic wall thickening and pericolonic
 stranding, compatible with reactive change.  additionally, reactive fluid
 stranding around the right kidney represents reactive change.  there is no
 free air.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  no free fluid
 or lymphadenopathy is seen.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 multiple abdominal fluid collections as described above, concerning for
 abscesses, the largest of which measures 4.4 x 2.5 cm in the axial plane and
 is amenable to percutaneous drainage from an anterior approach.  these
 findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 1350**] at 16:40 on [**2129-10-18**] by [**first name8 (namepattern2) 405**]
 [**last name (namepattern1) 406**] over the phone.

"
2163,"[**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  51f s/p polytrauma, mult bilateral rib fx, bilateral ptx, now with bilateral
  chest tubes
 reason for this examination:
  pls assess residual ptx
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh tue [**2116-10-27**] 3:46 pm
  pfi:
  1.  worsening bilateral pneumothoraces; chest tubes within the major fissures
  bilaterally, but the right one has a side hole outside of the chest cavity.
  significant collapse of portions of the right upper and right lower lobes.
  extensive chest wall emphysema.
  2.  unchanged bilateral rib and lumbar transverse process fractures; complex
  pelvic fracture better evaluated on pelvic ct performed on same day.
  minimally displaced sternal fracture.
  3.  retroperitoneal and right paracolic fluid; thickening of the cecal wall
  likely represents an injury to the bowel, such as bowel wall hematoma.
  4.  no evidence of left renal injury.
 pfi version #1 jekh tue [**2116-10-27**] 2:51 pm
  pfi:
  1.  worsening bilateral pneumothoraces; current chest tubes still within the
  major fissures bilaterally.  significant collapse of portions of the right
  upper and right lower lobes.
  2.  unchanged bilateral rib and lumbar transverse process fractures; complex
  pelvic fracture better evaluated on pelvic ct performed on same day.
  minimally displaced sternal fracture.
  3.  retroperitoneal and right pericolic fluid extending from the pancreatic
  head, likely representing an injury in that location; thickening of the cecal
  and internal ileal walls either represents reactive changes from the
  aforementioned fluid versus an injury to the bowel:
  4.  no evidence of left renal injury.
 ______________________________________________________________________________
                                 final report
 history:  a 51-year-old female with multiple traumatic injuries including
 bilateral pneumothoraces with chest tubes.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  trauma torso ct from [**2116-10-25**].

 findings:

 chest:  the patient is still intubated with the endotracheal tube in
 appropriate position.  an endogastric tube courses inferiorly to the distal
                                                             (over)

 [**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 esophagus (2; 48).

 bilateral chest tubes are seen, both entering the major fissures; the right
 one has a side hole outside of the chest cavity (2;23).  bilateral
 pneumothoraces have increased significantly from prior study, now encompassing
 40% of the right hemithorax and about 20% of the left hemithorax. neither
 chest tube sits within the pneumothoraces which are both positioned
 anteriorly, extensive subcutaneous gas has progressed tracking along the
 anterolateral chest wall.  there is no mediastinal shift or diaphragmatic
 flattening.  there is significant atelectasis of the right upper and right
 lower lung lobes.

 there is no pleural or pericardial effusion.  the aorta appears intact.
 minimal mediastinal hematoma persists in the region of a minimally displaced
 sternal fracture (2; 31).

 abdomen:  there is no perihepatic or perisplenic fluid.  the gallbladder
 demonstrates vicarious contrast excretion, indicating a degree of renal
 failure.  the adrenal glands are normal bilaterally.  the previously described
 suspected left lower pole renal contusion has resolved.

 the pancreas appears intact.  there continues to be retroperitoneal fluid
 extending from the head down to the right flank/paracolic gutter.  this fluid
 is not increased from prior study.  there is thickening of the cecal wall,
 possibly represent an injury to the bowel in that locale.  there is no free
 air.

 the previously described subcutaneous emphysema in the chest extends down into
 the left flank.

 pelvis:  streak artifact from external pelvic fixation hardware limits
 assessment of fine detail of the pelvis.  within that limitation, the bladder
 is somewhat decompressed around a foley balloon.  there continues to be a
 fibroid uterus and the rectum is unremarkable.  there is still a small amount
 of free fluid in the pelvis.  additionally, there is subcutaneous gas in the
 right inguinal region as well as anterior to the pubic symphysis, likely the
 sequelae of hardware placement.

 bones:  again multiple rib fractures are seen affecting the anterolateral
 portions of the right first through seventh ribs and the left first through
 eighth ribs.  the previously described fracture of the right clavicle is not
 well visualized on the current study.  again seen are left transverse process
 fractures of the left lumbar vertebrae, first through fifth.  again seen is a
 severe pelvic fracture with significant displacement about the pubic symphysis
 and right sacroiliac joint and comminuted fracture fragments at the right
                                                             (over)

 [**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 iliac crest.  this structure is better evaluated on the pelvic ct performed on
 the same day in which specific bone algorithms were used.

 impression:
 1.  worsening bilateral pneumothoraces.  this finding was discussed with
 [**first name8 (namepattern2) 2763**] [**last name (namepattern1) 2764**] at 11:42 am on [**2116-10-27**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
 2.  chest tubes within the major fissures bilaterally, but the right one has a
 side hole outside of the chest cavity.  significant collapse of portions of
 the right upper and right lower lobes.  extensive chest wall emphysema.
 3.  unchanged bilateral rib and lumbar transverse process fractures; complex
 pelvic fracture better evaluated on pelvic ct performed on same day. minimally
 displaced sternal fracture.
 4.  retroperitoneal and right paracolic fluid and thickening of the cecal
 wall is compatible with contusion. there is no free air to suggest perforation
 5. no evidence of left renal or pancreatic injury.

 findings 2, 4, and 5 were discussed with [**first name4 (namepattern1) 1789**] [**last name (namepattern1) 4749**] at 15:53 on [**2116-10-27**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


"
2164,"[**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old woman with ho diverticulitis with abd pain ttp llq
 reason for this examination:
  pls eval ro acute proc
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**hospital 5197**] fri [**2163-8-19**] 12:03 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 wet read version #1
 wet read version #2 [**first name9 (namepattern2) 5197**] [**doctor first name 73**] [**2163-8-18**] 8:16 pm
  s/p partial colectomy; no diverticulitis or abscess.

 ______________________________________________________________________________
 provisional findings impression (pfi): [**year (4 digits) 5197**] fri [**2163-8-19**] 12:02 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 ______________________________________________________________________________
                                 final report
 history:  75-year-old female with a history of diverticulitis, now with left
 lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with iv contrast; 130 cc of optiray
 intravenous contrast was given.  there was no adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases demonstrate a 6 mm pulmonary nodule.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder is distended but shows no stones or wall edema.  the spleen is
 normal in size.  the pancreas shows no masses.  bilateral adrenal nodules,
 each about 1 cm, are incompletely characterized.  the kidneys enhance with and
 excrete contrast symmetrically.  at the superior pole of the left kidney is a
 well-circumscribed hypodensity measuring 3 cm in diameter, most compatible
                                                             (over)

 [**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 with a simple cyst.

 the small and large intestines show no evidence of obstruction.  the appendix
 is normal.  anastomosis is seen in the distal colon, most compatible with
 prior sigmoid resection.  there is no free air or free fluid.  scattered tiny
 fat-containing midline hernias are noted.

 pelvis:  the bladder and rectum appear unremarkable.  the patient is status
 post hysterectomy.  there is no free fluid or lymphadenopathy.  bilateral
 fat-containing inguinal hernias are noted.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  status post sigmoid colectomy without evidence of complication.  no
 evidence of diverticulitis.
 2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
 factors (non-smoker and no cancer history), follow-up ct in one year is
 recommended to document stability.
 3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
 for further evaluation.

 findings discussed with [**first name5 (namepattern1) 5296**] [**last name (namepattern1) 5297**] 12:05 am on [**2163-8-19**] by [**first name8 (namepattern2) 873**]
 [**last name (namepattern1) 5298**] over the phone.

"
2165,"[**2150-5-16**] 1:47 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 58728**]
 reason: evaluate for lymphadenopathy, abscess
  contrast: omnipaque amt: 70
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  60 year old man with aml s/p allo-transplant presenting with nasal congestion
  and severe sore throat
 reason for this examination:
  evaluate for lymphadenopathy, abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with aml status post allotransplant, now with
 severe sore throat.

 study:  ct of the neck with contrast; coronal and sagittal reformatted images
 were also generated.  75 cc of omnipaque intravenous contrast was administered
 without adverse reaction or complication.

 comparison:  [**2150-2-20**], [**2150-2-4**].

 findings:  the visualized portion of the brain is unremarkable.  the orbits
 and globes are intact.  the visualized paranasal sinuses demonstrate minimal
 mucosal thickening in the right maxillary sinus floor.

 no retropharyngeal or peritonsillar fluid collection is present, although
 streak artifact from dental amalgam somewhat limits assessment of finer detail
 in this area.

 the parotid glands are within normal limits.  no lymphadenopathy is present.
 the thyroid is normal in appearance.  a right-sided central venous catheter is
 in place.  the visualized lung apices are clear; the 6-mm right lower lobe
 pulmonary nodule described on the [**2150-2-4**] scan is not imaged on the
 current exam.  incidental note is made of a common origin of the
 brachiocephalic and left common carotid arterial branches off the aortic arch.

 impression:  no evidence of retropharyngeal or peritonsillar abscess; no
 lymphadenopathy.


"
2166,"[**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 46m with abd pain, n/v
 reason for this examination:
  r/o appy, other acute intraabdominal process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2200-3-29**] 7:08 pm
  inflammed duodenum w/ surrounding fluid and focal area of wall discontinuity,
  concerning for contained duodenal perforation; no free air; normal appendix

 wet read version #1
 wet read version #2 jekh sat [**2200-3-29**] 6:23 pm
  duodenitis; no free air; normal appendix

 ______________________________________________________________________________
                                 final report
 history:  46-year-old male with abdominal pain, nausea and vomiting.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the lung bases are clear.

 the liver contour is nodular with caudate and left lateral lobe hypertrophy
 and atrophy of the right posterior lobe of the liver, compatible with
 cirrhosis.  there is no intrahepatic biliary dilatation or definite focal
 hepatic lesion. portal vein is patent. calcified stones within the gallbladder
 fundus and neck are present.  there is no wall edema or pericholecystic
 stranding.  the spleen is normal in size and appearance.  the adrenal glands
 show no nodules.  the kidneys enhance with and excrete contrast symmetrically;
 subcentimeter hypodensities in both kidneys are too small to characterize,
 likely representing cysts; focal cortical scarring in the left kidney is
 compatible with prior infection or infarction.

 there is marked wall thickening and extensive surrounding fat stranding and
 mural edema involving the distal stomach and proximal duodenum, centered about
 the duodenal bulb.  a focal outpouching of the duodenal bulb is present,
 concerning for an ulcer, less likely a diverticulum.  no free air is seen,
 though a fluid collection is noted posterior to the distal stomach in the
 lesser sac measuring 19 x 19 mm.  the pancreatic head is adjacent to this
 inflammatory process and appears indistinct, although the pancreatic body and
 tail are also mildly atrophic.

 the remainder of the small and large bowel show no evidence of wall edema or
 obstruction.  the appendix is normal.  there is no lymphadenopathy or free
                                                             (over)

 [**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 air.

 pelvis:  gas is seen in the bladder and correlation with recent
 catheterization is recommended.  the prostate and rectum appear unremarkable.
 there is no free fluid or lymphadenopathy. small bilateral fat containing
 inguinal hernias are present.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. findings concerning for a contained perforation of a duodenal bulb ulcer
 with adjacent surrounding inflammation and associated duodenitis.  small focal
 fluid collection is present in the lesser sac. findings discussed with [**first name8 (namepattern2) **]
 [**known firstname **] at 19:00 [**2200-3-29**] by [**first name8 (namepattern2) 510**] [**last name (namepattern1) 5773**] over the phone.

 2. cirrhosis.

 3. cholelithiasis.

 4. gas within the bladder lumen. correlate with any history of recent
 instrumentation; otherwise, findings are concerning for an infectious process.

"
2167,"[**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  50 year old woman with pedestrain struck by tow truck. no obvious injury other
  than head lac
 reason for this examination:
  trauma?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2133-3-19**] 7:55 pm
  1. no intrathoracic injury.
  2. distended stomach but no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old female pedestrian struck by a tow truck.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of thyroid demonstrates a 5-mm hypodensity in
 the left lobe of the thyroid (2; 6).  there is no axillary, hilar, or
 mediastinal lymphadenopathy.  the aorta is of normal caliber along its course
 without evidence of dissection or injury.  no mediastinal hematoma is present.
 the pulmonary arterial tree shows no central filling defect.  there is no
 pleural or pericardial effusion.  the lungs show a subtle ground-glass opacity
 in the right lower lobe which may represent an area of contusion or
 aspiration.  there is no pneumothorax.

 abdomen:  an area of enhancement in the left lobe of the liver likely
 represents a hemangioma or perfusion anomaly (2;50).  the gallbladder, spleen,
 pancreas, and adrenal glands appear unremarkable.  there is no perihepatic,
 perisplenic, or pericolic fluid.  there is no free fluid or free air.  the
 kidneys enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; bilateral subcentimeter hypodensities are too small to
 characterize but likely represent cysts.  the aorta is of a normal caliber
 along its course without evidence of injury.  small and large bowels show no
 evidence of wall edema or obstruction; the stomach, however, is notably
 distended with gas.

 pelvis:  the bladder is decompressed.  the uterus and rectum appear
 unremarkable.

 bones:  there is no acute fracture; old left rib fractures are present.  there
                                                             (over)

 [**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  small nonspecific area of ground glass in the right lung.  otherwise
 essentially unremarkable exam without acute intra-abdominal or intrathoracic
 injury; no acute fracture.
 2.  distended stomach may benefit from ng tube.

"
2168,"[**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 65f with clinical question:
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2142-3-17**] 11:09 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; surrounding hematoma but no pelvic free fluid; hematoma along l medial
  thigh as well; hairline fx through l iliac w/ probable involvement of l si
  joint, but no sacral fx.
 wet read version #1
 wet read version #2 jekh sat [**2142-3-17**] 10:25 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; hairline fx through l iliac w/ probable involvement of l si joint, but
  no sacral fx.
 ______________________________________________________________________________
                                 final report
 history:  65-year-old female pedestrian status post struck by suv.

 study:  ct of the torso with contrast; coronal and sagittal reformatted images
 were also generated.  130 cc of omnipaque 350 intravenous contrast was
 administered without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  the aorta is of normal caliber along its course without evidence of
 injury; incidental note is made of a common origin of the brachiocephalic and
 left common carotid arteries, a normal variant (2a; 14).  the pulmonary artery
 shows no central filling defects.  there is no pleural or pericardial
 effusion.  the lungs are clear without evidence of contusion.  there is no
 pneumothorax.

 abdomen:  a subcentimeter hypodensity in the dome of the liver is too small to
 characterize but likely represents a cyst rather than a contusion/laceration
 as there is no perihepatic fluid.  a subcentimeter hypodensity in the
 periphery of the spleen also likely represents a cyst or hemangioma rather
 than a contusion or laceration as there is no perisplenic fluid.  the pancreas
 and adrenal glands appear unremarkable.  the kidneys enhance with and excrete
 contrast symmetrically; a well-circumscribed 1-cm hypodensity in the mid pole
                                                             (over)

 [**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 of right kidney is most compatible with a simple cyst.  there is no
 retroperitoneal fluid collection.  the small and large bowel show no evidence
 of obstruction or injury.  there is no free air or free fluid.  the abdominal
 aorta is of normal caliber along its course without evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.  the left obturator musculature is thickened,
 likely representing intramuscular or contained hematoma.  additional
 incompletely image hematoma of the medial left thigh is present.

 bones:  there is a burst fracture of the l1 vertebral body with 8-mm
 retropulsed fragments into the central canal.  additionally, a minimally
 displaced fracture is present along the right aspect of the lamina of l1.  a
 small amount of adjacent hematoma is seen around the anterolateral aspects of
 the vertebral body.  loss of height is approximately 50%.

 additionally, minimally displaced fractures of the left superior and inferior
 pubic rami are present; the lateral aspect of the superior pubic rami is
 fractured while the medial aspect of the inferior pubic rami is fractured.
 additionally, a hairline fracture is present along the left iliac bone just
 adjacent to the si joint and extending into the si joint on the left.  the
 sacrum itself appears intact.

 impression:
 1.  no acute intra-abdominal or intrathoracic injury.
 2.  l1 burst fracture with retropulsed fragments and minimally displaced
 fracture of the right l1 lamina; these findings suggest an unstable fracture
 and if clinical concern for cord injury exists, mr would be recommended.
 3.  fracture of the left pelvis as described above.

 these findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 7304**] in person at 10:00 a.m. and
 again at 11:05 a.m. by phone on [**2142-3-17**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
2169,"[**2183-2-8**] 9:50 am
 ct l-spine w/ contrast                                          clip # [**clip number (radiology) 85002**]
 reason: ? l-spine fluid/disciitis
 admitting diagnosis: pneumonia;nstemi;sepsis
  contrast: optiray amt: 90
 ______________________________________________________________________________
                                 final addendum
 addendum:  the complex, unstable fracture involving the l2 vertebral body, its
 superior and inferior endplates, and pedicles is present.  the previously seen
 gas in the disc and vertebral body are likely the result of vacuum phenomenon
 in the setting of degenerative and post-traumatic change.  given that it has
 not increased, a worsening gas-producing infectious process is unlikely.
 surrounding fluid-stranding in the retroperitoneum may actually represent
 post-traumatic hematoma, especially given that the superior endplate of l2
 (except for the fracture) and inferior endplate of l1 are preserved, making a
 primary process of discitis/osteomyelitis less likely.  additionally, the
 fluid-stranding around the aorta is more likely hematoma than aortitis.  in
 the setting of fever, superinfection of the hematoma cannot be excluded.
 however, the hematoma is not organized/drainable, and its proximity to the
 aorta, left renal vasculature, and exiting nerve roots makes biopsy/drainage
 challenging.

 this revision was discussed with [**first name8 (namepattern2) 21839**] [**last name (namepattern1) 7355**] at 12:06 pm on [**2183-2-11**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


 [**2183-2-8**] 9:50 am
 ct l-spine w/ contrast                                          clip # [**clip number (radiology) 85002**]
 reason: ? l-spine fluid/disciitis
 admitting diagnosis: pneumonia;nstemi;sepsis
  contrast: optiray amt: 90
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  86 year old man with back pain, fevers and possible disciitis on osh scan
 reason for this examination:
  ? l-spine fluid/disciitis
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2183-2-8**] 11:50 am
  1.  findings concerning for discitis of the l1-l2 vertebral body as well as
  osteomyelitis of the l2 vertebral body.
  2.  concern for compression fracture of the l2 vertebral body with involvement
  of the inferior endplate and bilateral pedicle fractures.
  3.  extensive retroperitoneal inflammation in the region of the aforementioned
  discitis/osteomyelitis, and may involve the adjacent abdominal aorta.


 ______________________________________________________________________________
                                 final report
 history:  86-year-old male with back pain, fevers and concern for discitis on
 outside hospital scan.

 study:  ct of the l-spine with contrast; 90 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  mdct
 images through the lumbar spine were performed in the standard and bone
 algorithms; coronal and sagittal reformatted images were also generated.

 comparison:  outside hospital ct of the abdomen and pelvis from [**2183-2-6**].

 findings:  in the left [**year (4 digits) 85003**] gland, there is a 16 mm in diameter nodule of
 indeterminate characterization (3; 1).

 severe degenerative changes are noted throughout all levels of the lumbar
 spine, primarily in the form of large anterior bridging osteophytes and facet
 joint hypertrophy.  of greater concern are numerous locules of gas within a
 narrowed l1-l2 intervertebral disc with surrounding inflammation.  this
 inflammation also abuts and may even involve the adjacent abdominal aorta and
 left renal artery (3; 25).  additionally, a few locules of gas are seen within
 the l2 vertebral body as well as some mild loss of height; subtle
 non-displaced fracture lines are seen extending in the horizontal plane, but
 also extending to the inferior endplate.  more subtle hairline fractures are
 seen also in the bilateral pedicles (401b; 29 and 42) and (2; 26).  there are
 no locules of gas within the l1 vertebral body nor does there appear to be
 appreciable destruction or fracture of the l1 vertebral body.

 impression:
 1.  findings concerning for discitis of the l1-l2 vertebral body as well as
 osteomyelitis of the l2 vertebral body.
                                                             (over)

 [**2183-2-8**] 9:50 am
 ct l-spine w/ contrast                                          clip # [**clip number (radiology) 85002**]
 reason: ? l-spine fluid/disciitis
 admitting diagnosis: pneumonia;nstemi;sepsis
  contrast: optiray amt: 90
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  compression fracture of the l2 vertebral body with involvement of the
 inferior endplate and bilateral pedicle fractures; concerning for instability.
 3.  extensive retroperitoneal inflammation in the region of the aforementioned
 discitis/osteomyelitis, involving the adjacent abdominal aorta and left renal
 artery.
 4.  indeterminate left [**clip number (radiology) 85003**] nodule - mr [**first name (titles) **] [**last name (titles) **] ct may be considered
 if/when clinically indicated.

 findings [**12-24**] were discussed with [**first name8 (namepattern2) 416**] [**last name (namepattern1) 28438**] at 11:30 a.m. on [**2183-2-8**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.

"
2170,"[**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  52m, h/o longstanding crohn's, started on [**first name9 (namepattern2) 22562**] [**2187-2-3**], has had better but
  incomplete control (all to remicaid).  has had a couple flares in the interum.
  returns today with s/s c/w flare.  c/o increased abd pain, esp in lrlq to deep
  palpation.  denies f/c/v, does c/o n/d which is normal for pt.  does report
  lrlq pain immidiately after eating or drinking nearly every time.  pt states
  otherwise, he feels well.  with dirty uaiv/po contrast pleaseplease eval
  kidneys and bowel,
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2188-3-22**] 6:43 pm
  1. s/p cholecystectomy, splenectomy, and total colectomy.
  2. l-sided loop of bowel w/ thickened wall and surrounding inflammation, c/w
  crohn's flare; no abscess.
  3. mild perinephric stranding but no e/o pyelonephritis or perinephric fluid
  collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with a history of crohn's disease, now with
 abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  oral contrast was also administered.

 coronal and sagittal reformatted images were also generated.

 comparison:  [**2186-11-29**].

 findings:

 abdomen:  the visualized portion of the lung bases are clear.  the liver shows
 no focal lesion or intrahepatic biliary dilatation.  clips in the gallbladder
 fossa compatible with prior cholecystectomy.  the spleen is surgically absent.
 pancreas shows no masses.  the adrenal glands show no nodules.  the kidneys
 enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; minimal perinephric stranding is present without an organized
 fluid collection or striated nephrogram.  patient is status post total
 colectomy without evidence of obstruction.  loops of bowel in the left abdomen
 demonstrate thickened wall with subtle surrounding fat stranding.  possible
 early phlegmon may be present in the left lower abdomen (2:54,601:38) without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude.  nearby scattered mesenteric lymph nodes are seen.  equivocal
 tethering of bowel loops in this area is also noted.  trace amount of reactive
 fluid is also seen in the mesentery.  there is no free air.  incidental note
                                                             (over)

 [**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is made of ventral abdominal wall mesh.

 pelvis:  the bladder and prostate appear unremarkable.  there is a transition
 in the diameter of the lumen from the small bowel to the rectosigmoid colon
 region through which contrast is passing (2; 62).  there is no free fluid or
 lymphadenopathy in the pelvis.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 intervertebral discs
 primarily in the form of vacuum phenomenon and endplate sclerosis.

 impression:
 1. status post cholecystectomy, splenectomy, and total colectomy.
 2. left-sided bowel with wall thickening and surrounding inflammation; given
 patient history compatible with an inflammatory process such as the patient's
 known crohn's disease.  infection might have a similar appearance .
 possible early phlegmon may be present in the left lower abdomen without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude. mre is more sensitive and may be helpful for further evaluation.

"
2171,"[**2118-10-23**] 7:07 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 16327**]
 reason: r/o pe
 admitting diagnosis: pneumonia
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  53 year old man with acute hypoxia
 reason for this examination:
  r/o pe
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh sun [**2118-10-23**] 8:59 pm
  1.  no pe or acute aortic syndrome.
  2.  bibasilar opacities, likely reflecting components of early pneumonia and
  atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  53-year-old male with acute hypoxia.

 study:  chest cta.  mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after the
 administration of 100 cc of optiray intravenous contrast without complication
 or adverse reaction.  this is dominant in the pulmonary arterial phase.
 coronal, sagittal, and right and left oblique reformatted images were also
 generated.

 comparison:  none.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar or mediastinal lymphadenopathy.

 the aorta is of a normal caliber along its course without evidence of
 dissection or intramural hematoma.  incidental note is made of a direct
 takeoff of the left vertebral artery between the origins of the left common
 carotid and left subclavian arteries, a normal variant (4; 10).

 the pulmonary arterial trunk is of a normal caliber and there are no filling
 defects down to the subsegmental level.

 trace pericardial fluid is noted anteriorly (4; 52).

 bibasilar opacities, as well as focal opacity in the posterior rul adjacent to
 the minor fissure (image 4:22) are seen within the lungs, likely representing
 more than just dependent atelectasis, but rather an additional superimposed
 infectious process.as part of the opacities have a nodular appearance,[e.g.
 rll (4:34), lll (4:55)] follow-up ct when symptoms resolve is recommended.

 the visualized portion of the upper abdomen shows no gross abnormality.

 the visualized bones demonstrated incidentally fusion of the right lateral
 fifth and sixth ribs.  additionally, there is a bony bridge between the
 posterior aspect of the left sixth and seventh ribs (501b; 36).  there are no
                                                             (over)

 [**2118-10-23**] 7:07 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 16327**]
 reason: r/o pe
 admitting diagnosis: pneumonia
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  no pe or acute aortic syndrome.
 2.  bibasilar opacities, likely reflecting components of early pneumonia and
 atelectasis.however, due to several nodular areas, follow-up chest ct when
 symptoms resolve is recommended.

"
2172,"[**2166-2-11**] 9:14 am
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 8970**]
 reason: melanoma
 ______________________________________________________________________________
                                 final report
 history:  49-year-old female with melanoma in need of assessment for
 metastatic disease.

 study:  ct of the neck with contrast; 50 ml of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  pet-ct from [**2165-11-12**] and ct of the torso from [**2-11**], [**2165**].

 findings:  the visualized portion of the brain shows no evidence of mass or
 abnormal enhancement; the circle of [**location (un) 501**] appears grossly intact.  the
 visualized portion of the globes and oribts appears within normal limits.

 the visualized paranasal sinuses and mastoid air cells are clear.  streak
 artifact is present, mildly limiting assessment of the mandible but it too
 appears intact.  cervical spine shows no evidence of malalignment or more
 aggressive-appearing lytic/sclerotic lesion.

 the parotid and submandibular glands appear normal.  no lymphadenopathy is
 present.  the jugular and carotid vasculature are patent.  a linear
 hypodensity in the right lobe of the thyroid measures 6 x 2 mm (2; 62).

 the visualized portion of the lung apices and upper mediastinum appears
 unremarkable.

 impression:  no evidence of lymphadenopathy or metastatic disease.

"
2173,"[**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  [**age over 90 **] year old woman with mcv, positive fast
 reason for this examination:
  bleeding?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2102-1-26**] 4:38 pm
  1. r [**5-21**] lateral rib fx and l [**3-22**] lateral rib fx (segmental fx in l 9 and
  10).
  2. splenic lac and contusion; possible small liver lac; hemoperitoneum.
  3. dense fluid near r colon may represent contusion; no active extrav seen to
  suggest vascular injury.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  [**age over 90 **]-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  outside hospital ct of the torso without contrast from [**1-26**], [**2101**] at 13:43.

 findings:

 chest:  the visualized portion of the thyroid gland shows bilateral
 hypodensities in each lobe for which ultrasound may be considered if
 clinically indicated.  there is no axillary, mediastinal, or hilar
 lymphadenopathy.  the aorta is of normal caliber along its course without
 evidence of dissection or mediastinal hematoma.  the pulmonary arterial trunk
 shows no central filling defect.  the heart size is within normal limits
 without pericardial effusion.  there is no significant pleural effusion.  the
 lungs demonstrate bibasilar atelectasis but no consolidation or contusion.  a
 small hiatal hernia is present.

 abdomen:  a hypodense streak along the dome of the liver is equivocal for
 laceration versus a lobulation (2; 32-39).  extensive dense fluid is seen
 around the liver and spleen.  the uppermost portion of the spleen demonstrates
 a vertically oriented hypodensity that may represent a laceration (601b; 32).
 more inferiorly in the spleen is a hypodensity oriented in the ap dimension
 that may represent either laceration or lobulation (2; 45 and 601b; 38).  at
 the very least, there is a splenic contusion (602b; 54).  a calcified splenic
 artery aneurysm is noted measuring 9 mm in diameter (2; 46 and 601b; 28).

 a duodenal diverticulum is present.  the pancreatic duct appears contiguous
 and there is no peripancreatic fluid; the pancreas is atrophic.  the right
 adrenal gland appears normal; the left adrenal gland demonstrates a rounded
                                                             (over)

 [**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 soft tissue density measuring 13 mm in diameter that is incompletely
 characterized (2; 48) - ct or mr may be considered as clinically indicated.
 the kidneys enhance with contrast symmetrically without evidence of
 perinephric fluid.  incidental note is made of a calcified aneurysm of the
 left renal artery (2; 52) which measures 7 mm in diameter.

 the small bowel shows no areas of wall edema.  no free air is seen.  the large
 bowel demonstrates diverticulosis, but no evidence of bowel wall edema.
 complex fluid is seen sitting adjacent to the right colon (2; 61) within the
 mesentery (2; 62 and 601b; 26) and along a loop of jejunum.  a
 small-to-moderate amount of dense fluid is seen coursing throughout the
 mesentery and along the paracolic gutters.

 the aorta is of a normal caliber along its course without evidence of injury
 or active extravasation.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  dense free
 fluid seen in the pelvis, contiguous with that seen in the abdomen.  a
 left-sided [**doctor last name 13736**] hernia is present (2; 91).

 bones:  multiple minimally displaced fractures are present in the lateral
 aspects of the right ribs 6, 7, 8, 9, and 10 and in the left ribs 4 through
 11; of note, the fractures in left ribs 9 and 10 are segmental in nature.
 there does not appear to be an acute injury to the spine, although multilevel
 degenerative changes are present.  the clavicles are intact bilaterally.  the
 sternum is intact.  the pelvis and proximal femurs are intact.

 impression:  multiple rib fractures as described above with possible splenic
 (and less likely hepatic) lacerations with hemoperitoneum tracking along the
 right colon and jejunum concerning for bowel injury.  findings were discussed
 with [**first name4 (namepattern1) 9505**] [**last name (namepattern1) 612**] at 4 p.m. on [**2102-1-26**] in person by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
2174,"[**2123-1-3**] 9:35 am
 ct chest w/contrast                                             clip # [**clip number (radiology) 1645**]
 reason: placement of pigtail catheter [**1-2**], evaluation for improveme
 admitting diagnosis: pleural effusion;elev inr
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old man with lung adenoca and pleural effusion s/p pigtail catheter
  placement
 reason for this examination:
  placement of pigtail catheter [**1-2**], evaluation for improvement in lung volumes
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with lung cancer and pleural effusion status post
 pigtail catheter placement.

 study:  ct of the chest with contrast; 75 cc of omnipaque 350 intravenous
 contrast was administered without adverse reaction or complication.  images
 were generated using standard and lung algorithms.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2122-12-29**].

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 continues to be a large mass lesion occupying most of the region of the left
 upper lobe of the lung.  the left upper lobe bronchus and left upper lobe
 pulmonary vasculature continue to be occluded.  the left lower lobe superior
 segment pulmonary artery is narrowed but patent.  the left lower lobe bronchus
 is narrowed and even occluded over a short segment, but it is unclear if this
 is the result of mass effect or mucus plugging.  while the left upper lobe
 remains completely collapsed, there is minimally improved aeration of the left
 lower lobe.  the pigtail catheter is in place and there has been a decrease in
 the inferior portion of the left pleural effusion, the components of which are
 minimally complex fluid.  the upper portion of the left pleural effusion is
 also improved and the previously described pleural implants are unchanged.
 continued mediastinal lymphadenopathy is seen, most prominently in the
 subcarinal region where a 3 x 5 cm lymph node persists.  the aorta is of a
 normal caliber along its course and its arch branches are patent.  the heart
 and mediastinal have shifted into a more anatomically appropriate position
 compared to prior exam.  there is no pericardial effusion.  a small right
 simple pleural effusion persists on the right with small amount of dependent
 atelectasis.  additionally, a new focus of consolidation is present in the
 right upper lobe (4:45), which either represents a persistent area of
 atelectasis from the previous mediastinal shift versus an additional focus of
 consolidation/pneumonia.

 the visualized portion of the abdomen demonstrates widespread ascites, a
 nodular liver compatible with cirrhosis, a distended gallbladder, and an
 incompletely characterized hypodensity in the superior pole of right kidney.

 there are continued lytic lesions in the t10 through t12 vertebral bodies as
 well as in the t6 vertebral body.  the previously described pathologic
                                                             (over)

 [**2123-1-3**] 9:35 am
 ct chest w/contrast                                             clip # [**clip number (radiology) 1645**]
 reason: placement of pigtail catheter [**1-2**], evaluation for improveme
 admitting diagnosis: pleural effusion;elev inr
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture of the posterior right eighth rib persists.

 impression:
 1.  status post left pleural pigtail catheter placement with improvement in
 the volume of left pleural effusion and minimally improved aeration of the
 left lower lobe.  left lower lobe bronchus shows short segment occlusion,
 likely reflective of a mucus plug.
 2.  continued large left upper lobe mass with mass effect on the adjacent
 bronchus and artery; mediastinal lymphadenopathy, most prominent in the
 subcarinal stations.
 3.  new small consolidation in the anterior portion of the right lung apex may
 represent residual atelectasis versus a new focus of pneumonia; small right
 simple pleural effusion with minimal associated atelectasis.
 4.  ascites.
 5.  bone metastases as described above.

 findings were discussed with bracken [**last name (un) 1646**] at 10:48 a.m. on [**2123-1-3**]
 by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


"
2175,"[**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 43f with mvc, supobtimal fast,abrasion to abdomen, unrestrained
  driverclinical question: ? intrabdominal injury
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2150-3-5**] 5:33 pm
  1. bilateral dependent pulmonary edema.
  2. no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  42-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of normal caliber along its course without evidence of injury or
 mediastinal hematoma.  the pulmonary arterial tree shows no central filling
 defect.  the heart size is within normal limits and there may be trace
 pericardial fluid.  the lungs are clear of consolidation.  bibasilar
 ground-glass opacities, likely representing dependent edema. less likely
 contusions.  there is no pleural effusion or pneumothorax.

 abdomen:  the liver, spleen, adrenal glands, and pancreas appear normal.
 gallstones are present.  there is no perihepatic, perisplenic or pericolic
 gutter fluid.  there is no fluid in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically.  there is no free air or lymphadenopathy.
 the aorta is of normal caliber along its course of the abdomen without
 evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  foley catherter
 in place.  there is no free fluid or lymphadenopathy.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.  a wedge
 deformity in the t11 vertebral body is of indeterminate age but shows no
 retropulsed fragments or adjacent hematoma.

 impression:
 1.  dependent regions of ground glass in the lungs may represent edema, less
 likely contusion.  otherwise no evidence of intrathoracic or intra-abdominal
 injury.
                                                             (over)

 [**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  t11 wedge deformity of indeterminate age - correlate clinically.
 3.  cholelithiasis.

"
2176,"[**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  24 year old man with s/p mvc and was ejected from vehicle +etoh
 reason for this examination:
  ?intrathoracic or intraabdominal injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2186-1-28**] 6:33 am
  1. no intrathoracic injury.
  2. small subcapsular hematoma of liver (2:43 and 301b:25); no free fluid in
  abdomen or pelvis.
  3. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 wet read version #1
 wet read version #2 jekh sat [**2186-1-28**] 6:27 am
  1. no intrathoracic or intraabdominal injury.
  2. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 ______________________________________________________________________________
                                 final report
 history:  24-year-old male status post mvc and ejected from vehicle.
 left-sided upper extremity weakness.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.

 comparison:  none.

 findings:

 the visualized portion of the thyroid appears normal.  there is no axillary,
 hilar, or mediastinal lymphadenopathy.  the aorta is of a normal caliber along
 its course without evidence of mediastinal hematoma.  the pulmonary arterial
 trunk is of a normal caliber with no central filling defect.  the heart shows
 no pericardial effusion.  there is no pleural effusion or pneumothorax.  the
 lungs are clear.

 abdomen:  there is no free fluid around the liver or spleen or tracking along
 the paracolic gutters.  the spleen, pancreas, adrenal glands, and kidneys
 appear normal.  the bowel wall is not edematous.  there is no free air.

 pelvis:  a foley is in the bladder with excreted contrast within the bladder.
 the prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.

 bones:  horizontally oriented fractures are seen through the posterior
 elements of the t9 vertebra.  the vertebral body does not definitively show
                                                             (over)

 [**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture, but a small right anterior hematoma is present in the soft tissue
 surrounding the vertebral body at that level.

 impression:
 1.  no intrathoracic injury.
 2.  horizontally oriented fracture of the posterior elements of t9 with right
 anterior surrounding soft tissue hematoma; mr is recommended to [**clip number (radiology) 4247**] for
 ligamentous, disc, and cord injury.

"
2177,"[**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 50m with h/o cirrhosis, fever and ams of unclear [**name2 (ni) 97919**]
  question: intraabd infection?
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2186-1-11**] 8:28 pm
  1. cirrhotic liver w/ small amt of perihepatic ascites, splenomegaly, and
  recannulized umbilical vein (a portion of which sits in a small umbilical
  hernia).
  2. small pericardial effusion.
  3. no organized intraabdominal fluid collection; normal appendix; no bowel
  wall edema; no hydronephrosis; no peripancreatic stranding/fluid collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old male with cirrhosis, now with fever and altered mental
 status.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases are clear.  small pericardial effusion is
 present.

 the liver is shrunken and nodular compatible with cirrhosis.  small amount of
 perihepatic ascites is present.  the gallbladder is distended with a mildly
 thickened wall (likely secondary to hepatic disease).  small amount of
 pericholecystic fluid is also seen.  the spleen is enlarged measuring 14.8 cm
 in length.  the portal vein appears patent. there is a dilated recanalized
 umbilical vein, a portion of which has herniated through a small umbilical
 hernia (2; 60). the pancreas appears normal. the adrenal glands appear normal.
 the kidneys enhance and excrete contrast symmetrically without hydronephrosis.


 the small and large bowel show no evidence of ileus or obstruction.  there is
 no free air or lymphadenopathy.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  there is no pelvic free fluid or lymphadenopathy.  a
 small left buttock hematoma is present.

                                                             (over)

 [**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive appearing lytic or sclerotic lesions.

 impression:
 1.  cirrhotic liver with a small amount of ascites.
 2.  small pericardial effusion.
 3.  umbilical hernia containing a loop of the dilated, recannalized umbilical
 vein.

"
2178,"[**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old woman with paralysis of lower extremities
 reason for this examination:
  please eval for acute process - s/p fall, unable to move her lower extremities
  and no sensation
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2101-10-21**] 10:31 pm
  1. splaying of l1 and l2 spinous process w/ subtle malalignment of l2 and l3,
  concerning for ligametous injury, and in the setting of paralysis, consequent
  central canal injury - mr is recommended.
  2. herniation of stomach into thorax.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old female with lower extremity paralysis after fall.

 study:  ct of the torso with contrast; 130 cc of optiray intravenous contrast
 was given without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of a normal caliber along its course with a few scattered areas of
 calcified atherosclerotic disease in the aortic arch and descending aorta;
 there is no evidence of intramural hematoma or dissection.  there is no
 central pulmonary arterial filling defect.  there is no pericardial or pleural
 effusion.  a small amount of fluid is seen in the pericardial recess adjacent
 to the ascending aorta.  the lungs are clear with bibasilar atelectasis.  the
 stomach has herniated into the thorax.

 abdomen:  there is no perihepatic fluid.  a non-specific hypodensity is seen
 in hepatic segment iv, too small to characterize but most likely a cyst.  the
 gallbladder is decompressed.  there is no perisplenic fluid.  the pancreas and
 adrenal glands are normal.  the kidneys enhance with and excrete contrast
 symmetrically.  small and large bowel show no obstruction or wall edema.
 there is no free fluid or free air.

 pelvis:  the bladder is decompressed around a foley.  the uterus and rectum
 appear unremarkable.  there is no free fluid or lymphadenopathy.

 bones:  there is splaying of the posterior elements at the level of l1-l2 with
 more subtle malalignment of l2 and l3 (602b; 36).  [**year (4 digits) **] material is seen
 within the spinal canal at this level and above.  otherwise, the pelvis and
 proximal femurs are intact.  no rib fractures are noted.

                                                             (over)

 [**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 impression:
 1.  splaying of the l1-l2 spinous processes is concerning for ligamentous
 injury and given the patient's history of paraplegia, mr should be performed.
 relatively [**name2 (ni) 3409**] material within the spinal canal is concerning for epidural
 hematoma.  findings were discussed with dr. [**last name (stitle) 3382**] in person at 22:00 on
 [**2101-10-21**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] and [**first name8 (namepattern2) **] [**doctor last name 853**].
 2.  no intrathoracic or intra-abdominal injury.

"
2179,"[**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  31 year old woman with sudden onset abdominal pain, h/o cirrhosis
 reason for this examination:
  eval surgical pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2180-9-8**] 3:18 am
  1. cirrhotic liver w/ tips; patent portal vessels.
  2. decompressed gb w/ wall edema, unchanged from [**2180-7-21**] ct; likely reflective
  of hepatic dysfunction.
  3. small amt of ascites, increased since [**2180-7-21**] ct; if clincial concern for
  pancreatitis, correlate w/ lipase.
  4. normal appendix.
  5. no obstruction or free air.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  31-year-old female with sudden onset of abdominal pain and history
 of cirrhosis.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was used without adverse reaction and complication.
 coronal and sagittal reformatted images were also generated.

 comparison:  [**2180-7-21**].

 findings:

 abdomen:  the visualized lung bases are clear.  the liver demonstrates a
 portosystemic shunt.  the portal vein appears patent; assessment of the shunt
 is limited by the phase of the contrast although it also appears patent.  the
 liver demonstrates a nodular contour compatible with cirrhosis.  the
 gallbladder is decompressed although it shows small amount of wall edema.  the
 spleen is enlarged measuring 15.7 cm in its long axis (601b; 36).  coil
 material is seen in the region of the duodenum, likely to occlude varices.
 the splenic vein and sma are patent.

 the adrenal glands and pancreas show no masses.  subtle fluid-stranding is
 seen near the pancreatic tail and in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis.  the
 small and large bowel show no evidence of obstruction or wall edema.  there is
 no free air.  small amount of ascites is seen.  incidental note is made of a
 small fat-containing umbilical hernia.  the appendix is normal.

 pelvis:  the bladder, uterus and rectum appear unremarkable.  a small amount
 of fluid contiguous with the aforementioned ascites is seen.  there is no
 lymphadenopathy.

                                                             (over)

 [**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. cirrhotic liver with portosystemic shunt in place.  splenomegaly and small
 amount of ascites.  gallbladder wall edema most likely reflects sequela of
 hepatic dysfunction.
 2. if there is clinical concern for pancreatitis, correlate with lipase.

"
2180,"[**2191-9-29**] 3:17 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 1246**]
 reason: please eval for colitis, diverticulitis, intrabdominal infec
  contrast: visapaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  88 year old woman with altered mental status, increased diarrhea x10 bm
  yesterday, and llq abdominal pain.
 reason for this examination:
  please eval for colitis, diverticulitis, intrabdominal infection
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh fri [**2191-9-30**] 1:06 am
  1.  biatrial enlargement and edematous liver, compatible with right heart
  failure.
  2.  cholelithiasis without evidence of cholecystitis.
  3.  ascites and bilateral pleural effusions with associated left lower lobe
  atelectasis.
  4.  t11 compression deformity, new from [**2191-6-20**].
 pfi version #1 jekh fri [**2191-9-30**] 1:05 am
  1.  biatrial enlargement and edematous liver, compatible with right heart
  failure.
  2.  cholelithiasis without evidence of cholecystitis.
  3.  ascites and bilateral pleural effusions with associated left lower lobe
  atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  88-year-old female with altered mental status and increase in
 diarrhea; left lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 100 cc of visipaque was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  abdomen/pelvis cts from [**2191-6-20**] and [**2187-6-26**].

 findings:

 lumg bases:  there has been interval development of bilateral pleural
 effusions, simple and layering and small no right and moderate on left.
 bilateral lower lobe compressive atelectasis is more notable on the left.
 calcified atherosclerotic disease is seen in the coronary arteries.  marked
 biatrial cardiac chamber enlargement is noted.

 abdomen:  heterogeneous mottled enhancement of the hepatic parenchyma likely
 reflects passive congestion secondary to right heart failure. there is a
 stable  hypodensity in segment [**doctor first name **] that is too small to characterize, but
 likely represents a simple cyst.  there is no intrahepatic biliary dilatation.
 mild periportal edema is noted.  the gallbladder contains gallstones.  both
 the liver and spleen contain a few punctate calcifications, compatible with
 prior granulomatous disease.

 the pancreas is atrophic.  the adrenal glands appear normal.  the kidneys
                                                             (over)

 [**2191-9-29**] 3:17 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 1246**]
 reason: please eval for colitis, diverticulitis, intrabdominal infec
  contrast: visapaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 enhance symmetrically, although excretion appears delayed on the left with
 slight fullness of the left upper renal collecting system. there is no sign of
 distal obstruction and overall configuration is stable.   well-circumscribed
 hypodensities in both kidneys are most compatible with simple cysts, the
 largest of which is seen in the mid pole of the left kidney and measures 16 mm
 in diameter.

 the small and large intestine show no sign of obstruction.  a significant
 fecal and gas burden is demonstrated throughout the colon.

 there is an unchanged appearance to a calcified retroperitoneal mass anterior
 to the aorto-iliac bifurcation measuring 28 x 20 mm in axial plane (2; 47) and
 has been stable since [**2187**].

 a small amount of ascites is seen, simple in nature.  there is no free air.

 pelvis:  the bladder is distended.  the clips posterior to the bladder are
 compatible with prior hysterectomy. clips along the pelvic sidewall likely
 reflect prior lymph node dissection.  stool is seen in the rectum.  at the
 rectosigmoid junction, there is underdistension though no frank bowel wall
 thickening.  scattered diverticula are seen in the sigmoid colon, although
 there is no evidence of an inflamed diverticulum.

 bones:  again, compression deformities are seen at l4, l2, and l1 as well as
 t11.  the t11 compression deformity is new from [**2191-6-20**].  sclerotic
 changes are seen about the si joints. body wall edema noted.

 impression:
 1.  biatrial enlargement with bilateral pleural effusions, body wall edema,
 ascites and congested liver, likely secondary to right heart failure.
 2.  cholelithiasis without evidence of cholecystitis.
 3.  t11 compression deformity, new from [**2191-6-20**].
 4.  stable size and appearance of calcified mass in the lower abdomen anterior
 to the aorto-iliac bifurcation. given stability since [**2187**], a benign etiology
 is suggested.

"
2181,"[**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with new onset rlq abdominal pain, nausea, and vomiting
  starting last night. hx of percutaneous gallbladder tube that was removed
  earlier this year. pt is on coumadin
 reason for this examination:
  please eval for intrabdominal infection, sbo, nephrolithiasis, intraperiotneal
  or retroperiotneal bleed.
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2167-9-3**] 3:31 pm
  no acute intraabdominal process - specifically, normal appendix, no
  obstruction, no stones, no retroperitoneal collection, no abscess.

 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  a 57-year-old male with new-onset right lower quadrant pain, nausea,
 and vomiting.  on coumadin, and history of percutaneous gallbladder tube
 removed earlier this year.

 study:  ct of the abdomen and pelvis with and without contrast; mdct images
 were generated through the abdomen without iv contrast; coronal and sagittal
 reformatted images were generated.  subsequent mdct images were generated
 through the abdomen and pelvis after the administration of 130 ml of optiray
 intravenous contrast without adverse reaction or complication.  coronal and
 sagittal reformatted images were again generated.

 comparison:  [**2167-7-6**].

 findings:

 abdomen:  the visualized portions of the lung bases are clear.  calcified
 atherosclerotic disease is seen in both coronary arteries.

 diffuse fatty infiltration of the liver is noted. the liver otherwise shows no
 focal lesion or intrahepatic biliary dilatation.  the gallbladder is normal
 without stones, wall edema, or pericholecystic fluid.  the spleen is normal in
 size.  the pancreas and adrenal glands show no masses.  the kidneys enhance
 and excrete contrast symmetrically.  there is no hydronephrosis,
 hydroureteral, renal or ureteral calculi, or perinephric inflammation.  the
 small and large bowel shows no evidence of obstruction or wall edema.  there
 is no free air, free fluid, or lymphadenopathy.  no retroperitoneal fluid
 collections are seen. small fat-containing umbilical hernia is present.

 pelvis:  the bladder, prostate, and rectum are unremarkable.  the appendix is
 normal.  there is no free fluid or lymphadenopathy in the pelvis.
 calcification of the vas deferens suggests diabetes.

                                                             (over)

 [**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:  no acute intraabdominal process. fatty liver.
                                                                       dfddp

"
2182,"[**2171-10-23**] 7:35 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 15768**]
 reason: evidence of pe, mets, or other acute cp process?
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  63 year old man with active ca, acute hypoxia, tachycardia, rle edema.
 reason for this examination:
  evidence of pe, mets, or other acute cp process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2171-10-23**] 9:06 pm
  1. technically limited study - basal lungs excluded; no pe in visualized
  pulmonary arteries; no acute aortic syndrome.
  2. clear lungs; no pleural/pericardial effusion.
  3. r apical mass 30 x 24 mm; l 7th lateral rib lesion, 43 x 25 mm.
  4. r hilar and mediastinal lymphadenopathy.
  5. bony mets in t3 and t4 vertebral bodies.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  63-year-old male with hypoxia, tachycardia and right lower extremity
 edema.

 study:  chest cta; mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after
 administration of 100 cc of optiray intravenous contrast in the pulmonary
 arterial phase without adverse reaction or complication.  coronal, sagittal as
 well as right and left oblique reformatted images were generated.

 please note due to technical difficulties, the lower portion of the chest was
 not been completely imaged on the contrast-enhanced phase.

 comparison:  pet-ct from [**2171-8-16**].

 findings: the aorta is of a normal caliber along its course without evidence
 of dissection or intramural hematoma.  the pulmonary arterial trunk is normal
 in size and there are no filling defects in the visualized pulmonary arteries,
 though, the basal segments bilaterally are incompletely visualized on the
 contrast enhanced portions.  there is no pleural or pericardial effusion. the
 heart and remaining great vessels are unremarkable.

 there is no axillary lymphadenopathy.  extensive mediastinal lymphadenopathy
 is seen, including a pretracheal lymph node measuring 13 mm (3; 42) and a
 subcarinal lymph node conglomerate measuring 28 x 48 mm (3; 58).
 additionally, two right hilar lymph nodes are seen measuring 16 and 10 mm in
 their short axes (3; 49). prominent left hilar lymph nodes are also noted.
 these are similar compared to prior study.

 diffuse pulmonary nodules are visualized in both lungs, though comparison with
 the prior pet-ct is difficult given differences in technique. redemonstrated
 is nodularity along the right major and minor fissures, unchanged from prior
 study.  mucus plugging is seen in the left lower love bronchi.
                                                             (over)

 [**2171-10-23**] 7:35 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 15768**]
 reason: evidence of pe, mets, or other acute cp process?
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

 within the visualized upper abdomen, no gross abnormality is seen.

 an expansile lytic lesion arising from the second rib measures 30 x 24 mm (3;
 11) and extends into the posterior elements at that level including the lamina
 on the left; this represent progression compared to prior study.  a soft
 tissue mass expanding the left seventh lateral rib is seen measuring 43 x 25
 mm (3; 58), which has increased in size.  lytic lesions in t5 and t6 vertebral
 bodies have increased from the prior study.  lesions in t12 and l1 are not
 signficantly changed.  two new lytic lesions in the left scapula are noted.
 the lytic lesion in the sternum has not changed.

 impression:
 1.  limited assessment of the basal segmental pulmonary arteries. otherwise,
 no pulmonary embolism or acute aortic pathology seen.
 2.  multiple bony metastases, many of which have progressed as described
 above.
 3.  innumerable bilateral pulmonary nodules with persistent mediastinal and
 hilar lymphadenopathy.
 3.  left lower lobe bronchial mucus plugging.

"
2183,"[**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  84 yf presents from nursing home w/ dyspnea, tachypnea, tachycardia, otherwsie
  also complaining of abdominal pain, recently discharge from hospital with
  sepsis/bacteremia
 reason for this examination:
  ?pe, ?abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2180-9-20**] 5:39 am
  1. no pe or acute aortic syndrome.
  2. moderate r and small l pleural effusions w/ compressive atlectasis.
  3. reflux of contrast from r heart into hepatic veins, indicative of heart
  failure.
  4. continued rectal inflammation - proctitis.
  5. no abscess.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  84-year-old female with dyspnea, tachycardia, tachypnea and
 abdominal pain.

 study:  chest cta and ct of the abdomen and pelvis with contrast.  mdct images
 were generated through the chest without iv contrast.  subsequent mdct images
 were generated through the chest after the administration of 130 ml of optiray
 intravenous contrast in the pulmonary arterial phase without adverse reaction
 or complication.  coronal, sagittal, and right and left oblique reformatted
 images were also generated.

 subsequent mdct images were generated through the abdomen and pelvis in the
 venous phase of the same contrast administration.  coronal and sagittal
 reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis without contrast from [**2180-9-12**] and ct of the abdomen and pelvis without contrast from [**2180-9-5**].

 findings:

 chest cta:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course without evidence of intramural hematoma or
 dissection.  the pulmonary arterial trunk is of normal caliber, and there are
 no filling defects down to the subsegmental level.  there is no pericardial
 effusion.  bilateral simple pleural effusions are seen, moderate on the right
 and small on the left, with associated atelectasis; fluid is also tracking
 into the left major fissure.  fine assessment of the lung parenchyma is
 somewhat limited due to motion artifact.

 abdomen:  the liver shows minimal biliary prominence, an expected finding in a
                                                             (over)

 [**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 post-cholecystectomy patient of this age.  the spleen is normal in size, and a
 hypodensity in its anterior [**doctor last name 39**] is too small to characterize but is unchanged
 from prior studies.  the pancreas demonstrates no masses or fluid collections.
 the adrenal glands are normal appearing bilaterally.  the kidneys enhance with
 and excrete contrast symmetrically; hypodensity in the right lower pole is too
 small to characterize, likely represents a cyst.  the small and large
 intestine show no evidence of obstruction or wall thickening.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta.  there is no
 lymphadenopathy, free air, or free fluid.

 pelvis:  the bladder is decompressed around a foley and a single locule of gas
 within the bladder is likely from that catheterization.  the uterus appears
 unremarkable.  the rectum demonstrates hyperenhancing mucosa with thickening
 of the wall and a small amount of stranding in the perirectal fat, all
 compatible with proctitis and similar in appearance to the prior two ct scans.

 bones:  severe degenerative changes are seen throughout the thoracolumbar
 spine; compression deformity of the t10 vertebral body is similar in
 appearance compared to the ct of the torso from [**2177-11-7**].

 impression:
 1.  no pe or acute aortic syndrome.
 2.  moderate right and small left pleural effusions with compressive
 atelectasis.
 3.  rectal wall inflammation compatible with proctitis.
 4.  no evidence of abscess.

"
2184,"[**name (ni) 257**] pt on [**last name (un) 33**] a/c 12/550/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small amount of white thick secretions. mdi's administered q4 atr with no adverse reactions. 02 sats @ 99%. cuff pressure @ 21 cm h20.  rsbi performed but no spont resp.  plan is to wean to psv then possibly extubate. no further changes noted.
"
2185,"ccu (sicu border) nursing transfer accept note 7p-7a

64 yo male with pmh af, imi, ptca, cva x2(no residuals observed), asthma, lung ca, cabg x2 [**6-1**], chf, htn, bladder ca, mild copd, tia's, and mvr admditted to [**hospital1 2**] [**10-10**] with abd angina, diagnosed with mesenteric ischemia. pt underwent [**name (ni) 3549**] [**10-11**] of sma, developed sbo and later had ileocecectomy [**10-14**]. post-op course c/b chf/pneumonia. pt with difficulty breathing, low sats and pao2 44 last [**hospital 3550**] transferred to sicu service for closer resp monitoring/ ?cpap.

all: ativan, librium---adverse reactions

neuro: arrived alert, oriented x3, cooperative and pleasant. following commands appropriately. moving all extremities.

cv: hr 80-90's afib/vpaced. occ pvc's noted. bp 97-120/60's. denies chest pain/palpitations. ck neg x2 thus far. inr 2.7 yest. given 1mg coumadin x1, to be dosed per day.

pulm: ls bilateral crackles [**2-2**] way up. rr 20-30's. o2 sats 88-100% on 100% nrb. unable to speak full sentences but able to speak several words at a time. pt [**name (ni) 865**] rapidly to low 80's without o2 and takes a while to return to 90's. received lasix on floor prior to transfer, no further lasix given.

gi/gu: abd soft, +bs x4. abd incision with staples c/d/i. no drainage noted. pt with sips h20 and crackers only r/t desat without o2. no stool this shift. foley draining 20-30cc/hr clear amber/yellow urine. ho notified of low u/o, no intervention at this time.

id: afebrile. wbc yest 16.4. started on cipro and clinda for pneumonia.

endo: 11p fs 11. no coverage per ss.

social: wife called and updated by resident. other family members called also.

access: left dl picc. one port not flushing.

plan: observe resp status, cpap if needed. con't abx for pneumonia. diet as tolerated. full code. communication with family.
"
2186,"resp care
pt has allergic reaction to antibiotics and became tachynepic, diaphertic, and broncospastic. bs diffuse wheezes, greater on the right side. resp rr 40s - 50s, hr 110-123 and spo2 > 97%. abgs drawn and results came up within normal limits. albuterol ud neb x 3 given back to back, with good effect. bs: increase in aeration, rr decreased to 30s, hr 105 and spo2 100%. no adverse reaction noted. will continue to monitor.
"
2187,"condition update:
d/a:  t max 99.9 most of day, spike to 102.6 in ct.

neuro:  pt lethargic, [**name (ni) 759**] to voice, perl, at times will attempt to answer questions, at times no verbal response.  will locate painful stimuli, and mae's minimally on bed, not to command.  denies pain.  oriented x1 only.  pt with rigors at times, tremulous however no s+s of seizure activity.

cv:  hr 70's when afebrile to 120's when febrile.  neo titrated for [**name (ni) **] map > 60, [**name (ni) **] >90.  cvp 3-17.  fluid balance mn-1630 + 1111 cc's.  scant generalized edema, + ascitic abdomen.

resp:  ls clear, diminished.  when stimulated, pt rr increases and becomes wheezy at times.  ? if administration of meropenum contributes to overall worsening picture so benadryl now given before meropenum administration and it is given over 1 hour.  no s+s of adverse reaction noted today with x2 doses of meropenum.  pt on [**name (ni) 3674**] cool mist with am abg:  7.42, 46, 134, 31, 5.

gi:  abdomen distended, ascitic.  + bs.  no bm. tube feeds @ [**name (ni) **] via post-pyloric tube stopped this morning in preparation for procedure.  ivf started.  pt to angio and then to ct scan for ct guided placement of catheter.  pt remains in ct at this time intubated, with anesthesia, radiologist, and nursing in room.

gu:  foley-bsd with clear amber urine/icteric.

sx:  [**name (ni) **] [**name (ni) 731**] was [**name (ni) **] for consents.

r:  septic, dependent on pressors, currently in ct scan for drain placement.

p:  continue to titrate neo for [**name (ni) **] > 90, map > 60.  tobramycin levels due with next dose.  continue current close monitoring and management.




"
2188,"resp: [**name (ni) 257**] pt on simv 14/500/+5/50%.  ett 7.5 retaped and secured  20@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of bloody, clots secretions. mdi's administered q4 with no adverse reactions. am abg 7.39/42/69/26. fio2 increased to 60%. plan trip today to or for debridment.
"
2189,"resp:  pt continues to be mechanically ventilated on psv 15/+5/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve following suctioning. suctioned for small amount of thick white secretions. mdi's administed q 4hrs atr with no adverse reactions.  rsbi=117, plan to keep pt on psv and wean as tolerated.  no further changes
"
2190,"continuation of previous note.
cv:  patient originally with low grade temp,  now afebrile.  patient on multiple cardiac medications thoughout the day with various adverse and not adverse reactions.  patient currently on esmolol for rate control, norepi for bp management, heparin, insulin and currently versed.  patient with poor [** **] pt on right foot and no dp on right foot.  [**name (ni) **] pt and dp on left foot.

resp: no vent changes made this shift, patient overbreathing on vent, with adequate oxygenation and good gases.  patient with minimal amounts of ett secreations.

gi:  patient started on insulin gtt for elevated blood sugars with multiple foul smelling bloody stools.

gu:  patient with patent foley voiding minimal amounts of urine.  please see flowsheets for all other information.  thank you
"
2191,"7p-7a
neuro: pt opens eyes, does not follow commands, does not [**name8 (md) 506**] rn in room, does not move any extremeties. perrla. morphine 2mg ivp given for pain shown by increase in bp.

cv: hr 80-90s in and out of afib. at present 80s sr no ectopy, lytes repleted prn. sbp labile, see carevue, on and off neo. at present time sbp 102, on 0.5mcg/kg/min. picc to right arm patent and [**name8 (md) 235**]. left radial arm [**name8 (md) 235**] reddened. dopplerable pedal pulses. generalized anasarca. bilat upper extremties oozy moderate amts of serous fluid. sternal sutures cdi, covered w/ gauze and abd. binder [**name8 (md) 235**] to sternal area. received 1 unit of prbcs, no adverse reactions, repeat hct 28.

resp: ls clear- coarse, diminished bases. sats >98%. rr 25-35. trial of cpap rr increased to 40's. on cmv rate 10, fio2 40% peep 5, see carevue for abgs. suctioned for small amts of thick yellow secretions via ett.

gi/gu: abd soft, round, hypoactive bs. tf residual at 0030 250cc, given back to pt, tf on hold, pa [**doctor last name **] aware. dophoff +placement. foley [**doctor last name 3447**] adequate amts of clear yellow urine.

skin: stg 2 2cm round to coccyx area, duoderm on and [**doctor last name 235**]. see carevue for further details.

endo: riss.

plan: monitor hemodynamcis. monitor pulmonary status. follow labs and treat as appropriate. pain control. monitor neuro status.
"
2192,"resp: [**name (ni) 257**] pt on psv 10/5/50%. bs are clear bilaterally with diminished bases. suctioned for scant to small amounts of thick tan secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's or changes this shift. rsbi=54. plan to wean to extubate today.
"
2193,"npn shift 1900-0700:

neuro: a&ox3, periods of restlessness, anxiety. non-compliant w/ activity restriction. perrla. mae, equal strength.

resp: b/l bs coarse w/ rales mid to lower bases bilaterally. upper airway congestion, wet, unprod cough. resp tachypneic, labored, discoordinate. chest x-ray revealed fluid volume overload. lasix 20mg iv at 0000 w/ good response.  tol 4l nc for most of night. resp distress at 0500, desat to 80's, audible expiratory wheezing, verbalized feeling sob. 100% nrb on w/ good effect. alb/atro neb given. pt refused o2 humi face mask, ho aware. place on high flow nasal cannula, able to wean to 6l at 0600 w/ good effect. pt more comfortable.

cv: st, rare pvc's, pac's. sbp 130-170's. no s/s of cardaic distress. on metoprolol at home. lopressor 5mg iv ordered as tsanding w/ good  effect. no edema. +pp, feet pale, cool, dusky toes. ho aware. pt hypernatremic, 151, ho aware. other electrolytes wnl.

hem: tx prbc x3 for hct of 20 from 26. tol tx well, no s/s of an adverse reaction. post hct x2 stable at 29.0. no s/s of active bleed. inr=1.2.

id: wbc up from 12 to 17. afebrile.

gi: abdomin distended, rounded, firm. +bs x4. pt coughing w/ small sips of h20. made npo until am, will further eval. no bm.

gu: good amts of yellow urine, w/ sediment. pt w/ chronic renal failure, bun/cr=52/3.6.

plan: wife and family to come in for meeting w/ ho to discuss course of care, adviced to fill out health care proxy forms. possible mri? pt declines surgey so far for aaa, 6x6cm. full code. resusitation status must be addressed w/ family.
"
2194,"resp: [**name (ni) 257**] pt on psv 18/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. continued periods of extreme aggitation with rr into 60's. ativan given to calm with results. peep ^ to 8 abg's 7.43/35/104/24. rsbi=164. will continue to wean appropriately.
"
2195,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 20/5/50%. alarms on and functioning. ambu/syringe @ hob. portex #7 with spare inner cannula in room. cp @ 23 cmh20. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.39/36/133/23. rsbi=127. terminated with ^ rr to 40's. will continue to wean appropriately.
"
2196,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c14/550/+5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellowish secretions. mdi's administered q4 combivent with no adverse reactions. vent changes: psv 12/5/35%, abg's drawn (careview)ps ^ 15, fio2^40% abg 7.39/42/99/26. rsbi=40, ps decreasd to 10. will continue to wean for possible extubation.  ett retaped and secured @ 22 lip. no further changes noted.
"
2197,"npn 2300-0700:

pt tansfered from oncology floor, 7 [**hospital ward name 320**] at 2300 for gi bleed. +melanous stool, hct 21 down from 29.4. tx 2u at 7 [**hospital ward name 320**], 1 pack of platelets. after 1u prbc, hct remained at 21. neuro stable. a&ox3. oob supervised, gait slow, steady. equal strength, no weakness. perrla. no pain. ra, satting 95-100%. no distress. lungs clear. nsr-st, no ectopy. hypotensive, sbp 80's-90's, baseline as [**name6 (md) 20**] oncology rn. asymthomatic. pt w/ fuo, on prn tylenol 650mg given atc. pt spiked to 101.5. pt w/ chills at 0200. tylenol 650mg, benadryl 25mg po w/ good relief. ho aware, pan cx'd on floor. pt urinate in toilet, unable to get sample. npo, tolerated h2o with pills. no n/v/t. stool brown, small amt of blood clots evident, not bright red.  ordered for prbc x 4u, platelets 1 pack. tx'd 3u of prbc, 1pack of platelets via r subclavian hickman (triple port) w/ no adverse reaction. cortisol level test done and sent at 0700 w/ am labs.
"
2198,"[**2125-3-25**] 1:29 pm
 ct chest w/contrast                                             clip # [**0-0-**]
 reason: evaluate for abscess around surgery site. please extend to l
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 55m with recent rib r fractures, now with increasing pain around
  fracture site as well as pain
 reason for this examination:
  evaluate for abscess around surgery site. please extend to liver as he feels
  the liver is swollen and tender (murpy's sign negative)
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sun [**2125-3-25**] 5:18 pm
  1. s/p fixation of r lateral [**6-25**] rib fx; adjacent pleural thickening raises
  question of repetitive irritation by hardware/screws.
  2. persisting fx of posterior r 8 & 9 rib fx.
  3. healing posterolateral r 10 rib fx.
  4. no chest wall/pleural fluid collection.
  5. no fluid around the visualized portion of the liver.
 wet read version #1
 wet read version #2 jekh sun [**2125-3-25**] 2:32 pm
  1. s/p fixation of r lateral [**6-25**] rib fx.
  2. persisting fx of posterior r 8 & 9 rib fx.
  3. healing posterolateral r 10 rib fx.
  4. no chest wall/pleural fluid collection.
  5. no fluid around the visualized portion of the liver.
 ______________________________________________________________________________
                                 final report
 history:  55-year-old male with recent right-sided rib fractures, now with
 pain around the fracture site.

 study:  ct of the chest with contrast; 70 cc of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  [**2125-2-4**] chest cta.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course.  the pulmonary arterial trunk is also of a normal
 caliber.  there is no mediastinal hematoma.  there is no pleural or
 pericardial effusion.  a small locule of fluid just anterior to the superior
 aspect of the heart measures approximately 2 cm in diameter and is most
 compatible with a pericardial cyst (2; 41).

 the lungs are clear of masses or consolidation.  small amount of
 atelectasis/scarring is present in the right lower lobe in the region of the
 rib fracture repair.

 the visualized portion of the upper abdomen shows no abnormality; specifically
 there is no fluid around the liver or in the superior portion of the
 retroperitoneum.
                                                             (over)

 [**2125-3-25**] 1:29 pm
 ct chest w/contrast                                             clip # [**0-0-**]
 reason: evaluate for abscess around surgery site. please extend to l
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)

 examination of the bones again demonstrates lateral fixation plates of the
 right seventh, eighth, and ninth ribs with the screw tips extending just
 beyond the inner cortical rib margins, of uncertain clinical significance.
 adjacent mild pleural thickening is also present.  non-united fracture of the
 posterior aspect of the right seventh and eight ribs are also present.  the
 posterolateral aspect of the right ninth rib demonstrates a non-displaced
 fracture with callus surrounding it (2; 61).  otherwise, the spine and sternum
 appear unremarkable.  no fluid collections are present in the soft tissues
 adjacent to the fracture fixation.

 impression:
 1. status post fixation of the right seventh through ninth lateral ribs with
 non-united posterior fractures of right ribs eight and nine.  adjacent pleural
 thickening raises the question of irriation from hardware/screws.  this
 finding was discussed with [**first name8 (namepattern2) 305**] [**last name (namepattern1) 1509**] at 17:17 on [**2125-3-25**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**]
 over the phone.
 2. healing posterolateral right 10th rib fracture.
 3. no evidence of chest wall or pleural fluid collection.
 4. limited views of the upper liver show no perihepatic fluid.

"
2199,"[**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 52m with new r pleural effusion
 reason for this examination:
  charac of fluiid?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with new right pleural effusion and abdominal pain.

 study:  ct of the torso with contrast; 150 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest radiograph from [**2164-8-17**] at 9:59 a.m.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  scattered
 axillary and mediastinal lymph nodes are present, although none meet
 pathologic size criteria.  multiple prominent bilateral hilar lymph nodes are
 present measuring 14 mm in their short axis on the right and 12 and 6 mm in
 their short axis on the left (601:45).  the aorta is of a normal caliber along
 its course with incidental note made of a common origin of the brachiocephalic
 and left common carotid arteries, a normal variant.  the pulmonary arterial
 trunk caliber is at the upper limits of normal, and there are no central
 filling defects.

 again is noted a large loculated effusion with minimally complex to simple
 fluid, unlikely to be hemorrhagic.  there is associated consolidation of
 nearly all the right lower and right middle lobes as well as compressive
 atelectatic effect on the right upper lobe.  portions of these collapsed lobes
 show variable enhancement, and multiple rounded hypodensities may in fact
 represent saccular bronchiectasis versus multiple foci of necrotizing
 pneumonia.  the left lung shows a clear upper lobe and saccular bronchiectasis
 of the lower lobe with diffuse bronchial wall thickenking in addition to some
 dependent atelectasis.  there is no pleural effusion on the left, and there is
 no pericardial effusion.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 subtle dense material in the neck of the gallbladder may represent small
 stones or sludge, but there is no pericholecystic fluid, wall edema or
 gallbladder distention.  the pancreas shows no masses or peripancreatic fluid
 collections.  the spleen is normal in size and appearance with a small 1-cm
 splenule noted anteroinferiorly.  the adrenal glands show no nodules.  the
 kidneys enhance with and excrete contrast symmetrically.  multiple
 well-circumscribed hypodensities are present in both kidneys, too small to
 characterize but likely representing simple cysts.  the small and large bowel
                                                             (over)

 [**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 show no evidence of obstruction or wall edema.  the aorta, ivc and portal vein
 appear normal.  there is no free fluid, free air or lymphadenopathy.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  there is no
 pelvic lymphadenopathy or free fluid.

 bones:  a schmorl's node is present at the inferior endplate of l4 and t12.
 otherwise, there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  large loculated right pleural effusion; saccular bronchiectasis of the
 bilateral lower lobes and consolidation of the right middle and right lower
 lobes with heterogeneous hypoenhancement and rounded hypodensities that may
 represent either the underlying saccular bronchiectasis versus multifocal
 necrotizing pneumonia.
 2.  cholelithiasis without cholecystitis.
 3.  hilar lymphadenopathy may be reactive; follow up imaging after treatment
 is recommended to ensure resolution.

"
2200,"[**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  71 year old woman with pancreatic cancer s/p ex-lap with bx of periduodenal
  nodule, chole, [**last name (un) **], choledochojejunostomy, and gastrojejunostomy
 reason for this examination:
  for oncology staging
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 ct chest with contrast

 comparison:  none.  correlation is made with cta abdomen of [**2143-8-14**].

 technique:  multiple axial ct images were obtained through the chest following
 the administration of 75 cc of omnipaque iv contrast.  sagittal and coronal
 reconstructions were obtained.  no adverse reactions were reported.

 indication:  71-year-old female with pancreatic cancer, status post
 exploratory laparotomy with biopsy of peri-duodenal nodule, cholecystectomy,
 roux-en-y procedure, choledochojejunostomy, and gastrojejunostomy.  exam is
 done for oncology staging.

 findings:  right picc terminates at the superior atriocaval junction.  no
 supraclavicular, mediastinal, hilar, or retrocrural lymphadenopathy.  small
 right hilar lymph node measures 8 mm on short axis and does not meet criteria
 for pathologic enlargement by size.  scattered left hilar pulmonary calcified
 granulomas.  heart size is within normal limits without pericardial effusion.
 the thoracic aorta is normal in caliber without dissection or aneurysmal
 dilatation.  branches of the aortic arch are normal.  pulmonary trunk is
 within normal limits by size.  no central pulmonary thromboembolic disease is
 identified.  thyroid gland demonstrates homogeneous attenuation without focal
 lesions.

 there is a 4-mm nodule in the middle lobe and a 3-mm nodule in the subpleural
 right lower lobe (2:36).  no pulmonary mass is identified.  bilateral basilar
 subsegmental atelectasis.  small bilateral pleural effusions.  no
 pneumothorax.

 abdomen:  pneumobilia is likely related to recent changes of reported
 choledochojejunostomy. hypodensity in the gallbladder fossa with intrinsic air
 is compatible with surgicel packing although an abscess would have a similar
 appearance.  stable 0.9 x 1.3 cm hypodensity in the right hepatic lobe
 (segment vii).  small perihepatic and perisplenic ascites.  colonic
 diverticulosis without diverticulitis involving the visible splenic flexure.
 there is patchy fluid surrounding the splenic flexure, which may be due to
 post-surgical change.

 bones and soft tissues:  no acute fracture or destructive osseous process.
                                                             (over)

 [**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 multilevel degenerative disc disease.  advanced degenerative changes of the
 right and moderate degenerative changes of the left acromioclavicular joint.
 degenerative arthrosis of both humeral heads.  there is a calcific structure
 along the greater tuberosity of the left humerus which may relate to calcific
 tendinosis.  no acute fracture or destructive osseous process.

 impression:
 1.  indeterminate right middle lobe and lower lobe pulmonary nodules.  in a
 patient with history of prior malignancy, unenhanced ct chest is recommended
 in three months to monitor growth pattern and malignant potential.
 2.  no intrathoracic lymphadenopathy.
 3.  pneumobilia, abdominal ascites and pericolonic fluid involving the splenic
 flexure are likely related to recent surgery. hypoattenuation in gallbladder
 fossa with intrinsic air is compatible with surgicel packing, however an
 abscess would have a similar appearance and cannot be excluded.
 4.  scattered colonic diverticulosis.

"
2201,"[**2123-9-16**] 9:25 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 20502**]
 reason: please evlauate for occult malignancy
 admitting diagnosis: nausea;vomiting;liver tx
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with recent weight loss and dysphagia
 reason for this examination:
  please evlauate for occult malignancy
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  57-year-old male with recent weight loss and dysphagia concerning
 for occult malignancy.

 study:  ct of the neck with contrast; 70 cc of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the brain is unremarkable.  please refer
 to the head ct report performed from the same day.

 the orbits and globes are intact.

 the paranasal sinuses are clear.  the mastoid air cells are clear.

 the nasopharynx and oropharynx demonstrate no evidence of masses; streak
 artifact from dental amalgam limits assessment of the tongue and adjacent soft
 tissues.  the parotid glands are normal appearing bilaterally.  the
 submandibular glands are normal appearing, although slight asymmetry is
 present with the left gland larger than the right.

 the carotid arteries and jugular veins are patent; a small amount of calcified
 atherosclerotic disease is present at both carotid artery bifurcations.  no
 lymphadenopathy is present.

 the thyroid appears unremarkable.

 the lung apices demonstrate scattered areas of ground-glass opacity,
 compatible with sites of infection or inflammation.  a moderate right pleural
 effusion is present, non-hemorrhagic in nature.

 the bones demonstrate mild to moderate multilevel degenerative changes in the
 spine, but no aggressive appearing lesion is present.

 impression:  no evidence of occult malignancy.
                                                             (over)

 [**2123-9-16**] 9:25 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 20502**]
 reason: please evlauate for occult malignancy
 admitting diagnosis: nausea;vomiting;liver tx
 ______________________________________________________________________________
                                 final report
 (cont)

"
2202,"[**2130-8-3**] 2:15 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 100592**]
 reason: hx cough, pulmonary nodules and smoking, rule out mass or pn
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  67 year old woman with cough, copd, pulmonary nodules
 reason for this examination:
  hx cough, pulmonary nodules and smoking, rule out mass or pneumonia
 contraindications for iv contrast:
  possible adverse reaction
 ______________________________________________________________________________
                                 final report
 [**last name (un) **] ct without contrast

 indication:  history of cough, pulmonary nodules and smoking.  rule out mass
 or pneumonia.

 comparison:  multiple chest ct from [**2119**] to [**2124**].

 technique:  axial helical mdct images were obtained from the suprasternal
 notch to the upper abdomen without administration of iv contrast and 1.25 mm
 slice collimation.  multiplanar reformatted images in coronal and sagittal
 axis were generated.

 findings:

 airways and lungs:

 panlobular and centrilobular severe emphysema is predominant in upper lobes.
 the airways are patent to subsegmental level.
 there is no pneumonia.

 new 4 mm apical left lung nodule (4; 35) is probably bronchiolar.  all the
 other nodules are stable since [**2122**], series 4, image 37, 67, 162, 209).  the
 dominant one measures up to 6 mm in right lower lobe.  there is no lung nodule
 concerning for malignancy.

 mediastinum:  the thyroid is unremarkable.  there is no lymph node enlargement
 by ct size criteria.  patient had prior sternotomy for cabg with extensive
 calcification of her venous graft from the aorta to lad with probably a stent
 inside of it.  aorta is not dilated and is moderately calcified.  there is no
 pericardial or pleural effusion.  epicardial wires are still in the
 mediastinum.

 osseous structures:  there is no bony lesion concerning for malignancy.

 upper abdomen:  this unenhanced study is not tailored for assessment of
 intra-abdominal organs.  gallstone is measuring 1.2 cm.  abdominal aorta is
 slightly ectatic measuring 26 x 23 mm.

 conclusion:

 1.  there is no pneumonia.
                                                             (over)

 [**2130-8-3**] 2:15 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 100592**]
 reason: hx cough, pulmonary nodules and smoking, rule out mass or pn
 ______________________________________________________________________________
                                 final report
 (cont)

 2.  4 mm left apical new ground-glass nodule is probably bronchiolar.  a chest
 ct followup is suggested in a year.

 3.  all the other nodules are stable since [**2122**].

"
2203,"[**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 81m with sudden onset rlq pain at mcburney's point since yesterday.
  +rebound at pcp office
 reason for this examination:
  eval for appy, intra-abd process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh tue [**2194-9-23**] 11:02 pm
  1. no appendix seen, but no secondary signs of appendicitis.
  2. sigmoid diverticulosis w/o diverticulitis.
  3. l iliac vein [**year (4 digits) **]; early contrast phase limits evaluation of patency.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  81-year-old male with sudden-onset right lower quadrant pain
 yesterday.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2191-3-23**] ct of the torso with contrast.

 findings:

 abdomen:  visualized portion of the lung bases show minimal dependent
 atelectasis.  a moderate hiatal hernia is also present.  pacer leads are also
 present in the right ventricle.  the liver shows no focal lesion or
 intrahepatic biliary dilatation.  clips in gallbladder fossa are compatible
 with prior cholecystectomy.  the spleen is normal in size and appearance.  the
 adrenal glands show no nodules.  the pancreas shows no masses or fluid
 collections.  multiple hypodensities are present in both kidneys, too small to
 characterize, likely represents simple cysts.  the kidneys enhance with and
 excrete contrast symmetrically without evidence of hydronephrosis.  small and
 large bowel show no evidence of wall edema or obstruction.  diverticulosis is
 noted in the descending and sigmoid colon without diverticulitis.  there is no
 free air, free fluid or lymphadenopathy.  the appendix is not visualized.

 pelvis:  the bladder is unremarkable.  a left external iliac vein [**year (4 digits) **] is
 present, but due to early phase of contrast administration, its patency is not
 well evaluated on the current study.

 bones:  no aggressive-appearing lytic or sclerotic lesion is present.
 degenerative changes are present in the lower lumber spine, primarily in the
 form of facet joint hypertrophy and osteophytes.

 impression:
 1.  appendix not visualized, but no secondary signs of appendicitis.
                                                             (over)

 [**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  descending and sigmoid diverticulosis without diverticulitis.
 3.  status post cholecystectomy.
 4.  left external iliac vein [**clip number (radiology) **], incompletely evaluated for patency.

"
2204,"[**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 80f with nausea/vomiting, diffuse abd pain
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2188-10-10**] 5:17 am
  1. no acute intraabdominal process.
  2. cirrhosis, ascites, splenomegaly, and smv thrombosis w/ downstream
  reconstitution (similar to [**2188-6-8**] ct).
  3. stable panc tail ipmn.
  4. cholelithiasis w/o cholecystitis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  80-year-old female with nausea, vomiting and diffuse abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; omnipaque iv contrast was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2188-6-8**].

 findings:

 abdomen:  the lower portion of the chest demonstrates calcified
 atherosclerotic disease of the coronary arteries as well as mitral and aortic
 valve calcifications.  the central line tip sits in the upper part of the
 right atrium.

 again the liver demonstrates a shrunken nodular contour compatible with
 cirrhosis.  the portal vein is patent and thrombosis of the smv persists with
 downstream reconstitution, similar to prior exam.  the gallbladder is
 decompressed with dense layering material within it.  the spleen is large
 measuring 15.6 cm in its long axis (2:26).  the adrenal glands are normal
 appearing bilaterally.  again the pancreas demonstrates a 13 mm hypodensity in
 the tail that is circumscribed and stable from prior exam, likely an ipmn.
 kidneys enhance with contrast symmetrically but are noted to be atrophic in
 this patient with known end-stage renal disease.  incidental note is made of a
 circumaortic left renal vein.  the small and large bowel show no evidence of
 obstruction.  a thickened appearance of the wall is likely secondary to the
 large amount of ascites that is present.  there is no free air.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta and into its
 major branches.

 pelvis:  streak artifact from bilateral hip hardware limits assessment of fine
 detail.  within that limitation, the bladder and rectum appear unremarkable.
 calcified uterine fibroids are present.
                                                             (over)

 [**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 level in the form of vacuum
 phenomenon as well as at the l3-l4 level in the form of narrowing, endplate
 sclerosis, and anterior osteophytes.  a hip arthroplasty is present on the
 right and repair of a proximal femoral fracture is evident on the left in the
 form of screw and plate fixation hardware.  old healed pubic rami and
 bilateral rib fractures are unchanged from prior exam.

 impression:
 1.  no acute intra-abdominal process.
 2.  cirrhosis, ascites, splenomegaly, and stable smv thrombosis with
 downstream reconstitution.
 3.  stable pancreatic tail ipmn.
 4.  cholelithiasis without cholecystitis.

"
2205,"[**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 79f with fever, leukocytosis, elevated lactate, abd ttp.pt is on
  dialysis; renal aware of contrast and plan for dialysis.
 reason for this examination:
  acute abd process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2136-10-3**] 3:31 am
  1. no pe or aortic dissection.
  2. small b pleural effusions w/ mild pulmonary edema.
  3. cardiomegaly.
  4. nonspecific periportal edema in the liver.
  5. decompressed gb w/ mild wall edema - nonspecific but can be seen in chf,
  hypoproteinemia, or liver dysfunction.
  6. atrophic kidneys w/ multiple indeterminate lesions, some of which are
  cysts.
  7. sigmoid diverticulosis w/o diverticulitis.
  8. small amt of free fluid of unclear etiology, possibly reactive.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  79-year-old female with fever, leukocytosis, elevated lactate, and
 tenderness to palpation.

 study:  ct of the torso with contrast.  although the patient's creatinine was
 6.2, the patient is on dialysis and renal team is aware and plans for dialysis
 after the scan.  100 ml of omnipaque intravenous contrast was administered
 without adverse reaction or complication.  images were acquired in the
 arterial phase.

 images were then acquired in the chest, abdomen, and pelvis.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of the thyroid demonstrates a heterogeneous 1.8
 x 1.3 cm nodule in the left lobe of thyroid (2:7).  no axillary, hilar, or
 mediastinal lymphadenopathy is noted.  the aorta is of a normal caliber along
 its course without evidence of dissection or intramural hematoma; incidental
 note is made of a common origin of the brachiocephalic and left common carotid
 arteries, a normal variant.  the pulmonary arterial trunk is of a normal
 caliber and there are no filling defects to the subsegmental level.  the heart
 size is large, but there is no pericardial effusion.  small bilateral pleural
 effusions are present, but they are nonhemorrhagic in nature and minimal
 associated atelectasis is present.  scattered areas of ground-glass opacity
 are most compatible with pulmonary edema.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 abdomen:  within the limits of early phase scan, the liver shows no focal
 lesion and mild-to-moderate periportal edema.  contrast is seen refluxing into
 the hepatic veins, raising the possibility of hepatic congestion.  the
 gallbladder is decompressed, but shows moderate wall edema/pericholecystic
 fluid.  no calcified stones are noted.  the spleen is normal in size.  the
 pancreas and adrenal glands show no masses or nodules.

 the kidneys enhance symmetrically but are atrophic.  both kidneys demonstrate
 multiple hypodense exophytic indeterminate lesions, some of which are cysts,
 but some of which have more mass-like or have more soft tissue-like densities.
 neither kidney demonstrates hydronephrosis.

 the small and large bowel shows no evidence of obstruction or wall edema.
 there is no pneumatosis or portal venous gas.  scattered diverticula are
 present along the descending and sigmoid colon.  there is no free air or
 lymphadenopathy.

 the abdominal aorta is of normal caliber along its course.  the celiac and sma
 are widely patent.  the renal arteries and [**female first name (un) 85**] are not narrowed.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  small amount of
 free fluid is present in the pelvis.  sigmoid diverticulosis is present
 without evidence of diverticulitis.  no lymphadenopathy is seen.

 bones:  a lucent lesion with a sclerotic rim is present in the right iliac
 bone measuring 15 x 13 mm in the coronal plane (601b:49), and is
 benign-appearing.  mild-to-moderate multilevel degenerative changes are
 present throughout the thoracolumbar spine.

 impression:
 1.  no pe or aortic dissection.
 2.  cardiomegaly and pulmonary edema.
 3.  heterogeneous nodule of the left lobe of the thyroid as described above.
 ultrasound may be considered as clinically indicated.
 4.  atrophic kidneys with multiple indeterminate lesions, some of which are
 cysts, but many of which are incompletely characterized, so rcc cannot be
 excluded; mr may be considered for further characterization.
 5.  descending and sigmoid colonic diverticulosis without diverticulitis.
 6.  periportal edema and decompressed gallbladder with wall edema, which is a
 nonspecific finding and may reflect chf, hyperproteinemia, or hepatic
 dysfunction.
 7.  small amount of free fluid in the pelvis, possibly reactive.
 8.  benign-appearing but indeterminate lytic lesion in the right iliac bone
 without evidence of cortical disruption.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

"
2206,"[**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 83m with vomiting, fever, lethargy
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2191-7-28**] 3:33 am
  1. hiatal hernia.
  2. cholelithiasis w/o cholecystitis.
  3. nonspecific perinephric stranding.
  4. enlarged prostate.
  5. l fat-containing inguinal hernia, also containing a small portion of
  bladder, similar to prior ct in [**2188**].
  6. mild-to-moderate colonic fecal burden.
  7. no acute findings.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with vomiting, fever, and lethargy.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  abdomen ct from [**2189-10-7**], and abdomen and pelvis ct from
 [**2188-10-2**].

 findings:

 abdomen:  bibasilar atelectasis is present as well as a small hiatal hernia.
 calcified atherosclerotic disease is present in the coronary arteries, and
 mitral valve calcifications are also present.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder shows a single calcified layering stone, but no wall edema or
 pericholecystic fluid.  spleen is normal in size.  the pancreas is markedly
 atrophic with a punctate calcification, possibly representing a degree of
 chronic pancreatitis.  the adrenal glands are normal appearing bilaterally.

 the kidneys enhance with and excrete contrast symmetrically.  small
 subcentimeter hypodensities in each kidney are too small to characterize, but
 likely represents cysts.  mild urothelial thickening is present in the left
 renal pelvis.  non-specific perinephric stranding is present bilaterally.

 the small and large bowel show no evidence of wall edema or obstruction.  the
 colon demonstrates a moderate fecal burden.  the aorta is of a normal caliber
 along its course with areas of calcified and non-calcified atherosclerotic
 disease present.  scattered subcentimeter retroperitoneal lymph nodes are seen
                                                             (over)

 [**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in the periaortic stations, but none meet pathologic size criteria.  there is
 no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley balloon with herniation of
 the left aspect of the bladder into the primarily fat-containing left inguinal
 hernia.  the prostate continues to be enlarged.  there is no pelvic
 lymphadenopathy or free fluid, and the rectum appears unremarkable.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 mild-to-moderate degenerative changes are seen throughout the thoracolumbar
 spine.

 impression:
 1.  no acute intra-abdominal process; moderate colonic fecal burden.
 2.  hiatal hernia.
 3.  enlarged prostate and left fat- and bladder-containing inguinal hernia.
 4.  mildly thickened left renal pelvis urothelium of unclear significance; no
 evidence of hydronephrosis or pyelonephritis.

"
2207,"[**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  85 year old woman s/p colectomy for bowel ischemia, now with rigid abdomen,
  fever
 reason for this examination:
  s/p colectomy, now with rigid abdomen, fever. please do ct abd/pelvis with po
  contrast
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2194-9-1**] 7:13 pm
  1. sbo w/ transition pt at ileostomy exit site; cause appears to be mass
  effect from herniated mesenteric fat adjacent to the ileostomy.
  2. s/p r colectomy w/ tiny locules of gas adjacent to colonic staple line -
  may be post-operative although leak cannot be excluded.
  3. small amt of complex free fluid in abdomen/pelvis - ddx includes blood or
  bowel leak contents - correlate w/ exam and hct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  85-year-old female status post right partial colectomy, now with
 rigid abdomen, and fevers.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2194-8-18**].

 findings:

 abdomen:  the visualized lung bases demonstrate a moderate right and small
 left pleural effusion with associated atelectasis.

 the previously described hemangioma in the left lobe of the liver is not well
 visualized on the current exam given difference in the phase of the contrast
 administration.  the gallbladder is distended, but shows no hyperdense stones
 or wall edema.  the spleen is normal in size.  no peripancreatic fluid
 collections are present.  the cbd again is still prominent with minimal
 central intrahepatic biliary dilatation as well as a prominent pancreatic
 duct.  the adrenal glands are normal appearing bilaterally.  multiple
 hypodensities within both kidneys are too small to characterize but compatible
 with simple cysts.  the kidneys enhance and excrete contrast symmetrically.
 the aorta is of a normal caliber along its course with scattered areas of
 calcified atherosclerotic disease.  there is no lymphadenopathy.

 the stomach and small bowel are distended with multiple air-fluid levels all
 the way to the ileostomy exiting from the right lower quadrant of ventral
 abdominal wall.  a locule of mesenteric fat has herniated through the ventral
 abdominal wall narrowing the lumen of the ileostomy, resulting in relative
                                                             (over)

 [**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 transition point.

 the patient is status post right colectomy; a small amount of right paracolic
 gutter fluid is present with adjacent peritoneal enhancement, potentially
 reflecting post-surgical changes in the resection bed (2:38).  a blind-ending
 left/transverse colon is present with gaseous distention of the transverse
 portion and apparent wall discontinuity/hypoenhancement at its posterior wall
 (2:38) and potentially involving the aterior wall as well.  near the staple
 line and at the anterior wall of the transverse colon are few small locules of
 intraperitoneal gas (2:39).  additionally, there is a small amount of gas
 within a ventral wall subcutaneous fat.  small amount of intra-abdominal free
 fluid is present and is of borderline complexity.

 pelvis:  the bladder is decompressed around a foley balloon.  uterus
 demonstrates multiple calcified fibroids.  the distal colon shows sigmoid
 diverticulosis with no evidence for diverticulitis.  minimally complex free
 fluid is present in the pelvis.  multiple inguinal lymph nodes are present,
 prominent in size but not meeting pathologic size criteria and are likely
 reactive in nature.  the right sided intramuscular hematoma is unchanged.

 bones:  no aggressive-appearing lytic or sclerotic lesions are present.
 degenerative disc disease is present at the l4-l5 level with endplate
 sclerosis and small anterior osteophytes.

 impression:
 1.  post operative changes of recent right hemicolectomy.  distended remaining
 transverse colonic pouch with apparent area of wall
 discontinuity/hypoenhancement; given the small locules of adjacent gas and
 minimal complex free fluid, colonic perforation potentially from ischemia is a
 possibility.
 2.  status post right colectomy with end ileostomy.  small bowel distnsion
 with relative transition point and mesenteric fat herniation through the
 ventral abdominal wall resulting in possible small-bowel obstruction vs ileus.
 3.  new bilateral effusions and adjacent atelectasis.

 findings raising possibility of ischemia/postoperative leak of the transverse
 colon were were discussed with [**first name8 (namepattern2) 4486**] [**last name (namepattern1) 30172**] at 19:52 by [**first name4 (namepattern1) 30173**] [**last name (namepattern1) 30174**] by
 phone.

"
2208,"[**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 60m with hcc, abd pain and fever recently d/ced
 reason for this examination:
  1: eval for pe 2. ct abd for eval for fluid collection in ruq, possible
  hepatobilary etiology for ruq pain and fever
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2119-8-7**] 11:38 pm
  1. large porta hepatis mass invading the r portal vein w/ 2 crossing biliary
  stents, and multiple hepatic mets.
  2. 2 new (from [**2119-8-2**] ct) large dilated intrahepatic ducts (2: 16 and 22)
  that are more rounded and rim enhancing, appearing more abscess-like.
  3. stable collection near the pancreatic tail compared to [**2119-8-2**] ct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with hepatocellular carcinoma, now with abdominal
 pain and fever after recent discharge.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2119-8-2**] abdominal ct.

 findings:

 abdomen:  the visualized portions of the lung bases demonstrate streaky
 atelectasis. right gynecomastia is incompletely imaged. no pleural effusion.
 prominent 9-mm right diaphragmatic lymph node is unchanged.

 the spleen is normal in size and appearance.  the adrenal glands show no
 nodules.  the kidneys enhance with and excrete contrast symmetrically without
 focal lesion or hydronephrosis. the small and large bowel show no evidence of
 obstruction or wall edema.  a lobulated low-attenuation peripancreatic
 collection adjacent to the tail, is redemonstrated and currently measures 4.6
 x 3.0 cm in greatest conglomerate axial dimensions, which is similar to the
 prior study where it measured approximately 4.3 x 2.8 cm at similar level. the
 pancreas is otherwise unremarkable.

 a dominant ill-defined enhancing hypodense mass involving segments [**last name (lf) 70637**], [**first name3 (lf) 751**],
 and ivb measuring 6.1 x 5.4 cm in the axial plane (2:20) is similar in size
 and appearance from the prior study and results in biliary obstruction in both
 hepatic lobes.  it has invaded the bifurcation of the main portal vein as well
 as the left and right portal veins, and has occluded the anterior right portal
 venous branch, unchanged. multiple stable-appearing ill-defined, peripherally
 enhancing satellite lesions are present primarily involving the right hepatic
 lobe, concerning for metastases.  incidental note is made of a fiducial seed
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in segment [**clip number (radiology) 70637**] of the liver (2:22).  enlarged porta hepatis and
 paraesophageal lymph nodes are present, similar to the prior exam.

 since the prior study, there has been marked interval increase in size of
 lobulated tubular hypodensities with rim enhancement within segments vii and
 [**clip number (radiology) 70637**] compatible with marked worsening of biliary obstruction and cholangitis
 (2:16, 2:22). new rounded rim-enhancing hypodensities are noted adjacent to
 these dilated bile ducts compatible with abscesses (2:14), the largest
 discrete abscess measuring 12-mm which is located at the junctions of segments
 vii and [**clip number (radiology) 70637**] (2:14). additionally, the more inferiorly located blown-out
 intrahepatic bile duct in segment [**clip number (radiology) 70637**] demonstrates extension into the
 subcapsular space with a focal subcapsular abscess noted measuring 2.1 x 0.9
 cm (2:20).

 moderate intrahepatic biliary dilatation elsewhere in the right lobe as well
 as in the left lobe of the liver is not significantly changed. two metal
 biliary stents are seen coursing from the main left and right hepatic ducts
 through the common bile duct and terminate within the duodenum. as before, the
 left stent traverses the mass; the right stent terminates within the mass
 (2:23). a small amount of pneumobilia is present within the gallbladder and
 cystic duct, an expected finding in a patient with stents.

 there is no free air or free fluid.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  the appendix
 is normal.  there is no pelvic lymphadenopathy or free fluid.

 bones:  there is degenerative disc disease at l5-s1 intervertebral disc.
 additionally, there is subtle grade i anterolisthesis of l4 on l5.  otherwise,
 there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  worsening biliary obstruction in segments vii and [**clip number (radiology) 70637**] with peribiliary
 enhancement and multiple new adjacent rim enhancing round hypodensities
 compatible with cholangitis and abscess formation. the blown-out intrahepatic
 bile duct within the inferior aspect of segment [**clip number (radiology) 70637**] extends into the
 subcapsular space with a focal subcapsular abscess identified.

 2.  relatively unchanged appearance of dominant mass compatible with
 hepatocellular carcinoma within segments [**doctor first name 751**], ivb and [**doctor first name 70637**] with invasion into
 the portal venous system and biliary obstruction. numerous ill-defined lesions
 primarily within the right lobe of the liver which appear similar compared to
 the prior exam likely reflect metastases, although developing abscess
 formation cannot be completely excluded.

 3.  moderate left intrahepatic biliary dilatation is similar.
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)

 4.  no significant change in peripancreatic tail lobulated fluid collection.

"
2209,"resp: [**name (ni) 257**] pt on psv 15/8/40%. bs reveal noted aeration with sub q bilaterally. suctioned for moderate amounts of thick yellow secretions, copious thick clear from oral cavity. mdi's administered alb/atr with no adverse reactions. pt 02 sats to 80's with ^ wob then placed on simv (see carview). attempted rsbi but no resps. sedation lightened and plan is to change settings to psv.
"
2210,"resp: pt rec'd on simv 20/450/10/+5/40%. ett #7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration and sub q noted on ls and up front of chest. suctioned for small amounts of thick yellow/whitish secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions. am abg 7.44/47/95/33. rsbi=no spont resps. plan to attempt wean to psv today as tolerated.
"
2211,"resp: pt rec'd on simv 20/400/20/+5/50%. bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions with a few plugs. mdi's administered q4 hrs alb/atr with no adverse reactions. attempted to wean to psv this am and pt ^ wob,^rr to 38+ with vt's @ 200, so returned to simv. abg's 7.37/56/116/34. vent changes to  decrease fio2 to 40%, increase vt to 450. no further changes noted.
"
2212,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] 10/8/40%. alarms on and functioning. ambu/syringe @ hob.  cp @ 20, trach #8 portex. bs auscultated reveal bilateral clear sounds. suction for small amount of thick yellow. mdi's administered q4 hrs combivent with no adverse reactions. plan to continue t/c trials as pt tolerates.  am abg's 7.36/42/100/25. rsbi=56.  will continue to wean appropriately.
"
2213,"resp: [**name (ni) 257**] pt on psv 12/8/50%. #8 portex with positional [**name (ni) **] at times. bs are coarse bilaterally. suctioned small amounts of thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt still very anxious with rr 6 to 40's.  no abg's or vent changes this shift. vt's 300's
"
2214,"resp: rec'd on psv 8/5/40%. portex #8, ^ cuff pressures md aware. bs reveal bilateral aeration, chest tubes sealed. suctioned for moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. pt had episodes of ^ wob/rr. increased psv to 10, peep to 8 with vt's 300's, 02 sats 98%. no abg's.
"
2215,"resp: pt remains on pcv dp20/r20/+5/40%. bs are coarse with small amounts of thick yellow secretions suctioned. no changes or abg's noc. 02 sats @100%. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. will continue full vent support
"
2216,"ccu nursing progress/proceedure note 2:15pm-5;30pm
s:  i feel like i'm drunk!

o:  pt pre medicated on [**hospital ward name **] 3 with 5mg po benedryl prior to asa desensitization.  alert and cooperative throughout, but sleepy and does doze at times.

desensitization started at 2:30pm per protocol with doses administered every 15min.  pt tolerated without itching, sob, hives or other adverse reaction.

cv - hr 58-70 nsr/sb with rare pvc's.  bp 138-148/80's.  4pm lopressor held d/t hr parameters, but administered at 5:20pm.   heparin maintained at 400u/hr.

resp - ls are clear on ra with sats 96-100%.

gu - voiding in urinal q1-2hrs approx 400cc per void.   1 liter infusing upon admission, absorbed and dc/d.

gi- abd is soft with +bs.  tolerating clear liq with asa

a:  successful asa desensitization

p:  cath planned for [**7-11**], cont asa and heparin and monitor for s/s intolerance.  keep pt informed of poc per multidisiciplinary rounds.
"
2217,"resp: [**name (ni) 257**] pt on simv 20/450/+5/40%. alarms on and functioning. ett 7.5, 23 @ lip. bs are diminished bilaterally. ls chest tube in place. mdi's administered q4 hrs with no adverse reactions. abg's 7.39/49/98/29. rsbi=126. placed pt on psv 15/8/40%. vt's 400/ve's 6/rr 18/02 sats @99% with am abg to follow. no further change noted.
"
2218,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/+8/60%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal ls coarse, rs diminished with some aeration noted in apecies. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.40/44/144/28. decreased fio2 to 50%. rsbi=16. plans to wean to possible extubate this am.
"
2219,"resp:  [**name (ni) 257**] pt on [**last name (un) **] a/c 20/500/40%/+8.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal rs clear apecies with ls coarse, diminished bases. 02 sats ^ 90's, 98%.  suctioned for small to moderate amounts of thick yellowish secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=153. no further changes noted
"
2220,"resp: [**name (ni) 257**] pt on a/c 12/500/+5/40%. bs are slightly coarse. suctioned for moderate amounts of tan-yellow thick secretions. mdi's administered as ordered of atr with adverse reactions. am abg 7.41/39/104/26. plan is for possible extubation today.
"
2221,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 15/5/40%. bs are clean bilaterally with diminished bases. mdi's administered q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions. spare trach, ambu in room. no abg's. t/c trials to continue today as tolerated.
"
2222,"resp care
pt seen for prn nebulizer tx.  given 2.5 mg albuterol + 2 ml of normal saline.  breath sounds are wheezy bilat with increased aeration post-tx.  no adverse reaction.  spo2: 96 on 4l nc.  pt states that breathing feels fine.  will continue to monitor for bronchodilator tx.
"
2223,"resp: [**name (ni) 257**] pt on psv 22/10/50%. bs are coarse bilaterally. suctioned for small amounts of thick secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.43/47/148/32. vent changes; decreased ps to 20/fio2 to 40%. will continue to wean appropriately.
"
2224,"resp: [**name (ni) 257**] pt on a/c 26/350/12+/40%. pt is trached #8 [**last name (un) 3338**]. alarms on and functioniong. ambu/syringe @ hob. bs are coarse with noted improvement following suctioning. suctioned for moderate amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=no sponts. am abg 7.33/38/80/21. no changes noc.
"
2225,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  a+ox3.  speech clear.  mae ad lib.  med per [**month (only) **] with morphine for face/head/neck pain while double lumen balloon in place--pain tolerable with morphine however pt has not been pain free with balloon in place.

cv/pulm:  mp=vpaced with freq pvc's noted.  bp 140's-160's/40's-60's.  heparin titrated according to sliding scale/ptt's.  transtracheal 02 catheter in place at 1liter cont.  breath sounds clear upper lobes, crackles lower lobes.  bumex 1mg iv given with brisk diuresis, breath sounds clear/coarse after bumex.  at 1630 return of bibasilar crackles noted--team aware, no intervention at this time.  doe noted; no sob at rest.  [**first name8 (namepattern2) 3568**] [**last name (namepattern1) 3569**] in to see pt from outpatient pt; attempted to remove transtracheal catheter over wire for stripping; unable to remove.  several attempts following humidified air over next 4 hours unsuccessful.  dr. [**last name (stitle) 3570**] in to see pt, catheter removed over wire, cleaned and reapplied by dr. [**last name (stitle) 3570**]. sm amts mucous and old blood noted on catheter prior to cleaning.  o2 sats mid 90's throughout day, airway intact throughout day.  pt remains with double lumen balloon in r nares, scheduled for embolicectomy [**2131-5-18**] ? time.  vit k given both po and iv in addition to one unit ffp to correct inr in preparation for procedure in am.  one unie prbc's given for hct 27.3 with increase in hct to 32.0.  no adverse reactions noted with prbc, ffp or vit k iv.

gi/gu:  tol po's--does have some difficulty swallowing.  abd soft, non-tender, bowel sounds present.  no flatus, no bm.  voiding clear yel urine; [**name8 (md) 20**] md foley inserted following void--25ml residual obtained.  foley left in place, draining clear yel urine at this time.

id/integ:  tmax 99.1 po.  remains on cefazolin.  skin intact.  old scarring noted from r mastectomy.

psychosocial/plan:  husband in to visit.  emotional support given to pt and fam.  plan is to cont to titrate heparin according to sliding scale/ptt, npo after midnight for embolectomy in am, cont to follow labs, monitor i+o, assess for signs of bleeding, monitor airway/cont 02 sat monitoring.  cont with current nursing/medical regime.
"
2226,"resp: [**name (ni) 257**] pt on a/c 26/350/+12/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. abg' 7.31/46/78/24. vent changes to increase rr to 28, fio2 to 50%. am xray and additonal abg's pending. no further changes noted.
"
2227,"respiratory care note
pt received on ac as noted with no changes this shift. bs are slightly decreased, but clear bilaterally. pt suctioned for no secretions. mdi's given q4 - pt tolerated well with no adverse reactions. plan to continue on current settings at this time.
"
2228,"resp: [**name (ni) 257**] pt on nrb. hhn administered of xopenex 0.63 as ordered with no adverse reactions. pt placed back on niv @ 4:00 psv 15/5/60%. fio2 ^ to 60% due to 02 sats in low 80's. abg pending. will continue to monitor progress to wean.
"
2229,"resp: pt rec'd on a/c 14/400/+5/50%.bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q 4 hrs [** **] with no adverse reactions. no abg's. rsbi=>200. plan is to attempt wean today as tolerated.
"
2230,"resp: pt remains on a/c. bs are coarse with occasional wheezing. mdi's administered q4hrs [** 892**] with no adverse reactions. suctioned for moderate amounts of thick tan secretions.  will continue full vent support.
"
2231,"resp: pt remains vented on a/c 18/400/+10/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4h [** 892**] with no adverse reactions. plan to wean to psv as tolerated.
"
2232,"[**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  43 year old man with new diagnosis of [**hospital 21613**] transferred from outside hospital
  with possible septic arthritis and pneumonia, still spiking fevers despite
  treatment with vanc/meropenem/azithro, and with worsening abdominal pain and
  distension
 reason for this examination:
  ? acute intra-abdominal infection, ? degree of pneumonia, ? other acute process
  to explain abdominal pain and fevers
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  43-year-old male with new diagnosis of aml, now with fevers despite
 treatment with broad-spectrum antibiotics as well as worsening abdominal pain
 and distention.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest cta from [**2123-5-8**] from an outside hospital.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  a
 prominent lymph node in the right axilla measures 9 mm in its short axis (2;
 12).  scattered small mediastinal lymph nodes are present, the largest of
 which is in the precarinal station measuring 11 mm in its short axis (2; 25).
 additionally, a right hilar lymph node measures 10 mm in its short axis (2;
 34).  the aorta is of a normal caliber along its course.  an incidental note
 is made of the left vertebral artery filling directly off the aortic arch, a
 normal variant (2; 20).  the pulmonary arterial trunk shows no central filling
 defect.  the heart demonstrates a simple pericardial effusion measuring a
 maximum thickness of 11 mm in the axial plane (2; 38).  additionally, small
 amount of bilateral pleural effusions are present, simple in nature, with
 associated atelectasis.  additionally, scattered areas of airspace opacity in
 the right upper and superior segment of the right lower lobes are compatible
 with pneumonia.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 the gallbladder shows no stones or wall edema.  the spleen measures 14.8 cm in
 its long axis.  the adrenal glands show no nodules.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis or
 masses.  the aorta is of a normal caliber along its course; the celiac axis is
 mildly narrowed as it ducks beneath the diaphragmatic crus.  the small and
 large bowel show no evidence of obstruction or wall edema.  scattered
 retroperitoneal and mesenteric lymph nodes are noted although do not meet
 pathologic size criteria.  portions of the lower retroperitoneum have a
                                                             (over)

 [**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 ""[**doctor first name 2778**]"" appearance, of unknown clinical significance.  the appendix is
 visualized and is fluid filled but not dilated, nor is there adjacent
 inflammation (2; 106 and 301b; 33).  there is no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  bilateral inguinal lymph nodes are present measuring 9
 mm in their short axes (2; 124).  there is no free fluid.

 bones:  there is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  airspace opacity at the right upper lobe and superior segment of the right
 lower lobe compatible with pneumonia; small-to-moderate bilateral pleural
 effusions and small-to-moderate pericardial effusion, all of which fluid is
 simple in nature.
 2.  scattered areas of prominent lymph nodes and splenomegaly compatible with
 patient's known diagnosis of leukemia.

"
2233,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration in apecies with diminished lll noted.  mdi's administered q4 hrs combivent with no adverse reactions. episodes of desaturation during the noc, fio2 increased to 60%. 02 sats 95-97%.  rsbi=69. pt scheduled for trache today [**3-31**]. no further changes noted.
"
2234,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex. bs are clear in apecies with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. no abg's and rsbi=72. will continue with t/c trials.
"
2235,"resp: [**name (ni) 257**] pt on psv 12/8/50%. ett #7, 26 @ lip. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. suctioned for small amounts of yellow to white thick secretions. mdi's administered alb/atr with no adverse reactions. vt's 500-600, ve's [**11-22**], 02 sats @ 98%. [**month/year (2) **]=80. plan to wean to extubate this am.
"
2236,"respiratory care note:
     received patient on ac as noted in carevue.  ett is secured and patent.  no changes have been made this shift.  for specific settings please refer to carevue.  bs are coarse throughout with occasional wheezes noted on the left side.  sx for small amounts of tan thick secretions, blood tinged at the beginning of the shift.  no rsbi this am due to increased fio2 and peep settings (.60 fio2 and 10 peep).  patient remained afebrile this shift.  mdi's administered as ordered with no adverse reactions noted.  spo2 remains 94-95%.  plan is to maintain current therapy and wean fio2 and peep as tolerated.
"
2237,"resp: [**name (ni) 257**] pt on psv 12/8/40%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioning scant amounts. mdi's administered as ordered alb/atr with no adverse reactions. vt's 500-700, rr 20's to 30's when aggitated.  no changes this shift.
"
2238,"resp: [**name (ni) 257**] pt on 50% t/c. pt removed t/c and 02 sats to 60's with ^ rr. place on [**last name (un) 33**] psv 5/5/40% to rest noc. suctioned for moderate amounts of thick yellow secretions. mdi's administerd q4 hrs alb/atr with no adverse reactions.am abg 7.38/57/132/35. will place on 50% t/c in am.
"
2239,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/5/50%. alarms on and functioning.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  rsbi=168. 02 sats remain in ^ 90's @ 97%.  no further changes noted.
"
2240,"resp: pt rec'd on psv 5/5/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. pt had some episodes of anxiety. 02 sats @ 99% with rr 18. vt 400. rsbi=37. plan to continue with t/c trials.  will continue to wean.
"
2241,"resp:  [**name (ni) 257**] pt on psv 15/5/35%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned for small to moderate amounts of thick tannish secretions.  mdi's administered q4 alb/atr with no adverse reactions. pt rested noc on a/c 12/350/+5/35% where he remains. will return to psv this am.  no further changes noted.
"
2242,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 24/380/+8/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of greenish thick secretions. mdi's administered q4 alb/atr with no adverse reactions. no further changes noted.
"
2243,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate-copious amounts of yellow and some bloody tinged secretions.  mdi's administered q4 hrs with no adverse reactions. no further changes noted.
"
2244,"resp: [**name (ni) 257**] pt on a/c 14/700/+8/50%. ett 7.5, 26@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse with diminished bases. suctioned for small amounts of thick secretions.  mdi's administered as ordered with no adverse reactions.  no changes or abg's noc. md ask to hold off on [**name (ni) 817**] and to attempt around 10:00am due to pt's past hemodynamic instability.  plan to lighten sedation, attempt [**name (ni) **] then wean as tolerated.
"
2245,"resp: rec'd on psv 15/5/40%. bs are coarse bilaterally. suctioned for copious amounts of thick bloody secretions with large clot under tongue. pt has open cuts on tongue and md aware. mdi's administered q 4 hrs alb/atr with no adverse reactions. rsbi=101. will continue with present support.
"
2246,"resp:  [**name (ni) 257**] pt on 16/400/5/40%. bs auscultated reveal ls clear with diminished rll. suctioned for small amounts of yellow thick secretions, sample sent. mdi's administered alb/atr with no adverse reactions. vent changes to decrease r to 14, fio2 to 30%. am abg 7.47/43/109/32.  rsbi attempted with no resps results. will attempt again on day shift.
"
2247,"ccu npn
please see admit note for pmh, allergies and events leading to ccu admit.

pt arrived to ccu ~1500, awake, alert, oriented.
hr 75 sr no vea, 139/60.
lungs cta
sats 98% on ra
appitite fine
vdg qs
pt given benadryl 25mg po at 1830, prior to 1st dose of asa. benadryl iv, epinepherine at bedside, methyl prednisone will be tubed from pharmacy if needed.
a: pt admitted to ccu for asa desensitization, premedicated
p: administer metered asa per protocol, monitor for adverse reaction.
"
2248,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 15/+12/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick bloody tinged secretions due to new trach.  mdi's given q4 hrs alb with no adverse reactions. vt's 600/ve 16-19, rr 28. pt has tachy periods with ^ rr in ^ 30's at times.   no rsbi due to ^ peep. no a-line for abg's presently, but expect new a-line started today. 02 sats @ 97%. no further changes noted.
"
2249,"respiratory: pt remains intubated on psv 8/8/50%. ett retaped and secured @ 21 lip. bs are diminished with some crackles noted in bases. suctioned for copious amounts of thick yellow secretions and oral secretions. mdi's administered q4 hrs alb with no adverse reactions. vt's 500-600/ve 9/rr 17. rsbi=29. around 5:00 pt self extubated even though pt was restrained. pt was placed on nrb with sats @ 99%. wife was called and informed. will continue to monitor and will re-intubate if necessary.
"
2250,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 20/5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal diminished rll with aeration noted on ls/slightly coarss/occasional wheeze.  suctioned for moderate amounts of thick yellow/bloody secretions, as well as out of oral cavity.  mdi's administered q4 alb/atr with no adverse reactions. pt became ^ sob, vent settings changed to a/c 20/400/+5/35%. abg's this am 7.37/51/99/31.  maintain settings with no further changes noted.
"
2251,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv8/5/50%.alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal clear apecies with diminished bases. suctioned for small amounts of white thick secretions. mdi's administered q6 combivent with no adverse reactions. trip to mri without incident, results negative. am abg's 7.36/48/107/28. vent changes to decrease ps to 5 and fio2 to 40%. will continue to wean appropriately.
"
2252,"npn
n: pt agitated when light attempting to sit up/self extubate. reoriented->fc's inconsistently/mae's with equal strength. sedated overnight on diprivan gtt with no adverse reaction noted.
cv: nsr 60-80's. no ectopy. cks sent and flat. hct 31.8 and stable. coags nl. hypotensive to 80's-->given total 3l fld with improvement though following lr boluses worsening met acidosis-->lactate 4. given 1l bolus 1/2ns with improvement now be -1 (-7). currently sbp 95-110 with maps >65. lt ct to 20cm sxn with sang drainage. +fluctuate/-leak. -crepitus.
r: lungs course throughout. sxn'd for mod amt thick yellow sec. simv 20->16 x 600/peep 5/50%. improving lactic acidosis.
gi: npo. ogt to lcs with mod amt bilious drainage. abd soft/distended with hypo bs.
gu: urine clear yellow 30-70cc/hr.
id: afebrile.
soc: no contact with any family. when pt awake, rn asked if there was anyone to be notified and pt shook head no. sw to get involved this am.
a/p: clinically clear neck/spine. extubate. transfer to flr.

"
2253,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 28/500/12+/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 alb with no adverse reactions. vent changes reflect abg's. am abg's 7.45/45/109/29. no further changes noted.
"
2254,"7a-7p
neuro: pt alert, disoriented to time and place. perrla. mae. medicated w/ one darvocet po for c/o incisional pain.

cv: hr 60-70s sr no ectopy noted. epicardial wires secured and attached, see carevue for details, no paced beats noted. sbp >100. a- line [**name6 (md) **] [**name8 (md) 20**] md [**last name (titles) 132**]. pressure dsg applied. 2 units of prbcs given as ordered for low hct. no adverse reactions w/ blood transfusions. extra dose of lasix 20mg given iv secondary to extra volume today. hct after prbcs 31.

resp: ls clear/ rales at bases. sats greater than 97% on 4l nc. breathing regular, not labored. chest tubes [**name6 (md) **] by md [**last name (titles) 132**]. pressure dsg intact.  cxr done.

gi/gu: abd round distended. +bs. no bm. groin area swollen w/ ecchymosis. md [**doctor last name 132**] aware. no new orders. foley draining yellow -> [**location (un) 138**], decreased u/o in afternoon- extra dose of lasix given increasing u/o. see carevue for details.

endo: fs 176-198, covered by csru protocol. md [**doctor last name 132**] changed protocol to pt's own scale to cover fs.

plan: monitor resp. status. pulmonary toilet. replete electrolyes as needed. ? transfer to floor.


"
2255,"nursing (0700-1900)
todays events- right ij line dc'd by resident

a&ox3. dilaudid for abd. surgical pain with no adverse reactions, previous night experienced hallucinations. oob to chair tolerated well, no futher complaints of pain.

periods of sinus tachycardia otherwise cv signs wnl.  afebrile.

abdominal incision tender upon palpation, open to air, no drainage, jt.

nasal cannula 2l, independent incentive spirometery (1250ml) and cough deep breathe.

abdomen soft and distended. ngt dc'd by surgery, previously clws with moderate amounts bilious drainage. tolerating jt trophic feeds.  bg treated with 2units riss.

diuresing, urine potassium level-wnl; p.m. level pending.

pt. tolerated 6 hrs. in chair today.  stood and walked back to bed with max assist, but tolerated well.

patient and family met with surgery to discuss results of tumor debulking.

plan of [**hospital 5826**] transfer to floor (bed), continue diuresing goal is -3l, continue activity oob to chair as tolerated, pain management, skin care, keep family informed of plan of care.

[**first name8 (namepattern2) 5827**] [**last name (namepattern1) 5828**] bc student nurse

"
2256,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex trach. bs are diminished bilaterally. suctioned for small to moderate amounts of thick white/yellow secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. pt having ^ wob and ps ^ to 12. vt's 500's ve's [**6-4**]. am abg 7.48/45/141/34 and ps decreased back to 10. rsbi=90. plan to continue to wean ps as tolerated.
"
2257,"resp: [**name (ni) 257**] pt on psv 10/5/40%. bs are coarse bilaterally. suctioned for large amounts of thick white secretions. mdi's administered as ordered (see careview) with no adverse reactions. pt ^ rr to 30's and bp to 190, placed on a/c to rest. abg 7.47/40/146/30. rsbi=126. plan to wean to psv as tolerated.
"
2258,"resp;  [**name (ni) 257**] pt on [**last name (un) 33**] psv 5/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned for moderate-copious thick yellow secretions. mdi's administered q4 with no adverse reactions.  pt awake, not following commands. pt returned to a/c noc for ^ in rr, bp, hr. rsbi=65.  returne o psv this am. plan to possible extubate today.
"
2259,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+10/50%.  ambu/[**last name (un) 1299**] @ hob.  bs auscultated reveal bilater coarse sounds which clear with suctioning.  suctioned x3 small to moderate amounts of thick tan secretions.  also, had a substantial amount in oral cavity.  mdi's administered in line q4hrs (6 p) combivent with no adverse reactions.  rsbi performed = 19.4, then placed back on current settings.  no further changes are noted.

"
2260,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 14/600/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. re-taped and secured ett. mdi's administered q4 hrs alb/atr with no adverse reactions. pt is waking up. rsbi=68.  still not following commands.  will proceed to wean to psv trial in am.  no further changes noted.
"
2261,"resp: [**name (ni) 257**] pt on psv 10/10/50%.  ett # 7.5 taped @ 21 lip.bs are clear in apecies and diminished in bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. pt had periods of apnea, then placed on simv 14/500/10+/50% until 4:00 and returned to psv 10/10/50%. am abg 7.42/58/100/39. no further changes noted.
"
2262,"resp: pt placed back on mmv due to periods of apnea. psv 10/5/40% (see careview for mmv settings) bs are coarse to clear and suctioning for small to moderate amounts of thick white secretins. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=50. no abg's this shift. 02 sats @ 99%. adequate tv's/ve's.
"
2263,"resp: pt rec;d on a/c 20/500/+10/60%. ett #8.0 retaped and secured @ 26 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear apecies with diminished bases. mdi's administered q4 hrs alb/atr with no adverse reactions. no rsbi=^ peep. no abg's or changes this shift. will continue full vent support.
"
2264,"npn shift 1900-0700:

[**2107**]: pt extubated at [**2107**] by rt w/ anesthesia at bedside. pt lifting head, following commands prior to extubation. tol extubation. post abg wnl. weaned o2 to 2l nc. sat 100%. no s/s of resp distress. b/l bs clear, prod cough, clear sputum.

2200: prbc ordered for hct of 21.0. complete at 0100. at 1245 pt noted to have macular, red, generalized rash to hair line, bue, and ble. no s/s of resp distress. temp up from 97.7 to 99.4. vss. ho called and at bedside. tylenol 1000mg, benadryl 50mg iv given as per ho. blood done, not suspected to be cause of rash. prbc#2 tx 0200-0400. tol tx well, disaplaying no s/s of an adverse reaction. no recurrence of rash.

0600: pt a&ox3 at start of shift, approp. towards morning, pt w/ poor st memory, a&ox2, inapprop. abg sent, wnl. 7.35/29/181/17. pt in compensated metabolic alkolosis. hco3=16. am hct stable at 34.7. plt=66 wbc=1.4. pt in neutrapenic precautions. repleted last night of ca+,k+,mg+,kphos. am k+=4.4, mg+=2.6, phos 2.2, ionized ca+=1.19. no repletion ordered as of yet. tol clears. +bmx2, brown, loose, guiac neg.
"
2265,"resp: [**name (ni) 257**] pt on mmv (psv 10/5/40%). ett 7.5, rotated, taped and secured @ 21 lip. bs are coarse to clear and suctioning for white to yellow thick secretions. mdi's administered as ordered alb/atr without adverse reactions. no abg's this shift. pt weaned back to psv 10/5/40% this am. results from abdominal ct unchanged. rsbi=95. plan: trach/peg? continue on present settings.
"
2266,"resp: pt remains intubated on a/c 16/500/+5/50%. bs are coarse bilaterally. suctioning for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs. combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. no vent changes this shift. am abg's 7.52/36/95/30. will continue full vent support.
"
2267,"[**name (ni) 5986**] note
 pt arrived to sicu from ed with c/o n/v/d x3 days. pt a&ox3 upon arrival in ed, became agitated, recieved haldolx1, adverse reaction, intubated for airway protection. pt tachycardic and hypotensive, recieved a total of 6l ns in ed and 3 units of prbc's for hct of 23. placed on pressors and brought to ct for abd scan, showing ischemic bowel. pressors weaned off, maintaining sbp>100.

 upon arrival to unit, pt recieved 1 unit prbc's and 2 units ffp. pressors remain off. metabolic acidosis, recieving bicarb 150meq and 1 amp with some improvement. lactate increasing. lytes repleted. 40k in ns after bicarb finishes, 1l bolus ns inbetween.

neuro: pt remains sedated on prop gtt. sedation not shut off due to hemodynamic issues. pt able to mae, does not follow commands, withdraws to nailbed pressure, pupils equal and reactive. becomes agitated with increased activity.

resp: no vent changes made. ls clear bilat. suctioned prn for scant amount of thin white secretions.  svo2 in the 80's.

cv: remains in nsr, no ectopy. sbp wnl. fem aline placed at bedside upon arrival to unit. pressors remains off.

gi: abd firmly distended upon arrival. fib placed for lg amounts of melena stool, abd softer. ogt to lcs, scant output, flushed multiple times, placement checked.

gu: oliguric, clear yellow urine.

endo: blood sugars remain elevated. insulin gtt titrated per csru s/s.

plan:
 check abg, bs, and k q 1 hr. monitor lactate, monitor output. glucose control. provide pt and family with emotional support.
"
2268,"resp: pt rec'd on psv 15.+5/50% bs are coarse to clear. suctioned for small amounts of white thick secretions. mdi's administered q4 hrs combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt had ^ wob with rr to ^ 30's, bp >200, increased ps to 20 with no affect. place pt on a/c 18/500/+5/50%. abg' 7.50/40/87/32. pt comfortable noc. attempted to wean to psv this am and pt bp went over 220 immediately, then placed back on a/c.will attempt wean to psv in am.
"
2269,"resp: [**name (ni) 257**] pt on psv 10/5/40%. ett 7.5 secured @ 21 lip. bs reveal slightly coarse to clear and suctioned for small amounts of secretions. mdi's administered alb/atr with no adverse reactions. pt having periods of apnea and placed on mmv for noc. rsbi=48. pt opening eyes to name. plan: wean to psv in am. no abg's this shift.
"
2270,"71 y/o female with cirrhosis,esrd,l leg fracture due to fall at home now in hypotension currently on dopamine gtt 2 mcg/kg/mt attempted to wean and d/c but drpopped to sbp 60-80 with map < 40.

events;crit stable today but low to 23,transfused 1 unit prbc without any adverse reactions.

cvs;hr 73-80 nsr no ectopy,abp 94-126/40-60 on dopamine gtt unable to wean off.cvp 10-12.post transfusion crit send please see carevue for lab results.pedal pulses are doppled.

access;rij and rt r a-line remains patent.lt av fistula positive for bruit and thrill.

neuro;looks more alert today answers all question appropriately but remains confused at times and trying to pull out invasive lines ,rt hand restrained for few hrs and released with reorientation.lt leg spilnted and able to move lower extrimities on bed and upper extrimites are able to move off the bed,no tremors or flaps noted today.

resp;ls are clear to dim at bases o2 sats are maintained 100% on room air,breathing efforts are normal.

gi;abdomen soft,positive bowel sounds tolerating diet,no n/v pantoprasole increased to bd,gi followed up not planning for any invasive procedures at this time. draining brown colored liquid stool via mushroom catheter which is positive for guaic.on bowel regimen.

gu;not dialysed since 5 days due to hypotension.please see carevue for lab values.

skin;multiple areas of bruises all over teh body due to fall rt upper extrimities has weeping areas and bleeding.lt leg is spilnted.positioned as needed for comfort.

id;afebrile,wbc 7.5 on zosyn and daptomycin(recieved only one dose/on hd days)on contact precautions for mrsa/vre.

endo;blood sugar > 200 sliding scale renewed and started on fixed dopse today.

social;daughter called and updated and will be coming later to visit her.

plan;follow crit bd,transfuse prn
maintain  map>60
reorientation and restraints as needed
fs q6h,calorie count till monday.
 pt for left leg.
"
2271,"[**2170-8-10**] ""b"" admission note:

80 yr old pt came to ed with diarrhea&vomiting for 4 days, 1 day of burning on urination. fever up to 105.0. u/a+ and 3 bld cults+,still has some nausea.

pmh:  htn,cva with no residual effect,anemia,niddm.quit smoking 40yrs ago.

allergy:  codeine-makes her ""crazy""

cvs:  afebrile. hr=58-75 nsr no ectopy since arrival, reportedly in afib in ed.  sbp=110-135 in left arm and 70-80 in right arm.  given 6l of fluid in ed and 1500cc lr iv bolus upon arrival when bp low.  hct=23.4 down from 30.2, given 2 units prbc's with no adverse reactions noted.  mg=1.6 given 2gm iv mgso4.

resp:  o2 3l nc, lung sounds clear, diminished at bases.  sats=98-100%.  no sob noted.

gu:  sent u/a this am.  given 3 antibiotics in ed. u/o=30-55cc/h

gi:  +bs, ate small amt supper that family brought in, she says she doesn't eat much because she doesn't like the diet restrictions. no stools.  rectal guaiac was - in ed.

neuro:  a&ox3, mae. speech clear and appropriate.  follows all commands.  screaming and crying whenever aline or iv lines were attempted to be inserted.

skin:  no open areas noted.  old brown bruises noted on both knees, shins, upper back, legs.

plan:  continue antibiotics, monitor vss and labs. [**hospital **] transfer to floor when bed available.

"
2272,"micu nursing note 1900-0700
events:  hemodynamically stable overnight.  remains alert but confused.  ? of visual hallucinations at times.  continues on iv insulin gtt at 2 units/hr.  continues to require bear hugger for hypothermia.  remains on continuous infusion of iv anti-thymocyte globulin (atg) gtt at 10mg/hr for desensitization....no evidence of adverse reaction during the night.  stable hct at 9pm= 26----am labs still pending.

neuro:  alert to person and place and disoriented to time however requires freq. reminders on what is happening to her and requires freq. reminders regarding all care and explanations.  mumbles at times.  asking questions about things that aren't present ie:  what are all those pants hanging on the windows?""/ "" why is my room full of all those boxes?""  freq. reorientation.  pleasant and cooperative with care, follows all commands, moves all extremities, pearl.  freq. safety checks.

cardiac:  hr= 50-70's sr with occas pvc's.  occasional brief and self-limiting episodes of bradycardia to 40's---ekg obtained and no change from previous and no evidence of block noted.  bp= 98-130/40-60.  bp and hr slightly decrease when pt is lying on left side.  episode of bp to 80/40 while asleep---bp back to baseline with stimulation and no further hypotension during the night.  diuresed with 20 mg. lasix during evening.

resp:  lungs clear but diminished at bilat. bases.  room air sats= 96-99%.  dry nonprod. cough noted.  rr= 18-22

gi:  abd soft with + bowel sounds.   c/o abd cramps while moving bowels.  npo maintained.  continues on iv tpn at 63 ml/hr.  incontinent large amts brown liquid stool x 3---pt pulled fecal incontinence bag off and smeared stool with hands x 2---now with mushroom catheter in place.  stool brown in color but tested guiac +.

gu:  foley to cd draining clear dark yellow urine >40ml/hr.  diuresed with 20 mg. iv lasix during evening but remains 8 liters + for los

skin:  perineum pink with slight rash---miconazole applied.  buttocks reddened--barrier cream applied.  remains on air bed.

id:  continues on neutropenic precautions with wbc < 0.1.  remains hypothermic with temps 95-97 on bear hugger.   continues on multiple antibx. as ordered.  pt's temps drop when she takes off blanket and requiring freq. reapplication of blanket.  temp up to 97 and bear hugger off x2 hours but restarted for temp=95.

endo:  continues on iv insulin gtt at 2 units/hr with fingersticks 105-143 all night.

social:  no contact from family or friends during night.

plan:  possible tee today.  continue freq reorientation and safety checks, continue neutropenic and vre precautions, monitor closely for reaction to atg infusion, transfuse prn, support pt and family prn.
"
2273,"resp: [**name (ni) 257**] pt on a/c 22/500/+8/40%. bs are clear with diminished bases. suctioned for small amounts of white thicksecretions. mdi's administered alb/atr with no adverse reactions. no changes [**name (ni) **] or abg's pt remains on [**name (ni) 1858**].
"
2274,"7a-7p
neuro: pt alert and oriented following commands. mae. perrla. percocet for pain w/ good relief.

cv: hr 70-80s sr w/ occasional pacs, lopressor increased to 25mg [**hospital1 **], np [**doctor last name **] aware of pacs. sbp >90 , map >60, see carevue for details. +palpable pulses. introducer patent in rij, #20 rw patent and intact. epicardial wires intact, shut off secondary to inappropriate spiking, team aware on rounds. 1 unit of prbcs given in am, no adverse reactions.

resp: ls clear- diminished at bases, wheezy w/ activity, later in shift rales at bilat bases, np [**doctor last name **] aware. inhalers given. sats on 3lnc >94%. breathing unlabored. pt denies trouble breathing. no resp. distress noted. ct dc'd at bedside dsgs intact, cxr taken results pending. much encouragement needed for oob,coughing and deep breathing, and the use of is.

gi/gu: abd softly distended +bs, no bm. foley draining yellow urine, around 2pm u/[**name initial (md) **] decreasing, np [**doctor last name **] aware, labs sent to eval if pt needs increased dose of lasix, labs pending at present see carevue for details.

endo: insulin gtt weaned to off, po glyburide started and continuing riss.

social: family updated w/poc.

plan: monitor hemodynamics. monitor resp. status. aggressive pulmonary toilet. follow labs, including creatinine and glucose. increase activity and po intake as pt tolerates. ? transfer in am.
"
2275,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] simv 14/800/5/+5/40%.  alarms on and funtioning. ambu/syringe @ hob. cuff pressure @ 21.  bs auscultated reveal bilateral coarse sounds. suctioned x3 small to moderate amounts of thick pale yellow secretions.  mdi's administered q4 hrs with no adverse reactions.  vent changes to decrease rr to 12 vt to 650 to obtain improvement in abg.  rsbi=86, although no sbt initiated due to ^ in rr to 40's.  placed on psv [**2110-11-1**] where pt remains with 02 sats @ 100, rr 20-22 and not distress noted.  no further changes at this time.
"
2276,"resp: pt rec'd on 70% cam f/t. bs are coarse bilaterally with strong cough although pt unable to expectorate. nebs administered q6  hrs alb/atr with no adverse reactions. no nts this shift. will continue to follow.
"
2277,"resp: [**name (ni) 257**] pt on psv 5/5/50%. pt has #9 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs of atrovent with no adverse reactions. vent changes to decrease fio2 to 40%. am  abg 7.43/45/85/31. vt's 500, ve's 13, rr 22. rsbi=49. no further changes noted.
"
2278,"7a-7a
neuro: pt extubated at 11am, alert and oriented, following all commands. perrla. mae. morphine ivp and percocet prn for pain w/ fair relief.

cv: hr 80-100s sr/st, hr 100s st at beginning of shift, lopressor 12.5mg po started and digoxin 0.25mg started po bringing hr 80-90s sr. frequent pacs noted around 11am, mg 2 gm iv given, no ectopy noted since 12pm. sbp labile, as high as 120-130 while intubated and w/ activity, nipride as high as 1.2mcg, md [**doctor first name **] aware, at present 0.2mcg w/ bp 100/50. see carevue for details. ci [**3-20**], see carevue for filling pressures. cvp 10s. 1 unit of prbcs, no adverse reactions noted. +palpable pulses.

resp: ls clear, diminished bases- coarse. inhalers restarted. pt extubated at 11am, acidotic prior to extubation 7.29, 1 unit of prbcs given and 1 amp of bicarb as [**name8 (md) 20**] md [**last name (titles) **]. repeat ph 7.32. post abg 7.32/44/113/-3/24/98%, md [**doctor first name **] aware, no new orders. instructed how to use cough pillow and is. using is as high as 500-750cc. oob to chair.

gi/gu: abd softly distended, obese. +bs, no bm. ogt dc'd w/ extubation. tolerating clears. u/o low at beginning of shift, md [**doctor first name **] aware, blood given, lasix 20mg ivp started. foley draining adequate amt of yellow clear urine.

endo: insulin gtt restarted, as high as 9units/hr, at present at 2units/hr. see carevue for details of gtt.

social: many family members into see pt throughout day. spouse updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. follow labs including blood glucose. wean nipride as pt tolerates.


"
2279,"nursing update
   temp dropped 100-96.1.  hr stable nsr, no ectopy or arrythmias.  co/ci stable 6.45/3.52 @ 0400. pap's and cvp stable.
   plts 20 @ [**2141**], heparin stopped @ 2230 and 10-pack platelets tx @ 2300.  rec'd cmvig 3.2g @ 2330 - no adverse reactions.  hct 24.7 @ 2400, ho notified, recheck @ 0300 25.3. no new orders @ this time. continues to bleed from nasal to oral cavity.
   not retaining ca+, ica repleted with ca gluc 4g x4.  glucose rx per s/s, tolerating post-pyloric tf's well, green bile only draining per ngt.   stooling large amount loose green bile colored stool.
   abg's stable, weaned off nitrous oxide.

"
2280,"resp: rec;d pt on cam @ 100%. pt desating to 80's change to hi-flow with f/t. (see careview for changes in fio2) nasal trumpet inserted in l nare. suctioned for moderate amounts of bloody secretions. nebs ordered alb/atr and adminisered q6 hrs with no adverse reactions. will continue to follow.
"
2281,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 18/+5/30%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions.  pt gets anxious at times resulting in ^ rr, then settles down.  no resp distress noted. rsbi=200, no further changes noted.
"
2282,"7a-7p
neuro: pt [**last name (lf) **], [**first name3 (lf) **], follows all commands. right pupil 5mm sluggish, left 3mm briskly reactive to light. daughter [**name (ni) **] called re: eye gtts. np [**doctor last name **] aware. [**name8 (md) **] md following pt, opthamology called today so pt can be re-evaluated per daughter's request to review eye gtts and assess right eye. pt medicated w/ 1mg morphine sc for incisional pain, w/ relief.

cv: hr 60-70s sr. no ectopy qt 0.43. amio gtt dc'd and po amio started via ogt. sbp 100-130s. see carevue for filling pressures. ci>2. pa dc'd w/o incident. + palpable pulses. received 1 unit of prbcs, no adverse reactions. repeat hct 32. k+ repleted prn.

resp: ls scattered rhonchi-> clear diminished bases. sats 98-100%. orally intubuted. weaned vent to [**3-21**] 40% fio2, 7.50/36/80/4/29/95%, np [**doctor last name **] aware. plan to extubate in am, resumed 5/10ps fio2 50% at present, see carevue for abgs and vent settings. suctioned for small to moderate amts thin yellowish white via ett.

gi/gu: abd softly distended. +ogt placement. dophoff in stomach (clamped) [**name8 (md) 20**] np [**doctor last name **]. foley draining clear yellow urine lasix frequency decreased from tid to [**hospital1 **].np [**doctor last name **] aware of alkalotic abgs.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. awaiting eye re-consult. plan to extubate tomorrow am.


"
2283,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  pt remains alert but ? level of orientation.  moving r arm, r leg ad lib; no movement l arm or l leg noted.  mouthing words around trach, occasionally speaking in single word sentances, nodding ""yes"" and ""no"" appropiately.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  one unit platelets given without evidence of adverse reactions.  repeat plt count done.  remains on trach collar at 50% cont with sats mid to high 90's.  bs coarse, diminished bil.  expectorating lg amts thick white sec; did suction this am for blood tinged mucous plug.

gi/gu:  remains on tf fs probalance at goal of 60ml/hr via peg.  peg dsg d+i.  one lg formed soft bm this am.  u/o qs q1-2h via foley.  abd round, soft, bowel sounds positive.

id/endo/integ:  afebrile.  pipercillin dc'd as platelet count dropping. remains on contact precautions for +mrsa, +vre.  sliding insulin coverage for fingerstick glucose [**name8 (md) 20**] md orders.  buttocks raw, pink--barrier cream applied, duoderms reapplied prn.  l heel black area x2 unchanged.  multiple ecchymotic areas noted on arms (not new).

labs:  k repleted with 40meq via peg.  one unit platelets given; rpt plat count 96.

psychosocial/plan:  fam in to visit.  emotional support given to pt and family.  plan is to return to rehab in am.  family aware and agrees to plan.  cont to monitor loc, mp, vs, 02 sats, maintain o2, tf, monitor i+o.  administer meds as ordered/continue to follow medical/nursing regime.   cont to provide emotional support to pt and family.  replete labs as ordered.  repeat labs in am.
"
2284,"resp: pt rec'd on [**last name (un) 33**] simv 18/750/+10/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished sounds with noted aeration in apecies.  mdi's administered q4 hrs combivent with no adverse reactions. rsbi=49, am abg's 7.39/35/160/22.  vent changes to simv 10/750/+5/5/50%.  no further change noted.
"
2285,"nursing update
cv:
   tmax 100.2, remains in chronic afib.  receiving ntg gtts @ 1mcg/kg/min. bp stable, dipping into upper 90's @ tmies but generally ranging 100-116. lopressor increased to 10mg q6 for rate control with good effect, irregular ventricular response ranging from 84-116 most of noc.  co/ci 4.55/2.30 @ 0400 with pcwp 23.
   hct @ 2400 24.6, recheck 24.9,  ho notified and pt transfused with 1u prbc's over 3h. no adverse reaction.  huo 80-130cc.
   plan: ekg this am, continue cyclic ck/isos.


respiratory:
   finger sats 97% on o2 4l n/prongs.  breath sounds persistantly coarse, crackles @ bilateral bases persist but finer and substantially diminished.  continues to collect secretions in hypopharynx, but unable to suction due to resulting exacerbation of anxiety.  haldol 1mg x1 for anxiety state with good effect.  encouraged to cough but weak.  abdominal pain also on cough or activity, prn mso4 2mg given regularly q2h.
   latest abg's @ 0500  7.38/113/43/26/97% be 0.
"
2286,"resp: [**name (ni) 257**] pt on a/c 22/400/80%/10+. bs are clear with diminished bases. mdi's ordered and administered alb/atr with no adverse reactions. multiple abg's and vent changes (see carview) pt presently on psv 5/5/40%. plan to wean to extubate this am. am abg pending.
"
2287,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 32/450/12+/50%.  alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral clear apecies with diminished bases. suction for  scant amounts of white secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.31/45/126/24.  no further changes noted.
"
2288,"resp: pt is [** **] with #6 cuffless trach on 35% t/c. bs are coarse bilaterally with diminished bases. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. no distresss noted. will continue to follow.
"
2289,"social work note:

new trauma pt on t-sicu.  pt is a 23 year old man who is s/p fall/jump from 5 stories.  he has some head bleeds and an l2 burst fx.  pt was intubated this morning when this sw visited initially but has been extubated this afternoon.

[**name (ni) 25**] girlfriend, [**name (ni) 6199**] (misidentified as his sister initially) and pt's [**last name (lf) 344**], [**first name3 (lf) **] and les, are visiting this afternoon.  this sw met with pt and then his [**first name3 (lf) 344**], and then his girlfriend.  girlfriend's cell # is [**telephone/fax (1) 6200**] and work # is [**telephone/fax (1) 6201**].  she will likely return to work on thursday.

pt is a student at [**university/college 6202**].  he lives in [**hospital1 **] with his girlfriend, [**name (ni) 6199**].  [**name2 (ni) **] has one more semester of college.  family reports that only recent stressor is that their cat is quite ill and will likely be put down.

when this sw met with pt, he was alert and oriented to self and knew that he was in a hospital.  he was polite and engaged easily.  he was talking ""ragtime"" at various points and seemed concerned about getting in trouble legally.  he encouraged this sw to talk with his girlfriend for further information.  pt reports remembering being on a roof and that the people he was with were not strong enough to keep him from doing something that he wanted to do.  he referred to what happened as a ""dream"" and made reference to ""external reality"" and the involvement of his ""ego"" and the effect that had on his ""short term memory"".  pt denies wanting to hurt himself.  he feels comforted by his [**name2 (ni) 344**] and girlfriend's presence.

pt's [**name2 (ni) 344**] seem mutually supportive and expressed relief that pt is not more injured.  they report that they have been told that pt took some mushrooms last night and that his girlfriend has more information.  they said that one of pt's grandmothers had schizophrenia but that pt has no psychiatric hx himself.  he was evaluated during grade school and was found to have above-average intelligence and borderline add.  [**name2 (ni) **] said that pt does not use drugs and treats his body like ""a temple"".

[**name (ni) 25**] girlfriend reports that to her knowledge pt has never been suicidal and is generally quite ""happy"".  she said that pt tried mushrooms yesterday for the first time and had an ""adverse reaction"".  the friends that pt was with did not seek assistance for him (seemingly because they feared getting in trouble) and pt got away from them and got up to rooftop prior to fall/jump.  he left her a voicemail prior to fall/jump begging for help.  [**name (ni) 25**] girlfriend said that he does not otherwise use drugs.  the police have been involved and pt's [**name (ni) 344**] will be in contact with them.  [**name (ni) 25**] girlfriend does not think that there will be legal implication for pt from this incident following her conversation with police.

[**name (ni) **] and girlfriend given contact information for this sw for support as needed.  family given written information for themselves about emotional reactions to traumatic experiences.  pt is being evaluated by psychiatry and this sw met with them briefly to share above
"
2290,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] simv 20/300/10/10+/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amounts of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions. sensitivity decreased to 8, pt tolerated well. no further changes noted.
"
2291,"resp: [**name (ni) 257**] pt on 35% t/c with #6 cuffless trach. ambu/syringe @ hob. bs are coarse bilaterally which clear with suctioning. suctioned for small to moderate amounts of thick white secretions. mdi's atrovent  administered via trach with no adverse reactions. water bottle filled/trap emptied. will continue to follow.
"
2292,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 10/320/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats @ 100%.  rsbi performed without adequate results.  no further changes noted.
"
2293,"resp: rec'd pt on psv 10/5/40%. pt has #8 portex trach. inner cannula clean. bs are coarse bilaterally. suctioned for small amount of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions. no aline, or abg's 02 sats @ 99%. rsbi=78. plan to wean as tolerated and continue planning for d/c to rehab.
"
2294,"resp: [**name (ni) 257**] pt on psv 10/5/50%. ett #8.0, 25 @ lip. bs are coarse to clear. suctioned for x1 bloody thick secretions, subsided in am. no changes noc. vt 400's ve's [**8-27**]. mdi's administered alb/atr with no adverse reactions. rsbi=41. plan to wean to sbt this am with possible extubation.
"
2295,"resp care
attempted for a blood gas stick, could not obtain. md will attempt. no adverse reaction.
"
2296,"respiratory care
pt remains trached (#7.0 portex) with cuff inflated (3.5-4cc's of air) and positional [** **]. pt remains on a fio2 of 0.40 via trach mask. lung sounds were course t/o. suctioned for mod thk white. mdi's given with no adverse reactions. 1 prn dose of albuterol was given. last abg showed chronic resp acidosis with metabolic alk. care plan is to continue current therapy and to have pt remain off vent as long as tol. continue with trach care and suction as needed. will continue to follow pt.
"
2297,"7pm-7am([**2154-5-4**])

on full code

[**age over 90 148**]y/o female got admitted on [**2154-4-23**] in micu from ccu with c/o fatigue weaknes,increased abd girth,pedal edema and was found down at home.has pmh of cad,copd,htn,mi remains intubated since the day of admission.


cvs;hr-78-100 nsr,no ectopy.nibp-122-101/41-50 cvp-[**6-7**]. pedal pulses by doppler.

access: rij is patent.

resp;on vent,cmv-30/400/14/5,ls are dim at right side and coarse at left side.spo2-95-97,no vent changes are done at this shift.requires frequent oral sxn and et sxn were done minimally  and obtained small amt of thick white sxn.


neuro;not on any sedation, remains sleepy throughout but follows verbal commands by making facial expressions,no limb movements are noted.
received ivig last evening beginning at 1830,no adverse reactions noted on completion of infusion.

gi;abd soft and mildly distened with positive bs,tf@ goal with very minimal residual.small amt semi-formed stool passed at this shift.

gu;u/o-20-40 and nil  at 22hr informed ho,advised not to give fluid bolus since pt remains on + balance.urine is concentrated with sediment.

skin;temp-98.5,noted echymosis on right hand,has abrations on b/l elbows,duoderm in situ.

social: family visited last evening and were updated by this rn.

plan:monitor resp status,watch spo2,frequent oral sxn,observe muscle strength.watch u/o.


"
2298,"resp: pt rec'd on psv 15/10/40%. ett #8, 25 @ lip. bs are coarse to clear and suctioning for small to moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt continues to have periods of apnea, then placed on a/c 12/600/10+40%. am abg 7.41/59/69/39. no rsbi=^peep.  plan to wean to psv as tolerated.
"
2299,"resp: [**name (ni) 257**] pt on psv 15/5/40%. pt has #8 portex trach. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administed q 4 hrs with no adverse reactions. vt's 300-400, ve's [**7-7**], with periods of low ve's. ps decreased to 10. rsbi=100. plan to continue with t/c trials. rehab planning continues.
"
2300,"resp:  [**name (ni) 257**] pt on psv 8/+10/40%. alarms on and functioning. ambu/syringe @ hob. ett 7.0, retaped and secured @ 20 lip. ett tube has been cut back.  bs are coarse bilaterally and suctioned for small amount of white thick secretions. mdi's administered atr q4 hrs with no adverse reactions. abg 7.34/55/105/31. vent changes to ^ peep to 10.  no rsbi due to ^ peep. will continue to moniter to wean as tolerated.
"
2301,"resp: [**name (ni) 257**] pt on pcv 30/pinsp 35/10+/40%/dp25. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. rr at times to 40, no changes this shift. am abg 7.40/29/89/19. will continue full [**name (ni) **] support.
"
2302,"resp: [**name (ni) 257**] pt on n/c @ 4lpm. bs auscultated reveal bilateral wheezing throughout lung fields. discussed continous tx with md and agreed. set up 3.0mg albuterol for 4 hrs continous neb. no adverse reactions and notable improvement. proceeded to administer alb/atr as ordered. pt feels better this am with no distress noted.  will continue to follow aggressively.

"
2303,"resp: [**name (ni) 257**] pt on psv 5/15+/40%. ett#7.5 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse with diminished bases. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb with no adverse reactions. abg's (see carview). pt rr in mid 30's with ^ wob noted. bicarb drip initiated. placed on pcv pinsp 35/10+/dp 25/r30/40% with abg 7.28/35/89/17. will continue present settings.
"
2304,"resp: [**name (ni) 257**] pt on psv 12/10/40%. ett #8, retaped, rotated and secured @ 22 lip. bs are coarse to clear. suctioned for moderate amounts of thick white/yellow thick secretions. mdi's alb/atr administered with no adverse reactions. ps weaned to 7 due to periods of apnea, abg 7.29/77/94/39. ps ^ to 12. additional abg pending. will continue to wean as tolerated.
"
2305,"resp: pt rec'd on a/c 16/350/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions, although it does initiate a cough reflex. abg 7.47/32/87/24, rsbi >200. will continue full vent support.
"
2306,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminished l base.  suctioned moderate amounts of thick white secretions. re-taped and secured ett @22 lip. mdi's administered q4 alb/atr with no adverse reactions. pt placed on a/c 12/600/+5/50% noc to rest,then placed back on psv setting this am.  no abg's. rsbi=47
"
2307,"resp: pt rec'd on psv 10/8/50%. bs are coarse bilaterally. suctioned for small-moderate thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg's 7.41/50/95/33, removed vd with abg pending. will continue to wean appropriately.
"
2308,"continued npn 7 am 7 pm

continued see above...

pt receiving two units of blood, family came by at 5 pm and consented to tranfusion, unit up at 1730, temp 99.0 then 99.8, no adverse reaction noted. cvvhdf system clotted at 1800, syatem lasted 3.5 hours, team updated heparin dose increased.

respiratory- o2 sats 98-100 on 2l drops to 91-94 on room air, pt denies sob, no crackles.

[**name (ni) **] pt ox2-3, moves all extrem, strong, taking po fluids
without problems, awakens forgetful and slightly confused but reorients well.

gi- as above taking some regular diet, fruit, pudding , shakes,
eggs. loose stool with increase in afternoon team aware.

a: pt with arf, creat still high, on cvvhdf, however ? how well dialysis is going as it is contantly interupted with system clotting, team and renal are aware and are increasing the heparin. now pt with increased watery stools, ? c diff.

p: continue to follow lytes, ionised ca, ph, glucose, hct post blood transfusion, creat bun, continue cvvhdf with new clotting plan, continue monitor cv resp renal status, follow i/o goal is to keep pt even.
"
2309,"resp: pt rec'd on mmv 10/500/15/+5/40%. bs are clear with diminished bases. vt's 800-900, ve [**9-12**], rr 14, 02 sats @ 99%. suctioned for small amounts of thick yellow secretions. mdi's administered q4 alb with no adverse reactions. rsbi=60. will continue t/c trials.
"
2310,"resp: [**name (ni) 257**] pt on mmv 10/500/15/+5/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. vt's 700-900, ve 8-13l, rr 12-18.  rsbi=42. plan to continue with t/c trials as tolerated.
"
2311,"resp: [**name (ni) 257**] pt on psv 12/+5/40% (mmv) bs auscultated reveal bilateral clear sounds with slight coarse bases. suctioned for moderate amounts of white thick secretions. mdi's administered q4 hrs alb with no adverse reactions. no a-line. 02 sats @ 99%. vt's 400-500, ve's [**10-11**], rr 12-18. rsbi=21. plan to wean on t/c trials as tolerated.
"
2312,"resp: [**name (ni) 158**] pt on a/c 26/600/10+/40%. ett #8, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease tv to 550 and rate to 22. abg 7.46/34/79/25 with no further changes noted. will continue full vent support.
"
2313,"resp: [**name (ni) 158**] pt on a/c 32/500/12+/50%. ett #8, taped @ 22 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse and suctioned small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt is on rotating bed and pip's fluctuate with rs ^ tend to higher. no abg's or changes noc. will continue full vent support.
"
2314,"resp: [**name (ni) 158**] pt a/c 32/500/+10/40%. ett#8, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with occasional exp. wheeze. suctioned for copious amounts of thick tan secretions as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg' (see carview) and multiple vent changes. present settings a/c 22/600/10+/40%. no rsbi=^ peep. possible bronch today? will continue full vent support.
"
2315,"resp: pt rec'd on psv 15/+5/50%. bs auscultated reveal bilateral aeration. suctioned for moderate amounts of white thin secretions. pt has frequent episodes of coughing spells.  no mdi's administered due to adverse reactions of bronchospasms. no abg's a-line not working. pt schedule for or this am for trach insertion.  vt's 500, ve7-8l, o2 sats @ 99%.
"
2316,"s/p cabg
pt is a 71 year old male arrived from or s/p cabgx2. arrived on propofol, ntg, epi at 0.02mcg/kg/min. see carevue for details. continues to be cold. 1 unit of blood given, no adverse reactions noted. plan assess neuro status, monitor for bleeding, wean to extubate.
"
2317,"resp: pt rec'd on [**last name (un) 647**] psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds and suctioned for small amounts of tan/yellowish thick secretions. mdi's administered q4 [**last name (un) 741**] with adverse reactions. pt bronchospasms and complains of chest pain, rn aware as well as md. [**first name (titles) 742**] [**last name (titles) 741**], suggest try flovent to help with inflammation.  will continue full vent support. possible trip to ctscan today. no abg's. vt 500's ve 9-13l, rr 20, o2 sats 96-98%
"
2318,"resp: [**name (ni) 257**] pt on simv 20/600/10+/50%.  ett #7.5, 24 @ lip. bs are slightly coarse with diminished bases. suctioned for moderate to small amounts of bloody tinged secretions.  mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. vent changes to decrease peep to 5, am abg 7.40/40/125/26. rsbi greater than 200. plan to wean to psv as tolerated.
"
2319,"resp:  [**name (ni) **] pt on [**name (ni) **] pcv 35/peep +12/ 80% r 42 i/e 1:1. alarms on and functioning. ambu/syringe @ hob.  auscultated bs reveal bilateral clear apecies with diminished bases.  mdi's administered q4 hrs alb with no adverse reactions.  suctioned x4 copious amounts of bloody secretions/clots from oral cavity.  vent changes to accomodate improvement in abg's with ^ peep resulting in decrease in bp.  fi02 ^ 90%, driving pressure @35.  no further changes noted
"
2320,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 20/550/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies.  mdi's administered q4 alb with no adverse reactions. vent changes reflect am abg's (see careview). rsbi=67. plan to wean to extubate this am.
"
2321,"resp:  [**name (ni) **] pt on [**name (ni) **] pcv 35/rr 34/ 20+ itime .6 i:e 1:1.9 /90%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal ls clear apecies with diminished bases. rs coarse sounds.  suctioned x3 moderate amounts of thick bloody secretions/clots from oral cavity with improvement noted.  mdi's administered q4h alb with no adverse reactions. ett moved to ls taped and secured.  pt remains on present vents settings.  no changes.
"
2322,"ccu npn 1900-0700
s: "" i'm feeling antsy now ""
o:  at [**2048**], pt. appearing very awake but slightly anxious....c/o feeling restless.  pt. smokes 1 [**11-27**] ppd.  no etoh hx.  gave 1mg po ativan at [**2118**].  fell asleep and stable until 2200 (last check was 2110) when pt. was found standing at bedside.  iabp was disconected at the aline site.  pt. was disoriented....assisted back to bed.  vss at the time.  new aline tubing was reconnected and good iabp waveform was obtained.  cxr was obtained.  placement appears intact...did not detatch from sutures and marks on leg.

pt. appearing very lethargic and responding only with one word answers...skin warm, dry...pupils equal and reactive.  gradual increase in attentivness throughout night....a/o x3 by 0500.  pt. awake but does not remember getting oob.

cv:  hr 78-83 nsr.  one 11bt. run vt asymptomatic.  map 75-90.  slightly dampened waveform..unchanged from cath.  poor augmentation.  1-12pts. syst. unloading.
heparin gtt at 850u/hr.  ptt 67.2   post cath ivf completed.
plts 209.  cpk #2 329(416).  no cp/sob.  pulses 3+ bilat.
iabp site d/i.

resp:  ls clear.  2lnc sats 99%.
gu:  foley placed 400cc in bladder.  100-300cc qhr u/o.  neg. 300cc since 12am.
gi:  no c/o.  abd flat.  no stool.  eating ice chips.
access:  piv x3.  right fem. iabp.

neuro:  as above....currently pt. a/o x3 at 0500.  instructed to lay on back. leg immobilizer placed on right leg in eve.   pt. prefers to sleep on side and will move on own....needs freq. reminders and watching.  bed alarm on and all siderails up.

a:  adverse reaction to ativan.  d/c'd.
r/i for mi.  stable on iabp.  on asa. no plavix.  or fri.  ? d/c pump today....safety risk.
follow lytes, hct.  monitor pulses.
"
2323,"resp: pt rec'd on psv 10/8/50%. bs auscultated reveal bilateral clear with diminished bases.ett 7.5, 22 @ lip. mdi's administered q 4 hrs combivent with no adverse reactions. suctioned for small amounts of thick yellow secretions. no vent changes noc. rsbi=46. plan to wean to extubate this am.
"
2324,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] pcv 31/+12/80%/r 42 i/e 1:1 ambu/syringe @ hob.  alarms on and functioning.  bs auscultated reveal bilateral clean apecies with some fine scattered crackles.  suctioned x2 small to moderate amount of thick bloody tinged secretions.  mdi's administered q4hr with no adverse reactions.  vent changes as follows: peep^ 15, bp dropped, decreased peep to 12 where it remains.  abg's still acidoic with poor pao2.  no further changes noted. no rsbi performed pt is paralized.
"
2325,"resp: pt trached #8 portex rec'd on [**last name (un) 33**] a/c 20/400/10+/40%, bs are clear bilaterally. suctioned for small amount of tan secretions. mdi's administered q4 combivent, no adverse reactions. vent changes to decrease peep to 8, then 5 with 02 sats @ 98% and tolerating well. rsbi=61. plan to wean to psv this am.
"
2326,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**2165-5-2**] to er wtih fever, decreased u.o., received 1x dose of gent and iv hydration at [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levofloxacin and flagyl. pt refused presep cath in er. lactate 1.8. pt treated for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy but was ordered to try meropenem per [**hospital unit name **] and id team. overnight pt had an adverse reaction within minutes to the meropenem developing audible wheezing with sob and +n/v- see care vue for details. ivabx changed to iv aztreonam with no adverse reaction. cvp remained low ranging [**3-6**] with bicarb ranging 18-20. pt was given a liter of d5w with 150 meq na bicarb. k of 3.1 was repleted with 40 meq kcl total. will draw repeat labs at 6am.

neuro: a&ox3, mae, pt with l aka with some stump discomfort this am which pt reports is tolerable and he doesn't take any medicine for it at home. he was given tylenol shortly prior to the complaint for fever. t max 102.6 po. pt given total of 650mg tylenol x2 with t current 101.6po. bld cx x2 and urine cx sent. central line was pulled back 2cm as was in too far via cxr per team. repeat cxr confirmed proper line placement. pt following commands appropriately. requires max assist with adls.

cv: hr ranging 80s-100s sr/st with no ectopy noted. bp ranging 100s-150s/60s-90s. +pp via doppler in r leg. l stump warm to touch.

resp: lungs cta except developed wheezing shortly after receiving iv meropenem. then after meropenem stopped, pt with no further wheezing. sp02 ranging 97-98% on rm air. pt had been placed on 2lnc during time when pt had a reaction to the meropenem with sob but within a few minutes after the meropenem was stopped, pt was weaned back to rm air with sats in high 90s.

gi/gu: abd soft, nt, +bs, had small loose brown bm x2 smeared on his pad unable to send for cdiff. +n/v with meropenem reaction but no further incident afterward. foley patent draining adequate amts yellow urine with sediment in it. u/a c&s sent along with urine tox screen.

skin: warm, dry, and intact.

comfort: c/o stump discomfort this am shortly after tylenol given for fever. states pain level acceptable.

lines: r ij tlcl patent and was pulled back by 2cm and reconfirmed via cxr per team. r piv was found pulled out by pt d/t discomfort at insertion site. some small amt swelling at insertion site but subsided with pressure and elevation. l piv intact.

social: has been living at the [**hospital3 **] recently but prior to that had lived in own home.

plan: monitor temp, tylenol prn, monitor micro data, ivabx, make note of new meropenem allergy (also allergic to pcn). f/u with am labs and need for more k and bicarb repletion. monitor cvp and need for more ivf.


"
2327,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**5-2**] to er with fever, decreased, u.o., received 1x dose of gent and iv hydration and [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levoflox and flagyl. pt refused presep cath in er. lactate 1.8. pt tx'd for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy and developed a meropenem [**last name (un) **] noc of [**5-2**]-5 with audible wheezing with sob and n/v. pt was switched to iv aztreonam with no adverse reaction. pt continues to spike temps with 3 sets bld cx sent since adm.

neuro: a&ox3 with cueing. mae, l aka with some stump discomfort that is his baseline ""phantom"" pain relieved without intervention. t max 103.9. given tylenol 650mg with temp down to 98.9.

cv: hr ranging 90s-110s sr with no ectopy. bp ranging 120s-160s/40s-90s. +pp via doppler in r leg. laka. no edema noted.

resp: lungs cta, sp02 ranging 97-99% on rm air.

gi/gu: abd soft, nt, +bs, small bm x2 brown loose. drinking water with meds with no difficulty swallowing. foley patent draining adequate amt clear yellow urine 40cc+/hr. pt approx .5 liters negative since mn and 4.2 l + los.

skin: raw areas on coccyx and testicle area. aloe vesta cream applied to areas.

lines: r ij tlcl patent.

social: no contact from family. pt a dnr.

plan: continue to monitor temp and provide tylenol prn. iv abx, monitor micro data. ? call out to floor later today.
"
2328,"3p-7p
see carevue for vital signs and for full assessment. received 2 units of prbcs, no adverse reactions. temp 94-95.9 orally, np [**doctor last name **] aware. right groin [**doctor last name 2169**] culture sent. dophoff placed by np [**doctor last name **], awaiting cxr. see carevue for vent changes and abgs, np [**doctor last name **] aware of abgs, pco2 28-30, bicarb 19. plan: to go to ct tonight at 8pm. if needed, restarted neo gtt.
"
2329,"1100-2300 npn
see carevue for subjective/objective data.
neuro:  pt unresponsive to verbal stimuli; does withdraw to painful stimuli.  no movement of arms, legs noted.  no attempts to speak or communicate, does not track.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  daughter agrees to prbc;  first of two units prbc started without evidence of adverse reaction noted thus far.  kphos started, to infuse over 6hrs as [**name8 (md) 20**] md orders.  np at 1liter cont with clear breath sounds bil.

gi/gu:  one episode melena thus far this shift.  abd firm, no tenderness to palpation noted, bowel sounds present.  u/o borderline qs via foley.

id/endo/integ:  tmax 99.2 r.  sliding scale insulin coverage for fingersticks.  hands, feet edematous, elevated on pillows.  one .5x.5 pink area noted on coccyx--pt turned q2h with skin care given.  no other open areas noted.

psychosocial/plan:  fam in to visit.  emotional support given to pt and fam.  plan is to infuse two units prbc (first unit up), rpt labs, monitor for signs of active bleeding.  cont with current nursing/medical regime.
"
2330,"resp care
pt extubated tonight, present air leak. no adverse reactions. pt currently on nc 3lpm and sating 99. will continue to follow.
"
2331,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions.  mdi's administered q4 hrs alb with no adverse reactions.  02 sats remain in ^ 90's (96-99%).  attempted to lower the peep to 16, although pt did not tolerate.  increased rr to 35.  returned peep to 18 where it remains.  no further changes noted.
"
2332,"7a-7p
neuro: pt [** **] and oriented x2, knows pt is at [**hospital1 **] and knows self. [**hospital1 **]. follows commands. mae,weakly. denies pain when asked.

cv: hr 90s-100s. sr rare pvcs. sbp >100. map>60. +[**hospital1 **] pedal pulses.

resp: ls coarse. sats >93% on 5lnc. nebs x2. productive cough, not bringing up sputum. talc to ct by thoracic resident.

gi/gu: abd obese, hypoactive bs. dophoff placed, cxr done + in stomach [**name8 (md) 20**] md [**last name (titles) **]. tf started at 1600 as ordered, continue tpn [**name8 (md) 20**] md [**last name (titles) **]. foley draining greenish yellow urine (intensivist aware on rounds)- from dye. draining adequate amts.

endo: per own's scale.

id: afebrile. antibiotics changed- meropenem started, no adverse reactions noted. bc sent from central line, need peripheral.

plan: monitor hemodynamics. monitor resp. status. skin care.




"
2333,"condition update
d: please see carevue flowsheet for specifics
 pt running [**name (ni) 10073**] temps all day with tmax 100.4. hr 60-80 in nsr with occassional pac's noted this afternoon. nmed goal is to maintain sbp 100-150 this am pt required neo which was weaned to off for a couple of hours and then pt required labetolol gtt to be started. all solutions are mixed in ns per request of nsurg. mannitol was restarted with no adverse reactions after dosing, and glycerin po was d/c'd.
 pt's neuro status has waxed and waned throughout the day. at most alert moments will open eyes on command-at other times won't even open to sternal rub. perrla but does not track/attend. pt consistently has purposeful movement and normal strength in left extremeties. rue has no movement to withdraws slightly and moves on bed to pain.
 no vent changes made today. pt remains on simv 600x16 with 5peep and 5ips and 50%. thick tan to blood frothy secretions-sputum spec sent for culture. patient is not breathing over the vent rr 16 except when stimulated.
 wife in and spoke to dr. [**last name (stitle) 10074**] who had been updated by nmed and nsurg service. wife's nephew was present during visit and due to wife's expressive aphasia it was agreed with wife and nephew that he would be the contact person-phone # in chart. social worker also met with wife/nephew.
plan:
 neuro checks
 sbp 110-150
 dose mannitol according to serum osmolality
 notify h.o. with any change
"
2334,"7a-7p
neuro: pt alert and orientedx3. mae equally. perrla. intermittent twitching of left arm noted, pa [**doctor last name 372**] aware, no new orders. right eye droopy pt states ""has been like that for years"". perrla,smile symmetrical, mae equally.  morphine and percocets po for incisional pain, percocets po work better per pt. pt states is anxious at times,team aware.

cv: hr 70-110s. 110s at start of shift, lopressor started, received total of 10mgx2 ivp during shift. lopressor 50mg po started. sbp 110-140s. goal sbp<140 per pa [**doctor last name 372**]. ntg as high as 3mcg, pa [**doctor last name **] aware, captopril and hydralazine started, see med orders, captopril increased during day as per pa [**doctor last name 372**]. pt received 1 unit of prbcs no adverse reactions, repeat hct 27.2, pa [**name6 (md) 372**] and md [**doctor last name **] aware, no new orders. ci>2. svo2 57 when received pt pa [**name (ni) 372**] aware, recal'd, svo2 improved >60, see carevue. pa dc'd w/o incident. cordis flushes well though unable to draw blood from, pa [**doctor last name 372**] aware, ok to use per pa [**doctor last name 372**]. plavix started today 300mg loading dose today as ordered. epicardial wires intact, a side sense appropriately, do not capture appropriately. on vdemand 50, v wires sense and capture appropriately. lytes repleted prn. dopplerable pedal pulses.

resp: ls clear diminished bases. sats decreased on 6lnc to 91-93%, pa [**doctor last name 372**] aware, inhalers ordered. face tent and nc applied, see carevue for settings and sats. present sat 95% on face tent 50%, 4lnc. pt using is appropriately, 750cc. encouraged coughing and deep breathing. ct no air leak, draining 10-40cc/hr serosang drainage.

gi/gu: abd soft hypoactive bs. no bm. tolerating sips of clears. foley draining clear yellow urine, lasix 20mg ivp given this am, w/ minimal (1st hour only 140cc after lasix then tapered to 30cc/hr) results, pa [**doctor last name 372**] aware, additional lasix 40mg ivp given at approx. 1400 as ordered w/ improved results. see carevue for i+o's.

endo: insulin gtt as per protocol. fs 100-170s.

plan: monitor hemodynamcis. monitor resp. status. pulmonary hygeine. follow labs and treat as appropriate. wean ntg to keep sbp<140. pain control. increase diet and activity as pt tolerates.
"
2335,"resp: pt remains intubated on psv 10/+5/40% with no changes this shift. bs are coarse to clear. suctioned small amounts of tan/yellow thick secretions/moderate amounts of oral secretions. some seizure activity noted without incident. mdi's administered alb/[**last name (un) **] with no adverse reactions. abg 7.41/38/188/25. vt's 300-400, rr 20-24, ve7-8l. rsbi=93.
"
2336,"resp: [**name (ni) 257**] pt on psv 5/5/40%. ett 7.5 retaped, rotated and secured @ 25 lip. abg 7.46/45/126/33. placed back on a/c 12/500/5/40% to rest noc. bs are coarse bilaterally and suctioning frequently for copious yellow thick secretions. mdi's administered q4 atr with no adverse reactions. rsbi=68. plan to wean to psv in am.
"
2337,"resp: pt rec'd on a/c 12/500/+5/40%. bs are coarse bilaterally and suctioned frequently for copious thick yellow to tan secretions. mdi""s administered atr with no adverse reactions. rsbi =62. plan to wean to psv as tolerated. talk of possible trach? will continue to follow.
"
2338,"npn
n: unchanged neuro exam. remains unresponsive to painful stim. perrl ~3mm/bsk. ativan gtt d/c'd per team and currently on ativan 1mg/q6hr in attempts to wake pt. mso4 remains at 2mg/hr. icp teens until pt dropping sats and then became elevated to mid 20's. returned to teens as hypoxia corrected. ventric draining sm amts serous fld.
cv: neo titrated and currently 2.25mcg/kg/min to maintain cpp 65-70. k repleted with diuresis. nsr 60-70's- no ectopy. cvp high teens-20.
r: lungs course throughout and [** **]'d frequently this am for mod to lg amts thick tan secretions. after pt acutely [**name (ni) 2141**] to 85%, and pao2 61-->bronched for sm amt thick clear/white sec and peep inc 15 with much improvement pao2 130/sats >97%. remains on ac 600x15, 50%.
gi: abd firm/distended with absent bs. reglan in tpn. restarted vivonex at 10cc/hr. no stool.
gu: urine clear yellow. diuresed with lasix 20mg this am and currently ~1l neg. due for add'l dose this evening--?hold this eve if remains neg with inc need for pressor.
id: tmax 102.8-rec'd tylenol and current 100.3 levoquin/flagyl d/c'd. bld cx's x2 sent. sputum cx grew staph areaus. initiated oxacillin desensitization and so far no adverse reaction to drug.(noted pcn allergy.)
endo: gluc 86-114. insulin gtt titrated 2u/hr. 100u reg insulin in tpn today.
skin: back/buttocks intact. chin healed. lt forearm with adaptic/dsd. rt ankle with dime sized black decub. lt post ankle with red blister intact.
soc: [**name (ni) **] wife and daughter in visiting. approp concerned and updated on progress.
a/ trauma now with staph pneumonia s/p bronch today.
p/ monitor neuro/resp status closely. or when stable.
"
2339,"resp: pt rec'd on a/c 12/500/5+/40%. ett 7.5, 25 @ lip. bs are coarse bilaterally and suctioned for copious amounts of thick white secretions. mdi's administered atr as ordered with no adverse reactions. ps trials to continue as tolerated today. see careview for rsbi. no abgs this shift.
"
2340,"resp: rec'd on 50% t/c. bs are coarse bilaterally. suctioned for small amounts of [** **] yellow secretions. mdi's administered alb/atr via trach with spacer with no adverse reactions. pt remains on t/c. vent pulled.
"
2341,"npn shift 1900-0700:

neuro: a&o x3, no deficits. perrla. some generalized weakness. no c/o pain.

resp: b/l bs present, clear. dry cough. no resp distress. weaned o2 2l to off. tol well, sats 94-100%.

cv: nsr, occasional multifocal pvc's. [**2112**] lytes sent, wnk; k=5.2, mg=2.1. no c/o chest pain. bp wnl. am lytes pending. skin cool. no edema.

hem: [**2112**] cbc: h&h:22.5/8.1, plt:56, wbc:17.6. 0200 cbc: h&h: 21.2/8.1. plt:56. wbc: 17.6. 1st dose ivg given at start of shift per protocol, no s/s of an adverse reaction. prbcx 2 given w/ no s/s of an adverse reaction. plt x1pack  given. second dose ivg started at 0500.

id: afebrile. wbc=12.5 at 0200.

gi: abd distended, firm, baseline. +bs x4. golytley started. rectal bag applied. frequent liquid maroon stool, 1l tol for shift. npo except golytly since mn.

gu: foley patent, draining 60-150cc/hr hematuria, brown, sediments, rare clots. no c/o bladder fullness.

plan: colonscopy if plt wnl. ho will discuss further treatments plans w/ pt.


"
2342,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs ascultated reveal bilateral coarse sound which improve with suctioning.  suctioned x3 small to moderate thick yellow secretions.  mdi's admininstered q4 hr alb with adverse reactions.  pt vomited early this morning.  02 sats remain in ^90's @ 96%.  rsbi=130. no further changes noted
"
2343,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 12/600/40%/+[**6-16**].  alarms on and functioning. ambu/syringe @ hob.  cuff pressure @ 21 cmh20. bs auscultated reveal bilateral diminished sounds.  092 sats @ 99%.  mdi's administered q4 hrs alb with no adverse reactions.  no rsbi performed, pt had no spontaneous breathing rate.  rsbi to be performed on day shift as rn to lighten up on sedation.  no further changes noted.
"
2344,"resp: [**name (ni) 158**] pt on pcv 38/r27/50%/0+. pt has #8 shiley trach with audible leak. bs are coarse bilaterally. suctioned for small amount of tan thick secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions. am abg 7.26/74/127/35. pt following commands this shift. remains on cvvhd. no rsbi, pt is vent dependent. no changes noted this shift. will continue with present therapy.
"
2345,"resp: pt rec'd on simv 10/500/+5/40%. bs are clear bilaterally. suctioned for small amounts of bloody tinged secretions due to new trach. mdi's administered q4 combivent with no adverse reactions. abg 7.49/44/171/34. vent changes to psv 18/5/40% with abg pending. rsbi=85. will continue to wean appropriately.
"
2346,"resp: [**name (ni) 158**] pt on a/c 22/340/60%/0+. pt has #8 shiley. audible leak noted. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white/tannish secretions. mdi's administered alb/atr as ordered with no adverse reactions. abg's (see careview) ph consistant 7.1. bicarb drip initiated for ^ in bicarb to 30's. pt placed on pcv (see careview for settings) no change. am abg pending. will continue with present mode of ventilation.
"
2347,"resp: pt rec'd on pcv 44/32/+0/55%. pt has #8 shiley trach with audible consistant leak. vt's 300-400. bs are coarse  to diminished at bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no [** 353**] due to vent dependency. no changes or abg noc. will continue with present settings.
"
2348,"resp: pt rec'd on pcv 38/27/50%. pt has #8 trach. bs are coarse bilaterally. suctioned for small rusty secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg's 7.27/72/120/35. no changes noc. pt is vent dependent so no rsbi.
"
2349,"7p-7a
neuro: pt sedated on propofol as high as 50mcg/kg/min. increased propofol secondary to pt awoken during am care, nodding appropriately, mae. perrla. fentanyl 50-100mcg iv as needed for pain control.

cv: hr 90s-110s vvi permanemt pacer. epicardial wires attached and in place. noted occasional pvcs. repleted electrolytes as needed. sbp 90-110s. nitro gtt off. milrinone gtt at 0.5mcg/kg/min as ordered. epinepherine gtt infusing at 0.02mcg/kg/min as ordered. ci >2. md [**doctor last name 840**] aware of hr and hct 26.5, 1 unit of prbcs ordered and given. no adverse reactions noted. cvp 7-11. received 500cc ns fluid bolus for cvp 7 and sbp 90s w/ maps 55-60 as [**name8 (md) 52**] md [**last name (titles) 840**], see carevue for details. pap 40s/20s. doppler pedal pulses. hands and feet cool to touch. pt w/ hx of raynauds.

resp: pt orally intubated. simv rate decreased to 8, and fio2 decreased to 40% secondary to po2 170s, and pco2 low 30s. see carevue for details. ls clear but diminished at the bases. sats 99-100%. suctioned for small amt of thick white.ct intact draining serosang drainage.

gi/gu: abd soft, absent bs. ogt +placement. foley draining clear yellow 45-100/hr. see carevue for details.

endo: on insulin gtt as high as 9units/hr, fs checked per protocol and insulin gtt maintained as per protocol.

plan: monitor hemodynamics. monitor respiratory status. monitor blood sugars.
"
2350,"resp: rec'd on pcv pinsp 44/32/0+/55%. pt has #8 shiley traach. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. audible trach leak noted. vt's 200's ve-[**8-9**]. 02 sats @ 98%. plan to have family meeting today to discuss cmo status. will continue with present settings.
"
2351,"resp: [**name (ni) 158**] pt on pcv pinsp 44/32/+0/55%. pt has #8 shiley trach with notable audible leak. bs are coarse bilaterally. suctioned for scant to small amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no changes noc. no abgs. plan to continue with present settings.
"
2352,"resp: pt presently on 4 lpm n/c. bs reveal bilateral wheezing, mostly due to fluid.  hhn given alb/atr x2  ud with no adverse reactions. no other changes noted.
"
2353,"resp: pt remains intubated on simv 14/500/+5/40%. bs reveal bilateral diminished sounds. suctioned for small-moderate amounts of secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.50/51/123/41. no changes noc. plan to trach/peg. will continue full vent support.
"
2354,"resp: pt rec'd on a/c 20/500/+8/50%. ett 7.5, 26 lip.bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. abg with pa02 75, ^ fio2 to 60%. am abg 7.47/36/153/27. no changes noc. will continue full vent support.
"
2355,"resp: pt rec'd on pcv pinsp 44/r32/+5/60%.  pt has #8 shiley trach with persistant positional leak. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tannish secretions. mdi's administered as ordered alb/atr with no adverse reactions. abgs with decrease in pao2, fio2 ^ to 70%. am abg 7.13/146/87/13. family meeting expected tomrrow. will continue present settings.
"
2356,"resp: pt rec'd on psv 16/5/40% (mmv 500/10) bs auscultated reveal bilateral clear sounds. suctioned for small amount of tan secretions. mdi' administered q4 combivent with no adverse reactions. rsbi=85. am abg' 7.44/50/81/35. ps decreased to 10. vt's 400's. will continue to wean appropriately.
"
2357,"resp: pt is  [** **] and vent dependent (see careview for settings) no changes this shift or abg's. bs are coarse which improve following suctioning. suctioned for small to moderate amounts of yellow to tannish thick secretions. mdi's administered as ordered with no adverse reactions. pt is able to suction oral cavity and prefers too. no rsbi due to vent dependency. 02 sats @ 100. will continue full vent support.
"
2358,"resp: [**name (ni) 158**] pt on pcv pinsp 44/5+/rr 32/60%. pt has #8 shiley trach. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg 7.17/156/69/60. no changes noc. will continue with present settings.
"
2359,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 14/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration. mdi's administered q4 hrs atrovent with no adverse reactions.  pt complains she can't take it anymore.  rsbi=92 am abg'd 7.37/53/100/32.  continue to wean to extubate.  no further changes noted.
"
2360,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bialteral wheezes with some fine scattered crackles. mdi's administered q4 hrs alb with no adverse reactions. suctioned for small amounts of thick yellowish secretions. pt's rr^ to 30, ^ ps to 10.  no further changes noted.
"
2361,"0700-1900 npn
see carevue for subjective/objective data.
events of day:  weaning this am, getting ready to extubate when pt became extremely anxious, hr, rr and bp elevated--required ativan for anxiety.  did not extubate due to sedation; pt back on imv for now.  plan is to rest overnoc and reattempt in am.  one unit prbc given, tf resumed, cont'd with vanco enemas q6h however started stooling at 1615-->copious amts liq stool.  ultrasound done to r/o dvt (neg).

neuro:  currently a+ox2.  nodding yes and no, cooperative.  mae ad lib.

cv/pulm:  mp remains st-nsr--lopressor 20mg iv prn given x1 for hr 110's with hr decreased to 90's.  bp returned to baseline after lopressor.  propofol off in anticipation of extubation then restarted when pt placed back on imv.  esmolol remains off.  one unit prbc currently infusing without evidence of adverse reaction--will check cbc 1-2h after completed.  l tlc in place--unable to draw off of cvp line although flushes easily; unable to draw off or flush second port. third port patent.  remains vented at this time with coarse breath sound bil--plan to attempt to extubate in am.  sputum for c+s and gm stain sent.

gi/gu:  tf restarted via ngt at 10ml/hr with no residuals.  one huge liq bm this afternoon--fib applied.  cont with vanco enemas q6h although unable to administer at 1600 as pt actively stooling.  lasix 20mg iv given at 1200 with brisk response--cont to have u/o of >50ml/hr at this time.

id:  tmax=100.7 po.  wbc=33.0.  no change in abx.  sputum sent as noted above.

psychosocial/plan:  emotional support given to pt and fam.  rest on vent overnoc and reattempt to extubate in am.  rpt labs after prbc completed.
"
2362,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/+5/35%.  alarms on and functioning. bs ascultated reveal bialteral coarse sounds. suctioned for copious amounts fo bloody secretions as well as plugs. trach site [**name6 (md) **] [**name8 (md) 1290**], rn aware. trach care performed, changed dressings and tie. mdi's administered q4hrs with no adverse reactions.  rsbi=54.  no further changes noted.
"
2363,"npn shift 1900-0700:

neuro: intermittently dozes. arouses spon and to verbal stimulus. follows simple commands at times such as, ""open mouth."" makes eye contact at times. generalized weakness, mae. purposeful movement, localizes. off sedation. pt restless, agitated when awake. fentanyl given w/ good effect though caused hypotension. as per ho, ativan 1mg pngt w/ some effect. no adverse reaction. perrla, 3mm, brisk.

resp: oett day #4, 7.5 fr, 26 at lip. pcv fio2 40% rate 14 inp 35peep 10. tv range 600-700.  b/l bs present, diminished and coarse throughout. no s/s of distress. suctioned q3-4hrs mod amts, mod thick, yellow sputum. am abg improved: 7.27/35/110/-[**8-24**]. pt in partially compensated metobolic acidosis. serum hco3=12.

cv: sb-nsr, rare pac's. pt hypotensive post fentanyl 25mcq iv administration, sbp 80's while asleep. easily arousable. ho aware. dopamine started and d/c'd sec to frequent pac's. neosynephrine on standby, hypotension resolved spontaneously. qrs 0.08 pr 0.16 qt 0.40. pt anasarcic. extremities w/ dependent edema, +[**1-9**] pitting, weeping, kept elevated. all peripheral pulses palpable. skin jaundice, sclera ichteric. i/o +718 for shift. wt +5.6kg since admission. vasopressin gtt at 0.04u/min. am serum na+=147, ho aware, no interventions till rounds. k+=4.1 mg+=2.1.

hem: hct stable=30.4 hgb=9.9. plt decreased to 82, ho aware, no interventions till rounds.inr=2.1.

id: afebrile, wbc=10.6.

gi: abd distended, soft sec to ascites. +bs x4, normal. ngt intact, tf increased to target, nepro at 50cc/hr, tol, no aspiration, min residuals. no bm. insulin gtt, see flowsheet.

gu: foley c/d/i draining 70-120/hr, amber, clear. bladder pressure=13. bun increased to 85, cr decreased to 2.8.
"
2364,"pt given bronchodilators as ordered with no apparent adverse reactions, midnight tx withheld at rn request.
"
2365,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 7/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned moderate amounts of bloody tinged secretions.  mdi's administered q4 hrs alb with no adverse reactions.  am abg's 7.43/45/106/31. rsbi=174. continue to wean sedation. no further changes noted.
"
2366,"resp:  [**name (ni) 257**] pt on t/c then placed on [**last name (un) 33**] psv 10/5/40% to rest [**last name (un) **].  suctioned for moderate amounts of thick yellow secretions.  mdi's administered alb/atr with no adverse reactions.  pt placed back on t/c this am @ 6:00 am to proceed to wean.
"
2367,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/5/60%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral notable wheeze, related to fluid issues.  mdi's administered q4hr os combivent with no adverse reactions. 02 sats @ 97%. rsbi=30, although rr^ to ^ 30's so no [**last name (un) 607**] initiated.  fi02 decreased to 50%.  no further changes noted.
"
2368,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+5/50%.  alarms on and functioning.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral crackles with slight exp. wheeze noted.  suctioned x 3 moderate to copious amounts of thick bloody tinged secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=40, although no [**last name (un) 607**] initiated since ^ rr to 40's.  02 sats remain in ^ 90's @ 97%.  no further changes noted.
"
2369,"resp: [**name (ni) 257**] pt on [**name (ni) **] ph28/pl14/th4.5/tl0.5/60%. ett #7.5, 23 lip.  bs have noted aeration with slight exp wheeze on rs. suctioned for copious amounts of thick bloody secretions, then tapered off towards end of shift. mdi's administered alb/atr q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions.  am [**hospital1 **] pending. pt sats fluctuating between 92-97%.

"
2370,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for moderate amount of thick tan secretions. mdi's administered q4 hrs combivent with no adverse reactions.  cuff pressures @ 38, rsbi=80, rr ^ to 40's no [**last name (un) 607**] initiated.  no further changes noted.
"
2371,"ccu  nursing progress note
neuro:  pt a& slightly confused, pt given ativan secondary to aggitation due to etoh withdral.  pt had adverse reaction to ativan and began to become confused and had increased aggitation.  ativan order changed to valium.  pt mae, however cannot bend, must be supine until 2300.

cardiac:  pt initially on iabp.  pt in st hr 92-116 with occ [**name (ni) **], pt given multiple doses of iv lopressor, with minimal effect.  pt to be started on po b blockers.  bp 89-127/50-75.  pt weaned off dopa, iabp, swan all dc'd.  pt had r fem venous and a sheath, both dc'd keep supine until 2300.  questionable small hematoma in r fem, very soft and supple, however raised, possible swelling from pressure, con't to monitor.  pt has dopplerable dp, and very difficult to fell pt's.  pt given 3g cagluc iv.  con't serial ck and hct, next due at [**2186**].  echo showed ef 40% no other significance.

resp:  bs clear and equal bilaterally, o2 sat 98% on 2l via nc.

gi:  pt npo secondary to gib, pt has r nare ngt to lis with decreased amt (from inintial bleed) of coffee ground out.  +bs, -bm, abd soft nt.  pts hct stable at 0800, then decreased at 1200, by 5 pts, pt given 1u prbc hct now 29, questionable real drop or dilutional.

gu:  pt has f/c good  u/o, urine clear.  pt getting d5 1/2 ns at 75cc/hr x1l.

access:  pt has piv x2.

misc:  iabp, swan, dopa, heparin all d/c today.
labs due at [**2186**].  pt 5 l positive.  v sheath dc'd at 1845 and aibp at 1700.  con't to monitor ms and give valium as needed per ciwa scale.
"
2372,"micu nsg admission note
ms. [**known lastname 11491**] is a [**age over 90 **]yo [**hospital3 327**] resident who has been in her usual state of health until past few days when she states she has been ""falling alot"" at home.  multiple old bruises noted on torso, upper arms.  last evening pta she had 2 episoded of brb pr, came to [**hospital1 2**] er.  pmh significant for cad, cva with minimal residual effects, depression, asthma, gerd, diverticulosis by c-scope, paf, pvd, hemorrhoids, h/o falls, s/p appy, glaucoma and htn.  allerg->pcn (rash) and asa (rectal bleeding).  in er pt treated with fluids and prbc.  baseline hct=37; hct in er 29 range prior to prbc.  pt s/b surgery and gi in er.  tagged rbc scan done; results pending.  pt does have a daughter [**name (ni) 3095**] [**name (ni) 11492**] ([**telephone/fax (1) 11493**]) who is involved in her care, lives locally ([**location (un) 3163**]) and pt had a son who was a cardiologist but expired at age 38 due to mi.

current status:

see carevue for subjective/objective data.  pt arrived to icu via stretcher at 0330.  prbc #2 infusing upon arrival.  neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  vss.  mp=nsr, no vea noted.  bp 120's-130's/50's.  periph iv's x2.  prbc second unit hung in er infusing.  room air with coarse breath sounds bil.  no sob or doe noted.

gi/gu:  npo.  abd soft, tender but not tense.  no bm since arrival to icu.  three way foley placed with one attempt; irrigant port clamped.

id:  afebrile.  no abx at this time.

iv:  prbc completed with no adverse reactions noted.  ns 500ml bolus infusing to be followed by d5and [**12-10**] at 75ml/hr.  will rpt hct btw 0530-0600.

psychosocial:  pt sleeping once settled in room.  no visitors with pt.

plan:  monitor vs, hct, ? scope in am.
"
2373,"resp: pt rec'd on 4 lpm nc. ^ wob with sob. abg 7.32/78/92/42. re-intubated #8 ett, taped @21 lip as per previous intubation. cp @ 20 cmh20. vent settings; a/c 12/450/10+/40%.  bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.34/65/124/37. no a-line. no rsbi due to ^ peep. will continue full vent support
"
2374,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] simv12/600/5/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of bloody tinged thick secretions and some white.  mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=80.  placed pt on psv 15/5/50% and tolerating well, plan to continue to wean today with possible t/c trial. no further changes noted.
"
2375,"resp: [**name (ni) 257**] pt on psv 10/5/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi' administered q4 alb with no adverse reactions. am abg 7.43/41/137/28. rsbi=37. no further changes noted.
"
2376,"resp: [**name (ni) 158**] pt on psv 12/5/50%.positional trach [**name (ni) 156**]. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with diminished bases. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered with no adverse reactions. rsbi=82. plan to continue trach trials as tolerated.
"
2377,"resp: [**name (ni) 257**] pt on psv 10/10/40%. ett #8, 21 @ lip. bs are clear but diminished. suctioned for small amount of thick yellow secretions. mdi's administered q3-4 hrs alb/atr with no adverse reactions. am abg 7.37/60/110/36. no vent changes noc. rsbi=42. plan to wean to extubate this am.
"
2378,"resp: [**name (ni) 158**] pt on psv 12/5/50%. pt has #8 portex perc trach. inner cannula changed and was clear.alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick tannish secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=92. attempted abg, pt not cooperative.
"
2379,"resp: [**name (ni) 158**] pt on a/c 14/60/+5/50%. alarms on and functioning. ambu/syringe @ hob. suctioned for small-moderate amounts of tan thick secretions. mid's administered as ordered with no adverse reactions. pt has noted cuff [**name (ni) 156**]. rsbi=100. no changes or abg's this shift.
"
2380,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 14/500/35%.+5. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. abg's (see careview) fio2 ^ to 50% with abg pending. pt cardioverted tonight and stable. will continue full vent support.
"
2381,"resp. care
pt. remains intubated . pt. was weaned down on her fio2 from 70% to 40% per the ip team.sat's are in the low to mid 90s.sx sm amts white secr. mdis given at 0230 with good effect and no adverse reaction.no abgs were drawn during the shift . plan is to go to the or for a y stent then wean as tol.
"
2382,"resp: [**name (ni) 257**] pt on a/c 12/350/+5/30%. ett #7.5, 20@ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions as well as oral cavity. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg7.46/37/1741/27. rsbi=68. weaned pt to psv 12/8 for tv's 300-400, ve [**4-19**], rr 16. plan to continue to wean to possible extubation.
"
2383,"resp: [**name (ni) 257**] pt on a/c 10/350/+5/30%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick bloody secretions probably due to endo procedure yesterday.  mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.48/38/113/30. rsbi attempted but pt on sedation, results >200. no further changes noted.
"
2384,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 24/550/+10/60%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20, ett # 7.5 retaped, secured and advanced 23 @ lip (found @ 21). bs auscultated reveal bilateral aeration with diminshed bases. suctioned x1 for none. mdi-s administered combivent q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see carview) am abg's 7.40/51/68/33. 02 sats @ 92%. pt remians on paralytic noc, but plan to d/c today. no vent changes. plan to continue full vent support.
"
2385,"resp: [**name (ni) 257**] pt on psv 12/12/40%. ett #7.5, retaped, rotated and secured @ 23 lip. bs are coarse to clear. suctioned for moderate amounts of thick white/yellow secretions. [**name (ni) **]'d administered alb/atr with no adverse reactions. am abg 7.36/74/115/44. rsbi=155. team to discuss possible extubation even though failed rsbi.
"
2386,"npn shift 1900-0700:

pt status quo. pt remains confused, agitated, restless, attempting to self-d/c medical deviced. restraints remain on for safety. neuro otherwise stable. pt conversant, able to verbalize needs though inappropate words at times due to confusion. ativan 2mg iv, ok's by ho, with temorary effect, approx 2 hrs. no adverse reactions. haldol 5mg iv given w/ less effect. fenatnyl patch changed. c/o discomfort. morphine 4mg iv given with good effect. weaned o2 to ra, tol well. coughing productively on command. st 120-140's w/ agitation. when calm, hr spontaneously decreases to 80-90's. no [** **] episodes. sbp 130-150's. autodiuresing, output > 2l. started on ns maintenance ivf at 100cc/hr. am hct 23.1, down from 26.7. some may be dilutional. awaiting prbc x1u. rectal bag off, 300cc [**location (un) 138**] stool. applied new rectal bag. afebrile, tmax 100.4 orally.
"
2387,"resp: [**name (ni) 257**] pt on 70% t/c. emergency equipment @ hob. pt has portex #9 trach. pt ^ wob, placed back on psv 10/8/40% to rest noc. bs are coarse bilaterally. suctioning tan thick secretions. mdi's administered atrovent with no adverse reactions. trach care performed/inner cannula replaced and site cleaned. am abg 7.44/39/96/27. rsbi=71. plan to continue with t/c trials in am.
"
2388,"resp: pt rec'd on psv 8/8/40%. et 7.5, 23 @ lip. bs are coarse to clear and suctioned for moderate amounts of thick white frothy secretions. [** **]'s administered alb/atr with no adverse reactions.vt's 300, ve's [**7-27**]. 02 sats @ 100%. no abg's this shift or changes. rsbi=120. plan to continue to wean as tolerated.
"
2389,"progress notes
neuro= received lethargic, easily arousable, folows commands, confused at times, oriented x2, moves all extremities spontaneously but weakly, complains of right hip/leg pain, h/o right hip replacement, medicated with ultram/mso4 with good result, assisted in turning.

cv= s1 s2 regular with rare apc's, palpable peripheral pulses x4, normal capillary refill to nailbeds, denies chest pains or palpitations, hr 96-118, nbp 120-134/40-76.  on lopressor dosage increased from 1.5 mg to 2.5 mg q6hrs iv.

pulm=received on nc 4lpm, clear bilat breath sounds diminished on the bases, she's an mouth breather and her sat's dropped to 80's when she's asleep, placed her on face tent at 40% with spo2 readings 92-97%. had occassional expiratory wheezes relieved after coughing. unproductiove cough. encouraged deep breathing and coughing, she's complaint.

gi= soft, slightly tender to deep palpation, normoactive bs x4, no bm, passed out foul smelling flatus x1, attempted to used bedpan x2 but no bm, on clear liquid diet, given ice chips and po cold water for now, nauseous x1, no vomiting so far.  no melena.

gu= foley cath draining dark clear yellow urine u/o= 30-45cc/hr.

skin=dry and intact, no bedsores, turned and position q2 and prn, skin and back care done.

iv= right arm hl intact. no signs of infiltration/infection noted.
     left hand pvl intact, infusing ivf + 60 meq kcl at 100cc/hr. site intact/ no redness/infiltration noted.

labs= last hematocrit at 8:30pm is 29, transfused another 1 unit prbc, no adverse reactions noted post-bt.  will check cbc later this am.
serum k+ at 8:30pm= 4.1.

code status= dnr/dni.

plan= continue with current therapy, pain management, monitor h/h and transfuse as indicated, monitor lytes and replete prn.
"
2390,"resp: bs's clear.
gi: appetite improved.
renal: voiding. increased po intake.
neuro: alert and orientated.
hem: premedicated for procedure. no adverse reaction from plasma pheresis. post hct 29.7 and plts 53.
access: groin drsg [**name5 (ptitle) **] and [**name5 (ptitle) **] removed. no further bleeding noted.
endoc: ssi required for bs. k+ repleted.
cv; hemodynamically stable.
id: afebrile.
skin integrity; no rash. bruising diminishing.
plan: transfuse for hct <25. pc's require thawing and washing. recheck cbc at 21pm. possible transfer tomorrow after procedure.

"
2391,"micu npn 7pm-7am
neuro: pt. received on ativan gtt @1mg/hr and fentanyl at 50mcg/hour. initially pt. appeared comfortable, able to obey commands, and would withdraw to pain. l pupil reactive to light. very weak cough and gag. pt's ativan gtt increased to 2mg/hr due to pt. stacking breaths with ventilator. pt. currently appears comfortable, does open eyes to pain, and flexing extremeties to nail bed pain.

resp: remains on ac16,+5 tv 500, 40%. am abg pending. lungs are coarse with crackles in the bases. at times pt. is very rhoncorous, and sounds like she has alot of secretions, however she has scant to no secretions when she is suctioned. secretions are rust colored. awaiting results of bronch.

cv: received on 8mcg/kg/min of dopamine. dopamine has been weaned to 3mcg/kg/min and will continue to wean as bp tolerates. nsr with occ pac's and pvc's.

gi: ogt to lis, draining guiac + bilious drainage. ogt clamped this am. active bowel sounds, no stool. ?feed pt. is bleeding has stopped.

gu: voiding adequate amounts of urine >40cc/hr. clear, yellow urine.

heme: hct stable, 30@mn.

misc: per pt's oncologist she received iv ig. pt. initally given a test dose of 5gms and she tolerated it well. bp stable, and temp stable, no signs of adverse reaction. pt. then given remaining dose. pt. tolerated well. see carevue for vss and temp.

social: family member stayed the night in the waiting room. plan is to find source of infection, wean dopamine as tolerated.
code status: dnr
see carevue for further data.
"
2392,"resp: pt rec'd on a/c 15/550/+8+50%. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. sucitoned frequently for moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. no changes this shift. rsbi=58. will continue full [** **] support.
"
2393,"resp: [**name (ni) 158**] pt on a/c 22/600/+5/50%. ett #8, 23 lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amount of bloody tinged secretions. mdi's administered q4 alb with no adverse reactions. pt is being r/o for tb. am abg pending. will continue will full vent support.
"
2394,"resp: [**name (ni) 158**] pt on a/c 15/550/+8/70%. ett #7.5, 24 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick tan secretions. mdi's alb/atr administered with no adverse reactions. [**name (ni) **] changes to decrease fio2 to 60%. abg 7.37/41/100/25. no further changes noted. will continue full [**name (ni) **] support.
"
2395,"resp: rec'd on psv 14/+5/40%. ett 7.5 taped @ 23 lip. bs are clear with diminished bases. suctioned for small amount of white secretions. mdi's administered atr as ordered with no adverse reactions. vt's 500's/ve's 11/rr 23. rsbi=90. am abg 7.40/34/147/22. plan to wean as tolerated. no changes this shift.
"
2396,"resp: [**name (ni) 158**] pt on a/c 30/400/18/50%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, retaped, and secured @ 25 lip. bs auscultated reveal bilateral clear apecies with diminished bases. suctioned for small amounts of white secretions. mdi's administered as ordered with no adverse reactions. abg's (see careview) vent changes to decrease peep to 16, rate to 28 with am abg pending. will continue to wean as appropriate.
"
2397,"resp: [**name (ni) 158**] pt on a/c 14/600/10+/50%. retaped tube ett 8.0 @ 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no aline/abg's noc. no changes or rsbi due to ^ peep. will continue full vent support.
"
2398,"resp: pt remains vented on psv 5/5/50%. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered q 4h alb with no adverse reactions. rsbi=68. am abg's pending. o2 sats @ 100%. plan to wean to t/c as tolerated.
"
2399,"resp: [**name (ni) 158**] pt on a/c 30/400/+20/60%. ett retaped by rn, then found at end of shift @ 23 lip, retaped, advance and secured @ 25 lip. bs are clear bilaterally, with diminished bases. suctioned for small to moderate amounts of bloody tinged to rusty plugs. abg 7.39/41/78/26.mdis administed as ordered alb/atr with no adverse reactions. pt had episodes of desaturation to 80's then ^ fio2 to 70%. no further changes noted. esophageal balloon in place. will continue to wean fio2 as tolerated.
"
2400,"resp: pt rec'd on psv 10/5/40%. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.46/29/103/21. rsbi=74. plan to possible trach today. will continue to wean appropriately.
"
2401,"resp: [**name (ni) 158**] pt on 40% t/c with humidification. 02 sats @ 99%. bs are coarse bilaterally and pt is able to expectorate secretions. mdi""s administered q4 hrs alb/atr with no adverse reactions. pt has #8 shiley trach with cuff deflated. no abg's or distress this shift. pt scheduled for pmv [**name (ni) **]. will continue to follow.
"
2402,"resp:  [**name (ni) 158**] pt on 7200 psv 5/+5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 for small amount of whitish secretions.  mdi's adminintered q4hrs with no adverse reactions.  rsbi performed this morning resulting @ 71.4 and sbt initiated.  02 sats remain in ^ 90's and rr @ 24.  no further changes noted.  possible extubation today, awaiting sons arrival at hospital.

"
2403,"resp: [**name (ni) 158**] pt on simv 10/600/12/+12/50%. ett#7.5, 25 lip.  bs reveal bilateral crackles. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs of atrovent with no adverse reactions. abg drawn; results 7.34/49/179/28. vent changes to decrease rr to 8, fio2 to 40%. no further changes noted.
"
2404,"resp:  [**name (ni) 158**] pt on a/c 14/550/+8/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan with green plugs. mdi's administered as ordered with no adverse reactions. no changes or abg's this shift. 02 sats @ 100%.
"
2405,"[**name (ni) 158**] pt on [**last name (un) 647**] psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration noted in apecies with diminished bases.  mdi's administered q4 hrs combivent with no adverse reactions.  abg's drawn with worsening acidosis, placed on simv 22/600/+5/5/50%.  am abg's 7.37/31/178/19 with no further changes noted.
"
2406,"resp: [**name (ni) 158**] pt on psv 10/10/40%. ett 8.0 retaped, rotated and secured @ 23 lip.  alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally.  suctioned for large amounts of thick bloody secretions/clots. heated wire circuit changed. mdi's administered alb/atr as ordered with no adverse reactions. vt's 700's with occasional drop in ve's to 3l then back up to 8-9l. no rsbi due to 6 peep. am abg 7.46/41/84/30. no changes noc. [**name (ni) 4812**] started.

"
2407,"resp: pt rec'd on a/c 14/550/50%/8+. bs are coarse bilaterally. suctioned moderate amounts of thick greenish secretions. mdi's administed as ordered with no adverse reactions (see careview) no abg's/no aline. weaned to psv but didn't tolerate and placed back on original a/c settings. rsbi=68.
"
2408,"resp: [**name (ni) 158**] pt on simv 8/500/12/+12/40%. ett #7.5 retaped and secured 25@lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions with occasional tannish plug. mdi's administered q4 atrovent with no adverse reactions. no changes or abg's this shift. no rsbi due to ^ peep. will continue full support.
"
2409,"resp: pt rec'd on 50% t/c. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. nebs alb/atr administered with no adverse reactions. no changes noc.
"
2410,"resp: [**name (ni) 158**] pt on a/c 12/500/+5/50%. [**last name (un) 3028**] #8 trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick tan secretions. mdi's administered q4 alb/atr with no adverse reactions. no changes or abg's this shift. plan to attempt to wean to psv today.
"
2411,"resp: [**name (ni) 158**] pt on psv 12/+5/40% then placed on a/c 14/450/+5/40% to rest noc. ett #7, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amounts of bloody secretions. mdi's administered as ordered of combivent/flovent with no adverse reactions. pt has a tendency to bite on tube. no abg's this shift. 02 sats @ 99%. plan to tap bilateral pleural effusions today. will continue full vent support.
"
2412,"resp: [**name (ni) 158**] pt on a/c 14/550/+10/60%. bs are coarse bilaterally. suctioned for thick greenish secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease peep to 8, fio2 to 50%. no a=line, 02 sats @ 99%.
"
2413,"resp: pt rec'd on psv 16/8/50%. ett retaped, rotated and secured. alarms on and functioning/ambu/[**e-mail address 4476**] are coarse bilaterally. suctioning for moderate amounts of thick tannish secretions. mdi's administered q 4 alb/atr with no adverse reactions. pt ordered for potassium iodide, after consulting pharmacy was advised not to administer down ett, just po. pt placed on a/c 20/500/+8/50% to rest [**e-mail address **]. am abg 7.47/30/182/22. decreased rate to 14, fio2 to 40%, peep+5. plan to wean back to psv today.
"
2414,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/500/50%/+5. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned a moderate amount of thick yellowish secretions. mdi's given q4 alb with no adverse reactions.  [**last name (un) 353**]=135, cuff pressure @ 22cmhc0 with no further changes noted.
"
2415,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi""s administered q4 combivent with no adverse reactions. rsbi=98, no am abg. plan to continue to wean as tolerated.
"
2416,"resp: pt remains intubated on psv 10/5/50%. alarms on and functioning. pt had periods of desating to 80's, increased vent setting temporarily then returned to present settings. bs auscultated reveal bilateral clears sounds, suctioned for small amount of tan thick secretions.  mdi's administered alb/atr q4hrs with no adverse reactions. abg's 7.45/30/116/21. rsbi=76. vt' 500's, ve 13l, rr 25. will continue to wean appropriately.
"
2417,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 12/550/40%/+5.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with some coarseness noted on ls, diminished bases bilaterally.  mdi's administered q 4hr combivent with no adverse reactions. suctioned x3 small amounts of thick white secretions.  sputum sample obtained this am.  rsbi=172 and no sbt initiated.  no further changes noted.  02 sats remain in ^ 90's.
"
2418,"resp: [**name (ni) 158**] pt on a.c 14/550/5+/60%. ett #8, 24 @ lip. alarms on and functioning. ambu/syringe 2 hob. bs are clear bilaterally in apecies with diminished bs on lll. xray shows improvement from prior. mdi's initiated and administered as ordered atr/alb with no adverse reactions. suctioned for small amount of thick white secretions. pt is still tachycardic and may require cardioversion??. vent changes noc (see carview) am abg 7.44/44/119/31 at present settings. no rsbi due to hemodynamic issues.
"
2419,"resp:  [**name (ni) 158**] pt on psv 12/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilteral aeration with a noted wheeze. mdi's administered q4 hrs combvient with no adverse reactions. suctioned for small amounts of bloody tinged secretions. am abg's 7.42/61/98/41.  no further changes noted.
"
2420,"micu npn
see carevue for subjective/objective data.  neuro:  unresponsive to verbal stimuli, withdraws to tactile/painful stimuli.  no attempts to communicate or speak around ett.  minimal movements of arms, hands noted; no leg movements noted.

cv/pulm:  vs labile.  dopa titrated to maintain map>60--overnoc dopa max 12mcg/kg/min, currently at 9mcg/kg/min with map 60-64.  swaned at 1900--pa catheter at 65cm, intermittently wedges with 1and [**1-7**] ml air. pa's 20's/10's with cvp 11 to 5.  pcwp 13-11.  initial co/ci low at 4.5/1/5.  dobutamine added at 2.5mcg with co/ci improved to 5.3/2.5.  sensitive to dopa-->bp drops rapidly during even brief interuptions of infusion (bag change), takes 15-30min to return to baseline.  mp=nsr with occ pvc's at beginning of shift, now no ectopy noted.  completed prbc's hanging at 1900, hung third unit prbc's (total of 4 units including prbc rec'd in er).  no adverse reactions noted with blood transfusions.  maintained on vent-->ac12x700x50%x5peep.  bs coarse with bibasilar crackles.  lasix 40mg iv given prior to last unit prbc's with good diuresis; continues to diurese.  sputum sent for c+s.
suctioned for scant thick light yel sec via ett.

gi/gu:  ogt-->lcs drng bilious material.  bs absent.  abd soft, non-tender.  u/o qs via foley with brisk diuresis following lasix.  no bm.

integ:  incision on upper back noted (cyst removed pta)--drng sm amts light yel drng.  dsd applied/changed.  coccyx pink with sm area ""rough"" but not open--duoderm applied.  no other open areas noted however heels pink--elevated off of bed as much as possible.

id:  tmax=100core.  bc, urine cultures sent in er; sputum culture sent in micu.  started on vanco and levo (per pharmacy levo needs id approval following initial dose).

psychosocial:  emotional support given to pt.  no visitors or [**name2 (ni) **] contact thus far this shift.
"
2421,"blood administration
pt given one unit of prbcs for hct of 22.7.  pt tolerating procedure well at this time, no adverse reactions.  rn to follow up by checking hct and obtaining new iv access.
"
2422,"resp: [**name (ni) 158**] pt on t/c and place back on [**last name (un) 647**] psv 5/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral areation noted. some fine crackles.  suctioned for small amounts of yellow thick secretions. mdi's administered q 4 hrs of combvient with not adverse reactions. md [**first name (titles) 1531**] [**last name (titles) 2435**] today.  place back on t/c this am. tv low 300's.
"
2423,"resp: [**name (ni) 158**] pt on a/c 18/550/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amounts of thick secretions. mdi's administered 2p atr with no adverse reactions. trip to ct without incident, with results pending. am abg 7.40/41/75/26 with no changes noc. rsbi=no resps. will continue full vent support.
"
2424,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 10/500/10+/50%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. mdi's administered q4 hrs [**last name (un) 741**] with no adverse reactions. no vent changes noc. plan trach/peg tomorrow.  no rsbi due to peep.  am abg's 7.53/34/148/29.  no further changes noted.
"
2425,"resp: [**name (ni) 158**] pt intubated via or ett 7.0 retaped and secured 19 @ lip. place on a/c 18/550/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered 2p atr with no adverse reactions. vent changes to decrease fio2 to 40%. am abg 7.28/41/107/20. no further changes noted. will continue full vent support.
"
2426,"resp: [**name (ni) 158**] pt on psv 10/8/40%. ett #8, 27 @ lip. bs are coarse to clear and suctioning moderate to copious amounts of thick rusty/plugs secretions. mdi's alb administered with no adverse reactions. am abg 7.48/37/76/28. rsbi=43. plan is to extubate in am.
"
2427,"resp: [**name (ni) 158**] pt on psv 10/8/40%. ett #8 taped @ 27 lip. bs are coarse to clear. suctioned for large amounts of rusty/plug thick secretions. mdi's administered as ordered alb with no adverse reactions. rsbi=31. am abg 7.46/37/80/27. plan to wean as tolerated.
"
2428,"tsicu nursing admit note
pt s/p unwitnessed fall at home, possible mechanical cause.  no loc per family.  pt taken to [**hospital3 **] where scans revealed c1, c2 fx.  transfered to [**hospital1 41**].  initially given steroid bolus, stopped per trauma.  head ct revealed possible evolving stroke, to be evaluated by mri.  bilateral shoulder injury to be evaluated by ct.

pt with extensive hx including dementia (etoh vs alzhiemers), cad s/p ami, chf controlled with dialysis, htn, a-fib, copd, gi-bleed, esrd with hd 3x per week.  pt with multiple hospitalizations with fistula problems, line sepsis, now with graft.  baseline dementia generally exacerbated with delerium during hospitalizations.  pt with code purple previous hospitalization.  adverse reaction to haldol in past.  given sl zyprexa.

pt stating he has considered stopping dialysis treatments and ""throwing in the towel.""  he stated that he does not want to continue to live this way.  family will need to discuss pts wishes in light of significant dementia.

dr. [**last name (stitle) 898**] in to meet with family.  discussed collar vs. halo vs. surgery.  family does not believe collar is an option as pt would remove it.  family is requesting rehab placement as pt requires extensive care from wife at baseline.  dr. [**last name (stitle) 898**] to continue to discuss options.

ros:

neuro - aao x2.  pt knows name and that he is in the hospital.  [**name (ni) **] unclear why he is hospitalized.  unclear as to date.  asking to go home, easily redirected discussing x-rays planned before he can go.  mae with equal stregth.  sensation intact.  collar on with good fit, pt has not tried to remove collar over noc.  no restraints needed.  pt c/o right shoulder pain, reports good relief with tylenol.

cv - sr with [**name (ni) **] pvcs, pacs.  rate 60s to low 70s.  hypertensive at times with sbp 120s to 170s.  given po antihypertensives.  toprol held per dr. [**last name (stitle) 1859**].  peripheral pulses stronger in rle vs lle.

resp - lungs cta.  eupnic.  o2 sat dipped to 91% with deep sleep.  placed on 2l nc with o2 sats >97%.

gi - abdomen soft, flat, + bs.  tolerated sips of water with meds.

gu - does not make urine.  missed dialysis today because of fall.  will have dialysis today.  hold antihypertensives until after dialysis.

endo - elevated blood sugar since admission.  no known hx.  riss.

social - wife, [**name (ni) 1736**], is caregiver [**first name (titles) **] [**last name (titles) **].  family is caring and appear to have reasonable expectations.  they will continue to talk with neurosurgery re: plan for cervical fracture.  await plan of care for shoulder injury.  family requesting case management input re: rehab placement.  upon chart review, pt was dnr/dni during previous hospitalization.

a - neuro status intact, stable s/p c1, c2 fx.  dementia apparently at baseline.  good pain relief with tylenol.

p - continue serial exams.  mri of head to evaluate stroke.  ct to evaluate shoulder injury.  consult case management.  discuss code status with family.  dialysis treatment as needed.  sw consult for family coping in light of pt's statements re: quality o
"
2429,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett #7.5 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration with diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift or changes. rsbi=27.
"
2430,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett #7.5, retaped and secured @ 21 lip. alarms on and functioning. ambu/syringe @ hob. suctioned for small to moderate amounts of thick tan secretions as well as copious oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sat @ 100%. rsbi=28. no changes or abg's noc.
"
2431,"pmicu nursing progress note 7a-7p
review of systems

[**name (ni) 248**] pt is responsive to stimuli, both voice and pn. she still does not move her extremities, but opens her eyes inconsistently when asked. she was not given any medication for sedation today, both scheduled doses of valium were held due to hypotension.  she has cont to recieve 300 mcg/hr of fetanyl, the plan following evening rounds is to start to slowly wean the fetanyl. the pt is planned to have a pancreatic needle aspiration [**last name (lf) **], [**first name3 (lf) **] will cont. to need pn medication.

resp- ac 400/40%/18/5 peep.  has maintained sats btw 97-100% since the peep was decreased from 8to5.  ls coarse bilaterally, suct. scant amts of thick, white sputum.  ett rotated, 25 to lip.  significant amt of thick yellow drainage suctioned from nares. team aware.

cv- hr btw 102-122 today, b/c more tachycardic w/ inc temp.  no ectopy noted.  nbp 90's-102/40-60's. hypotension was tx w/ 1 u of prbc to inc. intravascular vol.  received 2 gm of ca today.

gi-  bs, present, stooling loose green stool per mush cath.  cont. to receive tpn, lipids have been added per dietary recommendations.  tf cont to be held due to severity of inflammation in pancreas, residuals have been < 20 cc on q 4 hr checks.

gu- 100 cc/u/o/hr, clr, yellow. 24 hr net body balance + 1114.3. given 1 l bolus of ns for dehydration per teams request.

heme/[**name (ni) 998**]  pt transfused w/ 1 u prbc to inc. intravascular vol. and for hct of 27.4.  prbc's infused without evidence of adverse reactions.  plan to dc insulin drip when last l of d5 finishes infusing.  sliding scale orders in chart for coverage.

id- febrile today w/ temp ranging from 100.5-101.7; pt received q 4 hr tylenol and remained on a cooling blanket. day # 10 of imipenim.
fungal isolators sent.

plan- social work met w/ pt's fiance and spoke w/ pt's sister today over the phone and a meeting is to held tomorrow with all members. please refer to note in chart.  cont to monitor resp, cv, fever status.  tomorrow ir is scheduled for a pancreatic needle aspiration.


"
2432,"12p-7p
pt readmitted from [**hospital ward name **] 2, ct draining bile ? anastomosis leak ([**11-14**] s/p esophagogastrostomy and jtube placement). pt went to ct prior to being transferred.

neuro: pt alert and orientedx3. mae. perrla. using dilaudid pca appropriately for pain management see carevue.

cv: hr 102-119 st no ectopy. sbp >90. see carevue. dopplerable pedal pulses. 2+ pitting edema to bilat ankles. porta cath to left cw patent and intact. #20 placed to rh, patent and intact.

resp: ls coarse throughout. face tent applied at 70%, desats to 91% on nc. sats on face tent >95%. rr wnl. ct intact, no air leak noted, see carevue for details of color. md [**doctor last name 6980**] in at bedside on arrival and aware of color and content, barium given down ngt in ct scan by md. [**first name (titles) 6981**] [**last name (titles) 4318**] in ct by md [**doctor last name 6980**] to declot ct to drain. no adverse reactions. ct w/ scant drainage after 1700, md [**doctor last name 6980**] aware.

gi/gu: abd soft, + bs. ngt to right nare, to lis draining bile, see carevue. no manipulation of ngt [**name8 (md) 52**] md [**last name (titles) 6980**]. j tube clamped [**name8 (md) 52**] md [**last name (titles) 6980**]. foley draining [**first name8 (namepattern2) 1074**] [**location (un) 206**] color urine. at 1600, lasix 20mg ivp given for decrease in u/o to 5cc for 1 hour. see carevue for details.

endo: covered per pt's own scale.

id: wbc 22-23. afebrile.

plan: monitor hemodynamics. pulmonary toilet. monitor temp. ? to or/ir tomorrow.
"
2433,"resp: pt rec'd on a/c 20/600/40%/5+. alarms on and functioning. ambu/[**e-mail address 5171**] #7 re-taped and secured @20 lip. cp @ 23 cmh20.  bs auscultated reveal bilateral coarse sounds with exp. wheeze noted. mdi's administered q 4 alb with no adverse reactions. suctioned for small- moderate amounts of tan secretions. am abg's 7.31/40/80/21. pt remains on cvvhd. will continue full vent support. no vent changes noc.
"
2434,"ccu progress note!  7a-7p
delayed transfusion reaction:
   pt began to feel uncomfortable around 930am, stating he was feeling 'awful'.  at 10am, team in to assess pt on rounds, pt feeling nauseous. droperidol 0.625mg given total of 3 times today w/ little effect. ekg done w/ no changes noted. labs sent, cks flat. pt sob resp rate 20-30s, laboured at times. ls clear, crackles to bases. tmax 100.4. st 1320-130s. milrinone gtt d/c'd d/t ?adverse reaction to drug. pt con't all afternoon w/ nauseous feeling and stating he felt awful. slept in naps most of afternoon. hematuria - u/a sent. unknown about why pt was feeling so awful.
  around 5pm, house staff notified by blood bank that pt recieved blood + for minor antigens that pt has antibodies for.(1 unit prbcs given [**2130-1-10**], checked via ccc and w/ 2 nurses and given over 4hrs - hung 10am-down 2pm. benedryl 25mg po and tylenol prior to transfusion.) blood bank stated that due to missmatch he may have a delayed transfusion reaction.  pt had temp of 100.4 today, nausea, resp distress and hematuria (signs of a transfusion reaction). labs sent. ivf d5w w/3amp naco3 @ 250cc/hr x 1l.


neuro: a+ox3 today. pleasant + cooperative. pt napped most of late morning/afternoon d/t feeling awful. moves self in bed.

cardiac: st 110-130s today. occ pvcs noted. integrillin d/c'd at 11am. post cath fluids stopped at 8am. milrinone d/c'd at noon. ekg showed no changes today. no c/o chest pain. rij swan intact, pad 28-32, pcwp 31->23. co 3.3->4.7, ci 2.2->3.1, svr [**2127**]->1200. dobutamine @ 15mcg/k/min, nitro @ 180mcg/min. for cath lab in am to fix lad, to recieve pre cath fluids tonite.

resp: ls clear, crackles to bases. rr 20-30s, o2 3l n/c. laboured breathing at times this afternoon. cxr unchanged. sats 94-100%.

gu: foley changed today d/t ?clotted catheter. u/a sent. con't w/ hematuria, pink urine w/ clots. poor u/o, noting decrease in u/o since ivf d/c'd at 8am. lasix gtt decreased to 5mg/hr. ns bolus given this afternoon w/ no results. currently recieving d5w w/ 3amps bicarb @ 250cc/hr x 1l to flush out patient (d/t transfusion reaction). last cr 2.6!

gi: abd soft, distented. bm this evening. nauseated most of day, droperidol given x 3 w/ little effect. took small amt dinner this evening since he has started to feel a bit better. npo at midnite for cath in am.


plan: monitor resp status d/t ^ivf. monitor for further delayed transfusion reactions. con't to monitor vs and do cardiac calcs q4h. npo @ midnite for am cath. start pre-cath ivf tonite.
"
2435,"resp: [**name (ni) 158**] pt on a/c 24/350/+10/40%. pt has #9 [**last name (un) 3028**] foam filled trach. alarms on and functioning.ambu/syringe @ hob. bs are coarse and suctioning small to moderate amounts of yellow to tannish thick secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's or changes noc. will continue full vent support.
"
2436,"7p-7a
neuro: at beginning of shift pt alert,sleepy, following all commands,mae,perrla, nodded yes when asked if wants ""breathing tube out"" able to move head forward. pt resedated after re-intubation, on propofol,perrla, mae to painful stimuli. no indictions of pain.

cv: hr 70-100s. >100 during episode of re-intubation. sr/st. sbp labile on and off neo and ntg. currently off of neo and ntg. sbp 110s. [**md number(3) 5118**]/15-20s. cvp 7-16. svo2 52-64, md bridges aware. ci>2 by fick, see carevue. low svo2 treated w/ fluid bolus x3 and 2 units of prbcs,no adverse reactions, see carevue. epicardial wires attached and on ademand backup, see carevue for settings. +palpable pedal pulses, verified w/ doppler.


resp: at beginning of shift, pt following commands, acceptable abgs on cpap 5/5, md bridges at bedside before extubation and aware of svo2 57-60 before extubation. ok to extubate, extubated at [**2095**], pt sats to 55, pt in resp. distress, pt oxygenation w/ ambu and oral airway w/ improved sats to 90%, anesthesia called stat and at bedside re-intubated 7.5 tube, see carevue for vent settings and changes. abg after re-intubation 7.21/62/108, md bridges aware, rate on vent increased to 18, w/ improved abg 7.32/48/106, md bridges aware. presently on cmv rate 18 tv  700, fio2 70% w/ acceptable abgs, see carevue for details. ls clear diminished at bases. sats 94-100% at present time. suctioned for scant amts of thick white.

gi/gu: abd soft, abesent bs. ngt replaced after extubation draining bilious to brownish drainage. foley draining 40-60cc/hr of clear yellow urine, see carevue.

endo: gtt per protocol.

social: daughter updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. once pt stabilizes, wean vent as pt tolerates.
"
2437,"ccu npn 7am - 7pm
s: ""  my anxiety level is so high.""
o:  cvs:  hr 60 -70 sr no vea noted.  bp 140/30 -40's.  continues on labetelol, hydralazine and norvasc.

resp.:  pt. c/o sob this morning. lungs were clear at the time and o2sat was 94 %.  o2 2lnp was placed and pt. is attributing this episode to anxiety and it resolved spontaneously.

g.u.:  creat. is up to 4.9.  u/o is minimal.  presently pt. is 500 cc's neg.  pt. was told that he probably would need some dialysis after the surgery.

g.i.:  pt.'s main complaint today was of nausea.  vomitted x1.  given zofran 4mg iv x2 with relief.  appetite has been poor.  pt. ate very little.  took medications sporadically throughout the day.

d.m.:  blood sugars continue to be high.  ss insulin was increased.  last sugar was 221.

i.d.:  pt. has remained afebrile.  needs to receive vanco in the o.r. tomorrow.  please send down.  continues on ceftriaxone.

mental status:  alert and oriented x3,  very anxious.  h.o. does not want pt. to have any antianxiety meds due to adverse reactions in the past.

a: nausea and vomitting, awaiting valve surgery tomorrow

p:  continue zofran for comfort, monitor blood sugars, monitor u/o, [**doctor first name 4**] tmr ? at 8am.
"
2438,"respiratory:  [**name (ni) 158**] pt on 7200 simb8/550/15/5/40.  alarms on and functioning.  ambu/syringe@ hob.  bs auscultated reveal bilateral diminished with a few coarse sounds. suctioned x2 small amount of thick yellowish secretions.  mdi's administered q4 with no adverse reactions. fio2 remains in ^ 90's with no futher changes noted.
"
2439,"resp: [**name (ni) 158**] pt on ac 24/350/10+/40%. #9 [**last name (un) 3028**] foam filled trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse which improve following suctioning. suctioned for small to moderate amounts of thick bloody tinged secretions. mdi's administered combivent as ordered with no adverse reactions. no abg's or changes noc. will continue full vent support.
"
2440,"nsicu npn
see carevue for subjective/objective data.  neuro:  confused to place and time.  does not attempt to answer questions or nod ""yes"" or ""no"" however does follow commands to ""squeeze my hand"" and ""move your toes"".  mae ad lib.

cv/pulm:  vss.  mp=nsr without vea noted.  face mask in place-->breath sounds coarse bil.  second unit prbc's infusing when accepted pt; remainder bag infused without adverse reactions noted.

gi/gu:  ogt for meds with effect.  fib in place, passing flatus.  bs positive.  no tube feedings at this time.  u/o qs via foley.  rec'd lasix 40mg iv after second unit prbc's at 0230 with good diuresis.

integ:  pink areas noted on both arms, torso.  no worsening or change in skin condition overnoc.  duoderm to coccyx intact.  skin dry.

id:  afebrile.  no change in abx overnoc.

endo:  no sliding scale insulin required at 2400; glucose pending this am.

psychosocial:  emotional support given to pt.  no visitors/[**name2 (ni) **] contact thus far this shift.
"
2441,"7a-7p
neuro: pt a+ox3, mae, perrla. oxycontin 10mg for chronic back pain, percocet prn for breakthrough pain.

cv: hr 50-60s sr/sb w/ occasional pvcs. sbp >120-140s.+palpable pulses. picc line in place and intact. 2 units of prbcs given this am w/o adverse reactions. lopressor dose held secondary to bradycardia as parameters are written.

resp: ls rhonchi to clear. sats > 97% on ra. rr wnl. oob to chair.
no c/o respiratory distress.

gi/gu: abd soft, no bm, +bs, +flatus. foley placed as ordered secondary to surgical recommendations to keep strict i+os. u/o as low as 10-30cc/hr after [**name6 (md) **] placed, md [**doctor last name 610**] aware, no new orders at present time.

endo: fs qid , requiring no coverage.

skin: see carevue.

plan: monitor hemodynamics. hct every 4 hours. monitor output. pain control. monitor respiratory status.
"
2442,"respiratory:  [**name (ni) 158**] pt on 7200 psv15/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x2 small amount of yellowish secretions. mdi's administered q 4 hrs of combivent with no adverse reactions.  sat's remain ^90's.  no further changes noted.
"
2443,"1900-0700
see carevue for assessment and vital signs.

neuro: a&o. perl. mae. following commands. sleepy due to analegesia but easily rousable.

cv: sr 70's. no ectopy noted. sbp 97-125. always >100 when awake.

resp: maintaining sats 94-100% on ra. encouraged to deep breathe. ls clear.

gu: foley draining adequate volumes of clear urine.

gi: good diet tolerated. ssi coverage. made npo from midnight for possible or today. lr @ 125mlsph.

skin: intact. pin sites to l leg clean.

pain: ketamine infusion continues @ 7.5mls/15mg/hr. no adverse reactions/effects noted. dilaudid pca (double strength) continues. 0.5mg/6min lock/5mghr tot. used less since ketamine infusion commenced. pt slept for long periods and pain reported to be better controlled. sharp intermittent l leg pain continues. 2am morphine sulphate sr 130mg held as pt resp rate 12-13, pt comfortable/sleeping and also npo.

id: t max 100.5. 650mg acetaminophen given with effect.

plan: remain npo for possible or for l leg orif.
      monitor neuro status while on ketamine/dilaudid.
      maintain traction to l leg.
      emotional/psychological support of pt.
"
2444,"resp: [**name (ni) 158**] pt on psv 18/+5/40%. [**last name (un) 3028**]#9 foam filled [**last name (un) **] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse and suctioned small to moderate amounts of thick yellow secretions. mdi's administered as ordered without adverse reactions. no abg's. will continue to monitor closely.
"
2445,"resp: [**name (ni) 158**] pt on a/c 12/450/5+/40%. pt has #9 [**last name (un) **] foam filled trach. bs reveal coarse sounds and suctioned for small amounts of thick white secretions. mdi's administered as ordered of combivent with no adverse reactions and some improvement noted. dr. [**last name (stitle) 1531**] not to drop peep below +5, so no rsbi performed. no abg's 02 sats @ 100%. will continue full vent support.
"
2446,"resp: [**name (ni) 158**] pt on a/c 35/500/+14/60%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. vt ^ to 550. am abg's 7.42/47/94/32. esophogeal balloon study to terminate today?. will continue full vent support.
"
2447,"ccu nursing progress note 7p-7a
s: ""that new medication is making me feel off"" (captopril)

o: please see careview for complete vs/additional objective data.

ms: received pt [**name (ni) 465**]3. clearly more frustrated and aggitated than prior night. pt stating he felt figgity since receiving new med (captopril). at 2200 pt c/o body ache. given 1 tablet percocet and 0.5mg iv ativan for figgitiness. pt asleep until 0230 when iabp alarm was heard and pt was found oob attempting to put on pants. pt had managed to do this even though all side rails were up. none of his invasive lines or ivs were disconnected. pt was disoriented at that time but clearing up by morning.

cv: vss. pt remains on 1:1 iabp support w/good augmentation. as mentioned above pt found oob w/ iabp still intact. augmented wave slightly more rounded but otherwise no s/s of vessel rupture or dislodgement. cxr obtained and no change in positioning noted. pt remains off all pressors and tolerating lopressor 25mg and increased dose of 25mg captopril. hr 68-85. nsr. rare-occ pvc noted. bp 85-97/49-67 via abp. maps 70-80s. pap 40-50/20-29. cath lab swan remains in right groin. no wedge attempted. co/ci following increased captopril dose to 25mg (12.5 mg) 8.9/3.98 w/ mv 73. repeat this am 5.0/2.43 w/ mv 70. pt cont on heparin at 500u/hr while iabp remains in. palpable pulses. warm extremeties. following diuresis last pm k+ 3.3 and ionized ca 1.0. repleted w/ 40 meq kcl and 4 mg cagluc. repeat this am k+ 4.9/ mg 1.21.

resp: ls cta. pt denies sob/difficulty breathing. pt tolerating lying flat. rr 16-20. o2 sats 94-100%. reapplied 4l supplemental o2 via nc for desaturation to 94% while asleep.

gi/gu: abd soft. +bs. no n/v. tolerated dinner per prior report. no stool. f/c to gravity. diuretics given prior to shift change. pt responded w/ approx 700cc over 2hrs. uo 90-120cc q 1-2 hrs [**name (ni) **]. -50cc for past 24hrs. pt remains -4l los.

id: afebrile. no abx.

skin: intact.

social: no calls or visitors [**name (ni) **].

a/p: presented to osh ^doe/ pnd w/ chest discomfort. transferred to [**hospital1 41**] for cath which revealed 3vd. iabp placed for support until surgery w/ or without mvr. pt refused surgery/ pci. weaned iabp but ci depressed. started on bb/ace-i and resumed 1:1 w/ heparin gtt. co/ci improved following ace-i dose. wean iabp today and cont to titrate bb/ace doses. cont to diurese as indicated. follow electrolytes and cont repletion as needed. ? adverse reaction to captopril. pt stating he doesn't feel right since initiation of med. ? change to lisinopril. cont to advance diet and activity as tolerated. medically manage and discharge home. discuss 3vd/ possible readmission given ds process and code status w/pt. cont to support pt and family as indicated.
"
2448,"resp: [**name (ni) 158**] pt on a/c 22/600/+10/50%. #7 [**last name (un) 3028**] trach. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds. suctioned for moderate amounts of thick tan secretions. mdi's administered q 4 alb/atr with no adverse reactions. nebulized tobra in line (filter used/removed) and tolerated well. rsbi=^ peep. abg's pending. will continue full vent support.
"
2449,"resp: [**name (ni) 158**] pt on psv 10/10/40%. bs auscultated reveal bilateral clear with diminished bases. suctioned for small to moderate amounts of bloody tinged secretions. mdi's administered q4 hrs alb with no adverse reactions. pt complains of ^ wob, and placed on a/c 18/360/+5/40. am abg's 7.48/32/151/25. will continue to wean appropriately.
"
2450,"nursing progress note for 7p-7a:
neuro: pt is a&ox3, mae, follows commands.
pain: epidural gtt in infusing at 2ml/hr with good pain control and no adverse reactions noted.(changed dose, see [**month (only) **])
cv: hr is nsr 60-70's, rare pac noted. sbp 90-100's with maps 55-65.
skin is warm and dry, color pink, ppp. pt asymtomatic. remains on neo gtt at .4-.6 mcg/kg/min. bp does drop when attempts made to decrease neo gtt. lr at 10 ml per hour, cvp at 5. no fluid [**name8 (md) 52**] md's.
resp: pt's sats dropped to 88% while on 4l/nc, changed to 50% face mask with sats now 92-96%. wean non-productive cough. uses is with encouragement. 2 rt pleural [**last name (un) **] ct's to 20 cm sx. low amt of drainage. small airleak, no crepitus. md aware. dressing cdi.
gu/gi: npo, bs absent.  foley to bsd with adequate hourly o/u.

s/p thoracotomy with wedge resection, bx, lobectomy, esophageal mass removal and repair to trachea.  plan to keep pt dry to prevent re-intubation and attempt to wean neo gtt to off. encourage is.
"
2451,"resp: [**name (ni) 158**] pt on a/c 14/600/10+/40%. ett 38, 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. no rsbi due to ^ peep am abg 7.40/48/165/31. vent changed to decrease peep to 5. no further changes noted. plan to wean as tolerated.
"
2452,"resp: [**name (ni) 158**] pt on 7200 psv5/+5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilat coarse/rhonchi that clear after sux.  suctioned x3 small-moderate amount of thick yellowish/green secretions.  mdi's administered q4 hr alb/atr with no adverse reactions.  rsbi performed = 78.1 and sbt initiated.  rr 25, 02 sats remain 96-98% with no disress.  no further changes noted.
"
2453,"resp:  [**name (ni) 158**] pt on 7200 psv 5/5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds in apecies with diminished bases.  suctioned x3 small amounts of thick whitish/yellow secretions which tend to pool in the oral cavity.  mdi's administered [**3-4**] p albuterol with no adverse reactions.  no further changes noted.
"
2454,"resp: [**name (ni) 158**] pt on psv 15/+8/30%. pt has [**last name (un) **] (airfilled) trach secured 12 @ flange. bs are coarse bilaterally. suctioned for small amounts of yellow secretions. mdi's administered as ordered combivent with no adverse reactions. am abg 7.41/35/108/23. rsbi=71. no changes noc. plan to continue to wean as tolerated.
"
2455,"resp:  [**name (ni) **] pt on 7200 psv10/50%/+7.5.  ambu/syringe @ hob.  auscultated bs reveal bilat coarse, no wheeze noted.  suctioned small amount of thick yellow/whitish secretions.  mdi's administered in line alb/atr q4hrs.  pt sats remain 98-99% with no adverse reactions or distress noted.  ps ^ to 12 but all previous vent settings remain the same.  no further changes noted.
"
2456,"resp:  [**name (ni) **] pt on 7200 psv 5/+5/50%.  ambu/syringe @ hob.  bs ascultated reveal bilateral rhonchi which clear with suctioning.  suctioned x3 small amount of whitish/yellowish thick secretions. mdi's administered q4 hr alb with no adverse reactions.  no further changes noted.
"
2457,"resp: [**name (ni) 158**] pt on psv 15/8/30%. pt has #8 [**last name (un) 3028**] (air filled cuff) [**11-12**] @ flange. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions,x1 for plug. mdi's administered combivent as ordered with no adverse reactions. am abg 7.34/42/86/24. rsbi =82. plan to wean as tolerated.
"
2458,"resp:  [**name (ni) 158**] pt on psv 12/8+/30%. pt has #8 [**last name (un) 3028**] (air filled) trach 12.5 @ flange. bs are coarse bilaerally with diminished bases. mdi's administered combivent as ordered with no adverse reactions. suctioned for small to moderate amounts of thick yellow secretions. no changes noc. am abg 7.35/42/1204/24. rsbi=98.  plan to continue with t/c trials as tolerated. discussions on possible dialysis and plan for rehab.
"
2459,"12a-7a
pt is a 66 year old male readmitted from sinia w/ increased sob,
fever. s/p cabg x3 on [**2174-9-29**], wound dehiscence, trach on [**2174-11-4**]. vent dependent. wbc on readmit 42.

neuro: pt a+ox3, forgetful at times. mae. perrla. morphine 2mg iv prn.

cv: hr 90-110s st w/ rare pvcs. increased hr w/ aggitation. sbp 150, nitro gtt started keeping sbp 110-130 map >60. 1 unit of prbcs given for hct 26, no adverse reactions. + palpable pulses. left a line placed at bedside by dr. [**first name (stitle) **]. +csm. double port picc to left ac, flushing well.afebrile 96.4-98.0.

resp: ls coarse, diminished at bases. trach [**first name (stitle) 657**], fio2 50% on cmv mode rate 20 tv 600 peep 5. abgs drawn on admission, md [**doctor last name 2641**] aware. sats 99-100%. suctioning small thick yellow via trach.

gi/gu: abd soft slightly distended +bs. ngt patent and [**doctor last name 657**] from rehab. pt states foley was placed today. foley draining adequate amts of yellow urine. urine cx sent in er.

[**doctor last name **]: sternal wound open w/ wound vac dsg [**doctor last name 657**], last change on [**12-23**]. see carevue.

plan: monitor hemodynamics. pulmonary toilet. ? ct today. pending cultures. ? id consult.continue triple antibiotics.
"
2460,"resp:  [**name (ni) 158**] pt ond simv 18/750/5/5/50%.  alarms on and functioning. ambu/syringe @ hob. during positioning of pt, ett tube dislogged from trachea, stat anesthesia called to re-intubate.  size 8 ett taped and secured  24@lip. bs auscultated reveal bilateral clear with diminished bases. mdi's administered q4 alb with no adverse reactions. vent changes reflect abg's.  am abg's 7.47/33/130/26. rr decreased to 16 and fio2 to 40%. additional abg to follow. continue to wean appropiately.  no further changes noted.
"
2461,"nursing update
   temp max 100.2.  map maintained >65, neo gtts weaned to off by 0300.  drained lg amount of dark red blood clots via ngt, irrigated q1h with n/saline 50cc.  hct @ 2300 - 26.6.  transfused with 2units prbc's, vs remained stable with no signs of adverse reaction.
   huo remains marginal, receiving ivf ns@ 300cc/h.
   insulin gtts restarted due to bs 161-163, and titrated to keep blood glucose < 150 as ordered.
   remains sedation and comfort status maintained by mso4 and ativan gtts.

plan: transfuse with ffp 2u and platelets 2packs @ 0600. pt will be returning to or @ approx 0730.
"
2462,"addendum
   approx 1.5h after weaning off neo gtts, pt spiked temp 101.1, sbp up 170, pas up to  69, tachy 110-116, desaturated to 88%.  seen by dr [**last name (stitle) 619**], neo restarted @0.38 mcg/kg/min for bp support with decreased pt compensation.....effective, resolved almost immediately, bp, hr and pap returned to baseline.  cxr done....ho reported no significant change.  abg returned to baseline. urine, cvl blood, jp fluid sent for cx.  2u ffp, and 2pks platelets transfused without adverse reaction.
"
2463,"7a-7a
neuro: pt a+ox3, mae, perrla. oxycontin 10mg scheduled [**hospital1 10**] for pain, and percocet for breakthrough pain for hx of chronic back pain.

cv: s/p mi w/ stent placement in [**month (only) **], hr 50-60s sb/sr w/ pvcs (lytes sent). sbp 130-150. ? endocarditis prior to this admission, picc in place and intact ( at home on continuous pcn gtt), given pcn q4 hours as ordered. received 2 units of prbcs this am, making total of 5 units thus far during this stay. 2 units of ffp given this shift also 1 unit of platelets. no adverse reactions.

resp: ls w/ faint rhonchi. non productive cough. sats greater than 95% on ra. denies sob. no resp. distress noted.

gi/gu: abd soft, +bs. 3 total bms during this 12 hours approx. 300-450cc each time of frank red w/ clots. gi study done w/ positive [**name8 (md) 8**], md [**doctor last name 610**] aware and gi team aware. at present plan to continue to monitor.  pt voiding, hard to assess color secondary to stool.

plan: continue to monitor hemodynamics. monitor resp. status. monitor labs. to get 2 more units of prbcs tonight. monitor gi status.

"
2464,"resp: [**name (ni) 158**] pt on psv 5/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for copious amounts of thin white secretions which then became bloody by early am. mdi's administed as ordered alb/atr with no adverse reactions. pt had ^ rr with decrease in sats and placed on psv 12/8/50%. vt 500-600, rr 19 and improvement noted. md notified and order placed. rsbi=84. plan to continue with wean and t/c trials as tolerated. no abg's this shift.
"
2465,"resp: [**name (ni) 158**] pt on psv 8/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small amounts of bloody tinged secretions due to trach insertion. mdi's administered as ordered alb/atr with no adverse reactions. abg 7.45/31/76/22. rsbi=73. [**name (ni) **] changes to decrease ps to 5. will continue to wean for trach collar trials.
"
2466,"resp: pt remains on psv 12/5/50%. vt's 600, ve's 8-9l, rr 14, 02 sats 100%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr without adverse reactions. am abg's 7.42/47/168/32. rsbi=44. will continue to wean appropriately.
"
2467,"resp: [**name (ni) 158**] pt on a/c 12/550/5+/40%. ett#8 24@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered alb/atr as ordered with no adverse reactions. rsbi=81. pt placed on psv 10/5/40%. vt's 450's, ve 8, rr 16. am abg 7.51/50/183/41. ps decreased to 5 with additional abg. plan to wean to as tolerated to possible extubation this am.
"
2468,"resp: pt rec'd on psv 20/10/50%. pt has #7 [**last name (un) **] water filled trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. am abg 7.44/57/112/40%. no further changes noted.
"
2469,"resp: [**name (ni) 257**] pt on psv 5/5/35%. ett #7, retaped and secured @ 20 lip. bs reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg's (see carview) 7.52/27/106/23. rsbi=34.
"
2470,"resp:  pt remains on t/c with cuff deflated noc. minimal secretions. 02 sats in ^ 90's.  mdi's administered via t/c alb with no adverse reactions.  plan to get pt up to chair, and possible ambulate if tolerates.  pmv during the day.
"
2471,"resp:  pt remains on t/c noc tolerating well. mdi's administered via t/c with no adverse reactions.  02 sats in ^ 90's noc with minimal secretions. plan to ambulate today if tolerated. pmv during the day.
"
2472,"npn 7a-7p
see carevue for specifics:

neuro status unchanged, quadraplegia, speaks both spanish & english attempts to mouth words, diff to understand, appears to nod approp to questions. denies pain. tmax 99.4, hr low 100s-120s, sbp 90s-140s, hct continued to drop 22.9, inr 1.7, 2 units ffp & 2 units prbc given without adverse reaction. to ir for ivc filter placement via r groin, tol procedure well. (+)fem & pps, site c/d/i. no vent changes, trached on ac 600x15, fio2 50%, peep 5, continues with mod amts of oral secretions needing freq mouth suctioning and oral care. ls coarse & diminished at bases spo2 99-100%. abd soft, nt/nd (+)bsx4, no bm this shift, tfs held for procedure, gt flushed without diff. foley with adequate u/o, bs qid with sc coverage. a/p stable,  continue with serial hcts if continue to trend down gi to repeat scope in am, monitor r groin/pulses may remove dsg in 24hrs per ir, pulmonary toileting with freq mouth care, ? restart tfs this evening vs am in case of need for repeat scope. provide emotional support.
"
2473,"resp: [**name (ni) 257**] pt on a/c 14/600/50/+5. pt has #8 portex trach. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions, as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes or abgs this shift. rsbi= no resps. will continue full vent support.
"
2474,"7a-7p
neuro: a+ox2. mae. perrla. follows commands.

cv: hr 60-70s sr. converted to afib 100-110s at 1500 for approx. 15min, then converted back to nsr. sbp 100-130. weakly palpable dp/pt. 2+ generalized edema. aline positional, unable to draw blood from line, team aware. 1 unit of prbcs given, no adverse reactions noted.

resp: portex #7 trach site oozing w/blood. trach care done. trial on trach collar done, tolerated for 30 min., placed back on ventilator cpap. see carevue for details. ls clear. sats above 95%. suctioned for thick blood tinged secretions via trach. yellow thick secretions via [** **]. left sided pleural  effusion by xray, lasix ordered.
tolerated oob to chair x3hours.

gi/gu: abd soft, hypoactive bs. tf restarted at 20cc/hr. minimal residuals. bm x1 formed brown stool. foley draining adequate clear yellow urine.

skin: rash noted on back.team aware. cont. vanco.

plan: pulmonary toilet. rehab screening. diurese.
"
2475,"resp: [**name (ni) 257**] pt on a/c 12/360/10+/40%. #7 [**last name (un) 4254**] (water filled) trach. ambu/syringe @ hob. alarms on and functioning. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered, alb/atr/[**last name (un) **] with no adverse reactions. no rsbi due to ^ [**last name (un) **]. no changes or [**last name (un) **]'s this shift. will continue full vent support.
"
2476,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 12/400/100%/+5.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with slight crackles over r base.  suctioned for small amounts of white secretions. mdi's administered q4 hrs combivent with no adverse reactions. cuff pressure @ 23 mmhz.  rsbi=>200. present vent settings;a/c 14/400/+5/30% with am abg's;7.44/49/89/34.  no further changes noted.
"
2477,"ccu nursing admission note  [**2081**]-0700
please see fhpa for complete history and sequence of events.  briefly, pt is a 77 yo male transferred from va to [**hospital1 2**] intubated and hypotensive after receiving diltiazem and lopressor for af with rate of 130's. in [**hospital1 2**] ew received 5 l ns and started on a levo gtt.

s:  shakes head ""no"" when asked if in pain.

o:  see ccu flow sheet for complete objective data

cv:  pt admitted in nsr, rate of 60's, pr 0.21.  hr slowly came up over course of shift to 70's-80's.  had 37 beat run of vt, broke without treatment, in the setting of a low k+.  k 3.1--> was receiving k replacement therapy at time of vt.  hands of defib in place.  received a total of 20meq iv k and 60 meq po k.  repeat k pnd.  also had ~ 1minute run of narrow complex regular psvt.  strips of both runs in chart.  bp 83-112/65-73, map 69-86, sbp transiently down to 70's.  arrived from the ew on levophed, weaned down from 0.25 mcg/kg/min to off @ 0200.  also given 1 l ns over one hour, but sbp had increased to 90-100 prior to receiving fluid.  bp equal in both arms, nibp comparable to cuff pressure.  heparin gtt started @ 1650 units/hour without bolus.  ptt pnd.

resp:  intubated on 100%/600/ 14 cmv, on 5peep.  attmepted ps trial shortly after admission, but periods of apnea, therefore placed back on a rate abg on 80% fio2 and above settings, breathing a few breaths over vent:  7.40/27/205/17/-5.  fi o2 weaned down to 40%, maintaining sats 99-100%.  ets--> no sputum.  spontaneous breathing trial done, rr 35  with tv 400 cc's.  lungs clear.

id:  on admission, t 91.1 po, 90.8 ax, and rectal temp not registering on rectal probe.  bare hugger placed on pt, with gradual ^ in temp.  by midnight t 99.8 rectally, bare hugger removed. pt c/o feeling hot, removing [**doctor first name 706**].  blood cultures x2 sent, urine sent. wbc 8.2.

gu:  cudette foley catheter placed in ew.  only 2cc pink urine in urimeter on admission.  foley irrigated--no resistance to irrigation, no clots.  bladder scan done, no urine in bladder.  bladder scan repeated at midnight-->19cc in bladder.  urine output improved over course of shift, but still only 16 cc/hour, intern and resident aware. bun 25, cr 1.6.

gi:  ng tube out of position on arrival to ccu.  re-inserted, placement confirmed by cxr.  ng asps light brown, ob +.  no stool.  abdomen soft, +bs

neuro:  pt arrived very sedated after versed in ew.  now opens eyes spontaneously, shakes head yes/no to questions.  mae.  inconsistantly follows commands.  pupils 3mm bilaterally, now briskly responsive to light.  on versed gtt at 1 mg/hour, and given 1mg iv bolus x3.  bilateral wrist restraints to protect inadvertant removal of ett.

skin:  no breaks.  feet dry bilaterally.  has old healed wound on left lower leg.

access:  left femoral tlc, r #20 piv, l #20 and #18 piv.

social:  md spoke with wife and updated her on pt's condition and poc.  do not know if pt. has a hcp.  [**name (ni) 25**] wife is reported to be a paraplegic.

a:  ? etio of hypotension--? adverse reaction to calcium channel bl
"
2478,"resp:  [**name (ni) 257**] pt on 7200 psv 15/15+/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small-moderate amounts of thick yellowish secretions.  mdi's administered q4 hr alb/atr (6 p  ea) with no adverse reactions.  rsbi=108.6 and no sbt initiated.  pt scheduled to receive trach today.  no further changes noted.
"
2479,"resp: [**name (ni) 257**] pt on a/c 12/360/10+/40%. pt has a #7 [**last name (un) 4254**] water filled trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/light greenish secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. no changes or [**last name (un) **]'s this shift. no rsbi due to ^ [**last name (un) **]. will continue full vent support.
"
2480,"resp: pt rec'd on a/c 12/360/+10/40%. pt has [**initials (namepattern4) **] [**last name (namepattern4) 4254**] #7 water filled trach. bs are coarse bilaterally. suctioned for small-moderate amounts of white/yellow secretions. mdi
"" administered as ordered  with no  adverse reactions. no [**last name (namepattern4) **]'s or changes noc. will continue full vent support.
"
2481,"resp: [**name (ni) 257**] pt on a/c 14/600/5+/50%. pt has #8 portex trach in place. alarms on and functioning. ambu/syringe @ hob. bs are coarse to diminished bilaterally. suctioned small amounts of white to yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi= no resps. no changes or abg's this shift. will continue full vent support.
"
2482,"resp: [**name (ni) 257**] pt psv 5/5/40%. bs are clear bilaterally. suctioned for scant - small amounts of tan secretions. mdi's administered q4 hrs with no adverse reactions. last abg 7.42/45/117/30. plan to place on t/c trials today as tolerated.
"
2483,"resp: [**name (ni) 257**] pt on ffv psv 10/5/60%, then placed on 60% f/t for about 3 hrs. hhn administered alb/atr with no adverse reactions. bs are coarse with occasional exp wheeze noted. pt placed back on ffv psv 10/5/50% due to ^ wob. pt tolerating mask, 02 sats @ 100%. will continue to wean to f/t as tolerated.
"
2484,"resp: [**name (ni) 158**] pt on pcv 40/25/55%/0+. pt has shiley #8 trach with audible leak noted. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes this shift. vt's 400's/ve's9. no rsbi pt is vent dependent. abg's (see careview) co2's still consistantly >100. will continue with present vent settings.
"
2485,"resp: [**name (ni) 158**] pt on pcv pinsp 44/32/55%/0+. pt has # 8 shiley trach with audible cuff leak. bs are diminished bilaterally. sucitoned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's or changes this shift. no [**name (ni) **] due to vent dependent. plan to continue full vent support.
"
2486,"resp: [**name (ni) 257**] pt on a/c 12/360/+10/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of yellow secretions. mdi's administerd q4hrs alb/atr with no adverse reactions. vent changes to ^ rr to 20, fio2 to 50%. am abg 7.46/55/87/40. no further change noted.
"
2487,"resp. care
pt. remains on mech. vent with a 8.0 portex trach secured and patent. pt being sx for copious amts of thick yellow secr. b/s are scat rhonchi t/o clearing with sxing. mdis given with min. effect but with no adverse reaction.pt. was given hyoscyamine todry up his oral secr. and had a great effect in the amt of oral secr. he was producing.abgs were 7.47/36/149/27/3 with a rsbi of 160 at 0430.
"
2488,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 22/550/50%/+5. alarms on and functioning. ambu/syringe @ hob. ett #8.0, retaped and secured @ 26 lip. bs are coarse with diminised lll. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 alb/atr with no adverse reactions. abg's (see careview) which vent changes refect. am abg's 7.42/32/89/21 on ^ peep to 10.  will continue full vent support.
"
2489,"resp: [**name (ni) 158**] pt on psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob. ett retaped and secured @ 25 lip. vt's 600's/ rr 15. bs auscultated reveal bilateral clear apecies with some coarse sounds. suctoned for moderate amounts of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions. some periods of decreased rr with drop in ve, suggested mmv during noc. plan to trach today @ 11 am. will continue vent support.
"
2490,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] 14/600/5/5+.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with coarse bases.  suctioned for moderate amounts of yellow secretions.  mdi's administered q4 hrs alb/atr 4 p with no adverse reactions. am abg's 7.42/36/110/24.
"
2491,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/500/10+/40%. alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions.  mdi's administered q4 hrs atr and [**last name (un) **] [**hospital1 10**] with no adverse reactions.  no rsbi due to ^ peep. am abg's pending.
"
2492,"resp:  [**name (ni) 158**] pt on (mmv) psv 10/7/40%. alarms on and functioning. ambu/syringe @ hob. 8.0 ett, taped and secured @ 25 lip. 23 cmh20 cp. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions. vt's 400-500's. plan to trach today. no abg's or changes noc. will continue support.
"
2493,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/600/50%/5+.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned moderate amounts of thick yellow secretions.  mdi's administered q4hrs alb/atr with no adverse reactions. no spont resp for rsbi. am abg's 7.38/36/140/22.  no further changes noted.

"
2494,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 18/600/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate to copious amounts of secretions tannish/white thick, as well as oral secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi-180. scheduled for trip to o/r today for additional wound graft.  no further changes noted.
"
2495,"resp: [**name (ni) 158**] pt on simv 10/600/15/+5/40%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20, ett @ 23 lip. bs auscultated reveal bilateral coarse sounds. suctioned for small amount of thick yellow secretions. mdi's administered q4hrs combivent/[**last name (un) **] [**hospital1 10**] with no adverse reactions. am abg's 7.44/37/116/26. no changes noc. 02 sats @ 97%. plan to continue full vent suppport.
"
2496,"resp: [**name (ni) 158**] pt n a/c 16/500/5+/50%. bs are clear with diminished bases. suctioned for scant amount of white secretions. [**name (ni) **]'s administered as ordered combivent with no adverse reactions. 02 sats @ 100%, fio2 titrated to 40%. no a-line. rsbi=63. plan to wean as tolerated.
"
2497,"resp: [**name (ni) 158**] pt on 40% t/c cool mist.  ambu/syringe/spare trach @ hob. bs auscultated reveal coarse bilateral sounds which clear after suctioning.  trach care performed x3, pt tends to plug up inner cannula.  sux x 3 for small to moderate thick bloody plugs/secretions.  mdi's administered q 4hrs alb/atr (4p) via air chamber through trach and pt tolerates well with no adverse reactions.  02 sats remain 99-100% with no distress.  no further changes noted. cuff remains deflated.
"
2498,"nursing care note
see careview for specifics.

neuro: propofol weaned to 50mcg/kg/min. pt arousable. oriented. follows commands. writing for communication. perl. strength in all four extremeties improving. lue remains weak. unable to lift and hold. unable to move neck, requiring repositioning of head.

resp: remains on cmv mode of ventilation. 40% 18x400, peep5. attempted a short trial of cpap +15ps. abg acceptable, obtained adequate tv's, but fatigued after 2 hours. suctioning for small amounts of thick yellow material. suctioned frequently for moderate amounts of oral secretions. lungs ctab.

cv: afebrile. vss.  rec'd ivig with no adverse reaction.

gi: abdomen soft with present bs. no bm this shift. ogt to lcws putting out moderate bilious material.

gu: autodiuresing.

labs: all noon lab results reported to dr [**last name (stitle) **].

plan: most iv meds changed to po as access is an issue. pt has 2 piv. provide support to pt & family. monitor neuro status. ? social work involvement.



"
2499,"resp:  [**name (ni) 158**] pt on 7200 a/c 24/450/50%/+5.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse/rhonchi which clear with suctioning.  pt suctioned x3/4 for copious thick tan secretions/plugs.  [**name (ni) **]'s administered q4 alb/atr with no adverse reactions.  abg's drawn throughout the noc with improvement noted.  sputum sample obtained.  vent changes noted, rr @18 with abg's pending.  no further changes noted.  pt resting comfortably.
"
2500,"7a-7p
neuro: pt alert and oriented x1, to self.anxious at times. reassured and reoriented many times during shift. pupils 7mm, left sluggish compared to right. np [**doctor last name 599**] in at [**doctor last name 302**] and assessed no new orders. pt moves all extremeties on command. percocet via gtube for pain this am w/ good effect.

cv: hr 80-100s. sr/st, w/ rare missed beat. sbp>90. see carevue for details. +weak palpable [**doctor last name **] pulses. agratroban infusing at 2.25mcg as per protocol, ptt 60s within range, no change as per protocol. 1 unit of prbcs infused w/o adverse reaction. generalized edema.

resp: ls coarse w/ insp. wheeze, nebs given as ordered. sats 99-100%. 4lnc. weak npc. rr 20-30s.

gi/gu: abd soft, round, +bs. no bm. tolerating tf promote w/fiber at goal of 60cc/hr. foley draining yellow urine. see carevue for hourly outputs. on lasix 80mg ivp tid, received extra dose of lasix 80mg this am approx. 5am.

activity: oob to chair x 2 hours via [**doctor last name **].

skin: dry scaly skin: creams applied as ordered. sternum dsg changed by thoracic team this am. see carevue for further details.

endo: as per own scale.

plan: monitor hemodynamics. monitor resp. status. oob to chair. monitor labs and treat as appropriate.
"
2501,"resp: [**name (ni) 158**] pt on a/c 14/550/5+/40%. ett #7, retaped and secured @ 23 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally and suctioned for small amount of white thin secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbt=71. attempted to place on psv although pt still sleepy. will wean in am to psv as tolerated to extubate today.
"
2502,"resp: [**name (ni) 158**] pt on psv 16/8/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/white thick secretions, as well as oral cavity. mdi's administered alb q4 with no adverse reactions. vt's 500-600, ve's 13-15, rr 24-27 with 02 sats @ 100%. no aline or abg's this shift. no changes noted.
"
2503,"resp: [**name (ni) 158**] pt on psv 16/8/50%. pt is trached #9 extra long portex. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white/clear secretions. mdi's administered q4 hrs alb with no adverse reactions. vt 500-600, ve [**11-4**], rr 18-25. rsbi=100. no abgs (no aline).
"
2504,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 24/450/+5/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. ett rotated re-taped and secured. suctioned small to moderate amounts of tannish secretions. mdi's administered q4 alb with no adverse reactions.  rsbi=110, ^ hr to 107/rr an exihibted atrial fib rsbi terminated.  am abg's 7.29/43/98/22.  no further changes noted.
"
2505,"micu npn

see carevue for subjective/objective data.  neuro:  initially sedated with propofol/morphine while intubated.  propofol off at 1140--pt moving in bed, semi-awake prior to shutting propofol off.  pt awake within 10min of propofol off, able to hold head off pillow, nodding ""yes"" and ""no"" appropiately, mouthing words around ett.  mae ad lib before and after extubated.  once extubated pt speaking clearly, continues to mae ad lib.  a+ox3.

cv/pulm:  vss per carevue.  hct 23 down from 25 this am--two units prbc ordered.  first unit infused without adverse reactions, second unit currently infusing without adverse reactions thus far.  serial hcts q4h.  k=3.4, currently being repleted with 20meq over 2hrs x2 for total of 40meq over 4hrs--(pt has only periph access).  iv d5lr with 20meq kcl at 125/hr except during prbc's then kvo'd.  afebrile.
pt intubated this am then rapidly weaned and extubated once propofol off.  placed on cmm at .40%; sats 100%.  pt continuously removing mask with sats remaining 99-100% even with o2 off.  pt agrees to keep mask near mouth and nose but not tight until this afternoon and has complied--currently on room air with sat 100%.  no sob or doe noted.  bs clear upper lobes, coarse lower lobes in am, clear bil this pm.  pt moving ad lib in bed (restless) and coughing without encouragement--thick/clear secretions, occ blood tinged.

gi/gu:  ngt removed this am when ett removed.  abd firm but not tense, sl tender, bs absent.  abd dsg d+i.  no flatus but pt does burp frequently.  u/o qs q1h via foley.  vaginal bleeding slowed this shift-->one pad q4h.  s/b ob/gyn this am and this [**name8 (md) 8972**] md spoke  with pt re: events of past 24hrs.  pt states comprehension of events.

integ:  intact.

id:  afebrile.  no change in abx.

psychosocial:  pt crying much of afternoon, restless, states ""i need to get my butt comfortable"".  pt stated concerns re: children at home. offered to call pts home but pt refused, stating she does not want to ""talk to anybody or see anybody"".  brother (? name) and son [**name (ni) 8973**] in to see pt--pt crying, moaning.  much emotional support given to pt and fam.  visitors left, attempted to assist pt with comfort and emotional needs.  med with ativan 1mg iv with little-->no effect.  remains on morphine at 1mg/hr cont.  will cont to provide emotional support and comfort measures.
"
2506,"resp: [**name (ni) 158**] pt on a/c 14/550/+5/40%. ett #7, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. suctioned for scant amounts of tanish/white secretions. mdi's initiated and administered alb/atr as ordered with no adverse reactions. rsbi=85. plan to wean to psv, then extubate this am.
"
2507,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett 7.5, taped @ 22 lip. bs are coarse to clear bilaterally and suctioned for moderate amounts of thick yellow to white secretions. mdi'd administered of alb as ordered with no adverse reactions. pt remains on sedation, when lightened is extremely aggitated. rsbi=36 no abg's/no a-line. vt's 400-500, 02 sats @ 99%. plan: wean to extubate today?
"
2508,"resp: pt rec'd on 14/600/+5/40%. bs are clear with occasional wheeze noted on ls. suctioned for small amount tan thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. ett #7.5. 25 lip. 02 sats @ 100%. am abg 7.37/46/108/28. rsbi=53. plan to possible psv today if tolerated.
"
2509,"resp: [**name (ni) 158**] pt on psv 8/5/40%. ett #7.5, taped @ 22 lip. bs are coarse bilaterally and suctioning for copious amounts of thick white/yellow secretions.circuit changed to heated wire circuit. mdi's administered atr with no adverse reactions. no changes noc or abg's. rsbi=42. plan: wean as tolerated.
"
2510,"resp: pt rec'd on a/c 14/450/+8/40%. ett#7.5/23 lip. bs auscultated reveal notable improvement w/o wheeze, with clear apecies bilaterally. suctioned for small amount of thick secretions. sputum sample sent. mdi's administered q4 alb/atr with no adverse reactions. no abg's (no a-line). rsbi=200. no changes this shift
"
2511,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] simv 20/500/ps15/+10/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with i/wheeze noted. suctioned for moderate amounts of thick yellow/tannish secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. 02 sats @ 96% with no further changes noted.
"
2512,"resp: [**name (ni) 158**] pt on psv 12/5/40%. ett retaped and secured.bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=79. md [**first name (titles) 7856**] [**last name (titles) 2377**]. place pt on psv 5/0 for 30-45 min and pt ^ wob,^ sob with 02 desaturations to 80's. abg 7.18/78/96/31. [**last name (titles) 2377**] terminated.(see carview for multiple vent changes)pt place on 100% temporarily, then decreased to 50%. bs reveal bilateral crackles and suctioning copious amounts of thick white frothy secretions. lasix given with good effect. present settings. 18/500/+10/50%. additional abg's to follow.
"
2513,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 14/500/5/+5/40%. alarms on and functioning.  ambu/syrnge @ hob.  cuff pressure @ 21.  pt trached and peg today.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 small to moderate amounts of thick bloody tinged secretions.  mdi's administered q4 hrs alb with no adverse reactions.  02 sats @ 100%. no further changes noted.
"
2514,"7a-7p
neuro: pt sedated on [** **], as low as 10mcg/kg/min, following commands increased for ir procedure as high as 80mcg for comfort at present at 20mcg to keep pt comfortable. perrla. mae. nods no if asked in pain.

cv: hr 80s. sbp labile. 90-110s. keep map>60. received total thus far 4 units of [** 458**], 1 unit of plt, 2 units of prbcs, no adverse reactions. afebrile. ordered for cryoprecipiate and more plt, to be given. see carevue. cvp 12-20[**street address(1) 7840**] aware of cvp. to ir w/ monitor and rn see ir notes for vs, angio site cdi, w/ pressure dsg+ saline bag over site. palpable pedal pulses. no aline put in from micu team secondary to bleeding issues. to lie flat until 9pm.

resp: no aline. venous gases [**street address(1) 7841**] aware of all labs including 7.55 ph repeat when back from ir 7.48 on cpap 50%, 5peep/15ps. ls clear diminished at bases. sats >98%.

gi/gu: abd soft, but distended absent bs. ogt + placement, receiving lactulose as ordered. ogt draining brownish in color. mushroom cath in place ok [**name8 (md) 52**] md [**doctor last name 1055**] for blackish brown liquid stool. foley draining iteric urine minimal amts 10-15cc/hr md [**name6 (md) 1055**] [**street address(1) 7842**] aware.

labs: see carevue for details. k repleted w/ 60meq iv kcl, 3 separate  20meq bags over an hour [**street address(1) 7843**] updated w/ labs and u/o and angio site when back from ir.

plan: monitor hemodynamics. monitor resp.status. improve coags so tomorrow ? stent placement to hepatic/bile duct, ir unable to find source of bleeding. monitor angio site and pulses


"
2515,"resp: [**name (ni) 158**] pt on psv 12/8/40% ett 7.5/25 lip.bs are coarse bilaterally. suctioned for moderate to copious amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no abg's or changes this shift. rsbi=80. plan to continue to wean as tolerated

"
2516,"resp: [**name (ni) 158**] pt on simv 10/500/15/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of frothy yellow/white secretions.  mdi's administered as ordered with no adverse reactions. pt is vent dependent. no changes noc. plan to be discharged today to rehab.
"
2517,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 143/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned for moderate amounts of thick secretions. changed out dry circuit for heated one.  mdi's administered q4 hrs combivent with no adverse reactions.  exutbation still planned for monday [**5-25**].  no further changes noted.
"
2518,"resp: [**name (ni) 158**] pt on psv 10/10/40%. bs are coarse bilaterally which improvement with suctioning. suctioned for small amounts of thick yellow secretions. mdi's administered q4 [**name (ni) 741**]/[**last name (un) **] [**hospital1 10**] with no adverse reactions. vent changes to ^ ps back to 15 due to ^ in rr. will continue to wean appropriately.
"
2519,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/5/40%. alarms on and functioning. ambu/syringe @hob. bs auscultated reveal bilateral clear apecies with some fine scattered rales, diminished bases bilaterally.  mdi's administered q4 hrs combivent, with no adverse reactions. suctioned/lavarged x3 for moderate amounts of thick white secretions.  x-ray indicates bilateral pleural effusions, questionable tapping. plan to extubate this am.  am abg's 7.45/39/85/28.  no further changes noted.
"
2520,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. eet #8 taped and secured @ 24 lip, cuff pressure @20. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick white, pale yellow secretions.  mdi's administered with no adverse reactions. am abg;s 7.43/33/126/23. vt' 900/ve20's. rsbi=22. pt reacts anxiously to any stimuli.  plan to continue to wean appropriately.
"
2521,"resp: pt rec'd on psv 10/10/50%. bs are coarse bilaterally which improve following suctioning. suctioned for copious thick bloody secretions with some clots. mdi's administered q4 combivent with no adverse reactions. am abg's 7.37/38/111/23 with no changes noc. rsbi=75. will continue on psv and wean appropriately.
"
2522,"resp: [**name (ni) 158**] pt on a/c 14/700/+10/70%. bs reveal bilateral crackles with slight wheezing noted. mdi's administered q4 combivent with no adverse reactions. suctioned for small amounts of bloody tinged secreitons (new trach). abg 7.36/40/161/24, fio2 decreased to 60%. am abg's 7.36/37/98/22. no further changes noted. will continue to wean appropriately.
"
2523,"ccu nursing progress note
s-""i feel ok""
o-neuro- alert and oriented x3, very pleasant and cooperative. understands and speaks english fairly well. alitttle sleepy after benadryl po.
cv-one episode of hypotension with sbp 84/40 after benadryl before asa densitization. ho aware and received ns 250cc bolus over 15 minutes.
vss hr 64-70 nsr, 104-135/50-61. received 10 ingremental doses of asa without signs of stridor, sob, rash, hypotension.
resp-ls coarse with occ esp wheeze, freq congested productive cough. sputum sent for c/s. sputum thick dark tan moderate amount.
id afebrile, mrsa precautions.
gu-voiding well in bed without difficulty.
gi-npo for possible heart cath.
skin- ruddy complexion but no rash noted.
activity-bedrest maintained during test.
access-rij tlc dressing changed and piv removed day 4.
dispo-transfer back to [**hospital ward name 3**] 3, health care proxy completed.
a/p-no adverse reaction s/p asa desensitization.
continue to assess and monitor for delayed adverse reaction

"
2524,"resp: [**name (ni) 158**] pt on a/c 14/450/+5/45%. bs are coarse bilaterally. [**name (ni) **] for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. pt expected to be d/c to rehab this am.
"
2525,"7p to 7a micu progress note

neuro - pt initially sedated with boluses of fentanyl and ativan immediately following intubation. placed on fentanyl drip which is currently infusing at 30mcgs/hr and propofol at 40mcgs/kg/min with greater sedative effect. pt opens eyes spont. localizes pain. mae.

resp - pt remains intubated with vent settings adjusted throughout the noc. see careview for details. currently on ac 600 x 10 with 50% fio2 and 5 peep with abg 7.36/39/140/-[**3-7**]. fio2 decreased to 40% - will draw repeat abg. lungs with inspir and expir wheezing, diminished lll. receiving albuterol nebs by resp therapist. sx initially for thick brownish plug ( specimen sent for c+s and gm stain). secretions eventually became more clear. ultrasound of left thoracic cavity showed small left pleural effusion which was too small to be tapped safely.

c-v - hr 88-111 st, no ectopy noted. bp 88-130/59-78 with map > 60 via aline. + peripheral pulses. pt with repeated needle sticks to right lateral neck and right groin for line placement. in lieu of elevated inr, pressure dssg applied to neck and iv sandbag placed on groin - no hematoma noted at either site.

gi - abd distended but soft, hypoactive bs. ngt placed, placment confirmed by x-ray. coffee-ground emesis noted on lavage, cleared with 200 ccs ns. ngt to lis currently draining bilious fluid. lactulose therapy initiated for ? hepatic encephelopathy. no stool at this time.
abd ct on [**1-8**] showed marked fatty infiltrates of the liver and sm amt of ascites as well as calcifications in the pancreas and colon wall thickening.

f/e - iv ns infusing at 250ccs/hr. pt with minimal u/o. voiding only 6-22ccs/hr via foley cath. given 3 1000 cc fluid boluses with no effect on u/o. md aware. urine lytes sent. initial k 3.0. given 40 meq kcl iv with repeat k of 3.2 at 0100. [**month/year (2) **] with an additional 40 meq kcl iv. ca 6.9. alb 2.1 phos 2.5 bun 4 creat .9. [**month/year (2) **] with 2 gms ca gluc iv.

heme - hct stable at 23.1 initially oozing from lip s/p intub. bleeding resolved.

id - temp sl hypothermic at 97 rectally. pna rx's with vanco q 12 hrs and flagyll q 8 hrs. ceftriaxone dcd. pt given 2 gms ceftaz iv x 1. awaiting id approval for subsequent doses. md aware of hx of allergy to kefzol, dose given without any overt adverse reaction.
pt on contact precautions for hx mrsa sputum.

skin - pt increasingly edematous around neck d/t lg amt of ivf administered throughout the day. already + 4 liters as of 0500 today.
skin intact except for dime-sized area on right buttocks - barrier cream applied.

endo - hx of adrenal insuff and diabetes. receiving hydrocortisone iv q8hrs. [**month/year (2) 770**].

access - r upper arm pic, multi-lumen r fem line, r radial aline.


social - numerous family and friends visited last eve. son slept overnight in the visitors lounge. updated on pt's condition by rn and md.



"
2526,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/460/+14/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with noted aeration in apecies. suctioned for small amount of tan thick secretions. mdi's administered q4 alb with no adverse reactions. fio2 decreased to 40%, with am abg's 7.28/58/115/28. no further changes noted.
"
2527,"[**2126-8-27**] admission note:

pt arrived from [**location **] at 645am. she reports a few days of having a cold and fever.  came to ed with increasing sob,wheezing,t=102.  in ed she received 4l iv fluid.  sbp=70's iv dopamine drip started at 2.5mcg/kg/min.  received tylenol after which temp =98.6po.  blood and urine cultures sent. cxr done.  received:  flagyl,levofloxacin,vanco-
mycin,benadryl,decadron, and neb treatments.

she arrived on 100%nrb with no sob or wheezing noted.  lung sounds coarse, sats=97%.  hr=84sr no ectopy.  sbp=128.  skin warm dry and intact.  +bowel sounds, abdomen soft nontender.  pulses palpable. alert and oriented but sleepy, follows commands and answers all questions appropriately.  pmh=asthma, copd, ms.[**first name (titles) **] [**last name (titles) **],g-tube placement.  allergies:  azmacort,clindamycin,clarithromycin,ceftri-
axone,optiray.   she also reports difficulty with versed,fentanyl and morphine but has received these at times with no adverse reaction also.  she lives at home with her husband, [**name (ni) 1717**] and expects to return home upon discharge.
"
2528,"resp: pt is on h/f02 @ 80% with 6 lpm n/c. bs are coarse bilaterally, pt able to expectorate some secretions. nebs administered q6 hrs atrovent ud with no adverse reactions. will continue to follow.
"
2529,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/280/+8/60%. alarms on and functioing. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of white secretions. mdi's administered x1 of alb with no adverse reactions. pt had episodes of desaturations to 70's and fio2 ^ temporarily to 100% then titrated down (see carview) to 50%. abg 7.47/49/127/37 with am abg pending. no further changes. will continue full vent support.
"
2530,"resp: [**name (ni) 158**] pt on a/c 16/280/+8/50%. alarms on and functioning. ambu/syringe @ hob. ett rotated and secured. bs are coarse bilaterally. suctioned for small to moderate amounts of white/pale yellow secretions. mdi's administered q4 alb with no adverse reactions. rsbi=no resps. plan to attempt rsbi to wean to psv.
"
2531,"resp:  [**name (ni) 158**] pt on 7200 simv 16/550/ps12/+5 40%.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned moderate to copious thick yellow secretons.  [**name (ni) **]'s administered q4 hr alb/atr with no adverse reactions.  no further changes noted
"
2532,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 14/600/10+/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminshed bases. suctioned for small amount of thick bloody tinged secretions.  mdi's administered q4 hrs combivent with no adverse reactions. rsbi=55. am abg's; 7.44/40/109/28 with no further changes noted.
"
2533,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c20/600/10+/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration noted in apecies with diminished bases. re-taped and secured ett. mdi's administered q4 hr alb with no adverse reactions. suctioned moderate amounts of tan secretions early in the [**last name (un) **] with pale yellow in am.  no vent changes [**last name (un) **]. am abg's 7.43/37/121/25.  no further changes noted.
"
2534,"resp: [**name (ni) 158**] pt on a/c 18/55/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and suctioned for small amounts of tan secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's or vent changes noc. pt is awaiting bed at rehab. will continue full vent support.
"
2535,"respiratory care
non-intubated bronchoscopy preformed on pt without apparent adverse reactions. 1% lidocaine used via atomizer followed by instilling 8cc of lidocaine at 2cc doses via bronchoscope. suctioned for moderate amounts of thick tan colored secreations. pt on 5 liters nasal cannula. sat's from 91%-94%.
"
2536,"resp: pt rec'd on psv 8/5/40%. pt has #8 portex trach. bs are coarse in upper lobes bilaterally and suctioned for small amounts of thick yellow secretions. mdi's as ordered alb/atr/[**last name (un) **] with no adverse reactions. abg 7.30/36/116/18 with rsbi=49. possible trach collar trials again today. vt400's ve 9l.
"
2537,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 18/550/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. notable leak at times, rn/md aware. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tan secretions. mdi's administed combivent with no adverse reactions.  no rsbi due to ^ peep or abg's no aline. 02sats to 96%. will attempt to wean as tolerated.
"
2538,"resp: pt rec'd on a/c 18/550/+8/60%. ett #7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tannish secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift. will continue full vent support.
"
2539,"resp: [**name (ni) 158**] pt on a/c 18/550/+8/60%. ett #7.5, retaped, rotated and secured @ 23 lip. 02 sats 97-99%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions, copious oral secretions. mdi's administered as ordered with no adverse reactions. no abg's or changes this shift. plan to trach. will continue full vent support.
"
2540,"micu npn
see carevue for subjective/objective data.  neuro:  started on cisatracurium at 1mcg/kg/min as continues to overbreathe vent.  morphine 0.5mg/hr added when paralytic initiated.  remains on ativan 2mg/hr.  pupils remain 6mm, non-reactive.  no movements noted prior to initiation of paralytic.

cv:  remains on levo and neo per carevue.  vasopressin added at 0.04units/min.  bp remains labile--low of 70's/30's with map 50's to high of 110/60's with map 70's.  hr initially low 100's but by 0815 hr 170's--remained 160-170's until swan dc'd then hr immediately decreased to 120's.  remainder of day hr 110's-120's.  mp=st; only ectopy noted during swan removal.  currently levo at 20mcg/min, neo at 10mcg/kg/hr, vasopressin at 0.04units/min.  bicarb gtt on throughout morning then dc'd then restarted.  calcium chloride given per [**month (only) 5**]; calcium gluconate gtt started.  k repleted with 20meq x3 for k of 3.1--rpt lytes this pm. maintenance iv 500-700ml/hr until 1800 then decreased to 10ml/hr.  tylenol for temp of 100 (core); cooling blanked placed on for temp of 101.1 (core).  temp decreased to 99.1, blanket off.  tmax remainder of day=99.7 po (no longer using core temps as swan dc'd).  rec'd 2units ffp and 6units platetes--both ffp and platelets given without adverse reactions.

pulm:  remains vented.  multiple vent changes throughout day; currently on ac28x750x80%x10peep.  bs coarse.  attempted to obtain sputum for c+s; no secretions despite lavaging.  scant oral secretions.  abg's per carevue.  on bicarb gtt as noted above.  ct to 20mm suction until 1500 then placed to water seal.  drained only 5ml straw colored fluid this shift.

gi/gu:  ogt-->lis drng scant amts coffee ground secretions.  remains on protonix.  nothing given per ogt.  bs absent.  no bm.  remains anuric.  quinton cath placed at 1845 as anticipating need for cvvh--no cvvh planned at this time.  bladder pressure done x1-->17.

integ:  extremities cool, mottled (on three pressors).  no open areas noted.  does have scleral edema, generalized edema.

id:  tmax=101.1 core.  tylenol and cooling blanket as noted above.  ceftazadime and vanco added to regime however vanco not started yet as waiting for vanco level.  rocephin dc'd.

psychosocial:  brother, sister and sister-in-law in to visit--updated by [**name (ni) 1302**] on current status/prognosis/plan (potential for cvvh).  emotional support given to pt and family.
"
2541,"micu nsg admit note
mr. [**known lastname **] is a 51yo male adm to micu as trans from cc6 s/p laminectomy from [**2176-9-26**].  pmh significant for etoh use, iv drug use, psych hx (on meds), copd, smoker, htn, (+) for hepatitis c, multiple old ortho injuries due to ""bar bralls"".  per family no etoh or drug use since [**month (only) 1279**] of this year; [**name6 (md) 52**] trans rn pt adamantly denies etoh or drug use since [**month (only) **] of this year.   pt had fusion of l5 and s1.  post op pt noted to be restless but no mental status changes.  friday he had increasing mental status changes, placed on ativan.  over w/e he cont'd on ativan.  mon am he was transferred to medicine.  mon am he also developed hypotension with o2 sats 80's; anesthesia paged to floor, pt intubated, sent to micu.

overview of day:  upon arrival pt intubated, hr elevated 150's->180's. lopressor 5mg iv with no effect given be dr. [**last name (stitle) 4952**].  bp low but map's greater than 60 until early afternoon when map dropped to 50's.  placed on neo, titrated for map of 60.  by mid afternoon levo added to maintain map.  multiple ns bolus' given, d5w given, ffp given, prbc's hung.  swan'd, cooling blanket on pt.  tmax=108.0 orally and rectally. ice under axilla, in groin and under head/around head.  minimal u/o.  hr remains elevated, temp remains elevated.

current status:  see carevue for subjective/objective data.  neuro:  pupils 5-6mm, non-reactive.  did note slight grimace in response to brother calling pts name.  no arm or leg movements noted.

cv/pulm:  vs remain labile with neo at 7mcg/kg/min and levo at 3.2mcg/min.  initial swan readings ra 15, rv 35/11, pa 37/14, wedge 5. have attempted to wedge post insertion-->unable.  pcxr post insertion no pneumo, line in good position [**name8 (md) 52**] md.  pa at 52cm.  remains vented on cpap+ps 20/5, 100%, tv600.  bs coarse bil.  suctioned initially for copious amts thick/tenacious tan sputum both orally and via ett.  now no secretions when suctioned.  prbc's #1and #2 currently infusing; no adverse reactions noted.  tmax=108 both orally and rectally.  axilla, groin, head and neck packed in ice with cooling blanket on.  current temp=107.1 core.

gi/gu:  ogt placed by md-->lg amts coffee ground material obtained.  lavaged till clear, intermittently lavaged.  on protonix.  u/o scant; md's aware.  urine concentrated.

iv access:  swan placed, r groin triple lumen catheter and 20guage periph iv.

id:  tmax=108 po and rectally.  on rocephin, vanco, flagyl and levo.  bcx2 sent, urine for c+s sent.  unable to obtain sputum for c+s.

psychosocial:  sister and brothers in to visit.  emotional support given to pt and fam.  fam updated by md--aware of grave prognisis.  pt is full code.
"
2542,"respiratory care note:
   patient presently on break from mask bipap via vision (see carevue flowsheet). she is s/p dialysis. bs=bilat, coarse. patient awake, alert, pleasant with no c/o sob though respirations appear shallow and rapid at 34-38bpm. placed now on a high flow neb at 80% unitl next round of bipap.
    nasal washing done arouond 2pm today with cultures sent via md. [**first name (titles) **] [**last name (titles) **] procedure well without adverse reaction.
"
2543,"resp: pt remains intubated on a/c 28/350/+5/40%. bs are slightly coarse with notable improvement from yesterday. suctioning small amounts of tan secretions. mdi's administered q4 alb with no adverse reactions. ve's 10l, 02 sats @ 99%. peep decreased from 10 to 5 this shift. rsbi attempted but no resps. am abg's 7.32/43/144/23. will continue full [** **] support.
"
2544,"resp: [**name (ni) 158**] pt on pcv pinsp 19/r18/+5/40%/dp 10. [**last name (un) 3028**] trach @8, 8 @ trach site. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amount of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. while performing trach care pt began to forceful cough and trach was disloged. re-inserted with 4cc sterile water for 30 cmh20 to seal, no cuff leak noted. x-ray reveals trach to be approx 2-3 cm above carina. md verified. vent changes to ^ pinsp to 22 with dp of 19. vt's 300-400. no further changes noted.
"
2545,"resp: [**name (ni) 158**] pt on a/c 20/500/10+/40%. ett 7.5, rotated, and secured @ 24 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow secretions. changed circuit to heated wire. mdi's administered as ordered with no adverse reactions. am abg 7.48/38/130/29. vent changes to decrease peep to 5 and rate to 16. rsbi attempted and bp ^ to 190 and terminated. plan: continue to wean as tolerated.
"
2546,"resp: pt presently on 5 lpm n/c maintaining 02 sats 94-96% and comfortable. nebs administered alb/atr with no adverse reactions. continue to monitor pt with bipap @ bedside when needed.
"
2547,"resp: [**name (ni) 158**] pt on ps 8/40%/0+.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. rsbi=47. pt presently on ps5/40%. 02 sats @97% rr 19. will continue to wean. possible t/c trial today.
"
2548,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] ac 18/600/13+/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases. mdi's administered q4 hrs combivent with no adverse reactions. suctioned small to moderated amounts of tannish thick secretions.  plan to lighten up on sedation and proceed to wean.  possible psv today? no rsbi performed due to level of peep. am abg's 7.47/33/118/25.
"
2549,"resp: [**name (ni) 158**] pt on pcv 18/12/dp 13/+5/40%. [**last name (un) 3028**] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white/yellow secretions. mdi's administered alb/atr with no adverse reactions. attempted psv although pt did not tolerated. no abg's rsbi=>200.
"
2550,"resp: [**name (ni) 158**] pt on a/c 22/550/10+/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amount of bloody secretions. mdi's administered q4 hrs alb with no adverse reactions. ett 7.5, 24 @ lip, 22 cp. pt had episode of desating, temporarily placed on 100%, then returned to 50%. [**name (ni) **] changes to decrease tv to 350 and ^ rr to 28. last abg 7.32/40/196/22. am abg pending. no further changes noted.
"
2551,"resp: pt intubated for impending respiratoy failure. bilaterally insp/exp wheezes with no improvement following nebs. ett #8 secured @ 22 lip. planced on a/c 18/500/+5/60%. mdi's administered alb/atr with no adverse reactions. abg 7.44/31/161/22. rsbi=54. wean rr to 14. plan maintain present settings.
"
2552,"resp: [**name (ni) 158**] pt on simv 6/400/15/5+/40%. ett 7.5 retaped, rotated and secured @ 23 lip.  bs are coarse with diminished bases. suctioned for small amounts of yellow/white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.45/37/123/27. rsbi=153. plan to continue to wean as tolerated.
"
2553,"resp: [**name (ni) 158**] pt on psv 10/5/40%.ett#8, 22 lip. bs are clear with diminished bases. suctioned for small amount of white secretions. mdi's administered q4 hrs combivent with no adverse reactions. abg's indicate uncompensated metabolic acidosis. am abg pending.
"
2554,"resp:  [**name (ni) 158**] pt on [**last name (un) **] a/c 12/450/10+/35%.  alarms on and functioning. ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x2 for small amount of  thick whitish/tan secretions. cuff pressure checked and noted positional leak.  mdi's administered q4 hrs of alb/atr with no adverse reactions. vent changes to psv 10/10/35% with 02 sats in ^ 90's. no rsbi performed ^ peep.  no further changes noted.
"
2555,"resp: pt rec'd on psv 15/5/40%. ett 7.5, 23 @ lip. bs reveal bilateral clear apecies with diminished bases, occasional coarseness noted. suctioned for small amounts of thick yellow and rusty plugs. pt circuit changed to  heated wire circuit. mdi's administered alb/atr with no adverse reactions. abg 7.41/43/94/28. pt ^ wob with rr's to 45 then placed on a/c 14/500/+5/40%. pt continues on cvvhd. plan to maintain present setting and monitor to wean back on psv when appropriate. rsbi=>200
"
2556,"resp: [**name (ni) 158**] pt on a/c 14/500/+5/40%. bs reveal noted aeration with some coarse sounds. suctioned for large amount of thick bloody tinged secretions with plugs toward end of shift. mdi's administered alb/atr with no adverse reactions. vbg's (see careview) which vent changes reflect. present settings a/c 8/400/+5/40%. rsbi=>200. family meeting to discuss cmo status. will continue full vent support. pt continues on cvvhd.
"
2557,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 14/+10/35%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick yellow secretions.  mdi's administered q4 hr of alb/atr with no adverse reactions.  cuff pressure @ 21 cmh20. 02 sats @ 98%.  no further changes noted.
"
2558,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/10/35%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suction x2 small amount of whitish/yellow thick secretions.  mdi's administered q4 alb/atr with no adverse reactions.  02 sats in ^ 90's.  no rsbi due to ^ peep.  no further changes noted.
"
2559,"resp: [**name (ni) 158**] pt on a/c 14/600/+5/30%. bs are coarse bilaterally which clear with suctioning. pt has strong cough/gag reflex.  suctioned for moderate to large amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. [**name (ni) **] changes to decrease rate to 10. no abg's pending. will continue to wean as tolerated.
"
2560,"resp: pt was extubated on [**3-29**] and placed on n/c @ 2 lpm. 02 saturation in 80's then ^ to 4 lpm.  ordered hhn ud atrovent q6 hrs and administered with no adverse reactions. pt is mouth breather so placed on humidified f/t @ 70% without n/c. 02 sats 95-97%. will continue to follow.
"
2561,"resp: pt rec'd on [**last name (un) 647**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20. ett re=taped and secured @ 24 lip. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered combivent q4 hrs/[**last name (un) **] [**hospital1 10**] with no adverse reactions. vent changes to +5 with am abg's 7.40/43/157/28. plans to wean to extubate, although secretions still copious. continue vent support.
"
2562,"npn7a-7p
neuro: pt using voc board to com. needs. dozing on & off all day, but easily arousable. anxious in am. tx'd w/ repos. 1mg ativan & 50mcg of fentanyl w/ good effect.
resp: recent abg's per pt's baseline. cont. to monitor sats & abg's as ordered. sxn' prn.
cv: hypotensive to sbp 80's following 50mg lopressor via ngt. team aware. bp corrected w/out need for ivf bolus & ivgtt. afebrile. nsr hr 90-106. no ectopy noted. +doppler bilat le pulses, cool to touch cyanotic in appearance. +2 edema r>l. rece'd ivig over 41/2 hr w/out adverse reactions.
gi/gu: npo. nepro tf @ goal of 40cc/hr. +bs +bm soft brown. foley draining adequate urine clear & yellow in color.
integ: skin tears w/ tegaderm drsgs reapplied over face & cocyx. staples in tact over lami inc site. no drainage noted.
endo: bs wnl. no coverage required w/ riss.
plan: goal for i/o negative to help prepare for possible extubation [**7-8**]. monitor hct, abg's as needed.
"
2563,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 12/5/50%/ alarms on and functioning.  ambu/syringe @ hob. minimal leak tech for notable leak in cuff.  bs auscultated reveal rs clear with ls diminished bs.  mdi's administered q4 alb with no adverse reactions noted.  suctioned x3 small to moderate amount of thick bloody secretions.  vt returned 400-500/ve [**7-29**].  02 sats remain in ^ 90's.  rsbi= 115. no vent changes noted.
"
2564,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/10/35%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small amount of thick white secretions. mdi's administered q4 hrs with no adverse reactions. pt does continue to have periods of bronchospasms, but no resp distress noted.  rsbi=163.  decreased peep to 8.  no further changes noted.
"
2565,"resp: [**name (ni) 158**] pt on a/c 12/500/5+/60%. ett #7.5, 23 @ lip. bs auscultated reveal bilateral exp wheeze. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered alb q4 with no adverse reactions. am abg 7.35/37/89/33. rsbi=115. plan is to wean as tolerated and extubate if possible.
"
2566,"resp: [**name (ni) 158**] pt on psv 16/8/50%. pt is trached #8 portex. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. pt has periods of anxiety with ^ rr to 40's. rsbi=65. am abg 7.45/42/108/30.
"
2567,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 10/5 50%. alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal increase in aeration with improvement noted.  suctioned small to moderate amounts of thick yellow secretions.  mdi's administered with no adverse reactions.  rsbi=58,sbt initiated.  pt [**name (ni) 6577**] 20minutes ^rr. ^bp, ^hr then returned pt to present settings of [**9-23**] where they remain.  no further changes noted.
"
2568,"resp: pt rec'd on a/c 30/380/16+/50%. bs are coarse bilaterally. suctioned for large amounts of bloody tinged thick secretions. ambu @ hob. mdi's administered as ordered alb/atr with no adverse reactions. no changes this shift. pt remains on cvvhd. no platetles given. no rsbi=^ peep. will continue with present mode of ventilation.
"
2569,"resp: [**name (ni) **] pt on a/c 30/380/15+/60%. ett 7.5, taped @ 23 lip. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of rusty/bloody tinged thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg's (see carview). vent changes to decrease peep to 14. am abhg 7.37/44/89/26. no rsbi due to ^ peep. pt remains on cvvhd. will contine to wean as tolerated.
"
2570,"resp: [**name (ni) **] pt on psv 10/5/40%. ett#8, retaped and secured @ 22 lip. bs are clear with diminished bases bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. rsbi=66. no changes this shift.family meeting today?  plan to wean as tolerated.
"
2571,"nursing note 7a-7p
neuro-sedated, when weaned off propofol pt is able to follow commands,and deny pain.  perrla.

cv- hr 60's, v-paced with frequent fusion of intermittant underlying a-fib.  pedal pulses l>r. rle cool, pale, md notified.  right groin angio site intact with bandaid.  us on ble's wnl.  bp's 120's 40's. right radial line zero'd and level'd.  cvp line zero'd and leveled. compression boots on, tol well.

resp- vented on assist control fi02 40% sat maintained at 100%. suct x3-scant thick clear, some blood tinged sputum noted.  lung sounds-rhonchi. see carevue for gases and lab results.

gi/gu- abd grossly distended, soft, nontender.  +bowel sounds.  rectal bag in place, maroon colored liquid stool noted.  scant amt from this shift.  foley patent-drg dk yellow clear urine. output is poor. < 150ccs this shift.  md is aware.  ng tube-cont low suction-bilious drg.

heme- mtemp 98.7ax. this shift.  this am temp 95, 96 po, intervened with bair hugger blanket, and fluid warmer.  temp is stable at this time.  pt received 6 units of prbc, 4 units of ffp and 1 unit of platelets, no adverse reactions noted.  hct previous to infusion was 19.5 post transfusion 26.4.  see carevue for more details. bc-still pending.

endo- propofol infusing at 40mcg/hour, insulin gtt infusing at 1.5units/hour.  last blood glucose at 1600 was 93.  pt was weaned off propofol twice this shift to assess for pain, denies pain and able to follow commands.

pt had an exploratory laparoscopy this am - bleed ruled out.  ct scan done at 1330 results- right groin, small hematoma found. rle us done- results wnl. left and right wrist iv's infiltrated, and dc'd.  l ac #18 wnl. right ij wnl. flagyl, levaquin, and vanco started secondary to ? sepsis.

assess- 83 yo w/acute lower gi bleed, s/p embolization; complicated by acute resp distress, intubation; s/p diagnostic lap. ? arf.

poc-will cont to attempt to wean 02, insulin and propofol gtt's. will cont to monitor hct & coags,stools,and urine output.

"
2572,"resp: pt remains intubated #8 ett, 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no abg's this shift or vent changes. rsbi=36. plan to trach/peg today in or.
"
2573,"resp: pt remains mechanically vented on simv 16/650/+5/10/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated with mostly clears sounds, and occasional rs wheeze noted. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. suctioned minimal amounts of white secretions. am abg's 7.41/32/119/21. reduction in temp. will continue to wean appropriately. no further changes noted.
"
2574,"npn 1900-0700:

ros:
neuro: pt remains paralyzed and sedated on same doses of cisatracuriun, versed, and dilaudid. no obvious adverse reaction to dilaudid. [**2-24**] twitches at 60mv on tof. no spontaneous movement; perrl.
resp: remains on pcv with driving pressure decreased to 23, peep decreased to 14; rate unchanged at 24. i:e 2:1. able to wean fio2 to 60% with most recent abg 7.38/36/104/22/-2. unable to obtain sats d/t peripheral vasoconstriction. ls coarse t/o; suctioned once for very scant thick bloody secretions.
c-v: hr 90's-100's, sr/st, no ectopy. bp via a-line generally correlating with [**month/day (4) 781**], though occasionally positional. able to wean levo significantly; remains on same dose of pitressin. .
id: temp >101 all night despite tylenol. cooling blanket added at 0500. wbc down to 17.5 with 5% bands. ceftaz added to abx coverage; bc x 2 sent from lines.
gi: tpn and tf's on hold. 25-500cc's bilious aspirates from ogt q6 hours; + placement by auscultation. pt regurgitating significant amts gastric contents to back of throat (ho aware); suctioned very frequently. belly firm, distended, hypoactive bs. no stool.
gu: u/o very poor much of night. given 40mg, then 80mg iv lasix with minimal response. now has become essentially anuric (ho aware), with bun/creat rising to 67/1.8.
heme: hct down a bit to 28.8; plt's down from 147 to 84, though the current level is much more consistent with where he's been. inr up a bit to 1.8. oozing from right femoral line site; otherwise no evidence of bleeding.
endo: no need for insulin coverage
skin: skin remains intact; eyes taped shut and given frequent eye care with natural tears alternating with lacrilube.
social: family members present in room till mn, then slept in waiting room. asking appropriate questions; unclear if they truly understand the irreversible nature of his disease. remains a full code.

a: a better night, though prognosis remains very poor.

p: continue sedation/paralytics as needed; wean levo as able; follow temps, wbc, cx results; tylenol, cooling blanket prn; ? reglan or other therapy for regurgitation; keep hob up and sxn frequently to prevent aspiration; follow up w/team re: renal fxn; monitor for evidence of bleeding; will tx for hct <27; continue skin care as we are doing; continue to inform and support family.
"
2575,"micu nursing progress note

pulm: pt to ct angio to eval pe. once on  ct table noted to have brb per ett, large thick amt. maintained o2 sats > 95%, airway remained patent. cont'd to sx moderate amts of bright red sputum during test. labs revealed hct drop from 35 to 30, inr 1.6-> rec'd ffp(2), vit k x 1. 4am labs revealed drop in hct to 26.2. cont to have bloody secretions overnight mod to large amts, appears to contain tissue, and to be less bright red than earlier in evening. now ordered for 2 additional units ffp (being thawed) and 2u prbc's typed and crossed. pt rec'd on a/c 450 x 20 peep 5, fio2 inc'd to 50% to maximize o2. am abg -> 195/31/7.45.

cv: sbp 80(sleeping)-126. hr 70's(nsr). repleted for k+, mgso4 and ca+. am labs drawn immediately after finishing repletion of lytes (md aware)

id/heme: spiked to 101.4 between rec-ing 2u of ffp. md [**doctor last name **] informed, bbank called. decision made to give apap and cont infusion d/t greater risk of bleeding vs probability(low) of adverse reaction. now ordered for 2 additional units-will pre medicate. pan cx'd, bc x 2 +fungal, urine sent. abx regimen un-changed.

gi/gu: no s or sx of bleeding via ogt. stool ob-. tolerating tf w/o difficulty though does cont to have large amt of diarrhea via mushroom cath. hypoactive bs. abd ^^girth though soft. u/o ~100-200cc/h.

skin: mediastinal,sternem dry and intact. r arm infiltrate site w/ some weeping, escar sloughing off.

social: aunt called for update, pt's mother has note been called by intern -needs to happen today.
"
2576,"resp: pt rec'd p/o intubated ett #7.5, 19@ lip retaped and secured. bs reveal coarse sounds bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. pt desated to 92, then ^ peep to 8, abg's 7.42/44/204/30. decreased peep to 5 with 02 sats 98%. rsbi=no spont resp. will continue full vent support.
"
2577,"resp: pt remains intubated/trached #8 portex. bs are coarse and suctioning moderate amounts of thick bloody tinged secretions. mdi administered q4 alb/atr with no adverse reactions. vent settings psv 5/5/50%. rsbi-43. no abg this shift.
"
2578,"resp: pt remains intubated on psv 10/5/30% with no changes noc. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. sputum sample obtained and sent. mdi's administered q4 hrs with no adverse reactions. pt remains on [** **]. possible trach this week. will continue on psv. no abg's, aline removed.
"
2579,"1900-0700a  nursing note


event-- @ 0330a pt developed [**4-15**] non-radiating left sided cp.  pt states this is a chronic problem for him and happens at rest at home. ekg obtained, cardiac enzymes sent and 1 ntg sl given.  within 5 min, cp resolved.  ekg reviewed by dr [**last name (stitle) 3381**] and no changes noted.  hct dropped 26 to 22.9.  pt transfused w/ 1uprbc, no adverse reaction noted.  repeat hct will need to drawn.

(c/v)-- remains in sb, hr 40-50's w/ pac's. on review of [**name (ni) **] pt is having intermittent episodes of 1st degree a-v block(hr 35-38)  asymptomatic.  pt occas dropped hr to 30's when sleeping.  +[**1-8**] pitting lower extremity edema.  b/p stable  98-114/44-54.  monitor cardiac enzymes and hct.  bc sent/pending.

(resp)--lungs remain clear after fluid bolus and blood.  pox 96-99% on ra.

(g/i)--  abd soft, med loose stool x1.  trace pos guiac stool.

(g/u)--outpu needs to be watched. only 500cc out but >1500cc in.  urine spec sent.  voids via urinal.

plan c/o  today
"
2580,"respiratory care note:
   patient s/p rml lobectomy now with white out of r lung despite daily bronchoscopies.  reintubated today (difficult intubation- multiple attempts without adverse reaction. tube guide used and a # 8.0 et tube placed 23cm @ lip). bs present bilat anteriorly, very decreased rll. suctioned for large amounts of tan and blood tinged mucous.  pt., sedated via peripheral line with propofol. +epidural. see carevue flowsheet for settings and abgs.
"
2581,"resp: [**name (ni) **] pt on psv 12/5/40%. ett#7.5 taped @ 25 lip. bs are clear with diminished bases. vent changes reflect abg's (see carview) suctioned for small amounts of yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.30/45/113/23. present settings psv 14/5/50%. vt's 350-400. plan to trach/peg in or today.
"
2582,"[**2192-11-28**] ""b"" nsg progress note:

cvs:  t=98.6-99.2 ax. hr=99-109 sr no ectopy. [**month/day/year **] down to 83, iv neo drip restarted and up to 0.75mcg/kg/[**month/day/year 199**]. iv fentanyl drip at 100mcg/hr, iv ativan drip at 0.75mg/hr.  received iv ig 800cc last night with no adverse reaction noted.  started on iv bactrim also which is 1000cc.  [**month/day/year **] kept>90 with neo. cvp=14-18.

resp:  vent tv 550 fio2 was at 50% peep5 on ac 14, abg's with ph=7.20. serum hco3=18, given 1 amp nabicarb iv. changed to ac 28 tv 550 fio2 100% peep8 with improvement of abgs. suctioned for small amt thin reddish sputum.  lung sounds very diminished at bases.  trach site draining thick tan [**month/day/year **]. sats=93 down to 83%.  then on new settings sats=95-99%.  sputum sent for cult.

gi:  tf [**month/day/year **] with no residual. banana flakes tid.  +bs.  moderate formed brown stool noted.

skin:  red pustules all over body.  [**month/day/year **] dsg changed with aquacel, area is necrotic in center, red at edges, no [**month/day/year **].  duoderms at various areas on arms and legs. wound vac dsg [**month/day/year 468**] to [**month/day/year 3522**] wound.
jp=10cc. chest tubes with small amt [**month/day/year **] both to waterseal. left leg edema noted.

neuro:  opens eyes, does not follow commands, very little movement of extremities.  smiled at wife but mostly does not interact.

labs:  mg,kcl,ca all repleted. bs coverage per ssri.

plan:  redialyze today.  try weaning vent settings.
"
2583,"resp: [**name (ni) **] pt on a/c 20/600/+5/50%. bs are clear bilateral. suctioned for scant amounts of white secretions. mdi's combivent q4 with no adverse reactions. vent changes relfect abg's (see carveiw) pt remains paralized/sedated. present settings. a/c 12/550/+5/30% with am abg's 7.41/40/121/26. no further changes noted.
"
2584,"resp: [**name (ni) **] pt on psv 8/2/40%. #8 portex trach. bs are coarse bilaterally with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. no abg's this shift. rsbi=39. will continue to wean as tolerated.
"
2585,"resp:  [**name (ni) **] pt on [**last name (un) 205**] cpap/ps [**11-20**] 40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral mild coarse sounds which clear with suctioning.  suctioned x3 scant-small amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  ett re-taped & secured.  no distress noted. rsbi=32, sbt initiated and maintaining tv's 500-600, with 02 sats ^90's.  no further changes noted.
"
2586,"resp:  [**name (ni) **] pt on [**last name (un) 205**] ps 5/+5/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse bs which clear with suctioning.  suctioned x3 small amount of thick yellow secretions, and oral cavity. mdi's administered atr/alb q4 with no adverse reactions.  rsbi=26 and sbt initiated.  no further changes noted.

"
2587,"resp: [**name (ni) **] pt on 7200 psv 10/+5/40%.  alarms on and functioning.  amubu/syringe @ hob with spare trach.  bs auscultated reveal bilateral coarse apecies with diminished bases.  suctioned x3 small to moderated amoutn of tanish thick secretions. mdi's administered q4 combivient with no adverse reactions. pt's trach positional.  pt is out of bed sitting in chair.  rr at base line 30's increases when anxious.  rsbi=112.5 with no further changes noted.
"
2588,"addendum to above note
labs back--plat low, pt to have 1unit plat and 2units [** 1684**].  plat infusing at this time without evidence of adverse reaction thus far.
"
2589,"resp:  [**name (ni) **] pt on [**last name (un) 205**] cpap/ps 12/10/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small amounts of thick yellow secretions, and oral cavity.  mdi's administered alb/atr 6p q4 hrs with no adverse reactions.  vent changes as follows; peep decreased to 8, where it remains.  rsbi performed =70.  no further changes noted.
"
2590,"resp care
pt remains on vent. changes made according to protocols. mdis given with good effect: decreased vent pressures.  no adverse reactions. will continue to mointor
"
2591,"resp: [**name (ni) 158**] pt on a/c 14/650/+5/40%. ett 7.5 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow to tannish secretions with some bloody tinged.  mdi's ordered alb/atr q4 and administered with no adverse reactions. large amounts of thick clear to white oral secretions as well. no aline, vbg's (see careview) vent changes to decrease vt to 550, ^ rr to 18. 02 sats @ 100% with am vbg  7.41/44/29. rsbi=70. no further changes noted, pt in/out of a-fib.
"
2592,"pt. completed asa desensitization protocol. last asa dose 2355. tol process well with no known adverse reactions at this time. slept well throughout the night being npo after midnight for ? cardiac cath today. one mod loose stool. voiding in commode.
plan cardiac cath today. ? plavix [**hospital1 **] vs. qd now pt. on asa. needs to be clarified. plavix was [**hospital1 **] at home and pt. got it [**hospital1 **] yesterday.
plan transfer to floor if needed. pt. stable. repeat k=3.8 not hemolized.
"
2593,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 10/550/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal diminished bases. mdi's administered q4 alb/atr with no adverse reactions. suctioned for small amounts of tan thick secretions. am abg's 7.32/47/111/25.rsbi attempted with no spont. resp. noted.  plan to wean sedation this am and place on psv when appropriate.
"
2594,"npn 7a-2p

events:  pt. restarted on heparin (at 800u/hr), sent to cath lab for cardiac cathertization at 1400.  pt. with transient hypotension and low u/o today.  c/o of cp x 1 resolving without intervention.

neuro:  a+o x 3.  pleasant and cooperative.  anxious about cath.  medicated x 1 w/ 1 tab vicodin for lower back pain; [**8-23**].  pt. takes vicodin at home per her report despite hx. stating she has morphine allergy.  pt. without adverse reactions and pain dissapated; 0/10.  pt. decribes that her pcp believes her to have sleep apnea with insomnia; takes ambien at home as well for sleep.

resp:  sat's maintained >95% on 4l nc.  + smoker 1/2-1 pack/ day.  ls- clear/ diminished bases.  productive cough.

cv:  team describing weekends' events as ischemia, not infarction d/t unstable angina.  cp x 1 with no other associated symptoms; denied sob.  of note, pt. reported cp when asked.  30 minutes prior to onset of cp, pt. received vicodin for back pain.  no further narcotics were administered as pt. stated that cp or ""pressure"" was resolving on own.  no nitrates administered.  sbp 90's (manually/ doppler).  ho called immediately.  pt. started on heparin prior to onset of cp as well at 800u/hr with no bolus.  pt. sent to cath lab at 1400 after consent obtained by pt. and son.  [**name (ni) **] at bedside.    hr 60's.  bp 90's.  ivf started prior to cath at 125cc/hr of ns with 500cc fb.

gi:  pt. encouraged to drink po's d/t poor u/o, then made npo for cath.  abd wound dressings done at 8am; packed with several yards of nu-gauze; wounds tunnel.  wounds with serosanginous output.  no bm.  + bs.

gu:  u/o minimal.  ivf started prior to cath.

id:  pt. receiving pcn and flagyl rtc.  afebrile.

plan-  s/p cath care, hct s/p cath with wbc.  check ptt on 800u at 6:30pm.
"
2595,"resp: pt rec'd on simv 18/500/12/+8/40%. ett 7.5, retaped, rotated and secured @ 23 lip. alarms on and functioning. ambu/syringe @ hob. bs reveal slightly coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. cuff pressure @ 20 with no notable [** **], foul odor still exists from oral cavity. no rsbi due to hemodynamic instability. no changed noc. will continue full vent support.
"
2596,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] psv 12/8/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear apecies with diminshed bases. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. ett @ 24 lip, cuff pressure 20. am abg's 7.43/47/73/32. rsbi=142. will continue to wean appropriately.
"
2597,"micu nursing progress note 11am-11pm:
neuro: pt having what is felt to be adverse reaction to the haldol which was given in previous 12hrs. periods of muscle stiffness and ridgidity noted felt to be dystonic reaction. each episode treated successfully with benadryl. twice given 50mg with good effect. third time was treated with 25mg iv benadry then 1mg po cogentin. seems  to be working fairly well. he is confused at times, thinks he can get up oob by himself and go to the bathroom. twice assisted back to bed and requires frequent reminders to stay in bed for safety. he was assisted bed to chair twice and tolerated this well. his family have been present on/off throughout the day. he is angry and rude to them at times. very short tempered. he seems to be easily agitated and bears watching for the same episodes of sundowning that has been occurring on previous shifts. ciwa scale has been followed but no ativan has been ordered as we usually treat for scale greater than 10. his intern is reviewing the order and may need to order ativan or valium prn.

cardiac: bp stable. hr elevated into 110 with agitation.

resp: o2 4l n/c most of the shift. rr high in the 35-40 range most of the time. good sat 94%-99%.

gi: eating small amts po's. has not moved his bowels since admission. given colace and ordered for dulcolax which i will give him soon.

gu: foley draining well. urine is slightly bloody tonight from him trying to get oob himself this afternoon and pulling which occurred. i can d/c foley tonight and pt will be dtv in am.

social: family was spoken to today by case management who mentioned that pt may be a candidate for drug rehab. they were not receptive to this and state that they are overwhelmed, just almost lost their son and do not want to talk about this at this time. this does need to be addressed but can wait till tomorrow when team are able to address these issues with him and his family.
"
2598,"resp: pt on 40% hiflow. bs are clear. nebs administered q6 hrs alb/atr. plumicort [**hospital1 **] with no adverse reactions. will continue to follow and treat.
"
2599,"respiratory: [**name (ni) **] pt on 7200 psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse bs which improve with suctioning.  mdi's administered q4hr combivent with no adverse reactions.  suctioned x3 small to moderate amounts of thick yellowish secretions.  rsbi=117.6 no further changes noted.










































"
2600,"1100-2300 npn
see carevue for subjective/objective data.
neuro:  a+ox1 only--not oriented to place or time.  attempted unsuccessfully to reorient.  moving arms ad lib; no leg movements noted.  l leg in alignment (l hip fx).  perl, 3mm, brisk.  speech garbled but occas able to understand single words.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  remains on heparin at 1000units/hr with next ptt due at 2400.  r cvp patent, zero'd and cal to monitor with good waveform.  remains on np at 3l with sats high 90's.  bs coarse bil.  one unit prbc infused without evidence of adverse reaction; rpt hct=30.6.

gi/gu:  remains npo even though hip surgery cancelled--will remain npo until speech/swallow evualated per intern.  no flatus, no bm noted.  u/o remains hematuric--urology consult to be ordered by micu team.

integ:  intact.  some lesions noted on skin.

psychosocial/plan:  emotional support given to pt and fam.  surgery re-scheduled for wed per ortho; pt to remain on heparin at 1000units/hr with next ptt at 2400--page ho with results.  cont to monitor vs, bs, mp, i+o, labs and provide emotional support.
"
2601,"addendum to transfer note
d.today pt is afebrile,sr 90 down to 80 after increase in lopressor.(it was determined that pt does not have an allergic reaction to lopressor but possibly an adverse reaction to dose thus removed from allergy list and explained to patient)bp by cuff 140-160/50-60.rr=14-20,o2 sat 98 on 4l np.pt started on asa and heparin continues at 250 units/hr.
 no chest pressure or pain today.no c/o sob..lungs remain clear.
 no hemodialysis today per renal and transplant teams..urine replacements and maintainence fluid discontinued .pt started on diabetic and renal diet and fluids ad lib.after 18 hrs..fluid balance pos by 1200.huo 30-80ml of pink urine.
 pt was medicated x1 with morphine with stated relief.
 activity was increased to oob to chair with assistance of 2.pt tolerated activity well despite 2+ body edema.
 abd incision d&i.abd. jp draining minimal sero-sang and a small amt around jp.
 bowel sounds present.pt eat a sm amt of toast but is drinking moderate amt of fluids.[**month (only) 12**] need a nutrition consult if appetite does not return in near future.
 pt received atg after steroid dose..
  see flow sheet for current labs..wbc down to 3.6(transplant team aware.hct stable at 29.5..bs 140-147 and has received insulin per sliding scale..ptt 29-30.
a.pt was encouraged to increase deep breathing and coughing..transfer to floor when bed available.
r.stable
"
2602,"pt update:
neuro:grossly intact see flow sheet.
cv:chest pain free, ekg repeated and back to baseline per cardiologist. lopressor started after it was determined her allergy to lopressor was probably an adverse reaction. pt had no untoward effects from lopressor given last night.
gi: sips of water tolerated
gu:urine is less bloody now pink 70mls at 0600.
resp:no difficulties last night. pt instructed on the importance of c/dbing. good cough effort.
              [**first name8 (namepattern2) 1257**] [**last name (namepattern1) 1258**]
"
2603,"1900-0700

general: pt remains sedated with cont'd mechanical ventilation. prbc transfusion completed with no adverse reactions: repeat hct-30.8,wbc-16.5. no changes made to vent through night, o2sat 92-97%.

neuro: pt reamins sedated, eye twitching noted to painful stimuli. minimal to no movement of ext noted. pupils 3mm bilaterally with r-brisk and l-sluggish.

resp: pt remains orally intubated with # 8.0 ett 24cm @ lip line. vent settings remain ac tv 600, 70% 35, peep 20. mv-22.o2sat 92-97%. suctioned for scant thick blood tinged secretions. abg 4am: 7.24, 69, 60, 27, lactic acid-2.2. lungs on r-rhonchi,l-coarse through lung field. oral cavity with bleeding gums and sinusitus noted.

cv: nsr-s.tachycardia with rare pacs noted. max temp 99.8 orally, bp 120-165/50's. hr 90-110. cvp-[**9-23**]. generalized edema noted to ext. pulses to lower ext by doppler. triadayne bed in use with rotation and percussion. compressive boots/foot drop splints on.

gu/gi: abd firmly distended with + bs noted. liquid diarrhea noted, occult neg-fecal incont bag applied with double skin barrier. ogt to liws draining bilious fluid, irrigated for questionable internal bleeding-negative. foley catheter to bsd draining clear yellow urine. lasix given at 2300. pt -800 at this point for 24hrs. na-152, bun-79, cr-1.7,

endo: insulin drip remains titrated to bs. bs 120-150.

iv: r radial aline zeroed and calibrated with sharp waveform. l ij tlc intact with [**month/year (2) **] @ 5mg/hr, fentanyl@ 80mcg/hr, lr@ 10cc/hr, insulin@3u/hr, [**e-mail address 6573**]/hr.

plan: continue supportive measures. family meeting today.

                       [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
2604,"resp: pt remains intubated on psv 10/5/50%. bs are clear in apecies with diminished bases. sucitoned for small amounts of thick white secretions. (see careview for abg's) rsbi=55. mdi's administered q4 alb/atr with no adverse reactions.
"
2605,"altered cardiac status
d: neuro: fentanyl gtt decreased to 60mcg/hr and versed gtt remains at 1 mg/hr. pt occasionally noted to move r arm  and left leg but does not follow simple commands. facial grimacing to sternal rub and attempts to open his eyes. at 1230 pt noted to be rigoring. at 1200 temp had been 99.5 orally and at that time temp noted to be 100.8 orally. medical team notified. pt medicated with demerol 50 mg ivp with resolution of the sxs.because pt is sedated on fentanyl and versed gtt medical tema was concerned that this might be seizure activity. neuro was consulted and eeg done  at the bedside  and results are pending. no further episodes have occured. neruo ffels that this  was not seizure activity. will continue to wean sedative gtts on daily basis and assess his neuro status. pupils equally reactive to light.

resp: orally intubated with vent settings of 40%/500/ac 24 with 5 peep. o2 sats> 98%. coarse bs bil on auscultation but diminished at the bases. suctioned for sm amts of thick yellow sputum and orally for copious clear secretions.plan is to optimize [**hospital **] medical status and if we are not able to wean vent and extubate pt by this weekend will plan for tracheostomy early next week.


cv: hr ahs been variablkel throughou the day and as high as 150's. this am occasionally pt was in atrial bigeminy but most of the day pt has been in afib. amioderone gtt d/c'd and pt now started on amioderone 400 mg po bid for 7 days and then will be changed to qd. ion ca=1.02 and repleted with 2 gm ca gluconate. received pt on neosynephrine gtt for bp support but that has been weaned off. with episode of rigors sbp had climbed to as high as 220. see careview for  specific vs. it appears that when pt is f ebrile he becomes more hypotensive. will continue to follow hemodynamics closely. pt was medicated with 5 mg ivp lopressor with little effect. goal is to keep map> 60.

gi: ogt in place and pt receiving criticare tube fdgs at 30cc's/hr with minimal residuals. reglan now d'c'd b/cause of fever  nad the adverse reaction that can be caused by reglan- neuroleptic malignant syndrome. abd soft and distended. hypoactive bowel sounds on auscultation. fecal incontinence bag in place with minimal liq brown stool. will send spec off for cdiff cx when available. checking blood sugars q 6 hrs and treating as needed with ssi. plt ct=16 nad pt was transfused with 1 u plts. plan is ot transfuse for plt ct<20. abd u/s done at the bedside and unremarkable.


gu: lasix 60 mg ivp given with neg fluid balnce. bun=137 and creat=4.6. renal consult team continues to follow pt on daily basis.  pt with metabolic acidosis and has received 2 amps of sodium bicarbonate. fluid balance for los still pos by 19 liters.

id: temp spiked to 104.2. blood cx's x 2 sent off. wbc=6. spource of fever still undetermined. ? drug fever vs infection vs neurological expalnation. pt startd on diflucanazole 200 mg ivpb q 24 hrs.id consult team also following pt on daily basis. follow fever curve await all final r
"
2606,"npn 7a-7p

events-  abd ct done with gastrografin (not barocat), results pending, conts to stool (500 out this shift), transitioned to psv this afternoon, hct stable, wbc increasing again...

review of systems-

[**name (ni) **]  pt. nodding appropriately, eyes closed most of the shift, denying pain except x 1 when she was medicated with 2mg of mso4 w/ good effect.  family cautions use of versed/ ativan d/t adverse reactions to benzo's in the past- pt. reportedly becomes confused and disoriented.

resp-  received on a/c, transitioned to psv- will obtain evening abg.  ls- diminished throughout... sat's stable.  sx'd for thick white secretions.  would obtain sample if turns purulent- appears to be nasalpharyngeal ? sinusitis...

cv-  hr 80's-90's sometimes appears to be in nsr, others appears to be in aflutter- conts on amiodorone iv d/t poor tolerance of pos. bp stable via arterial line.  pm hct stable >32.  e-lytes repleted this am received 80meq of kcl, ca+ and mg+.  skin appears distressed and friable, oozing from extremeties.

gi-  abd conts to be firm and distended, tender to touch.  flexiseal device inserted and appears to be draining and containing stool well- 500cc output thus far.  no further go-lytely given today, would consider after ct results interpreted.  lactulose d/c'd as it could be causing increased flatus.

gu-  u/o adequate.  d5w changed to po 250cc q 4hours to save on input. tpn also adjusted to decrease sodium and improve e-lyte imbalance.  nutritionist recommending we not replete imbalance tom'row am as new bag of tpn should correct.

id-  afebrile.  off abx.  ? sinus drainage causing secretions.

[**name (ni) 4**]  husband and youngest dtr, [**name (ni) 169**] to visit and updated on plan of care.  also talked with dtr, [**name (ni) **] and plans to meet w/ fellow dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 5901**] tom'row to discuss timeline.
"
2607,"resp:  [**name (ni) **] pt on a/c 16/500/+5/50%. ett #7.5 found @ 24, retaped,pulled badk to 22 as charted @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small amounts of white secretions. mdi's administered as ordered atr/alb with no adverse reactions. am abg 7.41/41/147/27. no changes noc. rsbi=50. plan to wean to psv as tolerated.
"
2608,"resp: [**name (ni) **] pt on niv psv 14/4/50%. placed pt on 50% cam and tolerated well for 2-3 hrs then ^ wob with ^ co2. mdi's administered a/b/atr and hhn with no adverse reactions. bs are clear bilaterally. placed back on niv am abg 7.38/45/147/28. will attempt to wean as tolerated.
"
2609,"respiratory care
pt remains trached (#8.0 portex) with cuff inflated and no [** **] present. pt remains on fio2 0.35 via trach mask. lung sounds were course to clear and dim in the bases. suctioned for sm-mod thk yellow and once for small thin bloody secretions. nebs were given with no adverse reactions. no abg's were drawn during shift. care plan is to continue nebs as ordered and continue to suction prn. rehab screen started. will continue to follow pt.
"
2610,"resp: [**name (ni) **] pt on psv 12/5+/40% bs are coarse bilaterally. suctioning small to moderate amounts of thick white to yellow secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. rsbi=28. plan to continue to wean down psv, with possible t/c trials as tolerated.
"
2611,"resp: [**name (ni) **] pt on simv 24/550/ps5/+16/50%. ett 7.5, retaped and secured @ 23 lip as per xray correct placement, although being charted at 21. bs are diminished with noted aeration in apecies. suctioned for scant amounts of white/yellowis secretions. mdi's administered combivent as ordered with no adverse reactions. cuff pressure @ 25 cmh20. am abg 7.42/44/101/30. no vent changes noc. no rsbi due to ^ peep. possible ct trip today?
"
2612,"resp: [**name (ni) **] pt on [**last name (un) 205**] simv6/650/5/+5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4hrs combivent with no adverse reactions. weaning initiated with vent settings @ psv 10/5/40%. am abg's 7.40/36/102.23. plan to continue to wean then extubate this am.
"
2613,"resp: [**name (ni) **] pt on psv 15/10 and pt became hyertensive then placed on a/c 16/500/+10/50%. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi' administered q4 (seecarevew) no adverse reactions. am abg's 7.39/378/111/24. plan to wean to psv this am
"
2614,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 16/500/+10/40%. alarms on and functioing. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate-copious amounts of thick yellow secretions. cp @ 22 cmh20. mdi's administered q4 hrs combivent q4/flovent [**hospital1 **] with no adverse reactions. vent changes reflect abg's (see [**hospital1 673**]) am abg's 7.39/39/97/24 on a/c 16/5///+5/40%. plan to continue full vent support.
"
2615,"resp: pt ordered for nebs alb q2 hrs/atro q6 hrs. pt on 2.5 lpm n/c. bs auscultated reveal bilateral insp/exp wheeze which improve following tx. had one short episode of bronchospasm with cough. no adverse reactions following administration of meds. 02 sats @ 99%. md to change order to q3 hrs alb.  will continue to follow. see carview
"
2616,"resp: [**name (ni) **] pt on psv 15/5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for copious amounts of thick bloody secretions/plugs. inner cannula changed. mdi's administered with no adverse reactions. am abg 7.42/35/85/23. plan to change trach to [**initials (namepattern4) **] [**last name (namepattern4) **] today.
"
2617,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with diminished bases. suctioned for small to moderate amounts of thick bloody tinged plugs. mdis administered q 4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. most recent abg 7.36/38/92/22. rsbi=52. no changes noc.
"
2618,"ccu npn
see carevue for subjective/objective data.  neuro:  confused to place and time, is oriented to self/family.  mae ad lib although weakly.  speech clear.  re-oriented frequently.

cv/pulm:  bp 90's-120's/30's-40's.  mp=afib 70's-80's with occ->freq mf pvc's.  cycling cpk's and hct's.  second of three units prbc currently infusing.  no adverse reactions noted during first unit, no adverse reactions noted thus far second unit.  developed bibasilar crackles, lasix 20mg iv given at start of second unit prbc.  rpt hct at 0200 done. hct 22.1 up from 19.9 (but done with blood infusing on opposite arm).  hct reported to dr. [**last name (stitle) **], third unit prbc ordered upon completion of current unit.  pt on room air with sats consistently 99-100%.  no sob or doe noted.

gi/gu:  npo.  two melena stools, liquid, approx 50ml each.  starting to diurese from lasix.

integ:  impaired--ecchymotic area noted l hip--pt states he ""falls alot"".   ecchymotic areas also noted on abdomen.  no open areas noted.

psychosocial:  daughter is rn w/vna of [**location (un) **].  emotional support given to pt and daughter.  sleeping in long naps.
"
2619,"resp: pt rec'd on psv 15/5/50%. pt remains on cvvhd. bilateral coarse bs. suctioned/lavarged for copious amounts of thick bloody/brown plugs. mdi's administered as ordered without adverse reactions. am abg 7.39/43/117/27. no further changes noted.
"
2620,"resp: [**name (ni) **] pt on psv 5/5/40%. #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for large amounts of thick tan secretions. mdi's administered as ordered alb with no adverse reactions. rsbi=62. am abg's 7.40/31/94/20. plan is to continue on trach trials as tolerated.
"
2621,"resp: [**name (ni) **] pt on a/c 10/500/+8/40%. trach #8 portex.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds. suctioned small amounts of white secretions. mdi's administered q4 hrs 6p alb with no adverse reactions. rsbi=67. placed pt on psv 10/5+/40% obtaining vt's 400-500's, rr 15, ve 6l. no further changes noted.
"
2622,"resp care

pt followed by respiratory for q6 neb treatments. atrovent given x2 via aerosol mask tol well with no adverse reaction. bs essentially clear/dim at the bases. no changes noted post tx, pt adequately oxygenating on 2l nc. will cint to follow as needed.
"
2623,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 20/600/+5/60%.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse bs which clear with suctioning.  suctioned numerous times for thick copious yellow secretions, as well as in oral cavity.  re-taped & secured ett.  mdi's ordered this am alb/atr given @ 6:00 with no adverse reaction.  02 sats at this time remain 93-95%.  vent changes as follows: tv ^ 600, rr^ 20, and fio2 decreased to 60%.  am abg's 7.39, 46, 96, 26, -0.  rsbi=32.  no further changes noted.
"
2624,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] on a/c 550/15/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of white thick secretions. mdi's administered q4 hrs of alb with no adverse reactions.  ett re-taped @ secured 21 lip line. cuff pressure @ 21. 02 sats 93, increased fio2 to 60% fio2 97%.  rsbi=136, no further changes noted.
"
2625,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/600/+10/60%.  ambu/syringe @ hob.  bs auscultated reveal ls clear with rs diminished.  suctioned x 3 small amounts of thick yellow secretions.  mdi's administered q4 hr alb/atr with no adverse reactions.  rsbi=26 and no further changes noted.
"
2626,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/500/+5/60%. alarms on and functioning. ambu/syringe @ hob. ett 7.5 retaped and secured @ 22 lip. cp @ 23 cmh20. bs auscultated reveal bilateral rhonchi, suctioning copious amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions.vent changes to ^ rr to 21, decrease fio2 to 50%.  am abg's 7.35/44/102/25. rsbi=54. no further changes noc. plan to bronch today in am. will continue full vent support.
"
2627,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/350/+14/70%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration in apecies with diminished bases.  mdi's administered q4hrs alb/atr with no adverse reactions.  fio2 ^ 90% due to desaturation in 80's.  abg's drawn (see careview) fio2 decreased to 70% were they remain. am abg's 7.29/69/88/35.  02 sats @ 97%.pt remains on ards protocol.
"
2628,"resp: [**name (ni) 158**] pt on a/c 21/500/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions, some improvement noted. mdi's administered q4 hrs. combvient with no adverse reactions. am abg's 7.40/45/96/29. rsbi attempted but no spont resps.  will continue full vent support.
"
2629,"resp: rec'd on psv 10/5/40%. bs reveal bilateral wheezing. suctioned for small amounts of thin white secretions. mdi's administered as ordered with no adverse reactions. vt's 450's, ve's 11, rr 22. am abg 7.42/37/105/25. rsbi=89. no further changes noted.
"
2630,"resp. care
pt. remains on mech vent. flipped from simv/ps to cpap/ps at 0500. pt. has a patent 7.0ett secured at 21 at the lip and is being sx for mod amts of bloody secr. b/s are dim with a few scat wheezes. mdis given with good effect and no adverse reactions. aeration was better bilat. post rx.plan is to wean as tol. and extubate.
"
2631,"0200-0700
neuro: pt alert and oriented to self and place, confused at times. perrla. mae weakly, stiff. medicated w/ fentanyl gtt at 25mcg/hr, appears to be comfortable, except w/ hands on care, continues to yell at staff w/ bathing turning and repositioning.

cv: hr 60-70 sr rare pac occasional pvcs. k infusing through ivf at 75cc/hr. mg to be repleted. sbp 130-140s. hct 22.3, 2 units of prbcs ordered, 1st unit up at 0500, infusing, no adverse reactions see carevue for vs. weak palpable pedal pulses. 4+ pitting edema to ble.

resp: ls clear diminished bases. sats >98% on 2 lnc. see carevue for abgs.

gi/gu: abd soft hypoactive bs. ileostomy stoma pink draining greenish stool scant amts. stoma care done at [**2106**], dsg changed at that time. tf at 30cc/hr presently, goal of 80cc/hr, no residual via jtube. g tube to gravity draining greenish bile. urine and irrigation draining aroung foley balloon, could feel balloon when palpating bottom of penis, pa [**doctor last name 486**] aware, attempted to place another cathether unsuccessful pa [**doctor last name 486**] aware, to keep foley out and urology to see in am per pa [**doctor last name 486**].

endo: no coverage needed.

skin: wound care per wound care orders. see carevue. penis and scrotum very edematous, pa [**doctor last name 486**] aware.

plan: monitor hemodynamics. one more unit of prbcs. monitor resp. status. stoma care. skin care. follow labs and treat as appropriate. urology to see pt to place foley cath.
"
2632,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/500/+10/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered q4 hrs alb with no adverse reactions. no wheezes noted. am abg's 7.46/44/131/32. scheduled trip to or for repair of pelvis. no further changes noted.
"
2633,"resp: [**name (ni) 158**] pt on a/c 20/450/+8/100%. bs are slightly coarse, and suctioning small amounts of tan secretions, trach site clear. mdi's administered q4 hrs alb/atr with no adverse reactions. abg's (see careview) vent changes to ^ rr to 22, decrease fi02 to 60%. am abg pending. will continue to wean appropriately.
"
2634,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] ps5/+10/50%.  ambu/syringe @ hob.  auscultated bs reveal coarse bs on ls with diminished on rs.  suctioned thick copious yellow secretions x3 as well as from oral cavity.  mdi's adminishered q4 hrs alb/atr with no adverse reactions.  vent changes as follows: ac 16/600/40% @ [**2097**] with no further changes during noc.  rsbi=34.
"
2635,"resp: [**name (ni) **] pt on psv 10/5/40%. bs reveal bilateral wheezing. suctioned for small amounts of thin white secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=77. no changes or abg's this shift.
"
2636,"resp: pt rec'd on psv 25/8/60%. bs are coarse bilateraly with noted wheeze. mdi's administered q4 alb/atr with no adverse reactions. am abg 7.37/46/98/28. decreased ps to 20, tv 400's rr, 20, 02 sats 99%. will continue to wean as tolerated.
"
2637,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 15/550/60%/+5.  alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with diminished bases. 02 sats 93-96%.  suctioned small amounts of thick white secretions, clear from oral cavity. mdi's administered q4 hr alb with no adverse reactions. am abg's 7.26/40/108/19 with no changes.  family to discuss possible withdrawal of support.
"
2638,"resp:  [**name (ni) **] pt on [**last name (un) **] psv 20/10/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick whitish/yellow secretions,pooling secretions in oral cavity.  pt rr ^ to 30's and pt becoming tired, placed back on simv noc to rest. placed back on psv 20/10/40% this am. mdi's administered q4 hr combivent with no adverse reactions.  02sats ^90's no distress noted.  vent settings remain at present settings.
"
2639,"1600-1900
pt is a 70 year old female admitted s/p cabg x4, see admission h+p for details of history and details of events in or. oozy through chest tube on arrival, act 159,  np [**doctor last name **] and dr [**last name (stitle) 1348**] aware, protamine 50mg iv given,peep increased, labs sent, np [**doctor last name **] aware, plts ordered and given, no adverse reactions.

neuro: pt sedated on propofol gtt. perrla.

cv: received from or w/ hr sr 80-90s. epicardial wires work per anesthesia. ekg done. sbp 110-120s on ntg as high as 1.5, see carevue. goal sbp<130. ci>2. pa 20s/15, cvp 7-11. 1l of lr given and 468cc of plts given for volume. dopplerable pedal pulses. k repeted. np [**doctor last name **] aware of mg and phosphate, repeat phosphate sent.

resp: ls clear. see carevue and ccc for abgs and vent changes. presently on fio2 of 60%, rate 12,peep 10. sats 100%. ct draining sang. drainage on arrival 30-60cc q 15min, np [**name6 (md) **] and md [**doctor last name 1348**] aware, protamine and plts given, at present 10-20cc q15-30min.

gi/gu: abd soft absent bs. ogt +placement, draining bilious secretions. foley draining adequate amts of clear yellow urine.

endo: gtt started at 1845 for glucose 116.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. monitor for bleeding, once stable, wake and wean as pt tolerates.
"
2640,"resp: pt rec'd on a/c 22/400/40%/+5. bs are coarse with diminished bases. suctioned small amounts of thick/thin white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=no spont resp. no changes noc.  will continue full [** **] support.
"
2641,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 20/450/10+/50%. alarms on and functioning.ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of tan secretions, as well as oral cavity. mdi's combivent administered with no adverse reactions. will continue full vent support.
"
2642,"resp: [**name (ni) **] pt on a/c 12/400/5+/40%. pt has #8 portex trach. ambu/syringe @ hob. alarms on and functioning. bs are diminished with occasional wheeze noted. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. abg's (see careview) vent changes to ^ fio2 to 60% following abg. no [**last name (un) 125**] due to hemodynamic status. no further changes noted.
"
2643,"resp:  [**name (ni) **] pt on [**last name (un) 205**] pcv 22/+5/rr 18/50%/dp 17.  alarms on and functioning.  bs auscultated reveal bilateral diminished sounds. suctioned for small-moderate amounts of thick white secretions. mdi's administered q6 hrs combivent/flovent [**hospital1 **] with no adverse reactions. rsbi=124. no abg's drawn (no a-line) plans to transfer to rehab when bed available.
"
2644,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions with occasional plugging noted.  mdi's administered q4 hrs combivent with no adverse reactions.  no further changes noted.
"
2645,"resp: pt remains on aprv 34/8/2.7/0.3.40% with no changes noc. mdi's administered q4 hrs alb/atr with no adverse reactions. suctioned for small amount of white secretions. am abg 7.42/44/176/30. will continue support.
"
2646,"resp: rec'd on simv 16/400/5/5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe 2 hob. bs are diminished bilaerally with scattered occasional crackles. suctioned for scant amounts of secretions. mdi's administered as ordered ofcombivent with no adverse reactions. no changes this shift. no [** **] due to hemodynamic issues. pt 02 sats decrease to 80's as well as bp. will continue on present settings. see careview for abg's.
"
2647,"resp: pt remains intubated on aprv 34/8/2.7/0.3/40%. bs reveal bilateral aeration. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.48/32/169/25. no changes noc. [**month (only) **] initiate wean this am.
"
2648,"micu nursing progress note
addendum;

pt family members entered room this am, and asked if he had rec'd meds they were told that he had rec'd haldol overnight [**name8 (md) 20**] md [**first name (titles) **] [**last name (titles) **] order. family members became very confrontational and angry accusing rn of giving a medication that should, in their understanding, have been discontinued d/t percieved adverse reaction. (further investigation of yesterdays rn --drug in question was morphine) this rn attempted to explain why the drug had been given-family members angry and threatening. md [**last name (titles) **] (covering) called and will be up to talk to family.
"
2649,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv 16/650/10+/5/60%.  ambu/syringe @ hob.  auscultated bs reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 moderate to copious amounts of thick yellow secretions.  mdi's administered of albuterol q4 hrs with no adverse reactions.  [**last name (un) **]=52.  no further changes noted.
"
2650,"micu npn
see carevue for subjective/objective data.  neuro:  alert to person, able to accurately state that is in [**hospital1 10**] however confused to time, events of noc, recent events--answering ""no"" to all questions.  moving arms, legs weakly.  speech clear.

cv/pulm:  vs per carevue--at beginning of shift bp low 80's on dopamine at 10mcg/kg/min.  d5ns at 250ml/hr given with bp gradually increased to 100's.  dopa decreased to 10mcg/kg/min with sbp maintaining 100 range.  np at 4l cont.  bs clear upper lobes, crackles developing lower lobes.  overnoc 4units ffp and 2units prbc's given--all without adverse reactions.

gi/gu:  pt npo.  ngt placed by dr. [**last name (stitle) 1752**].  baricat 900ml given however pt [**name prefix (prefixes) **] [**last name (prefixes) 2332**] 100ml around ngt.  to ct for ct of abd at 2400.  ct revealed ischemic colon-->pt rec'd ffp and prbc prior to transporting to or.  to or at 0430 by anesthesia for resection and ileostomy.  four of five sons with pt prior to leaving for or.  u/o borderline qs prior to fluids and blood/blood products not u/o qs q1h.

id:  tmax=100.7 po.  on gent, ampicillin and flagyl.  cultures pending.  ct positive for ischemic bowel as noted above.

integ:  buttocks excorriated.  stool grossly ob positive (dr. [**last name (stitle) 1752**] aware).  skin dry, no open areas noted.

psychosocial:  sons in to see pt upon adm to icu and again prior to leaving for or.  all pt's belongings (including clothes, purse, dentures and two rings--one yellow ring with green stone and one yellow ring with pink and white stones) sent home with son [**name (ni) 9494**].
emotional support given to pt and family.  trans to or at 0430 via bed with anesthesia.
"
2651,"resp: [**name (ni) **] pt on simv 16/400/5/+5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. inner cannula cleaned. pt remains on cvvhd with improved abg's. 7.39/44/108/28. [**last name (un) **]=113. during [**name (ni) **] pt bp decreased, 02 sats to 80's ^ wob. pt placed on 100% fio2 temporarily. plan to continue with support, no weaning expected today.
"
2652,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 16/10/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of thick whitish/yellowish secretions, as well as oral cavity.  mdi's administered q4 hrs combivent with no adverse reactions.  rsbi=60, sbt initiated.  no further changes noted.
"
2653,"respiratory care note:
     patient remains trached with a #8.0 portex.  cuff pressure measured and maintained at ~30.  bs are coarse throughout.  sx for small to often moderate amounts of thick pale yellow secretions via trach.  [** **]'s administered as ordered with no adverse reactions.  patient remained afebrile this shift.  rsbi this am is 57.6 on 0 peep and 5 psv.  spo2 remains 93-97%.  no abg's this shift.  will maintain current therapy.
"
2654,"resp: [**name (ni) **] pt on psv 10/5/50%. bs reveal clear apecies on ls, rs diminished. suctioned for moderate amounts of thick yellow secretions with some bloody tinged. mdi's administered q6 combivent with no adverse reactions. am abg's 7.33/46/115/25. fio2 decreased to 40%, ps to 5. rsbi=43. plan to continue with wean to sbt this am with possible extubation today.
"
2655,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 15/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds. mdi's administered q4 hrs combivent with no adverse reactions. suctioned for small to moderate amounts of tan thick secretions. fio2 decreased to 30%.am abg's 7.30/42/103/21. rsbi attempted and pt became very aggitated, ^ rr with low tv's. no further changes noted.
"
2656,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 18/10/40%  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned/lavarged for some thick tannish secretions & plugs. mdi's administered q4 hrs alb/atr / flov [**hospital1 **] with no adverse reactions. vent changes; ^ ps to 20 with no further changes noted. 02 sats remain @ 100%.
"
2657,"resp: [**name (ni) **] pt on a/c 14/600/+10/50%. pt has #8 portex trach with notable leak. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned moderate amounts of thick white/yellow secretions. [**name (ni) **]'s administered alb/atr/[**last name (un) **] as ordered with no adverse reactions. abg 7.38/61/119/37. no changes noc. will continue full vent support.
"
2658,"micu nsg admission note
25 y.o. woman admitted w/ drug od, s/p suicide attempt. intubated in ew to manage airway, sedated, narcan, mucomyst, ivf-> micu for management.

allergies: haldol (mother states she gets a rash and adverse reaction)
           thorazine (mother states she has adverse reactions)

phx: hx depression w/ multiple suicide attempts s/p sexual assault.
hx self mutilation, has multiple scars over arms and body. discharged from [**hospital 222**] hospital yesterday.

ros:

neuro: propofol off x 30 min to evaluate. +gag, mae, resedated until am.

resp: intubated w/ ventilatory support. 30%/ 600vt/ 14br/ 5cm peep.
clear resp, equal bs. scant blood tinged secretions, spec sent.

cardiac: 70-80nsr no vea, b/p 120/70

gi: ogt in place, no bs appreciated

renal: decreased u.o., monitoring s/p ivf replacement.

lines: #18 peripheralx2, function appropriately

skin: multiple scarring over body, no open wounds.

toxicology: + tylenol, uncertain about other substances.

assess: stable s/p drug od

plan: q4hr mucomyst, ivf, ekg, restrain prn, sedation and intubation throughout night, to reassess in am w/ probable extubation.
"
2659,"respiratory care note:
     received patient of ac as noted in carevue.  patient trached with a #8.0 portex perc. trach.  no changes have been made this shift.  bs are coarse throughout.  sx for small to often moderate amounts of tan thick secretions via trach.  [** **]'s administered as ordered with no adverse reactions noted.  patient remains afebrile this shift.  positional cuff leak noted.  cuff pressure measured and continues to be 30.  team aware of high cuff pressures for trach.  spo2 remains 98-100%.  will continue to monitor respiratory status.
"
2660,"cvvhd d/c'd at 2300fent <to 125/hr, but remained restless, moving about.  bp up to 150-180 w/ agitation.  no additional sedation ordered.  inr 2.3 this am and in order to d/c intrathecal cath and change rij trauma line over to tlc, need <inr.  pt received 4 units ffp (about 1 liter) and inr down to 1.7, but due to emergencies in the unit, unable to d/c lines.  pt will recieve 2 more units at 0400, repeat coags and if inr ok, will d/c intrathecal cath and change cl.   want to continue cvvhd to take off fluid after these infusions, so at 1700, pfr ^ to 700cc/hr.  (cvvhd to be d/c'd when filter clots anyway).  bp was elevated at the time and actually had started labetalol gtt.  bp came down to 110s/ right after starting labetalol and by [**2151**], bp down to 95-105/ - labetalol d/c'd. will continue to take fluid off as pt tolerates until 2330 when cvvhd will be d/c'd.

abg on cpap earlier in the day was 7.36/45/115/98%.

pt had been given haldolx1 earlier in the day in anticipation of going to mra to see if that would be enough sedation for the procedure.  pt actually had an adverse reaction where she became more agitated.

blood cx x2 sent this am.  urine cx also ordered, but not enough urine.

random vanco level sent - pending for pm dose.
"
2661,"7p-7a
neuro: pt sleepy at beginning of shift, following all commands, mae, perrla. pt presently a+ox3. denies pain.

cv: hr 80-90s sr w/ pacs, rare pvcs. at begiining of shift, pt on neo to keep sbp 90-110, sbp labile, on and off neo throughout shift, also on and off nitro during shift see carevue for details. ci>2. see carevue for details of filling pressures. pa nilssen aware of filling pressure readings and aware of cvp readings 0-6, pt received 1 unit of prbcs, no adverse reactions noted. epicardial wires intact, on v demand backup. +palpable pulses.

resp: ls clear but diminished. post abgs acidotic w/ pco2 50s, encouraged is and coughing and deep breathing, repeat abgs showed improvement, see carevue for details. sats >94%, at present on 6lnc sats 98%. much encouragement needed w/ use of is and coughing and deep breathing. ct at beginning of shift draining >100cc/hr, pa nilssen aware, coags sent, unit of prbcs infused as per order.ct dsg cdi, no crepitus no airleak.

gi/gu: abd softly distended, -bs. tolerating ice chips. foley draining clear yellow urine 100-300cc/hr.

endo: insulin gtt weaned to off. will continue to monitor glucose.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. wean nitro gtt as pt tolerates to keep sbp 90-110 maps <85. follow labs. deline in am, increase activity as pt tolerates. pain control.
"
2662,"resp:  resp pt on [**name (ni) **] a/c 26/500/+15/60% from tsicu.   alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal crackles with diminished bases.  suctioned for moderate amount of thick yellow secretions/bloody tinged from oral cavity.  mdi's administered of alb/atr/[**last name (un) **] with no adverse reactions.  02 sats 95-96%.  vent changes of ^rr to 28.  no further changes noted
"
2663,"resp: [**name (ni) **] pt on a/c 28/500/+10/70%. trach #8. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of rusty secretions at beginning of shift, yellow towards end. mdi's alb/atr administered as ordered with no adverse reactions. am abg pending.
"
2664,"resp: [**name (ni) **] pt on a/c 28/500/+10/70%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with diminished bases. suctioning copious bloody secretions. mdi's administerd as ordered with no adverse reactions. pt rr ^ 30's to 40's. morphine given with minimal affect. ct scan results negative. no changes or abg's noc. will continue full vent support.
"
2665,"resp: [**name (ni) **] pt on simv 14/500/15/+5/40%. ett #9 taped @ 24 lip. bs are clear with diminished bases bilaterally. suctioned for moderate amounts of thick yellow/bloody tinged secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. vent changes to psv 15/5/50% with am abg 7.47/40/80/30. rsbi=90. plan to continue to wean with possible extubation today.
"
2666,"cvvhd d/c'd at 2300fent <to 125/hr, but remained restless, moving about.  bp up to 150-180 w/ agitation.  no additional sedation ordered.  inr 2.3 this am and in order to d/c intrathecal cath and change rij trauma line over to tlc, need <inr.  pt received 4 units ffp (about 1 liter) and inr down to 1.7, but due to emergencies in the unit, unable to d/c lines.  pt will recieve 2 more units at 0400, repeat coags and if inr ok, will d/c intrathecal cath and change cl.   want to continue cvvhd to take off fluid after these infusions, so at 1700, pfr ^ to 700cc/hr.  (cvvhd to be d/c'd when filter clots anyway).  bp was elevated at the time and actually had started labetalol gtt.  bp came down to 110s/ right after starting labetalol and by [**2151**], bp down to 95-105/ - labetalol d/c'd. will continue to take fluid off as pt tolerates until 2330 when cvvhd will be d/c'd.

abg on cpap earlier in the day was 7.36/45/115/98%.

pt had been given haldolx1 earlier in the day in anticipation of going to mra to see if that would be enough sedation for the procedure.  pt actually had an adverse reaction where she became more agitated.

blood cx x2 sent this am.  urine cx also ordered, but not enough urine.

random vanco level sent - pending for pm dose.
"
2667,"npn 7a-7p

events:
pt. spiked to 101.6 this am and 102.3 this afternoon.  pt. pan cx'd x stool and sputum this am.  with this afternoon spike, pt. had resp. distress with hypoxia on abg (70's), tachypnea, htn to 220 and rigors. treated with apap, lopressor 10mg ivp with 25mg po, 12.5 demerol.  currently stablized.

review of systems:

[**name (ni) **]  pt. more lethargic and less interactive today.  conts to follow commands with right hand squeezing.  no spontaneous movements noted on left side.  perrla 3-4mm.  or cancelled in light of fever.  rescheduled for tom'row if not febrile.

resp-  received on fio2 of 35% currently requiring fio2 50-70% to maintain sat's >92%.  abg at 1540.  cxr done at the time of resp. distress, results pending.  sx'd q 4 hours for minimal to no secretions.  no sputum spec. obtained.  ls- clear anterior, diminished bibasilar posteriorly.

cv-  hr 70-100 nsr.  mg of 1.5 repleted with 2g.  received 1u prbc in prep for the or d/t hct <30%.  tolerated transfusion well, no adverse reactions noted.  pt. received tyelenol prior to transfusion.  suture sites appear clean and dry.  lue significantly more edemedous and hot compared to right ? dvt.  however, pt. has [**location (un) 890**] filter in place and could not be anticoagulated.  team considering ultra sound.  no signs of cellulitis noted at this time.  elevated on pillows at this time.

gi-  abd soft/ distended.  no bm this shift.  tf restarted at 1pm d/t cancellation of or.  to be stopped at mn for questionable v/p shunt placement tom'row.  ? start ivf at that time, no order presently.

gu-  u/o adequate 40-60cc/hr.  receiving lasix 20mg po qd.

id-  fever spikes x 2 today with tmax 102.3.  conts on iv levoquin.

[**name (ni) 4**] husband and son in this am and plan to visit again tom'row before surgery... appear to be updated on plan of care.
"
2668,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  remains [** **] on propofol currently at 30mcg/kg/min.  did hold sedation this am, pt making eye contact at that time but no attempts to communicate.  mae ad lib.  does pull hands toward ett while raising head off of pillow.  perl, 3mm, brisk.

cv/pulm:  mp=nsr-sb, no ectopy noted.  one unit prbc's given without evidence of adverse reaction; rpt hct pending.  piv x1 intact, site benign.  central line intact, site benign.  r rad a-line intact, site benign.  did receive all scheduled doses of metoprolol and hydralazine.  bp 106-150's/50's-60's.  remains vented with current vent settings ps20/5, tv's 480-520's, 40%.  bs coarse throughout with scattered intermittent wheezing noted.  increased amts secretions noted-->suctioned q2h for sm amts thick tan secretions.  bronchoscopy done by dr. [**last name (stitle) 2014**] with spec sent to lab.  sputum for c+s sent prior to bronch.

gi/gu:  abd soft, non-tender, bowel sounds present.  did start to stool via mushroom catheter at 1430-->melena stool (team aware).  pt to receive go lightly starting at [**2195**] overnight for colonoscopy in am.  pt remained npo except meds initially due to bronch then due to stooling and start of go lightly this evening.  u/o fair; pt received lasix 40mg iv with poor diuresis.  u/o 30-140 most of time although did drop to 12ml/hr x1hr.

id/endo/integ:  tmax 100.7 po.  pancultured at that time as well as fungal culture sent.  no change in abx.  remains on sliding scale insulin coverage per [**month (only) **].  skin care done per wound care recommendations--coccyx and scrotom remain red, raw.  turned q2h with skin care per flowsheet.

psychosocial/plan:  wife in to visit.  emotional support given to pt and wife.  [**name (ni) 14**] is for go lightly this evening, colonoscopy in am.  maintain vent support, monitor vs, i+o, breath sounds, labs/replete as ordered.  [**name (ni) **] with current nursing/medical regime.  pt remains full code, universal precautions.
"
2669,"respiratory care
patient remains trached with no leak noted.  no vent changes made this shift.  mdi's administered as ordered.  no adverse reactions noted.  sx'd for a small to moderate amount of thick tan secretions.  will continue to monitor as needed.

"
2670,"resp: pt rec'd on simv 14/550/+5/5/50%. ett 8.0, taped @ 22 lip. bs are clear with diminished bases. suctioned for moderate amounts of thick brown plugs at start of shift but subsided toward morning. sample sent. mdi's administered alb/atr administered q6 as ordered with no adverse reactions. pt pa02 @ 77 then increased fio2 to 60%, rr ^ to 18 due to ^ co2. am abg 7.28/44/107/22. rsbi=>200. plan to maintain present settings.
"
2671,"resp:  [**name (ni) **] pt on 40% t/c and sitting in chair. pt put back to bed and placed back on [**last name (un) 205**] psv 14/5/40%.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned small to moderate amounts of tan/bloody tinged thick secretions.  mdi's administered q4 hrs/hhn with no adverse reactions. tv's remain in 300's with 02 sats @ 98%. no further changes noted.
"
2672,"resp: [**name (ni) **] pt on psv 14/5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered combivent with no adverse reactions. vt's 400. ve's [**6-29**]. rsbi=57, decreased ps to 10 with 02 sat's @ 96%.
"
2673,"respiratory:  [**name (ni) **] pt on 50% cam.  pt placed back on [**last name (un) 205**] @ noc with settings simv 20/250/5/+5/40% as per dr. [**last name (stitle) **].  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small amount of thick yellow secretions.  mdi's administered q 4 atr with no adverse reactions. rsbi=40. no further changes noted.
"
2674,"resp: [**name (ni) **] pt on psv 18/5/40%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick white secretions. mdi's administered combivent with no adverse reactions. no abg's/no aline. code status changes, plans to be trached.
"
2675,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilater aeration noted. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions.  am [**last name (un) **]'s 7.43/44/97/30. rsbi=88.  continue to wean with possible extubation today.
"
2676,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv12/500/15/+5/40%.  alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small amounts of thick yellowish secretions.  mdi's administered q4 atrovent with no adverse reactions.  pt gets  very anxious at times ^ rr. 02 sats remain in ^90's. ps decreased to 10 where it remains.  no further changes noted.
"
2677,"1900-0700 csru npn
neuro: alert, ox2 at beginning of shift. accusing nursing staff of trying to kill her. ""tell me the nurse's oath so i know you aren't trying to kill me!"" given 1 dose haldol 2 mg iv with good effect. no dilaudid given as pt has denied pain. spoke with niece ""pat"" - strong family hx of adverse reactions to narcotics (i.e. change in ms, hallucinations, aggitation). new order for ibuprofen prn, however pt refusing to take po's at this time. did get pt to take po lopressor. remains wrist restrained for safety as when unrestrained, pt reaches for swan line & chest tubes despite reorientation.

cv: sr, rare pvc's. ntg weaned to off. started on scheduled doses of hydralazine iv & lopressor po. sbp <150. pacer wires attached & functioning - no pacing required. serosang drainage from chest tubes. co/ci by thermodilution wnl. continues on amiodarone iv for ventricular ectopy. filling pressures slightly elevated, see carevue for detailed assessment/vitals/i&o.

resp: o2 weaned to 4 lnc, abg wnl's. no cough/congestion. l/s clear with dim bilat bases.

gi: no bs. took small sips of clears without difficulty. pt refusing ice chips/sips at this time ? d/t orientation.

gu: foley cath not draining. flushed with 40 ml sterile water, only got return of 20 ml. foley cath changed, now draining without difficulty. u/o marginal - hx of 1 kidney. urine clear, no sediment.

lytes: k+ & ca++ repleated as indicated.

endo: insulin gtt on for short time, but now off. last glucose 80.

social: spoke to niece/spokesperson ""pat"".

plan: ? d/c swan & transfer to [**hospital ward name **] 2. monitor glucose/lytes and treat as indicated. oob>chair today in anticipation of transfer. ? po amiodarone when pt more alert & coherent.
"
2678,"resp: [**name (ni) **] pt on a/c 18/450/+5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody secretions to tannish. mdi's administered as ordered combivent with no adverse reactions. no abg's this shift. rsbi=169. will attempt to wean as tolerated.
"
2679,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 23/12/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x 3 small to moderate amounts of thick yellow secretions/bloody tinged/tannish plugs after lavarge.  02 sats @ 100%. mdi's given q4 alb/atr with no adverse reactions/ flovent [**hospital1 **].  vent changes: decrease ps to 18/peep to 10/fio2 to 40%.  am abg's 7.38/38/151/23.  no further change noted. family meeting expected today.


"
2680,"resp: [**name (ni) **] pt on psv 12/8/40%. ett#8.0 retaped and secured @ 23 lip. bs are clear in apecies with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's administerd q4 hrs alb/atr with no adverse reactions. abg's 7.33/52/83/29. rsbi=52. no further changes noted.
"
2681,"respiratory:  [**name (ni) **] pt on 40% t/c.  pt began to tired and was placed back on [**last name (un) 205**] psv 10/5/40%.  bs auscultated reveal bilateral diminished with scattered coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of thick yellowish secretions.  mdi's administered q4h with no adverse reactions. no further changes noted.
"
2682,"resp: pt rec'd via or on psv 22/12/40%. pt has #10 [**first name9 (namepattern2) 10396**] [**last name (un) 482**] trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4hrs with no adverse reactions. no abg's this shift. line not placed in or. plan is to place line today and dialysis before discharge to rehab.
"
2683,"resp: [**name (ni) **] pt on psv 16/10/35%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. no rsbi due to ^ peep. will continue to wean as tolerated.
"
2684,"resp: [**name (ni) **] pt on aprv 34/8/2.7/0.3/40%. ett #7.5, retaped and secured @ 21 lip. bs are clear bilaterally with diminished bases. suctioned for moderate amounts of white secretions. mdi's administered q 4 alb/atr with no adverse reactions. pt has strong cough. no [**name (ni) **] changes noc. am abg 7.41/40/181/26. will continue full [**name (ni) **] support. no schedule for trach as yet.
"
2685,"(continued)
 with gelfoam; no other obvious bleed.
gi: belly softly distended, active bs, no stool. nepro tf's at goal of 30cc/hr with no residuals.
endo: insulin gtt initiated for fsbs 180's; have achieved good control on current rate of 2u/hr (was as high as 5u/hr). cont's on hydrocortisone.
skin: bilateral ue's erythematous, edematous, weeping; elevated on pillows. no other skin breakdown.
social: several children and grandchildren visiting at start of shift; one dtr stayed the night in the room.

note: pt has doumented allergy to several drugs, including heparin and levoquin, both of which she is on. md's made aware, checked with family; apparently reactions not serious and pt wil remain on both, no adverse reactions noted.

a: remains critically ill with poor prognosis

p: continue all supportive measures; anticipate renal consult with possible initiation of cvvhd; support family; pt remains dnr but fill treat.
"
2686,"resp: [**name (ni) **] pt on a/c 22/450/+5/40%. pt has #8 portex trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift.02 sats @ 98%.  [**name (ni) **]=136. plan to wean to ps as tolerated.
"
2687,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv 18/550/10/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral crackles with slight coarseness which improve with suctioning.  suctioned x3 moderate to copious amounts of thick yellow secretions, as well as oral cavity.  mdi's administered q4 hrs combivent with no adverse reactions.  vent changes as follows:  fi02 decreased to 40% with o2 sats in ^ 90's where they remain.  no rsbi performed as [**name8 (md) 20**] md. no further changes noted.

"
2688,"resp: pt rec'd on psv 22/12+/40%. pt has #10 air filled [**last name (un) **] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administerd as ordered combivent with no adverse reactions. pt scheduled for or today for line placement. no abg's or rsbi due to ^ peep. no further changes noted.
"
2689,"resp: pt rec'd on psv 20/5/40%. pt has #8 portex trach. bs are coarse bilaterally. suctioned for small amounts of white thick secretions. mdi's administered combivent/alb as ordered with no adverse reactions.vt' 400-500, ve's 9, rr 25.  [** **]=171. will continue to wean as tolerated.
"
2690,"resp: pt rec'd on psv 24/10+/50%. ett # 7, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally and suctioning for moderate to copious amounts of thick yellow secretions. mdi's administered as ordered of combivent with no adverse reactions. vt's 300's ve's [**9-8**]. plan to trach today in or.  no further changes noted.
"
2691,"resp: [**name (ni) **] pt on psv 20/5/40%. pt has # 8 portex trach. ambu @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. 02 sats @ 100%. vt's 500's. ve 12, rr 24. no changes noc. [**name (ni) **]=196. will continue on present settings.
"
2692,"resp:  [**name (ni) 92**] pt on [**name (ni) **] a/c 14 600/70%/+15. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x 3 for small to moderate amounts of thick bloody tinged secretions.  mdi's administered q 4 of alb/atr with no adverse reactions noted.  minimal air technique used to ^ maintain adequate cuff pressures.  02sats remain  in^ 90's 94-96% with no distress noted.  no rsbi performed dueto high peep pressures.  no further changes noted.
"
2693,"resp: [**name (ni) **] pt on psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. mdi's administered 2 p alb/2p atr with no adverse reactions. pt was extubated without incident and placed on 40% cam.
"
2694,"resp: [**name (ni) **] pt on a/c 20/400/+5/40% alarms on and functioning. ambu/syringe @ hob. pt has #10 portex ([**name (ni) 10396**]) cuff. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. no changes or abg's this shift. will continue full vent support.
"
2695,"resp: [**name (ni) **] pt on psv 20/5/40%. bs are coarse bilaterally. suctioned for small amounts of white thick secretions. mdi's administered as ordered comb/alb with no adverse reactions. no abg's this shift. 02 sats @ 100%. vt's 400's,rr 25-27. [**name (ni) **]=181. no changes this shift. plan to wean as tolerated.
"
2696,"focus: status update
data:
pt much calmer in am and following commands easily and conversing at times. alert and oriented x2. became agitated again early pm and progressing to extreme agitation w/hallucinations,confusion and requiring restraints. ativan per [** 5671**] scale w/some effect.

junky productive cough--tonsil tip sx.

tachy to 120's w/agitation. lopressor and ativan w/effect.

adverse reaction to ambisone noted 5min into infusion start. pt c/o chest pain, dyspnea and became extremely agitated. ekg done w/o changes per dr. [**first name (stitle) **] and ck-iso done. ativan given and ambisone infusion slowed down with some improvement. dr. [**last name (stitle) **] also notified of reaction and wife present at time. agitation is known effect of drug. chest pain relieved with rate reduction.

r neck soft ""bump"" noted this pm--appears lymphatic. dr. [**first name (stitle) **] and dr. [**first name (stitle) 1777**] in to eval. non-line related. will monitor.

urine output bloody for several hours today. foley irrigated x2 clearing this pm. possibly d/t trauma as pt is in constant motion. u/a sent.

plan:
cont [**first name (stitle) 5671**] scale. tx 2u prbc. ct guided drainage postponed per team--f/u in am.
"
2697,"cardiovascular: pt. remains in a controlled sinus rythym in the 60-70's with no noted ectopy. r&l lower ext's require use of a doppler to note pulses, no noted edema at this time. hct:29.3 one unit of prbc's ordered and infused at 2100. tylenol & benadryl given p.o. to aid in adverse reaction prevention. epitaxis remains to saturate gauze every hour.  m.d's are aware and orders to continue integrillin gtt on pt's chart. plans to monitor and educate the pt. regarding adverse  signs. pt. states ""i understand what you are talking about."" pt. is able to repeat these instructions back to the nurse. [**first name (titles) **] [**last name (titles) **]. of hematuria noted in folet collection bag. m.d.'s are aware of this. with no orderes obtained at this time. daughter called last hs to check in on pt. she is a nurse, and is very nice. nasal packing performed once with [**last name (titles) **] [**last name (titles) **]. of petroleum ointment applied to aid in comfort level. no further bleeding is noted at this time. pt. rema1ns in good spirts.
"
2698,"see [**name6 (md) 673**] data, md notes/orders. neuro: very sedated this am, mae, perrl and following commands this pm. propofol and fentanyl gtts decreased as tolerated with [**hospital1 **] haldol initiated. prn ativan dc'd due to pt communicating a reaction to it in the passed, no adverse reaction noted to dose given earlier in shift. had one episode of shaking that accompanied tachypnea, pt nodded head to dt's and then nodded no when asked if he has had them before. shaking resolved spontaneously cv: sr/no ectopy, sbp 130's/80's. cvp 9-13. pulm: vent changes/abg's per [**hospital1 673**]. fi02 incr to 50% from 40% this pm for prolonged tachypnea and drop in 02 sats. tacchypnea  responded to fentanyl bolus but reccurred with activity of suctioning and pts using the bed pan. lungs coarse, decreased at bases, pt suctioned for mod/copious thick tan secretions. left chest tube to water seal, small amount crepitus on left side/abd. gu: uo 45-400cc/hr. gi: abd soft, bs +, passing flatus and large formed and liquid stool which was guiac neg. tube feed currently at 80cc/hr with goal rate 95cc/hr. skin: intact,  4+ pedal pulses. endo: has required no coverage, finger stick glucose decr to [**hospital1 **]. soc: [**hospital1 **] in this pm, updated on progress and poc. p: continue to wean sedation and vent as tolerated, observe for recurring symptoms of dt's, initiate ciwa scale as indicated. increase tube feed to goal rate if residuals <200cc. offer support and encouragement to family.
"
2699,"resp: [**name (ni) **] pt on a/c 22/450/+5/50%. ett #7.0, 22 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with slight coarseness on rml. suctioned for small to moderate amounts of thick tannish secrections. mdi's administered q4 hrs alb/atr with no adverse reactions. vent changes of decrease in fio2 to 40% with abg pao2 @ 76, then increased to 50%. am abg pending. no rsbi due to ^ peep. plan is to wean as tolerated with acceptable abg's,
"
2700,"resp: [**name (ni) **] pt on a/c 15/500/+5/50%. placed pt on psv 12/5/50% and didn't tolerate, placed back on a/c settings. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bialteral crackles. suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr q4 with no adverse reactions. abg 7.45/39/70/28 and no changes noc. rsbi-120. will continue to wean appropriately.
"
2701,"resp: [**name (ni) **] pt on psv 10/5/50%. ett #8 @ 23 lip.alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for moderate amounts of white frothy secretions. mdi's administered alb/atr with no adverse reactions. abg 7.31/68/99/36. rsbi=59.
"
2702,"resp: pt administered mdi's q4  hrs alb with no adverse reactions. some improvement noted following tx.
"
2703,"resp: [**name (ni) **] pt on a/c a/c 22/450/+1/50%. ett#7.0 taped @ 22 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral noted aeration with diminished bases. suctioned for moderate amounts of thick tannish secretions. mdi's alb/atr administered q4 hrs with no adverse reactions. abg's (see careview) am abg 7.29/37/95/19. will continue full vent support.
"
2704,"resp:  [**name (ni) **] pt on [**last name (un) 205**] a/c 10/500/+5/50%.  alarms on and functioning. ambu/syringed @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow/whitish secretions.  mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.36/38/97/22.  pt is full code, md to speak with family today for possible code status change.
"
2705,"resp:  [**name (ni) **] pt on t/c @ 40%.  pt placed back on [**last name (un) 205**] psv 5/5/40% to rest @ [**last name (un) **]. bs auscultated reveal bilateral clears sounds. improvement noted. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=61 this am.  plan to place back on t/c during the day and to get pt out of bed to chair.  will continue to wean appropriately.
"
2706,"nursing admission note:

pt is a very pleasant 51yo man admitted to micu a for pcn desensitization. please see fhpa for further details of pmh, hpi.

all: pcn (rash, ""throat tightenening""), last dose when he was in his 20's.

valuables: pt has cell phone, wallet w/id, watch and some clothing in his room. offered opportunity to lock valuables in safe, but he declined.

ros:
neuro: pt a&o x 3, very pleasant and cooperative. no neuro deficits. pt has intermittent ha which he presented with, which responds well to tylenol. he also has ""spinal ha"" post-lp. he describes this as pain at the back of his neck, radiating up the back of his head. this pain occurs when he is sitting up and is relieved by lying flat.
id: afebrile, wbc 3.1 (4.8). pt given escalating doses of pcn per desensitization protocol. recieved 5 doses without any evidence of reaction. within a couple of minutes of starting the 6th dose (50,000 units), he suddenly began to vomit bilious material, about 300cc's total. dose was immediately stopped, and within a couple of minutes he stopped vomitting. no treatment needed. team notified of this event; after consultation with allergist, doses 4, 5, and 6 were repeated. at this writing, dose 6 is infusing without difficulty, and pt is asymptomatic. plan is to give 7th (full) dose, then start on standing doses if he continues to do well (order not yet written for standing doses).
c-v: hemodynamically very stable; hr 70's, bp 90's-100's. lytes wnl.
resp: pt is on ra with no complaints. ls cta, sats high 90's, rr teens. slight brief desaturation noted at times when sleeping.
gu: voiding clear yellow urine in urinal. bun/creat wnl.
gi: belly benign, no stool. episode of vomitting as described under id.
endo: no issues
heme: hct stable at 31; plt's wnl. no evidence of bleeding.
skin: intact; faint rash on palms and soles of feet.
access: piv x 1.
social: married. wife is spokesperson.

a: tolerating pcn desensitization thus far

p: if he is able to complete desensitizatin protocol, anticipate return to cc7 and continuation of pcn for presumed neurosyphilis. if he has any adverse reaction, will need further desensitization.
"
2707,"addendum: pt has now completed the desensitization protocol without any further adverse reaction. solumedrol, epi, and benadryl at the bedside at all times.
"
2708,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow/white secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  rsbi=54. no a-line.  will continue to wean as tolerated.
"
2709,"admission
pt admitted from or at 1445 s/p maze, asd repair,cabgx4, left atrial appendage repair. to csru in sb 50s, a wires not working appropriately, despite polarities changed, a wires placed in v port to max ma [**name8 (md) 20**] np [**doctor last name **] working appropriately, v wires not capturing appropriatley. v wires secured. ekg not taken at this time d/t pt being paced and sbp decrease when not paced. to csru on neo and propofol. immediatley post-op, u/o 200-1000cc/hr, see carevue. 6 liters total given of crystalloid. 1 unit of prbcs no adverse reactions noted. ci > by fick, see carevue, np [**name6 (md) **] and np [**doctor last name 54**] aware of co/ci. mixed venous sent, result 54, np [**doctor last name 54**] aware, another liter of fluid given + 1 unit of prbcs.

neuro: pt sedated on propofol gtt. perrla. morphine for pain, noted change in vital signs.

cv: hr, noted as above, 84 apaced, no ectopy. goal sbp 110-120s. see carevue for details on neo gtts. see carevue for filling pressures and ci/co. np [**name6 (md) **] and np [**doctor last name 54**] aware, fluid and prbcs given. +dopplerable pedal pulses. right groin ecchymotic w/ small hematoma near right groin from old cath site, team aware.

resp: ls clear diminished. see carevue for details of abgs and vent changes. peep not needed to be increased to 10 [**name8 (md) 20**] np [**doctor last name 54**]. sats >96%.

gi/gu: abd soft, absent bs. ogt +placement, draining bilious/clear secretions, minimal drainage. ct oozy, see carevue for details, received protamine 50mg iv. foley draining clear yellow urine 200-1000cc/hr, np [**doctor last name **] aware, received total of 6 liters of crystalloid, np [**doctor last name 54**] aware.

endo: gtt not needed. fs 101.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. pain control. monitor ci.
"
2710,"resp: [**name (ni) **] pt on psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. mdi's adminisered comvbivent/flovent as ordered without any adverse reactions. suctioned for small amounts of white secretions. rsbi=81. am abg 7.39/45/85/28. plan to continue with wean to extubate.
"
2711,"7a-7p
neuro: pt alert and oriented, disoriented to time only. mae weakly, stiff when tuning pt. see carevue for details of pupils. tylenol po via dophoff for pain, generalized and c/o bilat back of knees aches, np [**doctor last name 54**] aware no new orders.

cv: at approx. 1230, pt to afib rate 80-100s. np [**doctor last name 54**] aware, iv lopressor given total of 10mg ivp [**name8 (md) 20**] np [**doctor last name 54**]. converted at approx. 1500, sb 50s, np [**doctor last name 54**] aware. pt on po dose amiodarone 400mg daily. sbp >90, pt did not tolerate afib sbp 80s, neo as high as 2mcg/kg/min, able to wean neo when pt in sinus rhythm. cvp 9-16. received 1 unit of prbcs, no adverse reactions. aline femoral right intact. see carevue for details. + dopplerable pedal pulses. dusky toes.

resp: ls coarse clears after nt suctioning. nasal trumpet to right nare for frequent nt suctioning. suctioning thick tannish secretions small to copious amts via nasal trumpet. sats >98% on 4-6lnc. see carevue for abgs.

gi/gu: abd soft obese +bs, passing loose dark brown stool via fib. pt failed swallow eval, dophoff placed by np [**doctor last name 54**], ok to use [**name8 (md) 20**] np [**doctor last name 54**]. tf changed to impact w/ fiber goal 60cc/hr at present tolerating 50cc/hr, no residuals. straight cath for amber cloudy urine 15cc. cvvhdf goal -50cc/hr. filter changed secondary to filter clotted while pt in chair. goal 1liter neg for 24 hours. blood given not taken off output [**name8 (md) 20**] np [**doctor last name 54**], goal try to get neo gtt off, then may increase cvvhdf to -100cc/hr. see carevue for details of quinton cath.

endo: riss + lantus dose given sc in am as ordered.

skin: bullae to pt's back, derm into assess pt. broken blisters to bilat legs, groin and labia. groin w/ blisters. see carevue for details of skin assessment. when straight cath, yeast vaginal discharge noted, np [**doctor last name 54**] aware, miconazole ordered.

activity: ok to get pt oob [**name8 (md) 20**] np [**doctor last name 54**] even w/ fem a line by [**doctor last name **]. bed changed to air bed.

plan: monitor hemodynamics. monitor resp. status. nts prn. -50cc/hr via cvvhdf. pain control. wean neo to keep sbp>90.
"
2712,"resp: rec'd on a/c 20/600/+5/40%.ett #7.5 retaped and secured @ 21 teeht. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse which clear following suctioning. suctioned for small-moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. am abg 7.40/52/110/33 with no changes noc. will continue full vent support.
"
2713,"resp: [**name (ni) **] pt on a/c 18/800/+5/70%. bs are diminished throught. suctioned for small amounts of thick tan secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg's 7.45/43/83/31 with no vent changes noc. plan trip to mri today to r/o osteomyletitis.  will continue full vent support.
"
2714,"npn 7a-7p

[**name (ni) **]  pt. remains febrile with low grade temp 100.7 pr tmax.  conts on a/c without vent. wean today d/t febrile state [**name (ni) 87**] as well as cardiac decompensation considerations.  sx'ing needs are diminished compared to yesterday's descriptions. will attempt to turn off propofol gtt tom'row and wean to psv if remains stable [**name (ni) 87**].

review of systems-

neuro-  on 60mcg/kg/min of propofol easily arousable to voice, does not follow commands, makes eye contact, appears frustrated but unable to nod appropritately when interviewed.  moves all extremeties.  occasionally rigid when temps are higher.  will intiate weaning of prop/ventilator tom'row.

resp-  a/c 650 x 24 40% peep 10.  abg on 50% 7.45/36/178/26 this am.  mv 18.5l to maintain pco2.  considerable dead space ventilation.  ls cont to clear with some coarse rales heard bibasilar and crackles prominent on left side.  sat's remain stable.  sx'd q3-4 hours which is much less than yesterday's requirements.  will attempt psv tom'row.

cv-  hr 89-100's sinus rhythm.  bp 110-130's via nbp cuff.  conts on ntg gtt at 1.7mcg/kg/min, lopressor 20mg qid, heparin stable at 1600uhr with [**name (ni) 490**] ptt checks.  edema throughout lower extremeties and dependent regions +[**2-5**].  will be dialyzed tom'row and saturday to remove 4+ l in total.

gi-  abd soft/sl. distended.  sm. smearing of stool this am.  mushroom cath d/c'd d/t low volume of output.  reglan d/c'd d/t possible drug adverse reaction (fever) with consideration that pt. had 1100cc of stool out yesterday and already 300 today.  tf advanced to 20cc/hr and appears to be tolerating.  would consider increasing to 30 this evening.  tpn conts.  need to send next stool for c.diff- toxin b. ? colitis on ct scan.

gu-  minimal urine out.  hd tom'row and saturday as mentioned.

id-  fever w/u persists, all recent culture data negative to date, negative abd ct scan from yesterday.  id following.  restarted zosyn and vanco dosed by level yesterday (31.7 today).  lactate 1.5.

[**name (ni) 4**]  father in today and updated by nursing and sub-i.  would like to speak with cardiology about recent findings before he returns to [**country 8754**] on the 20th.  dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] emailed about this request and should meet with him tom'row.  sw and cm working closely with pt's father to find placement in home country.  father is staying at [**doctor first name 8762**] apt. in [**location 8763**] and is using public transit system- appears comfortable with accomodations.
"
2715,"resp: [**name (ni) **] pt on psv 15/10/50%. bs are coarse bilaterally. suctioned for copious to moderate amounts of thick yellow secretions. mdi's adminstered q4 with no adverse reactions. no rsbi=^ peep or abg's this shift. plan to continue on present setting.
"
2716,"resp: [**name (ni) **] pt on psv 15/10+/50%. ett #7.0 taped @ 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered as ordered of alb with no adverse reactions. pt has episodes of ^ rr to 40's then settles down. am abg 7.50/36/79/29. no rsbi due to ^ peep. will continue to wean as tolerated.
"
2717,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 24/500/+15/65%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse. suctioned for moderate amounts of tan thick secretions. mdi's administered q 6 hrs with no adverse reactions. am abg's 7.40/50/108/32.  decreased fio2 to 50%.  questionable for ards protocol.

"
2718,"resp: [**name (ni) **] pt on psv 15/10/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged to tan secretions. q1-2 hrs. mdi's administered as ordered alb with no adverse reactions. no abg's this shift or changes. no rsbi due to ^ peep.
"
2719,"resp: pt rec'd on psv 15/10+/50%. alarms on and functioning.ambu/[**e-mail address 9422**] are coarse bilaterally. suctioned small to moderate thick yellow to greenish secretions. mdi's of alb administered as ordered with no adverse reactions. vt's 400-500, ve's 11, rr ^ 30's at times. no rsbi due to ^ peep. no abg's this shift. no changes. will continue with present settings. family meeting expected to determine [**e-mail address **] status.
"
2720,"nsg admit note npn
respir: arrived via eu s/p transfer from [**first name8 (namepattern2) **] [**last name (titles) **], with pnx.   had 100% nrb in place o2sats in eu 90-94% on 100% nrb with abg- 7.41/29/74/19, lactate up to 5.8. cxr- r ll pnx, l/s crackles on r clear to diminished on l. was @ first going to be admitted to the floor but with high lactate and rr, and hr was placed on sepsis protocol. central line placed, and was started on iv antibx's. wbc-18. does become very doe and desats very easily with any mask movement. rr 24-30. will be intubated if needed. no abg drawn since admit to micu does not have an a-line. last vbg- 7.36/37/38/22

c/v: sepsis central-line placed with cvp 4-6, in eu and since admit to micu- [**1-12**], did rec 2l's in eu, but with poor respir status and stable hemodynamics, cannot follow the protocol to keep cvp's-[**7-21**], would not tolerate them. has rec'd two 500cc ns boluses since admit, last one just given @ 1830 in attempt to have cvp-8, and to treat high cre. bp- 106-118/70, hr 98-110's st with occ apc's and pvc's. no c/o's cp.

id: temp max 98.8 ax with wbc- 18, was started on iv ceftriaxone and azithromycin, q24 given in eu. was also started zigris iv study, is a double blind study and is to remain continious infusion for 4 days. cultures were drawn @ [**hospital1 **]. [**location (un) **], still awaiting a sputum spec.

gi: is npo @ present is swabbing mouth with ice water. no stools.

gu: u/o 50-75cchr, bun/cre 72/2.4, rec'ing ivb's in attempt to decrease cre.

neuro: is alert and very pleasant. has(2nd) wife, and his daughter that are [**name (ni) **], are involved and very supportive.

lines: central sepsis protocol line r ij and #20 r arm.

a/p: continue to monitor respir status, assess o2 sats and abg's, cxr, aggressive pulmon toilet. monitor i&o's, and cvp's levels. administer iv antibx's. assess for adverse reaction to study drug.
"
2721,"resp: pt rec'd on ffv psv 8/5/50%. vt's 500's ve's [**12-5**], rr 20-22. placed on 70% f/t with cool humidification as tolerated. (see careview for series of abg's) following abg, pt placed back on psv 8/5/50%. hhn administered alb/atr with no adverse reactions. bs are coarse bilaterally. pt has r nasal trumpet. suctioned for moderated amounts of thick yellow and bloody tinged secretions. am abg 7.28/45/142/23. will continue alternating between ffv and f/t to hopefully avoid pt being trached.
"
2722,"resp:  [**name (ni) **] pt on a/c 20/600/+5/40%. ett #7.5,  retaped and secured 21 @ teeth. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally which improve following suctioning. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. no change noc, am abg pending.
"
2723,"micu nursing progress note 7a-7p
pt with increased work of breathing, rr 40s-50, pt increasingly rrestless. intubated for resp failure with 120 succ and 20 etomidate. pt sedated on propofol gtt initially, changed to fentanyl and versed d/t hepatitis. pt became increasingly hypertensive 180s/90s with increased doses. changed back to propofol for ? better sedation but not effective. pt t rapidly increasing to 103.8, rigoring and hr 150. demerol 25 x 2 with no effect. changed sedation to fentanyl and versed with increasing doses for sedation. abg 7.28/25/117/12. 2 amps bicarb given. cont tachycardic, hypertensive. dr [**last name (stitle) **] in to evaluate pt, will also consult toxicology.

neuro - currently on fentanyl 600 mcg/hr, versed 8 mg/hr. [**last name (stitle) 532**], brisk, no spontaneous movement. cont with rigoring but a little less so.

resp - ac 20x600, +5, 60%. rr 25 with sedation, was in high 30s before sedation increased. resp pattern pulling large volumes about 1 lite, mv 27. last abg as above, cont in metabolic acidosis. lungs coarse throughout. very thick, tenacious secretions at time of intubation, now sm/mod thick white secretions. cxr shows worsening pna l>r. zosyn added to antibx regime. sats 96%.

cv - bp 180s/90s. st 160s, ekg shows st. lytes from am repleted. pm lytes have not been repleted. hct stable, wbc 12.2. cvp 14. skin flushed, +[**2-5**] edema, facial edema.

gi - abd soft, + bs. no stool + flatus. ngt to lcs as pt vomitted after intubation, draining dark green bile, ob (+). na increasing 151, ivf changed to d5w with 150 bicarb.

gu - uop borderline 20-50/hr. creatinine increasing.

social - sister and [**name2 (ni) 163**] called and aware of pts worsening condition.

plan - worsening septic picture, ? adverse reaction to meds given peri/post intubation. will cont to follow abgs/labs. toxicology report. replete lytes prn, sedation.
"
2724,"resp:  [**name (ni) **] pt on [**last name (un) 205**] a/c 18/500/+10/60%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of white thick secretions.  mdi's administered q4 alb with no adverse reactions. am abg's 7.34/36/68/18. following family meeting pt is [**name (ni) **]/dni.
"
2725,"resp:pt remains intubated #8 ett, 22 lip and rec'd from or on a/c. bs are coarse with diminished rs.mdi's administered q 4 alb/atr with no adverse reactions. abg's 7.46/39/80/29. vent changes to psv 10/10/60% with additional abg's pending. will continue to wean appropriately.
"
2726,"admission
pt is a 77 year old male s/p cabgx3 and asd repair, see admission h+p for details of pmh and or events.

neuro: pt sedated on propofol. reversed per protocol as 1730, during pm rounds ? wean and extubate d/t earlier issues w/ low ci. pupils 2mm briskly reactive left slightly larger np [**doctor last name **] aware. demerol given x2 for shivers as ordered, resolved after 2nd dose.

cv: received av paced from or-> ekg done nsr pr 0.20- np [**doctor last name **] assessed. presently a paced 80s for sbp. sbp labile, on and off ntg and neo, presently on neo gtt w/ goal sbp 100-110 [**name8 (md) 20**] np [**doctor last name **]. ci<2 by thermodilution, fluid bolus x2 given bringing ci >2 by thermodilution briefly, see carevue for details, fick sent, ci>2 by fick. svo2 62-63%, see carevue, np [**doctor last name **] aware. 1 unit of prbc s given w/ no adverse reactions [**name8 (md) 20**] md [**doctor last name **] for low filling pressures. cvp 6-12. pa 25-30/15-20s. sternal dsg cdi, medistinal dsg cdi. + palpable pulses.

resp: ls clear. sats >98%. see carevue for abgs and vent settings. ct w/ minimal sang. drainage, see carevue.

gi/gu: abd soft absent bs. + placement of ogt. foley draining clear yellow urine 60-400cc/hr, see carevue.

endo: gtt per protocol.

social: son and daughter into visit and updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent, following ci.
"
2727,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 20/400/50%/+10.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of thick yellow secretions. mdi's administered q4 combivent/flov [**hospital1 **] with no adverse reactions. pt appreared rested and comfortable today. rsbi=37 with am abg's 7.37/47/101/28.  pt expected to go to or today for stent procedure.  no further changes noted
"
2728,"ccu nursing progress note
s:  nodding head ""yes"" when asked if in pain, and ""yes"" when asked if the pain was in her hip.

o:  see ccu flow sheet for complete objective data

right hip fracture:  given 1 u ffp and iv vitamin k to correct pt/inr prior to surgery.  repeat pt 14, inr 1.3.  surgery postponed until tomorrow in attempt to get inr <1.1. received 1u prbc over 4 hours, with adverse reaction.  repeat hct 26.1. turned from back to right side, with pillow between legs.  given 25-50 mcg of fentanyl iv prior to position changes.  hr increases to 80-90 with position change, but then quickly returns to patient's baseline 70-80.  remains on propofol 35 mcg/kg/min.

neuro:  shaking head yes, when asked if she can hear me.  also shaking head in regards to pain.  moving arms.  moves hands towards hip during position changes. does not attempt to pull at any iv's or ett.  wrist restraints removed, have remained off during this shift.  spoke with health care proxy today.  [**name2 (ni) **] states that at baseline, ms. [**known lastname 6703**] can ""carry on a conversation"" and ""exercises good judgement, but memory is very poor and would get lost if left on her own.""

resp:  remains intubated, 50% ac x14- 450cc, 5 peep.  pp 19-21.  breathing in phase with the vent.  rare spontaneous resp effort.  o2 sats remain 98-100.  lungs with coarse bs, ets-->small amount of tan secretions.

cv:  remains in nsr, 70-80's transiently up to 90 with position changes.  rare apc.  bp 92-162/48- 83 map's 62-109, with higher numbers occurring with position change.

id:  t max 101.8 rectally.  has been cultured in past 24 hours.  given tylenol via ogt q 4 hours-->t 99.6 rectally.  wbc 11.6 (9.4)  started on levofloxacin iv.

gu:  foley in place, u/o 60-80 cc/hour.  receiving ns @ 100 cc/hour.  bun/cr  22/1.1

access:  tlc in place, dressing changed, only old blood at site.  transparent dsg on, site, clean.

skin:  decube on left glute.  1cmx 1.5 cm, 2 mm deep.  cleansed with wound cleanser, duoderm applied.

a:  s/p right hip fracture, surgery on hold until tomorrow until inr improved.  pain controlled with fentanyl iv q 1 1/2-3 hours.  t controlled with tylenol.  old decube. o2 sats within good range, breathing in phase with vent.

p:  ffp and vitamin k as per team in prep for or in am.  continue position changes, pre-med with fentanyl.  assess response to fentanyl  monitor hct. follow temp, cultures pnd.  monitor lungs, follow o2 sats.

"
2729,"npn 1900-0700

neuro: awake and [** **] throughout night.no appparent nuero changes.recieved 5 mg of ambien @ 0300 to aid  w/ sleep.

resp: continued on cpap,was originally down to ps 12/5 55%fio2 w/ mv's [**1-2**].began slowly dropping sats down to 88-90.attempted suctioning w/ min return.increased fio2 and peep w/ min response.abg on ps 14/8 w/peep of 8 and 100% fio2 was 7.52 pao2 73 pco2 33.continues to go up on peep to possibly re recruit .presently on psv 16/10 fio2 80%. attmpting to wean down fio2 by 10% q hr, following sats.

c/v: aflutter occ pvc's bp low 100's , gave lopressor at this lower systolic rate for better hr control. no adverse reaction to bp.

f/e/n:recieved 10 mg lasix iv w/ brisk response. tol tf @ goal, no stool overnoc.

plan: cont to wean vent settings as tol, cont ab tx, monitor hemodynamics.
"
2730,"resp:  [**name (ni) 97**] pt on simv 26/700/10+/80%.  ett 8.0 24 @ lip.  alarms on and functioning. ambu/syringe @ hob.  bs are diminished bilaterally, with some aeration noted in upper lobes. suctioned for small amount of white secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. pt was bronched yesterday, then recruitment maneuver and became hypotensive.  fio2 ^ to 80%.  vent changes and abgs(see careview for settings and results) present settings simv 18/700/70%/12+.  am abg pending. possible bronch again today?
"
2731,"neuro:

neuro status remains unchanged; pt opens eyes but doesn't track this am. perl mae does not follow commands but is in constant motion in bed. required increase amts of ativan (6mg) w/o ability to sedate. spoke w/drs [**last name (stitle) 4367**] and [**name5 (ptitle) **] [**name5 (ptitle) **] ordered with hopes of producing sedation and pt's safety. total of 30 mg given in 4hrs w/o much change in behavior.
? adverse reaction to benzos, rash still present although not as firey red ? itching making pt so restless or some other issues of addiction resulting in withdrawal sx's.
? worthwhile consulting [**first name8 (namepattern2) **] [**last name (namepattern1) **] who specializes in addiction issues
"
2732,"micu npn  0700-1500
see [** 3326**] for subjective/objective data.  neuro:  remains unresponsive; intermittently moves head and body.

cv/pulm:  r groin dialysis catheter removed at 0800 by renal fellow, per fellow pressure held x15min.  no bleeding following removal of catheter however 10min later site re-bleeding.  fellow in, site held by fellow for additional 15min by fellow.  no bleeding at that time however approx 20min later approx 200ml brb noted at site.  pressure held, intern notified.  two units ffp given, txm for 2units prbc.  no bleeding for 1and 1/2 hr then re-bled approx 50ml.  intern in, site packed by intern, sandbag applied.  ddvph hung at 1300 x1 dose.  receiving first of two units prbc's (hung at 1130; no adverse reactions noted thus far).  no further bleeding at site noted.  remains on levo at 0.7mcg/min.  remains vented per [** 3326**] (on ps).  bs coarse bil.

gi/gu:  tol tf at goal.  fib in place.  receives hemodialysis.  dialysis catheter removed as noted above due to purulent, fowl smelling drainage at site.  to go to ir for new dialysis cath [** **] in am, to have dialysis following [** **] of new catheter.

integ:  see [** 3326**]--healing herpatic lesions, decub on coccyx-->
duoderm applied.

id:  afebrile.  no change in meds.

psychosocial:  social work involved.  no visitors this shift thus far. emotional support given to pt.
"
2733,"micu addendum
no further bleeding from r groin site.  to ir at 1415 for [** **] of new dialysis catheter.  first of two units prbc's infused without adverse reactions; ffp completed without adverse reactions.  remainder assess per [** 3326**]/unchanged.
"
2734,"resp: pt rec'd on psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. suctioned for small amounts of  bloody secretions. mdi's administerd as ordered with no adverse reactions. rsbi=28. will continue to wean as tolerated.
"
2735,"respiratory:  [**name (ni) 97**] pt on servo simv 16/650/12/+5/50%. alarms on and functioning. ambu/syrnge @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning.  pt [**name (ni) **] tonight for a moderate amount of thick bloody secretions.  mdi's administered of combivent q4/flovent [**hospital1 **] with adverse reactions. 02 sats 95-97% with no distress noted.  no further changes.
"
2736,"resp: [**name (ni) 97**] pt on a/c 22/650/10+/55%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, taped @ 22 lip. bs are coarse bilaterally. suctioned for moderate amounts of tan/yellow thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to wean as tolerated with present settings a.c 18/550/+8/55%. abg obtained with results 7.38/50/83/31. plan to trach today.
"
2737,"micu  npn
see [** 3326**] for subjective/objective data.  neuro:  opens eyes to verbal stimuli/tactile stimuli.  reaching r hand toward trach-->r hand restrained (see [** 3326**]).  no attempts to speak.

cv/pulm: bp low this pm-->72/40 with map 51.  intern notified, ns bolus 500ml over 2hrs hung with bp increased to 86-90/30-40, map high 50's to 60.  ns currently infusing, to be completed by [**2081**].  two lumen picc dsg changed.  rec'd 2units ffp prior to [**year (4 digits) **] of peg.  r ej dialysis cath dsg d+i.  remains vented on cpap+ps.  suctioned for sm amts thick yel-->clear sec via trach.  bs clear upper lobes, coarse lower lobes.  trach care done with 1/2 str h2o2.

gi/gu:  peg placed by dr. [**last name (stitle) **] at 1230 without incidence.  med with versed and [**name6 (md) **] by md; tolerated meds without adverse reactions.  peg may be used for meds this pm; to resume tf in am.  rec'd hemodialysis this am-->two liters off [**name6 (md) 9**] hemodialysis rn.  next dialysis due sat [**2153-11-17**].

integ:  healing zoster areas.  packing to r groin changed-->sm amts ser-sang drng on old dsg.  red area at base of coccyx; not open.  multi-podis boot [**month/day/year 3333**] r/l.  hand splints [**month/day/year 3333**] on/off.

psychosocial:  no family contact this shift.  emotional support given to pt.
"
2738,"resp: [**name (ni) 97**] pt on psv 5/5/50%. bs are diminished bilaterally. suctioned for small amounts of secretions. ambu/syringe @ hob.alarms on and functioning. mid's administered as ordered with no adverse reactions. no changes noc. plan is for pt to be trach possibly today.
"
2739,"resp: [**name (ni) 3373**] pt on a/c 28/500/+15/100%. alarms on and functioning. ambu/syringe @ hob. ett #7.5 rotated, retaped and secured @ 22 lip. bs are coarse with diminished bases. suctioned for scant to small amounts of bloody tinged secretions. mdi's administered alb with no adverse reactions. several attempts to place a-line without success. circuit changed to heated. vent changes to decrease fio2 to 80% and maintaing sats @ 96-97%. possible trach today? will continue full vent support.
"
2740,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 14/650/50%/+10.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases.  mdi's administered q4 alb/atr with no adverse reactions. suctioned small amount of thick pale yellow secretions. abg's=7.37/40/82, then increased fio2 to 60%, following abg's 7.37/40/103/24.  no further changes noted.
"
2741,"resp:  pt rec'd on [**last name (un) **] simv 14/550/5/+5/40%. ambu/sryinge @ hob.  auscultated bs reveal increased aeration bilaterally with a few scattered crackles which cleared with suctioning.  suctioned x3 small amount of thick yellowish secretions. mdi's administered q4hrs with no adverse reactions.  rsbi=24.  02 sats@ 100%. no further changes noted.
"
2742,"resp: [**name (ni) 97**] pt on simv/ps 26/700/18/+7/60%.  alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with diminished bases. suctioned for moderate amounts of thick white secretions. mdi's administed q6 hrs combivent/flovent [**hospital1 **] with no adverse reactions. am abg 7.40/32/82/21. no rsbi due to ^ fio2. plan to wean as [**name8 (md) 9**] md.

"
2743,"resp: [**name (ni) 97**] pt on a/c 15/500/+10/50%. trach 10 o.d/7 i.d. alarms on and functioning. ambu/syringe @ hob. bs are coase bilaterally. suctioned for moderate to copious thick yellow secretions. mdi's administered q4 hrs atr with no adverse reactions. no abg's or changes this shift. will continue full vent support.
"
2744,"admission note:

pt is a 83 yo healthy female admitted to [**hospital1 95**] with an embolic r stroke. pt was performing daily stretches this early am, felt weak and heavy on her left side, pt called her daughter then called ems, sent to er code stroke at 0945, ct scan showed embolic stroke to punctate areas of r parietal and frontal lobes (per er). tpa administered in er, focal sz activity noted in lle, mri obtained during sz activity, eeg leads placed after mri, 1 mg of ativan given---> resolution of focal sz activity, arrive in the tsicu at 1400.

neuro: alert and oriented to person place time and situation, slow to respond at times, l sided hemiparesis versus ataxia improving each hour, decreased l sided coordination and proprioception initially, decreasing l pronator drift, resolving l ptosis and facial droop, eom intact, no visual field deficits noted, impaierd sensation to light touch on l side but not deep pressure and pain, improving motor activity on l side in both ue and le, perrla 4mm, impaired cognition with simple addition and subtraction, clear speech.

cv: nsr, blp 120-160 systolic, goal bp between 110-180 systolic, easily palp pedal pulses on r, weak palp pedal pulses on l, afebrile, pneumoboot on, on anticoag for 24 hrs s/p tpa infusion, given 2 l ns bolus in er due to bradycardia during phenytoin administration, phuenytoin d/c'd.

resp: 98% o2 saturation on ra, blscta, on cough, + nasal congestion, nl rr and depth.

gi: last bm this am, active bs, soft abdomen.

gu: foley placed, adequate urine output > 100 cc per hour, on d5w with 150 meq of bicarb for 450 ml then ns at 100, labs sent for updated lytes.

endo: closely monitor bs q 2 hrs for elevated bs, 3 units og req insulin administrated for bs of 150.

skin: cdi with varicose veins.

id: afebrile, no wbc count.

assessment: s/p tpa admin for embolic stroke.

plan: monitor ns q 1 hour, maintain blood pressure 110-180 systolic, monitor bs frequently while on d5w, nursing treatments as indicated, watch for adverse reactions to tpa, cont to monitro and assess as ordered.



"
2745,"resp: [**name (ni) 97**] pt on psv 15/12/45%. ett retaped, secured and biteblock inplace. bs are coarse bilaterally. suctioned for moderate to copious amounts of yellow bloody tinged secretions. mdi's administered alb/atr q4 hr with no adverse reactions. am abg 7.44/47/124/33. vent changes to decrease ps to 12 peep to 10. will continue to wean appropriately.
"
2746,"resp: [**name (ni) 97**] pt on psv 10/5/40%. ett 7.5 23@ lip. alarms on and functioing. ambu/syringe @ hob. bs are diminished bilaterally. suctioned moderate amounts of thick tan to bloody secretions. mdi's administered comb q4/[**last name (un) **] [**hospital1 **] with no adverse reactions.  rsbi=68. plan to address code status with family meeting. no changes noc.
"
2747,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 10/500/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminished bases.  mdi's administered q 4 hrs of alb with no adverse reactions. rsbi=112.  will attempt to wean to ps this am as [**name8 (md) 9**] md. no further changes noted.
"
2748,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14 450/30/+5.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned small amount of thick tannish secretions.  mdi's administered q4 hrs combivent with no adverse reactions.  am abg's 7.44/36/130/25.  rsbi=133.  no further changes noted.
"
2749,"resp: [**name (ni) 97**] pt on psv 5/5/50%. ett 7.5, rotated, retaped and secured @ 20 lip. bs are coarse to clear and suctioned for moderate amounts of thick tan to yellow secretions. mdi's administered alb/atr with no adverse reactions. abg 7.36/40/147/24. see careview for rsbi. no changes noted. plan to keep on present settings.
"
2750,"resp: [**name (ni) 97**] pt on 50% t/c. bs are coarse bilaterally that clear following suctioning. suctioned for moderate amounts of thick yellow secretions. pt is able to expectorate some secretions with strong cough. mdi's administered via trach combivent with no adverse reactions. inner cannula replaced, drain sponge and new trach mask replaced. will continue to follow.
"
2751,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/600/+5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral wheezing. suctioned for small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs combivent with no adverse reactions. cuff pressure @ 21. rsbi=124.  vent changes: decreased fio2 to 40%.  02 sats remain @ 100%.  no further change noted.
"
2752,"resp: [**name (ni) 97**] pt on 40% t/c. ambu/syringe @ hob. bs are coarse bilaterally which clear following suctioning and cough. pt able to expectorate secretions.  mdi's administered q4 hr with no adverse reactions. will continue to follow.
"
2753,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with some scattered wheezing. spoke to team and suggested mdi's. mdi's administered q4 hrs atr/[**last name (un) **] [**hospital1 **]. administered with no adverse reactions. suctioned for moderated amounts of thick yellow secretions. rr ^ to high30's and ^ ps to 20. am abg's 7.47/42/192/35.  vent changes: decreased fi02 to 40%, ps to 15. [**hospital1 239**]=116 with no further changes noted.
"
2754,"resp: pt arrived from osh trached w/#6 portex and placed on [**last name (un) **].  02 sats decreasing and bronch performed.  suctioned copious amounts of thick tan secretions with plugs.  02 sats improved.  abg's (see careview) am abg 723/74/103/33 which shows improvment over prior gas.  rr decreased to 14/450/+5/70%.  mdi's administered alb/atr q4 hrs with no adverse reactions.  pt exhibits some auto peeping. no further changes noted.
"
2755,"resp:  [**name (ni) **] pt on 50% t/c. bs auscultated reveal bilateral coarse sounds. suctioned for thick amounts of yellow secretions. mdi's administered q4 hrs of combivent with no adverse reactions. pt rr ^ to 40's then placed on psv 8/5/35% to rest over night. rsbi=57.  will place back on t/c @ 50% this am.  no further changes noted.
"
2756,"resp: [**name (ni) **] pt on psv 10/5/40%. ett 7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick bloody tinged secretions with some brown plugs. mdi's administered q4 hrs alb with no adverse reactions. rsbi=52. am abg 7.44/35/110/25. no changes noc.
"
2757,"resp: pt rec'd on psv 20/5/40%.ett &.5 retaped x2 and secured @ 23 lip.  bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. pt ^wob with desats to 80's placed on a/c 20/500/10+/40%. am abg 7.46/41/83/30. plan to continue on present settings.
"
2758,"1515-1900 nsg admission note
mr. [**known lastname **] is a 70yo male with pmh/psh of lung ca [**51**] yrs ago with reoccurance of lung ca, renal cell ca, brain mets, s/p l nephrectomy, htn, asthma, hypothyroidism, partial resection brain mass l frontal lobe one month ago, s/p hernia surgery.  pta he was feeling poorly with increasing lethargy.  this am brought to ed by wife for inability to ambulate at home.  in ed initially po temp and bp wnl however o2 sat 80% on ra.  rectal temp checked, found to be 101.2 with lactate of 1.9, developed hypotension with sbp 80's.  treated with 3liters of fluid then levophed started.  pcxr in ed revealed lg r infiltrate, lg r pleural effusion.  rec'd zithromax 500mg po and ceftriaxone 1gm iv both at 1100 in ed, code sepsis initiated at that time.  r ij tlc placed.  ekg wnl.  k 6.7, treated with kayexelate and calcium gluconate with rpt k 5.9.  head ct unchanged from previous films.  abd u/s wnl, renal u/s-->hydronephrosis.  started on dobutamine, trans to micu on [**hospital ward name **] 4 (arrived on [**hospital ward name **] 4 at 1515).  remains on sepsis protocol, levophed, dobutamine.  insulin gtt started, one unit prbc started.
current status:
see fha and carevue for subjective/objective data.
neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  bp remains labile--titrated levo to maintain map>60. currently levo at 0.2mcg/kg/min.   remains on dobutamine at 4.7mcg/kg/min.  mp=nsr-st, no ectopy noted.  one unit prbc currently infusing without evidence of adverse reaction.  100%nrb in place with sats mid to high 90's.  bs coarse bil--rll pneumonia per intern.  congested sounding cough, is not expectorating at this time.

gi/gu:  npo.  abd round, soft, non-tender, bowel sounds present.  no flatus, no bm.  u/o qs q1h via foley; urine yel with sediment (urine for c+s sent in ed).

id/endo:  tmax=96.4ax.  remains on rocephin and zithromax.  fingerstick done, 329--[**first name8 (namepattern2) 20**] [**last name (un) 296**] protocol insulin gtt started--see flowsheet.

integ:  intact.  no open areas noted.

psychosocial/plan:  wife in with pt.  emotional support given to pt and wife.  [**name (ni) 14**] is to maintain sepsis protocol, infuse prbc's as ordered, support bp with levo/dobutamine, titrate insulin gtt per protocol, support resp status, administer abx as ordered, monitor i+o.
cont to provide emotional support/cont with nursing, medical regime.

"
2759,"resp: [**name (ni) **] pt on a/c 20/400/10+/30%. retaped and secured ett. bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. am abg 7.40/51/125/33.  plan to continue with present settings.
"
2760,"resp: pt rec'd on psv 15/5/40%. ett 7.5, retaped and secured @ 23 lip. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.49/46/99/36. rsbi=200. will continue with present settings.
"
2761,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%.  alarms on and functioning.  ambu/syringe @ hob.  cuff pressure @ 21.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 small amounts of tannish thick secretions.  mdi's administered q4hrs with no adverse reactions. no rsbi performed as [**name8 (md) 20**] md.  comfort measures only.  no further changes noted.
"
2762,"resp: pt presently on n/c @ 3 lpm. bs are coarse bilaterally with notable exp wheeze. nebs administered q3-6 hrs alb/atr with no adverse reactions.  pt says, ""she feels better following tx's"" although no significant change with tx.  xray shows no pleural effusions.  will continue to monitor and treat.
"
2763,"resp: pt remains on a/c 25/400/+10/60%. suctioning for moderate amounts of thick yellow secretions. mdi's administered q4 hr combivent with no adverse reactions. am abg 7.38/43/68/26. no rsbi due to^ peep.will continue full vent support.
"
2764,"resp: [**name (ni) **] pt on 40% t/c with humification. bs are coarse bilaerally. suctioned for moderate amounts of thick yellow secretions. mdi's adminstered q4 hrs alb/atr with no adverse reactions. pt has #7 [**last name (un) 482**] secured @ 12 flange. no distress noted 02 sats @ 98%. will continue to follow.
"
2765,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds.  suctioned for small amount of white thick secretions.  mdi's administered q4 alb with no adverse reactions.  rsbi perfomred although no spontaneous breaths noted.  02 sats remain @ 100%. no further changes noted.
"
2766,"resp: pt rec'd on [**last name (un) 205**] psv 12/10/40%.  alarms on and functioning. ambu/syringe @ hob. cp @ 20, trach #7 portex. bs auscultated reveal bilateral aeration with diminished bases. mdi's administered @ 4 hrs alb with adverse reactions. suctioned for small amounts of bloody secretions. am abg's 7.48/32/146/25. no rsbi due to ^ peep. no further changes noted. will continue to wean appropriately.
"
2767,"resp: [**name (ni) **] pt on a/c 15/500/+5/30%. ett 7.5, retaped and secured @ 21 lip. ambu @ hob. bs are clear to diminished at bases bilaterally. suctioned for small to moderate amounts of white to pale yellow thick secretions. sputum sample sent. mdi's administered alb/atr as ordered with no adverse reactions. weaned to psv although pt did not tolerated and returned to a/c (see careview) rsbi attempted resulted in no resps, will attempt again in am. am abg 7.35/45/130/26. family meeting today to discuss cmo status.
"
2768,"resp: [**name (ni) **] pt on a/c 15/400/+12/30%. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions. pt had episodes of ^ wob, sedation issues.  xray reveal bilateral hyperinflation slightly worse than previous. abg's (see careview) vent changes to ^ rate to 20. am abg 7.32/52/147/28. plan: family meeting to discuss cmo status.
"
2769,"resp: [**name (ni) **] pt on psv 10/10/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. ps weaned to 8. am abg 7.44/44/107/31. rsbi=111. plan to wean as tolerated. awaiting cmo status.
"
2770,"resp:  admitted to micu via er for resp distress and placed on ffv bipap. transported to micu on 4 lpm n/c and desated into 70's. pt is on home 02 @ 2 lpm. placed on nrb, then 50vm to maintain 02 sats in 90's. hhn given q4 hrs alb/atr with no adverse reactions.  pt became increasingly dyspnic, and tachy then placed on ffv.  pt tolerated most of the night and taken off this am and placed back on 50% vm.  will continue to follow.
"
2771,"resp: [**name (ni) **] pt on psv 10/8/40%. ett #7.5, retaped and secured @ 23 lip. bs are coarse bilaterally and suctioned for copious amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes this shift. pt continues to breath in ^30-40's. rsbi=147. plan to continue with present settings.
"
2772,"resp: [**name (ni) **] pt on psv 10/5/40%. bs are slightly coarse with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=188 am abg 7.43/44/128/30. vt's 300's ve 11, rr 30-50's at times.  bp ^ 200 pt still appears to be uncomfortable. plan to continue with present settings.
"
2773,"neuro: pt sedated with propofol 10 mcg/kg/min and haldol scheduled dose and prn. given 1 prn dose at 0330 for anxiety. any form of stimulus causes increased agitation. ? how much sleep pt has gotten as he moves around in the bed, appears uncomfortable  but denies pain. pt is more alert this morning. he wanted to watch tv, given tv control but has not used it to change the channel yet.

resp: cpap w/ps 12 peep 5 40%.. lungs clear but dim in the bases. sats 95-100%. abg's this am 7.44/53/92.

c/v: hr 80's to 90's with pvc's occasionally. map 60's to 80's but now lower with additional haldol. does require an occasional bolus of propofol of [**1-31**] ml.

gu/gi: foley patent, draining large amts pale yellow urine after 2 doses of lasix 40mg. abd is soft, distended. surgery in to consult on pt for a ?acute abd. pt was thought to be slightly uncomfortable with left abd palpation. pt is making urine and stool and his vs have been mostly stable, without indication of pain. they will be back to round on him in the am. tube feed infusing at goal. fecal incontinance bag in place with no additional stool noted.

social: daughter called last evening. she wanted to know how her father made it through his blood transfusions. she thought the pt was having an adverse reaction with the first xfusion.  assured her that pt was not having any problems, that he was pre medicated with benedryl and was also given lasix between the two units.

plan: labs drawn. repleat as necessary. surgery will round in the am. continue free h2o boluses until na+ under control. haldol when pt anxious and less propofol as pt shows less anxiety. pt is full code.


"
2774,"resp: pt rec'd on a/c 25/400/+12/60%.ett#7.5/21 lip. bs reveal bilateral aeration with minimal suctioning. mdi's administered q6 combivent with no adverse reactions. am abg 7.36/45/118/26. vent changes to decrease fio2 to 50%, and pt desated to 90, then returned to 60% where she remains. will continue full vent support.
"
2775,"resp: pt rec'd on 6 lpm n/c with 70% f/t. bs are coarse bilaterally with npc. hhn [** 860**] ud atrovent with 0.63 xopenex as ordered with no adverse reactions. will continue to follow. no changes noc. 02 sats @ 100%.
"
2776,"resp: pt ordered for hhn ud atrovent/0.36 xopenex and administered q4 hrs with no adverse reactions. pt also odered for advair discus although pt unable to perform and md/rn aware. 02 @ 3 lpm n/c with 50% f/t. bs are coarse with no changes noc. will continue to follow.
"
2777,"nursing progress note:
pt is alert and oriented x 3. no neuro deficits noted. pt does continue to have c/o severe headaches on level [**8-11**] on a [**2-13**] pain analog scale. relief from dilauded 2mg iv. pt refused toradol, states it gave her severe nausea earlier. pt states that she is not allergic to dilauded and no adverse reactions noted. team is aware. pt's assessment is otherwise negative. cv is nsr, no ectopy with sbp 100-120's per rad art line and nibp cuff.  goal is to keep sbp < 150's. this has been accomplished with po lopressor(now decreased to 12.5 mg po q 12 hr) pt on room air. resp even and unlabored. taking reg diet without difficulty. foley drains qs. no bm yet.

ct and cta both negative. hopeful plan for transfer or home soon,
continue to monitor until then.
"
2778,"npn shift 1900-0700:

neuro: a&ox3. restless. mae, equal strength. perrla. ambien for sleep w/ good effect.

resp: b/l bs present, clear. weaned to room air, tol well. sats 95-98%. no cough.

cv: pt in a-fib, rate controlled in the 90's. rare ectopy. no s/s of cardiac distress. no chest pain. sbp wnl, 90-120's. trace edema ble.  am k+=3.6, not repleted as of yet receiving blood.

hem: hct 28.8, down from 32. tx prbc x1, tol well, no s/s of anm adverse reaction. ptt=120 at 0300. hep decreased to 800u/hr from 1100 u/hr at 0400. ptt to be checked at 1000. ho aware. no s/s of bleed.

id: afebrile.

gi: npo. +bsx4. c/o nausea, no vommitting. compazine given w/ no effect. droperidol 0.675 iv given w/ good effect. no bm.

gu: foley intact. autodiuresing. yellow urine, w/ sediment.





"
2779,"1900-0700

general: pt recieved prep for colonoscopy through the night, bm remain tarry ho aware. pt removed ngt accidentally while sleeping @ 2300 pt given zyprexia.pt medicated for anxiety @ 2330 with lorazepam and replace ngt without difficulty, cxr confirmed placement. hct@2200-30. prbc infusing this am.

neuro: pt sleeping, arousable, responds appropriately but seems groggy. oriented x3, following commands well, maes. cataract bilaterally. anxiety noted once last pm. no restlessness noted.

resp: pt using 2l nc after anxious episode @ 2300. o2sat stable 97-100%. lungs clear/diminished at the bases. no cough noted. no sob noted.

cv: c-monitor a fib through the night, without ectopy. no episodes of cp/ hemodynamics stable. lopressor held due to bp 94/40. pt remains on heparin drip @950units/hour. ptt sent in am. pt remains hypernatremic and d5w increased to 150cc/hr @2300 after chemistry panel reviewed.

gi: abd round soft + bs, prep completed and tarry stools continue. fecal incont. bag placed, incont of stools at this time. stool remains guiac positive. ngt to l nare intact clamped for bowel prep. pt receiving prbc transfusion, no adverse reactions noted.

gu: foley to bsd draining clear yellow urine approx. 50-75cc/hr. minimal edema to ext.

iv: r ij tlc intact.

plan: complete prbc, assess pt for possible colonoscopy today. monitor for excessive bleeding.

                           [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
2780,"resp: pt rec'd on a/c 14/450/10+/60%. ett#7.0, 22 lip. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see carview) vent changes to decrease peep to 7, then 5, increase rate to 16. am abg pending. will continue full vent support.
"
2781,"0700-1500 npn

ms. [**known lastname **] is an 83yo female admitted from osh via [**hospital1 10**] ed to [**hospital ward name **] 4/icu this am.  pmh significant for cad, s/p cabg, angina, ef 35%, chronic renal insufficiency, htn, gout, epigastric pain, non-hodgkins lymphoma, hemolytic anemia, mrsa ? source, depression, s/p laminectomy, s/p bil tkr.  at home takes lasix, coumadin, ""heart and gout medications"", presdisone.    overview of events:  vomited vs. spitting up brb this am (pt not sure) as well as melena stools.  two units prbc's given, third unit up at 1430; two units ffp given.  all blood products given without evidence of adverse reactions.  cordis placed after three attempts, anesthesia in to electively intubate pt for endoscopy.  started on levophed for bp 70's/30's in addition to multiple liters of ns and lr.  endoscopy in progress at this time.

neuro:  was a+ox3; currently sedated on propofol at 20mcg/kg/min.  perl, 2-3mm, brisk.  mae ad lib.

cv/pulm:  mp=afib (not new).  serial cardiac enzymes sent.  bp labile, pt remains on lr at 500-1000ml/hr, ns at 500ml/hr and prbc's third unit currently infusing.  access:  r cordis, r triple lumen femoral line and r 20guage periph iv.  intubated, placed on vent at 1245--
current settings ac10x100%x600x5peep.  bs clear on r, diminished on l with fine crackles left base.  sats difficult to obtain however when able to obtain sats are high 90's to 100%.

gi/gu:  abd round, soft, non-tender to palpation.  stooling melena-->
fib applied but ? stool too thick for bag.  endoscopy in progress at this time.  ngt removed by gi for endoscopy; prior to removal was lavaged x2, draining brb with clots-->500ml total this shift.  u/o clear yellow yellow urine, qs.

id/endo/integ:  afebrile.  sliding scale insulin coverage per [**month (only) **].  skin tear r shin (pt reported to previous shift rn that she hit her leg at home).  no other open areas noted.

psychosocial/plan:  md spoke with family re:  pts status.  endoscopy in progress at this time (lg ulcer found, surgery paged).  will continue fluid resuscitation, levo, labs.  cont vent support, sedation as needed.  emotional support given to pt while awake.  pt is full code, on contact precautions for history of mrsa.

"
2782,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 20/600/50%/+[**1-2**].  alarms on and functioning. ambu/syringe @ hob.  ett taped and secured.  bs auscultated reveal bilateral coarse sounds with an exp. wheeze noted.  mdi's administered q4hr alb with no adverse reactions.  suctioned x3 small to moderate tan thick secretions.  vent changes to decrease peep to 10 where it remains. no further changes noted.
"
2783,"resp: pt rec'd on psv 18/8+/50%. ambu/syringe @ hob. bs are reveal bilateral wheeze. suction moderate amounts of tan secretions and copious clear amounts from oral cavit.  administered mdi's atr as ordered with no adverse reactions. some improvement noted, although pt still has notable wheeze. ^ rr to 30's and placed on a/c 21/400/+8/50% as [**name8 (md) 9**] md to rest noc then to place back on psv in am. rsbi=164. pt is easily aggitated, and bites on tube. sedation issues to be addressed?? no plans to extubate today.
"
2784,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 24/600/+12/5/50% alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  mdi's administered q4 alb with no adverse reactions. eet repositioned and secured.  rsbi=190. no further changes noted.
"
2785,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 24/600/5/50%/+12.  ambu/syringe @ hob. alarms on & functioning.  bs auscultated reveal bilateral coarse sounds which clear with suctioning. suctioned x3 small amount of bloody tinged thick secretions.  mdi's administered q4hrs with no adverse reactions.  rsbi=170, no sbt initiated. pt remains comfortable with no further changes noted.
"
2786,"resp: pt rec'd on psv 15/+8/70%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. vent changes to decrease fio2 to 60%. attempted 50% which resulted in pao2 of 72. mdi's administed of alb as ordered with no adverse reactions. vent changed out due to 02 sensor failure. pt placed on heated circuit. am abg on 60% 7.40/39/88/25. no further changes noted.
"
2787,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv10/550/5/5/40%.  ambu/syringe @ hob.  auscultated bs reveal bilateral slight coarse sounds which clear with suctioning.  suctioned x3 small to moderate amounts of thick yellowish secretions.  mdi's administered of alb/atro q4 with no adverse reactions.  rsbi=25. 02 sats @ 100% with no further changes noted.
"
2788,"resp: pt rec'd on psv 10/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of tannish secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg (see carview) vent changes to ^ fio2 to 60%. am abg 7.44/35/74/25. no rsbi due to ^ fio2.
"
2789,"resp:  [**name (ni) **] pt on [**name (ni) **] psv20/10 50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of tan thick secretions.  mdi's administered q4hr alb with no adverse reactions.  rsbi=230, no sbt initiated.  02 sats @97% with no further changes noted.
"
2790,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 10/550/+5/40%.  alarms on and functioning.  ambu/syringe @ hob. cuff pressure @ 22 cm h20.  bs auscultated reveal bilateral coarse sounds that clear with suctioning. suctioned x3 small to moderate thick lite yellow secretions.  increase in areation noted following suctioning., ^ temp noted.  mdi's administered q4 hrs with no adverse reactions.  02 sats remain @ 100%.
rsbi=35 with no further changes noted.
"
2791,"resp: [**name (ni) 97**] pt on psv 14/5/35% then placed back on a/c 16/350/+5/35%, due to periods of apnea. bs reveal bilateral aeration with diminished bases. mdi's administed alb/atr as ordered with no adverse reactions. small amount of yellow secretions suctioned. changed to heated wire circuit. am abg 7.49/51/141/40%. rsbi=no resps. plan to continue with wean to psv as tolerated.
"
2792,"resp:  [**name (ni) 97**] pt on [**last name (un) 444**] psv 10/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral slightly coarse sounds which improve after suctioning.  suctioned x3 small to moderate whitish/yellowish thick secretions.  mdi's administered combivent q4 hrs with no adverse reactions.  eet secured and retaped.  rsbi=80, sbt initiated.  no further changes noted.
"
2793,"msicu npn 0700-1400
 a&o x3. more alert this am. states bed (1st step) has made a big difference in comfort level. plan was to try to give her pain meds atc. in a.m. we started with 2 tabs of darvocet and 4 mg dilaudid po but she was very sleepy all morning. for next dose, in ? 6hrs, we plan to decrease dilaudid to 2mg and depending on pain level and alertness, decrease darvocet to 1 tab. ketamine has been weaned off with no increase in pain at this time.
 given 1st dose of xeloda. had sm amt of emesis 2hrs post dose but no other adverse reactions noted. treated with 0.5 mg iv ativan with relief.
 uo ~30cc/hr. she remains very volume overloaded for los. currently recieving d5.45ns at 50cc/hr. her po intake is very poor and she can't take most of her oral medication. nutrition to consult for ?[** 1466**]. she does not have a clean line for tpn.
 afebrile.
 family very supportive and in most of day. aware of transfer to medical floor.
"
2794,"resp:  pt received from or and placed on [**last name (un) 444**] psv 15/5/30%.  alarms and functioning.  ambu/syringe @ hob.  bs auscultated reveal sl coarse sounds which improve with suctioning.  suctioned x2 small to moderate amount of thick yellow secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=100.  02sats 97-99%. no other changes noted.
"
2795,"resp: rec;d pt on a/c 16/350/+5/35%. bs are clear with diminished bases. suctioned for small amounts of bloody tinged thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's. 02 sats @ 100%. rsbi =150. plan to wean to psv as tolerated.
"
2796,"resp: rec'd on psv 15/5/40%. bs are clear bilateally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. tv's 400. ve 11 with 02 sats @ 99%. rsbi=or procedure for trach/peg today. will continue with present settingss.
"
2797,"resp: [**name (ni) 97**] pt on a/c 14/450/+5/60%. ett #7.5, 19 @ lip. bs are clear with diminished bases. suctioned for small amounts of yellow secretions. mdi's administered alb/atr with no adverse reactions. vent changes (see careview) with abg's. wean to psv 10/5/35%. abg 7.47/45/88/34. rsbi=115. plan to continue to wean as tolerated.
"
2798,"resp: [**name (ni) 97**] pt on psv 5/5/50%. ett #7.5, retaped, rotated and secured @ 20 lip. bs are coarse to clear and suctioning moderate amounts of thick yellow frothy/thick secretions. mdi's administered alb/atr with no adverse reactions. no vent changes noc. am abg 7.38/38/164/23. rsbi=19. plan is to extubate when pt is more awake.
"
2799,"resp: pt rec'd on psv 5/5/40%. ett 7.5 rotated, retaped and secured @ 22 lip. bs are coarse bilaterally and suctioning for small amounts of bloody tinged secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.43/34/146/23. rsbi=29. plan to wean as tolerated.
"
2800,"resp: pt rec'd on psv 16/8/100%. trached #8 portex. bs are coarse bilaterally which improve with suctioning. suctioned moderate to copious bloody thick secretions. mdi's administered q4 hrs combivent with no adverse reactions. abg's (see careview)pt had episodes of desaturation which reflect vent changes. presently on psv 14/8/50%/. 02 sats @ 98%, vt's 700-800, ve 15l, rr 20's. no further changes noted.
"
2801,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. [**last name (un) **] small amount of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  vent changes psv decreased to 10.  rsbi=142, no sbt initiated.  no further changes noted.
"
2802,"npn 7 am - 7 pm

s: "" i don't want to take epogen, it is not good for me""

o: please see caeview for vitals and other objective data

pt sp extubation yesterday for pna and chf. doing well respiratory wise, continues to diurese, able to wean off o2 as pt refuses to wear it most of the time. pt was improving mental status wise this am, with moments of clarity "" i was at [**hospital **] hospital yesterday"", however after his am dose of dilaudid pt awoken and became paranoid, and at times refusing meds, refusing care, able to follow commands but unable to focus on anything. feels ""he has to get up"" unable to say why. team updated, dilaudid now dc'd, may continue oxycodone but perhaps wait until tonight as he is better off with out it currently. pt was at times refusing medication today, however when his wife came in she did convince him to take all his meds. tolerating po meds, refuses any food or liquids except pills with apple juice.

cv- sr, hr 70's up to 90 this afternoon when very agitated, back down to 80's after labetolol. nifedipine held as pt is on alot of bp meds and bp remained 103-120 systolic until 4 pm today. pt was hypotensive last night after nifedipine. edema is markedly decreased but persists
 lower extremities.

respiratory: pt has rll pna and some pulm edema persists, crackes to dim at bases. cxr is improved over last two days. pt coughing up thick
secreations and spits or swallows them. samle from [**last name (un) 1180**] washing pending identification. vanco was dc's today ( level 20.3) and continues on po azythromycin and iv zosyn. afebrile today. pt on 4l nc, but complaint of nasal congestion and removed o2, refused mask,  sats stayed 94-97 percent on room air.

[**name (ni) 554**] pt has several loose stools this afternoon, team updated, slightly quiac positive, send any further stools for c diff per team.

endocrine: fs lower today, 93. 107, 120 spoke with [**name8 (md) 373**] md we will place pt on decreased  lantis at 12 unts per day, given at 6 pm.

a: pt with improving pna and chf, extubated x 24 hours, doing well but having adverse reaction to narcotics ( as pt is prone to this).

p: continue to monitor resp status, cv, q 6 hour bs with ss, continue antibiotics, send stool for c diff if loose stool continues, dc dilaudid, pt may take 0.5 mg ativan for sleep as he does at home. follow neuro status and comfort pt, safety risk, will require [**name8 (md) 3152**] if he goes to floor today.
"
2803,"resp:  [**name (ni) **] pt from [**name (ni) 104**] intubated and placed on [**last name (un) **] simv 10/850/50%/[**4-23**].  alarms on and functioning. ambu/syringe @ hob.  bs auscultated revealed bilateral coarse bs. suctioned for moderate amount of green/yellowish thick secretions.  mdi's given q2 hrs of alb with no adverse reactions.  bs presently are bilateral clear apecies with rs insp wheeze noted.  rsbi=25. no further changes noted.
"
2804,"resp:  [**name (ni) 97**] pt on a/c 18/400/+5/30%.  pt has #7 portex trach. bs are coarse to clear. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. pt had i/d abdominal abscess procedure in or and remains on a/c.  rsbi attemped resulting in no resps. plan to wean to psv as tolerated.
"
2805,"resp:  [**name (ni) 97**] pt extubated and on 70% f/t with 4 lpm n/c in order to maintain sats in 90's.  bs auscultated reveal bilateral coarse sounds with some scattered wheezes noted. hhn given alb/atr q4 hrs with no adverse reactions. pt placed on ffvm @ [**name (ni) **] and remained on psv for a significant amount of time, then placed back on f/t 70%/4 lpm n/c.  questionable mental status? will continue to follow.
"
2806,"resp: [**name (ni) 97**] pt on t/c @ 60%. pt ^ wob then placed back on psv 10/5/50% to rest noc. suctioned for small amounts of thick yellow secreitons. mdi's administered of alb/atr as ordered without adverse reactions. rsbi=89, then ps decreased back to 5. will continue with trach trials today.
"
2807,"resp: [**name (ni) 97**] pt on psv 10/5/50%. portex #7 trach. bs reveal bilateral aeration noted with diminished bases. suction small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. trach care performed, some oozing around trach site. pt does have some episodes of ^ wob to 30's. no a-line/abg's this shift. rsbi=129. plan to wean as tolerated.
"
2808,"resp: [**name (ni) 97**] pt on psv 8/15+/60%. pt has #8 portex trach in place. alarms on and functioning. ambu/syringe @ hob. pt placed on a/c 18/550/15+/60% to rest noc. bs are coarse bilaterally which improve following suctioning. suctioned for moderate amounts of thick tan to bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. no further changes noted. 02 sats 93-96% with no abg's this shift. will continue to wean as tolerated.
"
2809,"0700-1500 npn
see carevue for subjective/objective data.  events of day:  attempted to wean ventilator this am--rsbi 65, pt placed on ps.  tolerating sbt for first 2hrs then developed increased sob, hr 120's.  placed back on ac with resolution of symptoms within 20min.  no further weaning this shift.  single dose vanco given for vanco level 11.5; kphos infusing over 6hrs at this time.

neuro:  at this time pt is [** **], nodding ""yes"" and ""no"" appropiately. mae ad lib.

cv/pulm:  mp=afib, isolated pvc's noted.  hct 25.5 this am; rec'd one unit prbc without evidence of adverse reaction.  rpt hct due at 1600.  remains on heparin gtt at 1700units/hr; next ptt due at 1800.   remains vented ac24x500x40%x5peep.  bs coarse, diminished bil.  suctioned for thick white secretions via ett.  weaning attempt as noted above--no further weaning this shift.

gi/gu:  ngt clamped at this time--will need tf resumed if not extubating soon.  mushroom cath placed for stooling.  anuric--receives hd m/w/f.

access:  l double lumen picc in place.

id/endo/integ:  tmax=99.1 po.  sliding scale coverage for fingersticks.  buttocks-->open area as noted on carevue.  both heels with black areas therefore multi-podis boots applied to both feet.

psychosocial/plan:  family in to visit.  emotional support given to pt and fam.  pt remains full code at this time.
"
2810,"resp: pt remains intubated on a/c 15/500/+10/50%. bs are coarse bilaterally. suctioned for thick amounts of tan secretions. mdi's comb q4 hrs with no adverse reactions. am abg 7.40/35/116/22. no vent changes noc. will continue full vent support.
"
2811,"resp: [**name (ni) **] pt on psv 12/5/50%. ett #7.5, taped @ 23 lip. bs are clear with diminished bases. suctioned for scant amount of white secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.43/45/140/31. rsbi=88. no changes noc. plan sbt in am then extubation.
"
2812,"resp: [**name (ni) **] pt on a/c 20/400/+5/40%. alarms on and functioning.  ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 of combivent with no adverse reactions. no changes or abg's this shift. will continue full vent support.
"
2813,"resp: rec;d pt on psv 15/10/30%. ett #8.0 retaped, rotated and advanced from 20 to 22 cm @ lip as per xray/md. 02 sats @ 100%. vt 600's, ve's 7. bs auscultated reveal bilateral clear apecies with slightly coarse bases. mdi's administered as ordered alb/atr with no adverse reactions. pt scheduled for or @ 1300 today. am abg 7.50/40/90/32. no rsbi due to ^ peep.
"
2814,"resp: [**name (ni) **] pt on psv 10/10/40%. ett #7.5, 23 @ lip. bs are coarse, diminished on rs. suctioned for large amounts of thick white/with occasional plugs. mdi's administered alb/atr with no adverse reactions. vt' 300-400, ve's 13-17, rr 36-47. pt had episodes of ^ wob [**name (ni) **], bolus given, bp issues, pt family meeting to change status to cmo. am abg 7.37/45/126/27. no rsbi due to ^ peep. will continue with present settings.
"
2815,"resp: pt rec'd on psv 7/7/50%. bs are coarse bilaterally. suctioned for small amounts of thick tan secretions. mdi's administered alb/atr/[**last name (un) **] as ordered with no adverse reactions. no abg's this shift with rsbi=99. will continue to wean as tolerated.
"
2816,"resp: pt rec'd on 35% humidified t/c. pt has #7 portex trach with cuff deflated. bs are coarse to clear and able to expectorate secretions. coughing up thick tan to bloody tinged secretions. mdi's administered via trach of combivent with no adverse reactions. or procedure today (stent).
"
2817,"resp: pt rec'd on 35% t/c with humidification. bs are coarse to clear and pt has strong cough. some bloody secretions expectorated, possibly due to aggressive suctioning during day. mdi's administered via trach of combivent with no adverse reactions. pt has #7 portex trach with cuff deflated. no resp distress noted. will continue to monitor.
"
2818,"resp: pt on 40% t/c with portex trach#8. bs are coarse bilaerally and suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. 02 sats continue @ 100% with plans for rehab. will continue to follow.
"
2819,"resp: [**name (ni) **] pt on a/c 16/470/+10/40%. ett 7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with occasional wheeze noted. suctioned for small to moderate amounts of yellow to white thick secretions. mdi's administered q4 combivent with no adverse reactions. no rsbi due to ^ peep. no abg's this shift or changes. plan is to wean as tolerated.
"
2820,"resp: pt remains on a/c 12/500/+10/50%. bs coarse to diminished with noted aeration. suctioned for small amounts of thick yellow secretions. mdi's administerd q4 combivent with no adverse reactions. no changes noc. am abg 7.42/45/124/30. will continue full vent support.
"
2821,"resp: [**name (ni) **] pt on a/c 12/500/+15/50%. bs are clear bilaterally/diminishe bases. suctioned for small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. rsbi= 7.46/39/175/29. will continue full vent support.
"
2822,"resp: [**name (ni) **] pt on a/c 16/500+5/60% ett #8.0 retaped and secured @ 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear to coarse with minimal suctioning required. mdi's started and administered qid 4 p atr with no adverse reactions. no abg's or changes this shift. will continue full vent support.
"
2823,"1900-0700

general: received pt with labored resp and audible exp wheezing noted. abg 7.44/56/41/29/+3. resp treatment administered with minor relief. face tent increased to 70%, o2sat remained 88-100% through evening. intermit. periods of agitation noted. morphine 2mg given at 2230 with minimal benefit. cardizem 10mg ivp given at 2230. lasix 20mg given at 2330. potassium supplement ivpb completed. pt became more comfortable as the evening progressed. ptt 53, 3am bolus of heparin given + increased drip to 600u/hr.am labs drawn.

neuro: pt awake/alert/oriented, perla,follows commands well. moves all ext. uncooperative at times, attempting to remove o2.soft wrist restraints applied as needed. no neuro deficits noted.

resp:labored resp through evening, using accessory muscles. o2 sat 88-100%. lungs with exp wheezing and diminshed bs bilaterally. no cough noted. pt denies sob. multiple resp treatments received throughout the night. face tent remains at 70%.

cv: nsr-st through the evening with occaional pvcs noted. denies cp. weak but palpable pulses to ext. afebrile. bp 170-120, hr 115-88. nitroglycerin drip started and titrated to 2mcg/kg/min. no adverse reactions noted. skin warm/dry/intact.

gi: abd round slightly distended. +bs x 4 quad. receiving tpn for nutritional supplement. guiac neg stool x1.

gu: foley intact draining clear yellow urine.

iv: rij tlc intactdsg changed. heparin@600u/hr, nss@kvo, nitroglycerin@2mcg/kg/min, [**e-mail address 10421**]/hr. r piv d/c'd due to reddness and irritation.

plan: supportive care for unstable resp status. evaluation of fluid balance and treatment.
                          [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
2824,"resp: pt on 40% t/c with #8 portex trach.  [**e-mail address 10312**] reveal bilateral coarse sounds with occasional exp wheeze wi.th forced expiration. pt continues to have periods of anxiousness. mdi's administered via trach alb/atr with no adverse reactions. pt being screened for rehab. will continue to follow
"
2825,"resp: [**name (ni) **] pt on 50% t/c with 02 sats @ 100%. bs are coarse which clear with suctioning. suctioned for small amount of white secretions. mdi's adminisered alb/atr via trach with no adverse reactions. ambu/syringe @ [**name (ni) **]. fio2 decreased to 40% with 02 sats @ 100%. pt remains on t/c through night with no resp distress noted. will continue to follow.
"
2826,"resp: [**name (ni) **] pt on psv 5/5/30%. ett 7.5 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral coarseness which improve with suctioning. suctioning small to moderate amounts of tan-yellow-clear secretions. mdi's administered atr with no adverse reactions. am abg with results pending. rsbi=57. vt's 400-500. ve 11, rr 20-23. plan is to attempt extubation this am.
"
2827,"resp: pt rec'd on a/c 151/550/+5/40%. ett 7.0 rotated, and retaped @ @3 lip.  bs are coarse to clear with suctioning. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. pt remains on pressors. abg 7.42/27/89/18 with 02 sats @ 100%. rsbi=no resps with plan to continue working of guardian/cmo status. pt remains on full vent support.
"
2828,"resp: pt rec'd on simv 10/600/10+15/50%. pt has portex #8 trach. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administerd as order alb/atr with no adverse reactions. (see careview for vent changes and abg's). am abg 7.40/47/115/30. rsbi=68.  will continue to wean as tolerated
"
2829,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500+5/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of tannish thick secretions, later in am greenish/yellow.  pt pushed out biteblock, reinserted, pt biting down on ett, decreasing sats to 88. hr ^ to 140's.  mdi's administered q4 combivent with no adverse reactions. rsbi=140, no further changes noted.
"
2830,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c14/500/10/50%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for thick yellow secretions. mdi's administered q4 with no adverse reactions.  no vent changes noc.  plan to trach today.
"
2831,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500/+5/60%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal ^ aeration on ls with notable decrease on rs. cxr taken revealing eet slipping into r mainsteam.  eet pulled back to 20 cm @ lip. equal bs noted.  mdi's administered q4hr combivent with no adverse reactions.  suctioned x 3 moderate amount of thick bloody tinged secretions.  pt is anxious when not sedated and tried to self extubate.  no further changes noted.
"
2832,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500/50% /+5.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned moderate amount of thick tanish secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi initiated, no spontaneous breath taken.  02 sats @ 97%.  no further changes noted
"
2833,"resp: pt remains on pcv with changes in peep ^18/pinsp ^38 to maintain a dp of 20. multiple abg's (see carview). vt's 350, ve's [**9-4**] with 02 sats mid 90's. suctioned for small amounts of pale yellow secretions, some bloody tinged from oral cavity. mdi's administered as ordered with no adverse reactions. no further changes noted. will continue to wean as tolerated.
"
2834,"resp: [**name (ni) 97**] pt on pcv 42/+22/dp 20/r34/40%. ett #7, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and diminished at bases. suctioned for moderate amounts of [**name (ni) **] yellow secretions. mdi's administered q 4 alb with no adverse reactions. had episodes of desaturation, then increased fio2 to 50% where it remains. no further changes noted. will continue full vent support.
"
2835,"resp: [**name (ni) 97**] pt on psv 12/7/40%. bs are coarse bilaterally.suctioned for moderate amounts of thick yellow secretions. mdi's administered combivent/[**last name (un) **] as ordered without adverse reactions. no abg's this shift. rsbi=85. plan to continue to wean psv as tolerated.
"
2836,"ccu nsg progress note 7p-7a/ s/p cva

s- not speaking, not answering questions

o- see flowsheet for objective data

[**name (ni) 112**] pt remains hemodynamically stable- hr- 70-80's sr, no vea. bp- 140/70-162/81- no need for prn hydralazine this shift.
no issues currently.

resp- clear lungs, resp rate- 16-22- o2 sats on 2l mid to high 90's, no sign of distress, no cough this shift, no sputum production.

id- afebrile- plan for ? lp/tee to r/o endocarditis this monday for (+) wc.

lines- 3rd iv in 2 days- d/c this time d/t infiltration- restarted 4th iv- #20 rt ac- remains patent.

[**name (ni) 87**] pt [**name (ni) 7207**] [**name (ni) 7208**] 3, [**last name (lf) **], [**first name3 (lf) 20**]- rt side weaker grasp than left. to command not holding up rt arm as high, as strong a grip but
when agitated later in shift, moving both arms almost equally- grasping up at the air, etc.
not speaking to wife, to family, nor to staff. early in shift- sometimes tracking and following when speaking to him. later in shift, after ativan iv for ct scan- sleeping,not opening eyes.
ct scan reveals no change from initial no worsening from prelim report.
pt started on dilantin 100 tid iv ,after load of dilantin with level of  14 last evening.

[**name (ni) 89**] pt requiring [**name (ni) 7084**] called ho from ct scan - for agitation, inability of scan to be completed with movement. pt [**name (ni) 57**] 2 mg ativan, then repeated 15 minutes later. able to complete scan finally after 1 hour in ct. see above for prelim results.

upon arrival to room, pt more agitated and wife becoming very upset upon learning pt received sedation meds. pt has a documented ""adverse reaction""- confusion to this class of drugs but it was explained to wife [**name (ni) **] calling the daughter) that this was necessary per medical judgement and clinical status of pt. son came in to pick up pt's wife to bring home and he was very upset as well.

both t sicu and neuromed resident informed as to family's issue with pt receiving med and also with son not being notified as to pt going for ct scan. son also upset over interpreter not being called in ct scan as opposed to pt being medicated, even though it was explained to him that the wife, who speaks portugese as well, indicated the pt was
confused pre - transfer to ct scan.

t sicu resident came up to speak with family. nsg clincal advisor came up to speak with family as son is interested in making a formal complaint- he was referred to pt relations and given insturctions and phone # to call them monday morning.
of note, there is a signed icu consent in chart dated [**7-13**] from phone consent/translation from daughter of pt that gives permission and consent to icu procedures and modes of care, including ""sedation""..

pt son said he clearly stated in er (where pt had first received ativan with a ct scan and became confused) that he had wanted to be called for all meds/procedures and for pt to not get that medication anymore. neither of the icu/neuro medical teams nor ccu nsg staff were apparently aware of this wish of the son.

son, daughter in law and wife via translation understand current plan of care, pt
"
2837,"resp: [**name (ni) 97**] pt on a/c 20/500/+12/40%. bs reveal bilateral aeration with some coarseness, no wheeze noted. suctioned for small amounts of bloody tinged secretons. mdi's administered alb/atr with no adverse reactions. abg's pa02 decreased, then ^ fio2 to 50% with no improvement, then ^ to 60% and ^ peep to 15. am abg on changes pending. will continue to wean as tolerated.
"
2838,"resp: [**name (ni) 97**] pt on psv 10/10/40%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. sample sent. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg 7.34/38/101/21. pt placed on simv 18/600/10/10/40% to rest noc. plan to continue to wean to psv as tolerated.
"
2839,"resp: [**name (ni) 97**] pt on a/c 18/600/+5/40%. ett 8.0 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally which improve following suctioning. suctioned for small amounts of thick yellow secretions as well as oral secretions.  mdi's administered q4 hrs [**last name (lf) 7186**], [**first name3 (lf) **] [**hospital1 **] with no adverse reactions. am abg 7.41/34/110/22. rbsi=98. plan to discuss with family code status. family does not want pt to be trached.
"
2840,"resp: [**name (ni) 97**] pt on a/c 30/550/18+/60%. ett#8, retaped,roated and secured @ 24 lip. esophogeal balloon in place. bs are clear bilaterally in apecies with diminished rs. 02 sats 93-95,then suction for copious amounts of thick brown plugs. vent changes to ^ peep to 20 and fio2 to 70%. (see careview for abg's) mdi's administered q4 combivent with no adverse reactions. am abg 7.44/48/88/31 then decreased peep to 18. will continue to wean fio2 as tolerated.
"
2841,"resp: [**name (ni) 97**] pt on psv 10/8+/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of white thick to thin secretions. much improvement noted. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. no aline/abg's 02 sats @ 100%. rsbi=77. plan to continue t/c trials.
"
2842,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/400/+5/40%.  alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral crackles with a few scattered wheezes.  suctioned x3 for moderate amounts of thick yellow secretions. mdi's given q4 hrs atr/alb with no adverse reactions.  rsbi=144 this am.  pt is alert and awake. 02 sats @ 100%. ett retaped and secure @ 20 cmh20/lip.  no further changes noted.
"
2843,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #8.0 taped @ 25 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for bloody thick secretions. mdi's administered alb as ordered with no adverse reactions. rsbi=43. am abg 7.44/36/111/25.  plan to extubate today.
"
2844,"resp: [**name (ni) 97**] pt on psv 10/8/50%. pt has #8 portex trach. ambu/syringe @ hob. alarms on and functioning. bs are coarse. suctioned for moderate amounts of tan to bloody tinged thick yellow secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. vt's 400's, ve's 11, rr 24. 02 sats @ 100%. no aline/or abg's this shift. rsbi=53. plan to continue with t/c trials today.
"
2845,"resp: [**name (ni) 97**] pt on psv 5/5/50%. pt has #8 portex. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tan secretions. mdi's administered of combvient/[**last name (un) **] as ordered without adverse reactions. pt had episode of ^ wob and rr, then ^ ps to 16, peep 8.  vt's 400-500, ve 12, rr 27. rsbi=92. no abg's (no a-line). will continue to wean with t/c trials as tolerated.
"
2846,"resp: [**name (ni) 97**] pt on 70% t/c and was on all day. bs remain coarse bilaterally. mdi's administered combivent/flovent with no adverse reactions. pt lasted to 3:00 am then became sob, ^ wob, suctioned for moderated to copious thick yellow secretions. pt was lavarged and ambued resulting in removal of plug. placed pt on vent psv 10/5/50% and has been comfortable with 02 sats @ 100%. plan to continue with t/c trials as tolerated.
"
2847,"resp: [**name (ni) 97**] pt on a/c 20/500/+15/60%. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration with occasional wheeze, although improvement noted. suctioned for small amounts of tannish thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg  7.42/44/87/30. vent changes; decrease fio2 to 50%. 02 sats @ 95%. will continue to wean as tolerated.
"
2848,"nsg progress note
overview of history:
ms. [**known lastname 7142**] is an 83 yo female admitted to [**hospital1 95**] [**2172-7-24**] from home following a fall down the stairs, fx r tib/fib secondary to fall.  to or for repair of fx.  in pacu received morphine for pain, became confused, hypoxic, hypotensive.  levophed started, swan'd, trans to micu for further care.  ruled in for mi. pmh significant for old mi with stents placed, htn, as, chf, type ii diabetic, dialysis x5yrs, tia's, old cva without residual effects, rectal ca, fem [**doctor last name **] bpg, osteoporosis and depression.  in micu remained on levo, intubated-->weaned off levo, off vent.  [**2172-7-27**] afternoon developed afib, cardiovered x2 without success, intubated for airway protection then started on amiodorone.  following start of amiodorone converted to nsr, has remained in nsr.
current status
neuro:  sedated with propofol at 20mcg/kg/min.  pt opens eyes to tactile stimuli but no attempts to speak or mouth words around ett.  moving arms on bed, no leg movement noted.  r pupil brisk, 2mm.  l pupil irregular, fixed (many old eye surgeries).

cv/pulm:  mp=nsr, no ectopy noted.  remains on levophed currently at 0.103 mcg/kg/min with map's 60's.  one unit ffp given without evidence of adverse reaction; will hold second unit ffp until transferred to ccu.  r cordis with tlc through cordis intact.  r periph iv capped.  remains vented ac12x500x40%x5peep.  bs clear upper lobes, coarse lower lobes.  suctioned for sm amts thick white secretions.

gi/gu:  ogt in place, clamped.  abd soft, non-tender, bowel sounds present.  no flatus, no bm.  pt rarely voids (0-1x/day), no foley in place (had uti upon admission to hospital).   receives hd 3x/wk; last dialysis mon [**2172-7-27**].

id/integ/endo:  tmax 99.5 po.   no change in abx.  r leg dsg changed by ortho; per ortho incision approximated.  scant amt old ser-sang drainage noted on old dsg and new dsg.  multi podis boot to stay on r leg at all times per ortho.  no open areas noted.  sliding scale insulin coverage.

psychosocial/plan:  fam in to visit, updated on plan of care.  emotional support given to pt and fam.  plan is for pt to trans to ccu; will be swan'd in ccu.  cont pressors, vent support, sedation.
"
2849,"resp: [**name (ni) 97**] pt on psv 5/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow to tan secretions. mdi;s administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt had episode of desaturation and ps ^ to 15 peep ^ 8 02sats % 99-100%. weaned psv back to [**3-27**] with vt 400/ve 9/rr 22. rsbi =75. plan to attempt t/c trials as tolerated.
"
2850,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #7.5, 19@ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. mdi's administered q 4hrs atrovent with no adverse reactions. am abg 7.45/34/121/24. rbsi=40 no changes this shift or gag reflex noted.
"
2851,"resp: [**name (ni) 97**] pt on a/c 18/450/+5/40%. ett#7.5, 19 @lip. alarms on and functioning. ambu/syringe @ hob. bs are clear with occasional coarse sounds which improve with suctioning. diminished bases bilaterally. suctioned for small amounts of thick white secretions. mdi's administered q4 hrs atrovent with no adverse reactions. trip to ct with results pending. am abg's7.50/26/363/21 with no changes. family meeting today to discuss cmo.
"
2852,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett 37.5, 19 @ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear with diminished bases. suctioned for small amounts of yellow secretions. mdi's administered q4 hrs atrovent with no adverse reactions. [**name (ni) 239**]=44. am abg's 7.43/37/110/25. plan today is to wean to extubate.
"
2853,"resp: pt remains on vent a/c 12/500/+8/40% and is vent dependent. bs are slightly coarse which improve following suctioning. suctioned for small amounts of white thick secretions. mdi's administered as ordered with no adverse reactions. no changes or abg's this shift. 02 sats 2 97%. no rsbi due to vent dependency. will continue full vent support.
"
2854,"resp: [**name (ni) 97**] pt on a/c 24/450/+5/50%. alarms on and functioning. ambu/syringe @ hob. pt is [**name (ni) **] with # 8 [**last name (un) **] (foam filled) trach. bs reveal occasional wheeze with slight coarseness. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease fio2 to 40%, rate to 20, and tv 400 reflects abgs. am abg 7.40/58/88/37. no further changes noted.
"
2855,"npn 7a-7p

events- c. diff positive, 2.5l ns bolused, vasopressin added, neosynephrine off, echo done showing suppressed ef consistent with sepsis, le u/s done results pending, abx regimen changed.

review of systems-

neuro-  fentanyl gtt increased from 30mcg/hr to 75mcg/hr (gradually) in the setting of attempting to decrease respiratory drive and manage metabolic acidosis.  pt. remains very alert to voice, easily arouses.  family describes adverse reaction to use of versed, would cont to use fentanyl to achieve desired level of alertness.

resp-  vent changes- tv increased to 600cc from 550, peep increased from 8 to 10, fio2 decreased from 100% to 90%.  latest abg pending, most recent 7.27/43/114/21.  ls- bronchial on right (has rll pna on cxr), diminished on left.  abx regimen changed from ceftriaxone to ceftazadime.  sat's maintained >94%.  currently, unable to obtain peripheral sat.

cv-  hr 80-90's nsr with some ectopy.  map >60 maintained with pressors.  vasopressin started at 11a at 0.04u/min.  neo weaned quickly off thereafter.  levophed is coming down nicely as well.  however, lactate conts to be 3.4 range, and creat has bumped from 1.3 to 1.5.  mixed venous sats 74, 84.  cvp 12,7. echo showing depressed ef (unmeasurable d/t poor study). dobutamine was discussed.  however, given ability to come down off pressors, will hold on inotropy for now.  plan-  goal cvp >12, map >60, decrease pressors as tolerated, bolus for low u/o and higher lactates, consider dobutamine if svo2 drops, cont to follow hct q4, next full set of labs due at 8p.

gi/heme-  abd distended, c.diff +.  conts on flagyl.  highish gut residuals (120 cc at 1600).  tf started at 10cc/hr, not advanced d/t high residuals.  500cc of stool out, [**male first name (un) **] colored, liquid, heme +.  hct stable 38 througout the day.  plt trending down to 44.

gu-  u/o problem[**name (ni) **] today only 5-10cc/hr.  given 2.5l ns.  bun/creat elevated throughout the day as mentioned.

id-  abx changed as mentioned, needs vanco trough tonight.  most likely source of infection is nosocomial pna and c.diff as well as uti from [**1-24**].

social-  multiple family members in today, coming in [**apartment address(1) 5958**] by 2, fellow updated on plan of care for today.
"
2856,"resp: [**name (ni) 97**] pt on psv 8/5/50%. bs reveal noted aeration. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.46/35/91/26 on 40% fio2. rsbi=63, cuff check and adequate leak noted. continue to wean appropriately.
"
2857,"resp: [**name (ni) 97**] pt on a/c 18/450/+5/40%. alarms on and functioning. trach#8.0 shiley with no inner cannula. bs are coarse bilaterally. suctioned copious amounts of thick green secretions. mid's administered as ordered of atrovent with no adverse reactions. am abg 7.38/55/116/34. will proceed to wean as tolerated.
"
2858,"resp: [**name (ni) 97**] pt on a/c 24/500/+5/40%. pt has #8 portex trach. bs are coarse to clear bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. am abg 7.40/50/106/32. rsbi=62. plan: wean as tolerated.
"
2859,"resp: [**name (ni) 97**] pt on 50% t/c. pt became tired and complained of ^ wob then  placed back on vent to rest noc. psv 8/8/40%. suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. no abg's this shift. rsbi=33. plan: continue with t/c trials as tolerated.
"
2860,"resp: [**name (ni) 97**] pt on psv 8/8/40%. pt has #8 portex trach. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no abg's noc. rsbi=57. plan: continue with t/c trials as tolerated. pt being screened for rehab.
"
2861,"resp: [**name (ni) 97**] pt on a/c 32/600/10+/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. pt biting on ett, block placed. ett retaped and secured. mdi's administered as ordered with no adverse reactions. abg's (see careview) vent changes to decrease rr to 28. am abg 7.30/36/146/18. rsbi= no resps.
"
2862,"7a-7p
neuro: pt alert, nodding appropriately, moving all extremeties. following all commands.perrla. morphine ivp given prn pain. denies pain at present time.

cv: hr initially 70-90s sr 1st degree avb. converted to raf 130s-140s, w/ stable sbp 110-120s at 1230, ntg weaned to off. lopressor 5mg given. total of 20mg ivp as ordered per pa [**doctor last name **]. mg 2gm given. amiodarone iv bolus 150mg x 2 given, gtt started at 1mg/hr as ordered. at present still hr 100-130 on gtt, pa [**doctor last name **] aware. during event, pt alert and nodding appropriately. swan placed at bedside, see carevue for filling pressures. ci >3 before af, after af ci>2, pa [**doctor last name **] aware. 1 unit of prbcs given for hct <28, no adverse reactions. repeat hct 33.2. epicardial wires in place atrial ma turned to off secondary to inappropriate atrial pacer spikes. v wires not capturing or sensing appropriately. palpable pulses.

resp: ls coarse. suctioned for scant thick tan. trial on cpap fio2 40%, 5peep, 8ps. abgs 7.30/47/133/24/97%, pa [**doctor last name **] called and aware, vent change to ac 8, improving abgs. see carevue for details.

gi/gu: abd soft hypoactive bs. ogt replaced secondary to tee done in am, +placement verified by two rns. lasix 200mg and diuril 500mg iv given as ordered, bringing u/o >100cc/hr.

endo: insulin gtt restarted, as high as 6units/hr.

social: husband visited and updated, sister called and updated w/poc.

plan: monitor hemodynamics. monitor resp. status. monitor blood glucose. monitor hr. monitor u/o. keep pt comfortable.
"
2863,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/400/+5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with slighlly diminished bases. mdi's administered q4 of alb with no adverse reactions. suctioned small amounts of yellow/white secretions with an occasional plug. am abg's 7.40/62/97/40.  rsbi=26. no further change noted. extubation expected this am
"
2864,"resp: [**name (ni) 97**] pt on psv 15/8/50%. ett #8, 23 @ lip. bs are coarse bilaterally. suctioned for copious amounts of thick tan secretions. mdi's admistered as ordered alb/atr with no adverse reactions. am abg 7.40/45/99/25. rsbi=66. will continue to wean as tolerated.
"
2865,"resp: [**name (ni) 97**] pt on psv 10/10/40%. bs are coarse bilaterally. suctioned for thick amounts of tannish secretions. mdi's administerd as ordered alb/atr with no adverse reactions. pt desat in 80's with ^ wob and placed back on a/c. multiple abg's (see careview) with vent changes to decrease r to 20. rsbi= no resps. am abg pending. will wean to psv as tolerated.
"
2866,"resp:  rec'd a/c 20/600/+12/40%. bs are slightly coarse with diminished bases. suctioned for small amounts.suctioned moderate amounts from oral cavity. mdi's administered as ordered with no adverse reactions. am abg 7.30/43/90/22. no changes noc. no rsbi due to ^ peep
"
2867,"resp: [**name (ni) 97**] pt on psv 12/10/40%. ett 7.5 24 @ lip. bs are coarse bilaerally with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's adminisered as ordered with no adverse reactions. vt's 400-500, ve's 12'[**49**], rr 24 with ^ to 30's at times.  am abg 7.43/44/101/30. rsbi=^peep. no changes noc. continue to wean as tolerated.
"
2868,"resp: [**name (ni) 97**] pt intubated via er for airway protection. placed on a/c 16/500/+5/50%. bs are clear bilateraly with diminished bases. mdi's administered as ordered with no adverse reactions. rsbi=no resps x2.plan to wean as tolerated.
"
2869,"resp: rec;d pt on psv 15/10/50%. ett #8 retaped and secured @ 23 lip. bs are coarse bilaterally. suctioned for small to moderate amounts of thick yellow to tannish secretions. mdi administere as ordered alb/atr with no adverse reactions. pt had episode of tachycardia around midnight, lopressor administred pt back into sinus.  peep decreased to 8. am abg 7.40/45/99/29. rsbi=76. willl continue to wean as tolerated.
"
2870,"resp: pt remains intubated ett#8, 23 @ lip. psv 15/+/50%. bs are coarse bilaterally and suctioning copious amounts of thick white secreitons. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.34/42/160/24. rsbi=66. plan to trach and peg today.
"
2871,"nursing note 7p-7a
s:""can i get some water father"".
o: see flow sheet for all objective data.
[**name (ni) **] pt remains confused to place/time, awake most of noc. restless with periods of calling out names, frequent reorienting needed. given seraquil/olanzapine doses, held ativan d/t ? adverse reaction.
cv- in af with rare pvcs, hr 70s-90, nbp 130-140s/70s. conts on po captopril/lopressor. post transfusion hct 33.1, k+ 3.5, repleated with 60meq po, mg 2.3.
resp- ls clear diminished in bases. conts on 2l nc sats 98-100%. r flank ct site dsg cd+i, no oozing.
gi/gu- tf promote+fiber conts @ 70cc/hr via peg tube, site cd+i. incont of stool x3, [**name (ni) **] pt is on c-diff precautions, drinking fluids. foley patent voiding qs clear yellow urine. diuresed with 100mg iv lasix with good response. i+o neg 1l this shift.
skin- buttocks red/raw, duoderm intact to r cheek.
a/p: 72yo male admitted on [**3-31**] with hypoxia requiring intubation d/t chf exacerbation. s/p r thoracentesis c/b pneumothorax requiring chest tube placement. pt extubated and ct pulled [**4-4**]. hematoma @ ct site requiring sutures. s/p cabg [**1-14**] c/b a long icu stay d/t chf, pericardial effusion and pneumonia, c-diff. [**year (2 digits) **] to monitor i+os, hct and lytes with diuresing. monitor for safety d/t confusion.
"
2872,"resp: [**name (ni) 97**] pt on [**last name (un) **] simv 12/600/5/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs reveal i/e wheezes with rs diminished. suctioned moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr and [**last name (un) **] [**hospital1 **] with no adverse reactions.  abg's 7.34/41/118/23. rsbi=44. no further changes noted.
"
2873,"resp: [**name (ni) 97**] pt on psv 12/10/40%. ett 7.5, 24 @ lip. bs are slightly coarse with diminished bases. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. vt's 500-600, ve's13, rr 28. no changes or abg's this shift. 02 sats @98%. family meeting today to discuss cmo with possible withdraw in afternoon. will continue with present settings.
"
2874,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 18/550/40%/+[**4-23**]. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds with slight coarse bases. suctioned x3 small amount of bloody secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=65, sbt initiated.  02 sats @ 99%.  no further changes noted.
"
2875,"resp:  [**name (ni) 97**] pt intubated from or.  ambu/syringe @ hob. placed on 7200 briefly then extubated and placed on sm @ 6lpm.  bs auscultated reveal bilateral diminished sounds, pt complains of not being able to breath.  02 sats remain 98-100%, rr 16-15. hhn ordered and administered x3 during noc alb/atr with improvement noted. no adverse reactions noted. pt on n/c @ 4lpm with no distress.  no further changes noted.
"
2876,"micu 7 rn report 0700-1900

events: wean to trache collar o2 40%, bleeding from rsc dialysis cath site.

neuro:  [** 19**] oriented x3 periods of anxiety, follow commands. communicated by writing and mouthing words. @ 1600 ^anxiety and adb/incision discomfort [**5-8**] received dilaudid 1mg and ativan 0.5mg w/effect.  mae,equal strength, pupil 2mm brisk.

cv:  hr 50-72 a fib, sys bp 130-180/85, hypertensive episodes sbp>170 noted when anxiety, iv ns kvo. rsc hd tunnel cath bleeding drg changed x3 eval by ir injected site w/fibrin. lt brachial picc working well. rt arm piv.

resp:  received on vent cpap 5/5/40%. @1130 vent weaned to trach mask 40%. spo2 92-98%. tol for shift plan to reamin on tm for noc. lungs coarse bil. productive cough thick yellow sputum.

gi:  abd soft  + bs, tf nutren pulmonary 30 cc/hr tol well. mushroom cath draining brown color liquid stool.

gu:  anuric,during 12 hr shift 10 ml urine drained.hemodialysis done removed 2200cc. no adverse reaction noted. plan for another hd [**6-5**].

endo: fs q6h as per sliding scale

skin: wound coccyx dressing intact. abd surgical wound debridement done by [**doctor first name **] collangenase oint and packing dsd,  no drainage,

social:  relative visited. dnr, dnh

plan: supportive care
      hemodialysis [**6-5**]
      [**hospital 1366**] rehab [**6-5**]
"
2877,"resp: pt rec'd on psv 10/5/40% ett 7.0 18@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick yellow to white secretions. mdi's administered alb with no adverse reactions. abg's (see careview)ativan administered and changes to place pt back on a/c. rsbi attempted. will try again in am when sedation lightened. plan to wean to psv as tolerated.
"
2878,"resp: pt rec'd on psv 5/5/40%. ett #8, taped @ 24 lip. ambu/syrine @ hob. bs are clear with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. vt's 500-600, ve [**11-10**], rr 25. 02 sats @ 100%. am abg 7.38/40/114/25 with rsbi=74. plan to continue to wean as tolerated.
"
2879,"resp: [**name (ni) 97**] pt on psv 2/5/40%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, taped & secured @ 23 lip, 23 cp. vt's 500, rr 16. bs auscultated reveal bilateral crackles. suctioned small amounts of thick white secretions. mdi administered q4 hrs with no adverse reactions. will continue full support.
"
2880,"resp: pt remains intubated on a/c 18/650/+10/50%. bs are clear bilaterally. suctioned for small amounts of secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.44/35/159/25. no vent changes noc. will continue full support.
"
2881,"resp: [**name (ni) 97**] pt on psv 10/5/40% (mmv back up rate) bs auscultated reveal bilateral crackles. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. vt's 400-480, rr 18-22.am abg 7.40/59/97/30. no further changes noted. will continue to follow.
"
2882,"admission
pt is a 77 year old female admitted from cath lab, s/p stenting of left cx and rca. presented to er this am ~0600 from nh due to pt being lethargic,code stemi done after ekg done, intubated in er due ? responsiveness. on dopamine as high as 15mcg/kg/min in cath lab, at present time dopamine at 5mcg/kg/min.

neuro: pt tracks rn when being spoken to, does not follow commands, perrla. no indication of pain.

cv: hr 60-80s sr. arterial sheath [**name6 (md) **] by md [**last name (titles) 7625**], act 160. right groin cdi, no bleeding, no hematoma venous sheath kept in. dopamine at 5mcg/kg/min. sbp labile, 70-110s. fluid bolus 500cc given as ordered, improving sbp. hct for 23.9, transfused 1 unit of prbcs, no adverse reactions/ ekg done on arrival as ordered, elevated st, slightly improved per ccu team. +dopplerable right dp/pt, +dopplerable left dp, absent pt on left. ccu team aware, no new orders. next ck due 1900. bp on left arm only per ccu team, right has old fistula that does not work.

resp: ls clear. orally intubated, weaned vent to cpap [**5-10**] fio2 40%. ccu team aware of abgs (md [**doctor last name **]). see flowsheet for details. unable to get sats at times, ccu team and md [**doctor last name **] aware. sats when showing 100%. sputum culture sent.

gi/gu: abd soft hypoactive bs. ogt +placement. clamped at present [**doctor first name **], ok to hook up to lcs [**name8 (md) 9**] md [**last name (titles) 7626**]. foley draining 0-10cc/hr of amber color urine. left subclavian hd cath [**last name (titles) 240**]. ua and uc sent.

endo: per sliding scale.

plan: wean vent. assess neuro (pt with hx of dementia). ck due 1900. hct pending. blood cultures when aline placed. ?aline placement. wean dopamine. full code.
"
2883,"resp: [**name (ni) 97**] pt on psv 12/5/40%. alarms on and functioning. ambu/syringe @ hob. 7.5 ett taped and secured @ 23 lip. cp 23 cmh20. bs auscultated reveal bilateral crackles. suctioned for scant to small amounts of thick white secretions. mdi's administered q 4 hrs with no adverse reactions. vent changes to decrease ps to 10. am abg's 7.36/56/94/33. rsbi=63. no further changes noted.
"
2884,"resp: [**name (ni) 97**] pt on ac 12/600/+5/50%. ett #7.5 24@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick tannish secretions. mdi's administered q4 alb/alb with no adverse reactions. am abg 7.40/32/140/21. rsbi=125. pt is scheduled for trach/peg in or today.
"
2885,"resp: [**name (ni) 97**] pt on a/c 18/650/+10/50%. ett#7.0, 24 @ lip. bs are slightly coarse. suctioned for small amounts of tannish secretions. mdi's administered q 4 hrs. alb/atr with no adverse reactions. am abg's 7.47/32/207/24. no vent changes noc. will continue full vent support.
"
2886,"resp: pt rec'd on 18/650/+12/50%.  bs are clear. mdi' administered alb/atr with no adverse reactions. vent changes to decrease peep +10. abg's 7.43/34/169/23. no further changes noted. will continue with full vent support.
"
2887,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/550/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral slight coarse sounds with crackles in bases. suctioned small amounts of white/yellowish secretions.  mdi's administered q4 atr/alb with no adverse reactions. placed pt on psv and didn't tolerate.  rsbi=155.  am abg's 7.33/44/101/24.  will continue to wean as tolerated.
"
2888,"resp: [**name (ni) 97**] pt on a/c 14/500/+5/40%. ett 7.0, 22 @ lip. bs are coarse to clear and suctioning small to moderate amounts of thick yellow secretions. mdi of atr administered as ordered with no adverse reactions. no abg's or changes noc. will continue present support.
"
2889,"0700-1900 npn
alert, oriented, coperative with care.  mae.  pain not well controlled this am, c/o sharp stabing pain with cramps, [**10-21**] pain.  neurotin dose started with minimal effect. pca increased and ativan iv given with limited effect.  aps into consult and epidural placed and started on bupivicane/dilaudid epidural with good effect.  able to titrate up without adverse reactions. given valium and ativan for breakthrough.  tmax 99.9, hr 60-60 nsr 4 beat run vtach x1, asymptomatic.  bp stable 130-140's.  pp palpable, sm amt generalized edema.  lungs clear, using is with encouragment.  abd tender, greatly improved with epidural, hypoactive bowel sounds.  ngt lcs.  urine adveraging 30cc/hr.  dsg intact, jp sites intact, no breakdown.  stoma pink, sm amt serosang output.  plan to increase activity as tolerated, monitor pain and medicate prn, monitor hemodynamics, provide emotional support to patient and family.
"
2890,"resp: pt on hi-flow mask @ 40%. nebs administered as ordered alb/atr with no adverse reactions. bs are coarse bilaterally with no change following tx. will continue to follow and monitor.
"
2891,"neuro: pt. is a&ox3, cooperative, followign commands, +mae, +perrla, intact gag/cough. had 1 episode of anxiety attack after tee, treated with ativan 1mg ivp. pt. is on clonopin [**hospital1 26**].
resp: ls diminished bilat, in am sats 80s-90s on 40%fio2 oft. encouraged to cough and deep breath with sats up to 90s immediately after. cxr showed emphysematous changes, lll atelectasis, no chf. at 1200 pt preped for tee by cardiology, medicated with 50mcg of fentanyl, 2mg of versed ivp per orders, cardiology administered hurricane spray for the procedure, during the procedure pt became cyanotic with face and extremities turning purple-[**doctor last name 797**], sats droped to 70s, pt developed hurricane induced methenoglobulemia treated with methylene blue iv (total of 38ml ivp per orders). serial blood gases obtained via periph. stick with improvement (see careview for results). fio2 increased to 100%, pt. diaphoretic right after procedure, but with stable bp, denied sob or breathing discomfort. at 1600 sats up to 80s, pt. verbalizing, appeares more comfortable. at 1700 pt. taking a nap with sats in high 70s-80s.
cv: hr 70s-90s, nsr, no ectopy, bp 100-130s/50s-60s.remains on captopril, lopressor po. tee done to r/o endocarditis, revealed ef of 55%, mild mitral regurge, no signs of infection. hct 26, started on iron po
gi/gu: abd. soft, distended, +bs, no bm today. npo for tee, started on ice chips and sips of clears, maintain free h2o restrictions [**2-3**] na 130. foley patent, clear yellow urine out, turned green after methylene blue administration, to be expected per team.
skin: lt. foot dsg changed, cultures obtained by podiatry, multipodis boots applied bilat. per orders.
id: t max 101, remains on iv piperacillin, vanco.
access: a-line discontinued due to call out status which was changed after hurricane induced adverse reaction.
social: son with wife visited, updated by md and nursing on events of the day, plan of care.
"
2892,"resp: pt rec'd on mmv (see carview for psv back up settings). bs are coarse bilaterally and suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. am abg 7.37/36/143/22. rsbi=78. plan to wean psv to possible extubation today.
"
2893,"resp:  [**name (ni) 97**] pt on 7200 ps 20/+15/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that clear with suctioning.  suctioned small to moderate thick yellowish/whitish secretions, and also out of oral cavity.  mdi's administered q 4hr alb/atr with no adverse reactions. eet retaped, moved and secured.  vent changes as follows; a/c 18/650/+15/40%.  02 sats remain in ^90's over noc with no additional changes noted.
"
2894,"resp: [**name (ni) 97**] pt on a/c 10/450/+5/45%. bs are coarse bilaterally. suctioned for small to moderate amounts of white secretions as well as oral secretions. mdi's administered alb as ordered with no adverse reactions. rsbi=127. pt more awake. plan to wean to ps as tolerated. no abg's no a=line
"
2895,"resp: [**name (ni) 97**] pt on a/c 20/500/+5/40%. bs reveal bilateral aeration. no wheeze noted. suctioned for small amounts of yellow secretions and bloody secretions x1, rn/md aware. mdi's administered q4 hrs combivent with no adverse reactions. rsbi attempted=no resps. no changes noc.  will continue full vent support.
"
2896,"resp: [**name (ni) 97**] pt on [**last name (un) **] simv 15/600/10/14+/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished bases with aeration noted in apecies. mdi's administered combivent 2 p with no adverse reactions.  suctioned for small amounts of white/yellow secretions. am abg's 7.38/44/98/27.  vent changes reflect abg's (see careview) no rsbi due to ^ peep. no further change ntoed.
"
2897,"resp:  [**name (ni) 97**] pt on 7200 a/c 18/650/50%/+20.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies,with some coarse bs in bases which clear with suctioning.  suctioned x2 small amounts of thick yellow secretions.  mdi's administered alb/atr q4h with no adverse reactions noted.  no rsbi performed due to ^peep.  no further changes noted.
"
2898,"npn shift 1900-0700:

neuro unchanged. very anxious, inappropiate behavior. yelling, crying, whining, flailing extremities. comfort measures and emotional support given w/ little effect. verbalizes wnats to drink. explained reason why npo, unreceptive to teaching. swabbed mouth, magic mouth wash as needed. other times refuses to verbalize whats wrong at times. medicated w/. ativan 0.5ng iv w/ good effect. humi air 35% for dry oral airway. satting 97-100%. no s/sof distress. pulm toileting. cough prod.  nsr-st, rare ectopy. no s/s of cardiac distress. sbp wnl. hct=26.0. tx rprbc x2 u w/ good effect, no s/ sof an adverse reaction. am hct=31.2. k+=3.4, mg+=1.9. repleted w/ kcl 20meq iv x1, mg+ 2amps x1. need add'l kcl 20meq iv. ho aware and in to assess pt throughout the night aware of inapprop behavior. [**month (only) **] order psych consult.
"
2899,"nursing update
   abdomen drained 250cc sanguenous fluid overnoc. transfused with 5-pack platelets, no adverse reaction. post transfusion plts 92, 95 this am. hct stable @ 31 this am. bp stable, nipride utilized x 1h only for brief episode of hypertension with sbp 140-150's. blood sugar stabilized on insulin gtts 0.5u/h. ativan, dilaudid and cisatracurium gtts cont -> ativan and cisat gtts increased slightly to resolve tachypnea and facilitate ventilation.
"
2900,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/650/+20/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned small to moderate amounts of thick bloody tinged secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats remain in^ 90's 96-98% with no distress noted during the noc.  current vent settings remain and recent abg noted as 7.33,44,94,24,-2.  no further changes noted.
"
2901,"resp: [**name (ni) 52**] pt on a/c 22/600/+5/40%. ett # 8 @ 21 lip. bs reveal bilateral aeration with diminished bases, no wheezes noted. alarms on and functioning. ambu/syringe @ hob. suctioned for small amounts of tanish secretions. mdi's administered  q 4 alb/atr with no adverse reactions. abg (venous) 7.39/40/39/25. 02 sats @ 100%. attempted rsbi although pt not awake enough. will attempt again this am. plan is to wean as tolerated to ps with possible extubation.
"
2902,"resp care note

pt given 300 mg pentamadine in 6 cc sterile water via respraguard neb and mouth piece. no adverse reaction noted
"
2903,"resp: [**name (ni) 52**] pt on simv 7/450/5/+5/40%. pt has #7 [**last name (un) **] trach. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. [**last name (un) 1017**]=113. no abg's or changes this shift.
"
2904,"resp: [**name (ni) 52**] pt on simv 7/450/5/+5/40%. trach #7 [**last name (un) **] [**last name (un) 1999**]. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs of alb/atr with no adverse reactions. abg's 7.36/71/71/41. md aware and satisfied with results. will continue to maintain current vent settings.
"
2905,"resp: pt rec'd on a/c 14/500/+5/60%. bs auscultated reveal bilateral aeration in apecies with diminished bases. mdi's administered q 4 comb/[**last name (un) **] [**hospital1 **] with no adverse reactions. am abg's 7.44/38/93/27. suctioned for small amounts of thick bloody tinged secretions. proceeded to initiate wean decreasing fio2 to 50%. will continue to wean appropriately.
"
2906,"npn: s/p cabg

neuro: drowsy and lethargic at times. easily arouses. oriented to self,hospital,or family. occ sl confused to day/time. mae with equal strength. knees sl buckling with oob to chair. perrl. visited with husband and [**name2 (ni) 2585**]. [**name (ni) 2586**] hopes to be back to work in 4 weeks.
cv: 100-70's sr-st with occ to freq pac's-rare pvc's seen-triplet x2. on/off neo to .75 to keep map>60. ci>2.5. swan dc'd.  k repleted. lytes wnl. pacer set a s a demand at 60. pedal pulses by doppler. hct stable 32.6.
id: tmax 99. wbc 9. cont on postop vanco.
resp: lungs diminished in bases. cough prod of bloody to blood tinged secretions early. requiring 4l nc and 40% ftneb especially when dozing. ct/mt to sxn-no airleak-serosang dng decreasing. sats > 95%. gu: foley to gd with initially good uo-now trending low0500cc ns given. cr .5.
gi: abd obese,soft, nt, nd. periods of nausea especially with movement which pt states happens r/t her meniere's. reglan given x1. tol small amt clears.
endo: on insulin gtt per cts protocol-gl to 71-gtt now off.
comfort: dilaudid .5 mg iv q 2-3 hrs for pain with effect. pt cont to state multiple allergies to everything you try to give her. no adverse reactions seen. to have vicodin ordered for po pain med.
activity: oob to ch with 2 assists-tol well but very slow-c/o knees buckling and very tired.
incisions: sternum and ct with original dsd-old staining on sternum-d/i. l leg ace wrapped d/i.
a: stable -still requiring volume and +/- neo
p: wean neo as tol, 500cc ns bolus, monitor uo-? lasix later if needed. po pain med, replete lytes.
"
2907,"nsicu npn 0700-1500
see carevue for subjective/objective data.  neuro:  pupils 2mm, sluggish most of shift however at 1430 pupils 3mm, brisk.  does move all extremities on bed when propofol lightened, does withdraw to pain. purposeful movement-->consistently lifts left hand toward ett when un-
restrained.  icp drain in place, icp 12-22, drng blood tinged sec 11-24ml/hr.  spec obtained by md and sent to lab.  poor waveform--md aware.  icp flushed by md with minimal improvement in waveform.  +gag, +cough, +corneals.  dsg-->icp drain d+i.  one suture on icp drain out; again, md aware (not new).  to ct at 0800 for ct of head; results pending.

cv/pulm:  initially on neo--gradually weaned, turned to off at 1400 with bp 120's.  goal is to keep bp 120's-140's.  ekg done.  started on sq heparin.  hct=25; one unit prbc's hung at 1430 with no adverse reactions thus far.  mp=nsr, no vea noted.  maintenance iv kvo'd while prbc's infusing.  remains vented on ac10x600x50%x5peep.  peep was 10, decreased to 5, abg's pending.  suct for mod amts thick yel sec via ett and thick clear orally.  bs coarse bil.  no other vent changes made this shift.  ett rotated to l side mouth, [**name8 (md) 76**] md pulled back to 21cm lip line.  no rpt cxr done.

gi/gu:  ogt-->lcs drng 75ml coffee ground material.  tf started at 1430 fs promote with fiber at 10ml/hr.  goal=60ml/hr.  no bm, +flatus. hypoactive bs.  u/o qs q1h via foley.

integ:  no open areas noted.  changed to air mattress with 5assists tol well.  turned s/s but consistently left in supine position.

id:  tmax=100.1 po.  no change in abx.

psychosocial:  fam in to visit.  emotional support given to pt and fam.  per fam they will return this pm to visit again.
"
2908,"resp: pt rec'd intubated via or placed on [**last name (un) **] a/c 14/500/+5/60%.ett 7.5, taped @ 19 lip.  bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick bloody secretions with occasional plug. mdi initiated and administered q4 alb/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see careview) am abg's 7.38/42/86/26.  will continue full vent support.
"
2909,"ccu nursing progress note
neuro:  pt a&o tpp, pt able to follow all commands, and move all extremeties well.  pt had difficulty sleeping overnight, pt unablet o receive aids, pt had adverse reaction to ambian and ativan.

cardiac:  pt in af rate 100-120, bp 110-130/60-70.  pt has swan pa 36-42/16-22, no co drawn, cvp not [**location (un) **] appropriately.  pt on dilt at 15 mg/hr, heparin 1000 u/hr, ptt 53.3 inr 1.5; and ntg 20 mcg/min.  will go to cabg today.

resp:  pt on 2l via nc, with o2 sats, ranging 92-96%.  pts resp pattern [**last name (un) **]-[**doctor last name **] breathing, o2 sats will drop to low 90's during apenic period.  bs are exp wheezes on r, clear in lul, and decreased in lll.  ? of influtrate.

gi:  pt npo since midnight, +bs, -bm.  abd soft distended nt.

gu:  pt has f/c producing >30 cc/hr, urine is pink, blood tinged.

id:  pt had one bottle of blood cultures grow out g+ cocci in pairs and clusters.  pt afebrile.  pt currently on levo.
"
2910,"ccu nursing progress note
s""i want to go home""
o: pt s/p right carotid stenting. pt alert, oriented x2. answers questions and speaking w/o aphasia. no difficulty swallowing liq.  follows commands. pt was not able to  sleep   frequently disoriented with escalating agitation. med w/ xanax w some effect.  daughters stayed w/ pt throughout the noc.
cv:mhr vp, no vea, sbp 120-130, +mur, dp palp bilat. r groin dsg d+i.
resp:lungs clear, sats 98% on ra.
gi:+bs, sm stool, guiac neg
gu: u/o 80-100cc/hr.
a/p: pt hemodynamically stable post stent. evidence of sundowning/acute delirium vs pt psychosis neurosis. this is the second night the pt has not slept according to family. family not wishing to try other sedatives or zyprexa due to adverse reactions to these meds in the past.
"
2911,"resp:  [**name (ni) 97**] pt on 40% cam (t/c).  bs auscultated revealed bilateral i/e wheeze. placed pt back on [**last name (un) **] mmv 12/500/+5/5/30% noc.  mdi's administered of comvbivent q4 hrs with no adverse reactions.  suctioned x3 small amounts of white thick secretions.  trach care performed, stitches removed, trach collar placed.  cuff pressure @ 20 cmh20.  02 sats ^ 90's 98%.  no rsbi performed since pt is being placed on t/c during the day.  no further changes noted.
"
2912,"resp: [**name (ni) 97**] pt on psv 10/10/50%. alarms on and functioning. ambu/syringe @ hob. ett #8.0 @ 21 lip. bs are coarse bilaterally. suctioned for small amounts of white secretions. sample obtained and sent. mid's administered as ordered alb/atr with no adverse reactions. am abg's 7.43/41/137/28. no rsbi due to ^ peep.
"
2913,"resp: [**name (ni) 97**] pt on 40% t/c. ambu @ hob. bs are coarse bilaterally with diminished ls in base. mdi's administered q6 hrs of alb with no adverse reactions. pt able to expectorate with spc. rusty thick secretions. 02 sats @ 100%. will continue to follow as per trach protocol.
"
2914,"resp:  [**name (ni) 97**] pt on 7200 psv 18/40% +5.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that clear with suctioning. suctioned several times during the night for thick yellow/greenish secretions. pt tends to accumulate moderate amounts of whitish secretions also in oral cavity.  mdi's administered q4 hr, 6 p combivent with no adverse reactions.  pt was place on a/c 10/400/+5/40% at noc to rest.  rsbi=108 this morning so no sbt initiated.  returned pt to psv 18/5/40 this am and tolerating settings well.  no further changes noted.
"
2915,"data/action: afebrile, hr 80's w/o ect. sb/p<160. heparin 200u/hr gtt.
o2sats 97% on room air. doing incentive spirocare well q4hrs. coughing
not raising. c/o abd. pain-relief w/ pca ms04 1mg-has used 30mg over 12 hrs.  bs q1hr ranging 77-133->ins. gtt off since 2100 last evening w/ bs's remaining <150. jp draining sm. amt sero-sang. atg infused over 6hrs w/o no adverse reaction. ngt-mod. watery drainage-no bowel sounds heard. abd. dsg d&i abd. soft.
"
2916,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 10/500/+12/50%. alarms on and functioning. ambu/syringe @ [**last name (un) **]. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of bloody tinged secretions with noted plugs.  mdi's administered q 4 hrs combivent with no adverse reactions.  no rsbi's performed due to ^ peep. am abg's 7.52/45/109/38. attempted to wean on psv, maintaining tv's/ve's appropriate although pt had periods of apnea. suggest possibly mmv to wean.  no further changes noted.
"
2917,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 20/400/40%/+8.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.   suctioned x3 moderate amount of thick bloody tinged secrections.  mdi's administered q4hr alb/atr with no adverse reactions.  o2 sats remain in ^90's.  no further changes noted.

"
2918,"resp: pt remains on psv 10/10/50%. bs are coarse bilaterally. suctioned for moderate amounts of tannish thick secretions with some bloody tinged. mdi's given q4 hrs combivent with no adverse reactions. abg's (see careview) am abg pending. no rsbi due to ^ peep. will continue to wean appropriately.
"
2919,"resp: [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small to moderate thick yellow secretions.  pt is able to self suction oral cavity.  mdi's administered alb/atr with no adverse reactions.  02 sats remain between 98-100%, maintaining adequate tv during the noc @ 350-400. pt does continue to have periods of apnea during noc, but in no distress.  no [**name6 (md) 239**] performed rn suggests let pt rest.  will advise day therpist to perform when pt is more awake.  no further changes noted.
"
2920,"resp: pt remains on psv 12.5.50%. vt's 600-700/ve 10/r 19, bs are slightly coarse suctioning small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.41/50/118/33. rsbi=166. no vent changes noc.
"
2921,"npn 1900-0700:

events: pt has required low-dose levo for bp management. crrt/uf resumed without complication.

ros:
neuro: pt remains on fentanyl 150mcg/hr and versed 1mg/hr with good effect. she is generally comfortable at rest and requires [** **] for turning. moving l arm only, weakly and without purpose. perrl, sluggish. did not appear to respond to her son.
resp: [**name2 (ni) **] vent changes made; most recent abg 7.33/43/121 on cmv .4/550/14/5. minimal thick tan, [**name2 (ni) **] blood-tinged secretions. although she has minimal secretions, her pp's increase significantly when she needs to be suctioned at all. ls: e wheezes, diminished lower. sats consistently 99-100%.
c-v: hypotensive at start of shift, requiring initiation of low-dose levo, which she has remained on. hr mostly 70's-90's, afib, with [**name2 (ni) **] pvc's. during the evening she had period of time during which she had intermittent slowing of hr with different-appearing qrs complex, representing a different conduction pathway. beats were well-perfused, with no significant drop in bp. she has been in her usual rhythm for the past several hours. ck's 218. 280, mb flat. troponin slightly elevated at .09, but pt has renal failure. cvp 20-21; lytes wnl.
gi: tf's continue at goal; belly obese but benign, no significant stool past several days.
gu: ampho bladder irrigation changed to continuous infusion; uo difficult to measure exactly, but seems to be running 10-30cc/hr. crrt/uf resumed at 0030, with current goal of -100cc/hr, which we are meeting without difficulty. please note that fluid balance on flow sheet is off by ~42cc/hr d/t ampho irrigant not accounted for in intake. ca gtt per sliding scale. bun/creat stable at 71/1.6.
id: afebrile, no need for bair hugger. wbc up to 18.8 (15.4). single dose of vanco given over 4 hours after pre-medication with benadryl. dose was well-tolerated with no evidence of adverse reaction.
heme: ptt therapeutic at 49.1; plt's wnl, hct stable at 30.3. no evidence of further bleeding.
endo: insulin gtt titrated prn.
skin: skin folds under breasts and in groin remain cracked/bleeding slightly. areas cleaned gently, double [**last name (un) **] and gauze applied. coccyx/perianal areas unchanged. upper l thigh blistering and draining now. l breast erythematous; both lower legs more red and blistering. ? if she has cellulitis in legs and breast.
access: r ij hd cath, r radial a-line, l sc mlc.
social: son [**name (ni) **] in to visit; he was updated on events of the day.

a: more stable night; tolerating crrt/uf once again.

p: current plan is to continue to remove fluid with goal of 3-4l/day off. would favor supporting bp as needed to facilitate this goal, as it appears to be about the only thing we can offer that might make a difference. per renal notes, plan to reassess when we have removed ~25kg (pt is ~55l positive for los, though this is improved from 59l a couple of days ago). otherwise, continue current management, ensuring pt comfort as a primary goal.
"
2922,"7a-7p
neuro: pt a+ox3,mae,perrla. dilaudid sc 2mg for pain.

cv: hr 80-100s sr no ectopy. sbp labile, on and off neo throughout day, see carevue for details. received one unit of prbcs, no adverse reactions. received lasix 20mg ivp after transfusion. +palpable pulses. generalized edema. at present to keep map >60, [**name8 (md) 9**] md [**last name (titles) 822**].

resp: ls wheezing throughout, audible at times especially w/ exertion. nebs q4 hours as scheduled. sats >97% on 4lnc.

gi/gu: abd soft,+bs,+flatus per pt. foley draining adequate amts of yellow urine-> light yellow after iv lasix.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. keep in unit overnoc, ? transfer to floor if remains off neo.
"
2923,"blood transfusion: 1 unit prbc started as per protocol. vss throughout. pt tolerating transfusion displaying no s/s of an adverse reaction. will monitor.
"
2924,"7p-7a
neuro: pt chinese speaking. pt alert granddaughter at bedside at beginning of shift translating, pt answering appropriately, follows commands,perrla, mae. granddaughter told pt in chinese not to touch ngt. medicated w/ dilaudid 2mg ivp q2 hours for incisional right ct pain, pt points to area and states ""pain"" or ""hurt"". at 0430, c/o left neck pain near jp and left shoulder, md [**doctor last name 896**] aware no new orders.

cv: hr at beginning of shift 110s, sbp 170 while intubated, md [**name6 (md) 1081**] and md [**doctor last name 896**] aware, additional lopressor iv given + hydralazine 10mg ivp. at 2100, hr again to 110s (after lopressor hr dips to 90 sr), md [**doctor last name 896**] aware additional lopressor iv 10mg given bringing hr down to 90s for approx 45min-1 hour. md [**doctor last name 896**] aware, labs ordered and sent. troponin 0.11 ck 488 md [**doctor last name 896**] aware, ekg done and reviewed by nd [**doctor last name 896**]. 1 unit of prbcs ordered and lopressor increased to 15mg iv q6hours. prbcs infused w/ no adverse reactions, md [**doctor last name 896**] aware of temp prior to transfusion, ok to give [**name6 (md) **] [**name8 (md) 9**] md [**last name (titles) 896**]. sbp 100-130s, see carevue. + palpable pulses.

resp: ls clear diminished. pt extubated at [**2109**], see carevue for post abg. sats >98% on 35% fio2 face tent, face tent kept on to keep pt's mouth and throat moist. sats on ra 94%-94%. see carevue for ct amts 2 right 1 left ct. jp to left neck draining serosang to bulb suction.

gi/gu: abd soft, tender to touch. multi abd dsgs from minimally invasive procedure, scant amt of serosang to dsgs. absent bs. j tube to gravity w/ scant amt of bile drainage. ngt to lwcs draining scant amt of thick [**name8 (md) **], md [**name6 (md) 896**] and md [**doctor last name 1081**] aware. continues at 3 [**11-26**] line as ordered, ngt not manipulated. foley draining clear yellow urine 30-80cc/hr. see carevue.

endo: per pt's scale. am glucose 69, 1 hour later 91.

plan: monitor hemodynamics. pain control. pulmonary toilet. increase activity. follow labs and treat as appropriate.



"
2925,"resp: pt rec'd on psv 5/5/30%. ett #7.5/22 lip. bs are coarse bilaterally. suctioned for copious to moderate amounts of thick bloody secretions iin beginning of shift then tapered off towards end. mdi
s alb/atr administered q4 with no adverse reactions. pt does have coughing episodes. rsbi=84. no changes this shift
"
2926,"shift note:  1900-0700
please see careview for all objective data:

neuro:  pt a+ox3, sleeping well t/o most of shift.  received percocet 2 tabs po as ordered x 1 for c/o [**7-28**] sharp, non-radiating, substernal cp as pt has been having.  pt denies changes in pain quality or increased sob. multiple ekg's w/ cp have been negative for acute changes and per report team feels pain is likely r/t pulmonary hypertension.  pt reporting pain free after percocet and has since been sleeping well.  pt remains free of diaphoresis or distress t/o shift.  pt able to reposition self in bed.  pt continues on seroquel as ordered for ptsd w/ good effect.  per report pt w/ adverse reaction to ativan.

resp:  pox remains stable 88-93% on 95% fio2 via t-peice w/ 10l via nc.  bbs remain cta to diminished at bases. snx w/ lavage x1 by rt for mucus plug.

cv:  hr 70's to 90's wap to afib/flutter w/ bbb w/ occasional pvc's.  bp remains stable.  trace ble edema continues, though improved from 3+ pitting edema on admission.  inr has been sub-therapeutic s/p vitamin k for picc placement.  no inr was checked on [**2-8**] and dr. [**first name (stitle) **] reports aware and orders coumadin 6mg po to be given as ordered w/ inr to be rechecked this am.  compression sleeves remain in place for dvt prophylaxis.  picc difficult to flush per report and alteplase had been ordered though able to flush slowly by this rn.  alteplase held and ns at kvo infusing through port to maintain patency.

id:  pt remains afebrile.  pt continues cefepime for pseudomonas pna.

fen:  pt tolerating diet well.  fsbs at 2200: 71mg/dl.  120ml apple juice and [**last name (un) 3612**] crackers were given.  fsbs up to 141 at 2230.  am labs to be checked though hct and lytes have been stable.  bun and creatanine continue to improve nearing baseline creat. of 1.2 to 1.3.  foley catheter d/c'd last shift per pt request.  pt has been voiding clear yellow urine in urinal, qs.  fluid status <2.3l> los.

social:  no contact from family this shift.

plan:  continue to wean fio2 and increase activity as pt tolerates.  pt has been oob to chair during day.  continue to monitor vs and labs.  continue abx as ordered. paper pg. ii started and placed in chart in anticipation of d/c to rehab facility when bed available.
"
2927,"pt came to micu6 from [**wardname 1699**] for merepenem desensitization because of multiple allergy.pt got here around [**2089**].completed desensitization without any complication.? c/o.

neuro: ox3.calm and cooperative.

id: frequent uti,now with e-coli. no signs of adverse reactions to merepanam.

cardio: nsr.vss.am lab pending.heparin drip per protocol.ptt qd.

resp: ls cta.

gi; abd soft. bowel sounds present.fsbs as noted.

gu: voids.minimal pain upon urination.clear yellow urine.

pain: severe left flank pain pain mgmt improved after multiple pain med adjustments as noted.

pain: ?c/o to floor today.

"
2928,"nurse progress note 0700-1900

events: po vanco started @1800[**name8 (md) 3097**] md order to uptitrate dose with goal 125mg po q6hrs.  no adverse reaction with starting doses- anaphylaxis kit @ bedside. hd @ bedside. see carevue for details.

neuro/pain: alert, oriented, dosing @ times. pain when cleaning from frequent stooling-denies further pain/discomfort.

resp: resp rate regular nonlabored, rr 19-26, ls clear bilat upper lobes, deminished bilat lower lobes-known right pleural eeffusion. trace scattered crackles on r-is encourage and at bedside. sat 93% resting in bed, placed on 1l nc currently 96-98%. cough/deep breath encouraged.

cv: hr 88-109 sr/st with rare pac, occ pvc's. hx labile bp, bp goal 130-170/ per pt am po meds held [**2-16**] hx hypotension during hd. hd- bp brief 105/60 ""i feel dissy and my vision is poor"" recieved 200cc back via dialysis. bp 132-191/57-89 map 73-112. no edema noted. riopathy, hx vascular dz, r bka. + weak pulses, thin dry skin.

gi: tolerating po's,  poor/changin appitie, wife bringing in food. has fd and riss-see [**month (only) **] for pt specific dosing. fs 204-286 -hx labile fs. inc frequent sm, green loose bm- cdiff +.

gu: anuric. hd @ bedside-started 1550-goal 3hrs. pos 1260 past 24hrs, pos 1860 los.

fen/endo: no ivf. heart healthy/consistant carb diet. iddm, dm 1 x 45yrs.

id: t max 98.6 po, cont iv flagyl, starting po vanco - recent cdiff and pna. blood cultures drawn during hd, thoracentesis results pending. vre/mrsa/cdiff precautions.

skin: excoriated peri area-no open sites, covered with barrier cream.  general thin dry.  no further breakdown in skin integrity noted.  sitting on side of bed.  heal elevated on pillows.

social: wife [**name (ni) **] @ bedside-updated on poc, medications.

poc
1. vanco desentitization- cont vanco per order, anaphylaxis kit @ bedside- monitor s/s given hx allergy to iv vanco
2. cont monitor resp status, encourage is
3. cont emotional support of pt and family
4. ? hd in am for ultrafiltration-renal following
4. cont all routine icu care, maintain bp goals
"
2929,"[**2204**]-0700

neuro: received pt from or awake, alert, oriented. follows commands well. maes. rigors noted. pt cooperative and exhausted. partner to visit at bedside.

resp: pt tachypnic resp 20-28 thru the night. c/o of sob with exertion. not tolerating activity well. o2sat remain stable. lungs clear/ex wheezing to bases bilaterally. nc 3l. no am abg done.

cv: s.tachycardia without ectopy noted. max temp 102.4-tylenol given. hr 110-130, sbp 90-130, complains of generalized discomfort. full body rash noted. ?adverse reaction to bactrim or transfusion reaction when on floor. piv x2. nss with 40 kcl bolus given. nss/20kcl@ 50cc/hr. + pulses to ext. no edema noted. porta cath removed and cultured-dsg changed this am. posterior neck dsg d+i. mg-1.5, k-3.8.

gu/gi: abd soft + bs, copious liquid stool-fecal incontinent bag intact draining liquid green stool. foley placed draining clear yellow urine.

plan: continue monitor cvp/fluid status due to not tolerating pd.
"
2930,"admission note
   this 75yr old woman was admitted at 2130, c/o dr [**first name (stitle) **], following a 13hour surgery - biorbital-frontal craniotomy for resection of 5cm meningioma.
   anesthsia was reversed and pt was extubated in or prior to admission to nsicu.  slow to wake up, but startled easily when arousing for neuro exam. s/b dr [**last name (stitle) **] @ 0130 and neuro exam done.  at this time, pt moving all extremites, speaking a few words clearly but tires easily after effort. following commands of opening eyes, hand squeezing and toe wiggling inconsistently.  c/o headache @ 0300, mso4 2mg ivp with good effect.  pupils equal in size and reactivity, but pupillary exam causes pt increased distress making exam difficult.  craniotomy incision draining mod amount sanguinous drainage, original dressing intact.
   nipride gtts continued to maintain sbp<140, dose increased slightly as bp elevated with waking up.  post-op hct 26.6, transfused with 2u prbc's without adverse reaction. ica of 1.04 repleted with ca gluc 2g iv.
"
2931,"resp:  [**name (ni) 97**] pt on psv 15/5/40%. alarms on and functioning.  ambu and syringe @ hob.  bs auscultated reveal diminished bilateral bases, aeration noted in apecies. mdi's administered of alb q 4hrs with no adverse reactions.  suctioned x2 moderate amounts of thick yellow secretions. pt has episodes of ^rr and decrease in tv with suctioning.  pt was placed on a/c in order to stabilize and decrease the wob. bp decreased then pt again returned to psv at above settings where she remains. rsbi=135 with no further changes noted.
"
2932,"resp: [**name (ni) 52**] pt on a/c 14/450/5/50%. ett 8.0, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and suctioning moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. no vent changes noc. am abg 7.45/39/97/28. pt scheduled for cabg x4 today with mv. rsbi=72.
"
2933,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/500/+5/50% alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clears sounds with diminished bases. suctioned for scant amounts of white secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions. am abg's 7.39/45/179/28.  decreased fio2 to 40%. no further changes noted. will continue to wean appropriately.
"
2934,"ccu nursing note 0700-1900

s/p r groin av fistual repair under conscious sedation; return to ccu @ 1130

neuro: pt neurologically intact, ao x3, speech clear, maew with equal strength, follows commands, denies pain, lightheadedness, sob or cp.  bedrest till 5 pm today.

cv: hr 60-80s nsr with rare pvcs.  sbp 120-140 map > 60.  new peripheral iv 18g placed in l fa by or staff.  no ivf ordered. old r ac iv dc'd with cathereting intact; drsg [**name5 (ptitle) **].  hct 24.3 this am; 1 unit rbc ordered and transfused; no adverse reactions noted.  repeat hct 27.3.  peripheral pulses palpable. r groin ecchymotic, or drsg [**name5 (ptitle) 819**].  l groin drsg [**name5 (ptitle) 819**].

pulm:  received pt from or on facemask.  o2 weaned to off; spo2 94%; resps even and unlabored; no acute distress noted.  lungs clear bilaterally. no cough.

gi:  pt tolerating ice chips without difficulty. abdomen benign; bs present.

gu: voids clear yellow urine per bedpan.

skin:  skin grossly intact; no breakdown noted;

social:  numerous family members have telephone and spoken with the patient following the procedures.  all family members updated on pt status and plan of care.

plan: transfer to floor today (?[**hospital ward name **] 9) and d/c home tomorrow.
"
2935,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 12/550/+5/60%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's given q2 hrs alb. with no adverse reactions. am abg's 7.37/52/92/31.  expect to wean to psv today and if tolerated, then possibly extubate
"
2936,"nsicu nsg adm note
ms. [**known lastname 6616**] is a 79yo female admitted to nsicu post op axillo [**hospital1 **]-fem bypass grafts to both legs.  pta she had abd, back and leg pain for 24hrs at home.  pain became severe and she presented to [**hospital1 95**] [**2191-2-8**]. pmh significant for mi, cabg [**2188**], htn, hypercholesterolemia, diabetic, ef 20% and depression.  she had been hospitalized 3days prior to this adm for r/o mi (neg for mi at that time).  she speaks [**year (4 digits) 413**], minimal english.  contacts are [**name2 (ni) 2905**]--phone [**telephone/fax (1) 11317**] and [**doctor first name **]--phone [**telephone/fax (1) 11318**].  [**doctor first name **] speaks english and [**doctor first name 413**]; [**doctor first name 2905**] is primarily [**doctor first name 413**] speaking.  in the or she rec'd a total of 1875ml prbc's and 6l cryst followed by lasix with a fair response.  in the icu she has rec'd additional 2units prbc's, 3units ffp, one 6pack platelets and numerous fluid boluses (goal is to keep pre-load high--cvp of 15 or greater).  she is currently on dobutamine at 5mcg, propofol at 30mcg, levo at 0.07mcg/kg/min and a bicarb gtt.

review of systems

neuro:  off propofol pt squeezes hands to command, opens eyes to command.  no attempts to speak around ett.  moving arms ad lib; no movements legs noted.  last assessment off propofol done at 0600.

cv/pulm:  dobutamine titrated up to maintain cvp>15 and ci>2.0.  blood products given as noted above; all transfused without adverse reactions.  levo remains at 0.07mcg/kg/min with map consistently>60.  dobutamine currently at 5mcg/kg/min.  fluid boluses per carevue in addition to blood products.  cvp trending down to 11-12--dr. [**last name (stitle) **] notified, additional ffp given.  remains vented with abg's improving--see carevue for vent settings and abg's.

gi/gu:  ogt placed, clamped.  no fluids given as ?bowel function.  hypoactive bowel sounds.  abd distended, soft.  mucous/bloody [**last name (un) 1366**] from rectum noted x3, foul smelling.  u/o qns--dr. [**last name (stitle) 11319**] notified, additional fluid and blood products given per carevue with little effect.  u/o now decreased to 5-8ml/hr.

integ:  l leg doppler pulses both dp and pt q1h.  l leg warm to touch with cap refill <3sec.  r leg pulses absent, leg increasingly mottled from toes to upper thigh, cold to touch.  r groin staples intact, dsg d+i.  l groin dsg d+i.  r side of buttocks white with ecchymosis, cold to touch.  r flank with ecchymotic area.  increasing edema throughout shift to hands and face.  no open areas noted.

id:  temp initially cool--bair hugger on, gradually warmed to current temp of 100.8 core temp.  bair hugger off when temp 99 range.  remains on kefzol.

psychosocial:  no fam contact [**name (ni) 23**].  [**name6 (md) 413**] speaking rn spoke to pt when lightened off propofol, briefly explained ett, restraints and that ""had an operation""; pt seemed to comprehend information.

"
2937,"resp:  [**name (ni) 97**] pt on 7200 a/c 20/500/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with improve some with suctioning. suctioned x3 small to moderate amounts of thick yellow secretions. mdi's administered q4hr of alb with no adverse reactions. rsbi=135, pt not initiating any breaths.  02 sats @ 100%. no further changes noted
"
2938,"npn shift 1900-0700:

neuro: attempted to wean fentanyl as per ho because of hypotension. wean to 400mcg/hr was unsucessful. pt exhibited s/s of discomfort. ho aware. fentanyl increased back to 500mcq/hr. nimbex titrated secondary to increased resp efforts. infusing at 0.75mg/kg/hr. ho aware. train of four remains at 4/4 on 8ma of energy. b/l pupils 4mm, r sluggish, l brisk. +corneals. pt remains unresponsive w/ no spon nor purposeful mobility.

resp: b/l bs diminished, coarse w/ rales throughout. oett, vent settings at start of shift;  a/c/ 34/ .70/ 350/ 14. i:e at 1:1, abg improved. pip 50-60's, periods of desaturation; nmb titrated w/ some improvement, pip in 40's. 0200 abg; 7.18/80/63/31. pt satting at 90. i:e reverted back to 1:1.5, rate increased to 36. 0430 abg; 7.20/78/64/32. abg w/ miniscule effect. pt remains hypercarbic and hypoxic. fio2 increased to 80% satting at 98% pulminary toileting q2hr. suctioned small-mod amt of thick yellow. chest pt via bed. tongue edematous. oral airway inserted to prevent injury to tongue and to facilitate oral suctioning.

cv: pt in st for most of the shift, rate 100-120. afebrile. qrs 0.08 pr 0.18 qt. 0.38. hypotensive at start of shift resolved w/ ns 1l bolus total. neo started temporarily during this time and d/c'd. cvp 12-14. 0200 hct=22.9. tx 1u prbc, tolerated well, no s/s of an adverse reaction. pt anasarcic throughout. i&o approx 3l positive for shift.  all pulses via dopper. skin warm, pale. am k+=4.0, mg+=2.0.

gi: abd more distended, possibly sec to third spacing. trouble shooting implemented; no residuals, no gastric build-up via ogt, bladder pressures wnl, no urinary retention. passing large amts of green, liquid [** **]. lft this am wnl. hypoactive bs to blq. tpn at target. tol peptamen tf at 20cc/hr via peditube; increasing slowly as per ho.  insulin gtt at 19u/hr to maintain bs 80-100.

gu: foley c/d/i, good urine output, patent.


"
2939,"resp: [**name (ni) 52**] pt on a/c 22/650/+7/100%. ett #9, taped @ 27 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of frothy bloody secretions. mdi's ordered and administered 2p atr q4-6h prn/alb 2p q6h prn with no adverse reactions. pt remains on 100% fio2, with sats @ 96%. peep ^ to 10, bp is stable on such. last abg 7.34/47/96/26 with am abg pending following changes in peep. will continue full vent support.
"
2940,"resp: [**name (ni) 52**] pt on a/c 22/650/70%/+13. ett#9, taped @ 28 lip. alarms on and functioning. ambu/syringe @  hob. bs are diminished bilaterally wish some coarseness noted. suctioning for small amounts of tan/bloody thick secretions. sputum sample obtain and sent. mdi's administered 6p alb/atr with no adverse reactions. last abg 7.40/39/77/25. 02 sats @ 97%, additional abg pending. plan to wean fio2 accordingly. continue full vent support.
"
2941,"resp: [**name (ni) 52**] pt on a/c 22/600/20+/60%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases, improvement noted from previous days.  suctioned for small amounts of thick yellow/white secretions. mdi' administered as ordered combivent/flovent with no adverse reactions. several abg's (see careview) vent changes to decrease fio2 to 50%, and ^ peep to 22 following esophogeal ballon numbers.  no further changes noted. will continue to wean off fio2 as tolerated. no rsbi due to ^ peep.
"
2942,"resp: [**name (ni) 52**] pt trach/vented via sicu on psv 10/5/40%. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick tan secretions. mdi's administered q4 hr alb with no adverse reactions. abg 7.35/59/181/34. rsbi=48. t/c trials to continue today as tolerated.
"
2943,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds. no wheeze noted. mdi's administered of alb/atr with frequency changed to q4 hrs. adverse reactions of ^ hr. suctioned for small amounts of thick white secretions. rsbi initiated and terminated due to ^ hr to 160's. vent changes to decrease ps to 10. abg's pending. will continue to wean appropriately.
"
2944,"resp: pt trached #7 portex on [**last name (un) **] psv 10/5+/35%. vt's 300's, ve 7l 02 sats@100%. bs auscultated reveal rs clear with ls coarse. lavaged and suctioned for moderate amounts of thick tan secretions. mdi's administered q4 alb with no adverse reactions. pt becomes anxious at times and continues to be tachy. am abg's 7.51/40/156/33, rsbi=73. decreased ps to 10. plan is to continue to wean and possible t/c trials today as tolerated.
"
2945,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/10+7/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with some rhonchi in apecies.  suctioned for thick amounts of yellow/tannish secretions. mdi's administered q4 hrs combivent with no adverse reactions.  am abg's 7.42/42/93/28. rsbi=147
"
2946,"resp: [**name (ni) 52**] pt on a/c 22/550/15+/60%. ett 7.5 taped @ 23 lip. bs are  diminished bilaterally with aeration noted. suctioned for large amounts of oral secretions with scant from ett. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. vent changes to decrease fio2 to 50%. am abg 7.34/38/92/21. no rsbi due to ^ peep. will continue to wean as tolerated.
"
2947,"resp:  [**name (ni) 52**] pt intubated from osh. eet #7 taped and secured 22@lip and placed on [**last name (un) **] a/c 10/500/+8/60%.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of charcoal tinged secretions.  mdi's administered q 4 combivent with no adverse reactions.  vent changes to decrease tv to 450/^ peep to 10. am abg's 7.35/37/83/21. no rsbi.  no further changes noted.
"
2948,"7a-11a
see carevue for details of assessment and vs. 1 unit of prbcs infusing no adverse reactions. lopressor and lasix given per pa [**doctor last name **]. pa [**doctor last name **] aware of hypotension when pt sleeping, continue w/ po meds as ordered per pa [**doctor last name **]. pa [**doctor last name **] aware of ct drained 100cc w/ getting oob. continue to monitor.
"
2949,"resp: [**name (ni) 52**] pt on a/c 22/550/25+/60%. ett 7.5 23 @ lip. bs are diminished bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q6 combivent/[**last name (un) **] with no adverse reactions. vent changes to decrease fio2 to 50%, peep to 20, ^ tv to 600. am abg 7.31/34/172/18. plan to wean as tolerated. bicarb to be administered.
"
2950,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/500/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small - moderated amounts of thick yellow secretions.  mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.45/44/149/32.  rsbi=73. no further changes noted.
"
2951,"resp: pt rec'd on psv 5/5/40%.  ett#8, [**e-mail address 9512**] are coarse bilaterally. sucitoned for copious amounts of brown thick secretions frequently. mdi's administered as ordered with no adverse reactions. no changes [**e-mail address **]. am abg 7.32/35/78/19 with [**e-mail address 239**]=84. plan to trach @ bedside this am.
"
2952,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #8 portex. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4 hrs combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. [**hospital1 239**]=43. am abg pending. plan to wean to t/c trials today.
"
2953,"resp: [**name (ni) 97**] pt on psv 5/5/40%. pt has #8 portex.  bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered as ordered combivent/flovent with no adverse reactions. am abg 7.32/46/120/25. [**name (ni) 239**]=24. plan to continue with t/c trials as tolerated today.
"
2954,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 12/15/50%. alarms on and functioning.
ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds, slightly coarse in apecies.  suctioned for small amounts of thick white secretions.  mdi's administered q4hrs alb with no adverse reactions.  no rsbi due to ^ peep. am abg's 7.36/48/94/28.  plan to continue to wean as tolerated. no further changes noted.
"
2955,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/12/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned small amounts of thick white secretions. mdi's administered q4 hrs alb with no adverse reactions. periods of agitation when suctioning.  am abg's 7.35/39/99/22.  will continue to wean appropriately.
"
2956,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds.  mdi's administered q4hrs [**doctor last name **]/alb/atr with no adverse reactions.  02 sats remain in^ 90's @ 98%.  rsbi=40, although no sbt initiated.  pt is scheduled for trach/peg this friday.  no further changes noted.
"
2957,"nsg admission note
ms. [**known lastname 341**] is a 75 yo female admitted to [**hospital1 95**] from ed for ? gi bleeding, hct drop.  see fhp for complete history.  this am pt was walking, felt weak, bystanders called 911, transported to ed via ambulance.  in ed found to have hct 23.0.  treated with fluid, trans to micu a for serial hcts (q4h), prbc and close observation.

current status
neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  mp=nsr, no ectopy.  vss.  hct at 1800 21.7; one unit prbc hung at 1850; no adverse reactions noted thus far.  breath sounds clear bil.  no sob or doe noted, pt on room air.

gi/gu:  abd soft, non-tender, bowel sounds present.  no flatus, no bm. no evidence of gi bleeding thus far.  u/o qs ad lib.

id/endo/integ:  afebrile.  endo--no issues.  skin intact.

psychosocial/plan:  emotional support given to pt.  no visitors this shift.  pt had many valuables with her (credit cards, money, id cards)--all sent to security--pink receipt in front of chart.  plan: q4h hct checks, transfuse prbc as ordered (started), cont to monitor i+o, cont with current nursing/medical regime.  to be scoped in am.
"
2958,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 20/500/10/+12/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of yellow thick secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.38/49/92/30. no rsbi due to ^ peep. no further changes noted.
"
2959,"resp:  pt rec'd on [**last name (un) 993**] simv 18/650/ps 8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear after sux.  sux x's 3 for some small to mod amount of yellow/greenish thk secretions.  mdi's administered through in line alb/atr [**3-12**] p q4hrs with no adverse reactions.  pt 02 sats remain in ^90's 95-97% during the night/rr 20-23 with no distress noted.  pt appears comfortable with no further changes noted.
"
2960,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 18/650/60%/ps8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  mdi's administered q4 hrs alb/atr with no adverse reactions.  vent changes to rr as per abg's. decrease to rr @ 12:00 to 16, @ 2:00 to 14, and @ 5:00 to a rate of 12 with no further changes, pending additional abg.  pt is awake and alert, follows commands.  no further changes are noted.
"
2961,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/60%/ps8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with clear with suctioning. sux x 3 for small to moderate yellowish thick secretions.  mdi;s administered alb/atro q4hrs with no adverse reactions.  no further changes noted.  pt resting comfortably.
"
2962,"resp: pt rec'd on psv 16/10/40%. ett #7.5, 22 @ lip.  ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amount of white thick secretions, rn suctioned for copious tan. mdi's administered as ordered of alb with no adverse reactions. am abg 7.44/31/131/22. no rsbi=^ peep. will continue present support.
"
2963,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/ps 8/+15/60%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sound which clear with suctioning.  suctioned small amounts of white thick secretions.  mdi's administered q4 alb/atr with no adverse reactions.  vent changes with a decrease in fio2 to 50%.  no further changes noted.
"
2964,"resp: pt rec'd on psv 12/10/40%. ett #8, retaped and secured @ 22 lip. bs reveal bilateral crackles with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered alb as ordered with no adverse reactions. no changes this shift. am abg 7.46/35/146/26. no rsbi due to ^ peep. will continue to wean as tolerated.
"
2965,"resp: [**name (ni) 52**] pt on psv 18/5/40%. ett 7.0 19@ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases.mdi's administered as ordered with no adverse reactions. pt continues with low vt's and apnea @ times. vent changes to place on mmv with back up rates of vt 350/18/10+5/40% during night. am abg 7.51/35/115/29. rsbi=109+. placed pt on psv 5/5/40%.  will attempt sbt this am with possible extubation.
"
2966,"resp: [**name (ni) 52**] pt on psv 15/5.40% following trip to mri. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with diminished bases. suctioned for small amount of light tanish secretions. mdi""s administed alb/atr as ordered with no adverse reactions. changes to decrease ps to 5. rsbi=98.am abg 7.36/48/108/28. sbt initiated @ 5:45.
"
2967,"resp: [**name (ni) 52**] pt on psv 5/5/40%. ett 7.5, 18@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. vt's 600. ve's [**6-22**]. rr 16. rsbi=34. no changes noc. am abg 7.34/35/121/20. plan to monitor metabolic status and treat accordingly.
"
2968,"resp: [**name (ni) 52**] pt on psv 10/8/40%.  ett 8.0 retaped and secured 23 lip, not rotated due to sore on r side of mouth. bs are coarse bilaterally. suctioned for moderate amountsof thick brown/plugs. mdi's administered as ordered of alb with no adverse reactions. am abg 7.44/39/100/27. rsbi=101. no changes this shift, will continue to wean as tolerated
"
2969,"resp: pt remains intubated ett 7.5, 22 @ lip on psv 10/8/40%. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered alb as ordered with no adverse reactions. no abgs this shift. rsbi=54. pt remains on cvvhd. will continue to wean as tolerated.
"
2970,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 15/10/60%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions, and from oral cavity.  mdi's administered q4h alb with no adverse reactions.  pt ^ rr to 40, place back on ac 12/ 450/ 10+/ 60% where the settings remain. 02 sats between 92-97% during noc.  no [**last name (un) 1017**] performed due to ^ peep/^ fio2.  no further changes noted.
"
2971,"resp: rec'd on a/c 20/500/12+/30%. ett #7.5, 25 lip.bs are coarse bilaterally. suctioned for moderate to copious amounts of thick bloody tinged secretions. mdi's administered q4 hrs. alb/atr with no adverse reactions and some improvement noted. am abg 7.43/42/126/29. open abdomen. no rsbi. will continue full vent support.
"
2972,"resp: [**name (ni) 52**] pt on mmv switched to psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished sounds. suctioned for small amounts of thick bloody tinged secretions. mdi's administerd q4 hrs combivent with no adverse reactions. am abg's 7.38/49/115/30. rsbi=30. plan to extubate today.

"
2973,"resp:  [**name (ni) 52**] pt on [**last name (un) **] cpap 5/+0/40%. ambu/syringe @ hob.  bs auscultated reveal sl coarse sounds which clear with suctioning. suctioned x3 small amount of thick whitish secretions. mdi's administered q4 hrs with no adverse reactions. rsbi=48.  no further changes noted.
"
2974,"resp: [**name (ni) 52**] pt on a/c 14/550/+5/40%. ett #8, taped and secured @ 23 lip. bs auscultated reveal bilateral diminished bases with slight coarse sounds in middle lobes. suctioned for small amounts of bloody thick secretions, copious amounts from oral cavity. mdi's administered q4 alb with no adverse reactions. no abg's today, pt scheduled today for trach in or @ 9:00. no vent changes noc.
"
2975,"resp: pt rec'd on psv 10/10/50%. pt has #8 [**last name (un) **] trach, secured @ 12.5 flange. bs are clear bilaerally and suctioned small amount of [**last name (un) 4953**] yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats @ 100%. no abg's or changes this shift. no rsbi due to ^ peep. plan: wean as tolerated.
"
2976,"resp: pt remains on psv 14/10 noc. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow (greenish) secretions. sending sputum sample this am. mdi's administered q4 hrs combivent with no adverse reactions. pt more alert today following commands. am abg pending. will continue to wean appropriately.
"
2977,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 24/550/+10/60%. alarms on and functioning. ambu/syinge @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick white secretions. [**last name (un) **]'s administered q4 alb/atr/[**last name (un) **] [**hospital1 **] with no adverse reactions. am abg's 7.45/43/95/31. no vent changes noc.
"
2978,"resp: [**name (ni) 52**] pt on a/c 15/550/5+/40%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are clear bilaterally. suctioned for moderate amounts of thick yellow secretons. mdi's administered alb/atr with no adverse reactions. no abg's this shift or changes. rsbi= no resps. will continue with present settings.
"
2979,"ccu nursing progress note 7p-7a
s: "" i am just really tired""

o: please see careview for complete vs/ additional data

ms: aaox3. pleasant and cooperative. pt very tired and declining pm care and repositioning. denies any pain or discomfort. pt dozing in naps [** 100**] following 5mg po [** **] dose.

cv: vss. pt remains vpaced w/ hr 60-66. very rare pvc noted. transvenous pacer site cdi. abp via right radial arterial line 92-124/37-54. initial assessment found maps to be in the 50s. received pt with bld transfusion in progress. following bld transfusion abp improved w/ sbp>100. maps ^ 60-70s (^50s). posttransfusion hct 31.1(29.7). heparin gtt remains at 1350u/hr. + distal pulses. am labs stillen

resp: ls cta posteriorly. pt denies sob. rr 16-24. o2 sats 95-98%. while asleep sat 95% on 2l nc. increased supplemental o2 to 4l nc while pt asleep. good cough.

gi/gu: abd soft. +bs. no stool. pt denies any episodes of nausea [** 100**]. pt standing at bedside voiding via urinal in marginal amts q 6-8hrs. pt approx -300cc [** 100**] and remains -2l los. despite bld transfusion and improved maps bun/cr remained elevated 28/2.3. urine lytes sent on prior shift to r/o atn.

id: afebrile. tmax 98.1 po. wbc is currently11.9(12.5). pt is currently on day 10 zosyn for vent assoc pna. pt is on vanco for ? line infection. per id zosyn and vanco are to be continued until surgery.

skin: intact. no breakdown.  encouraged repositioning, yet pt is quite resistant at times. reiterated importance of changing positioning to maintain skin integrity.

social: wife called at bedtime. no other calls or visitors [**name (ni) 100**].

a/p: very pleasant 60 yo male w/ significant pmhx including phtn, afib, r-sided chf, sob and ^cr. decreased fx at home initially admitted for chf managment. hospital course c/b brady arrests x2. pt noted to have severe mr. [**first name (titles) **] [**last name (titles) **] consulting. mvr/maze on hold until cr returns to baseline. pt had adverse reaction to natrecor gtt today which was turned off. bld transfusion improved vss. cont on abx until surgery which is currently planned for monday. follow vanc levels qday. follow i/os and cont to follow cr. support pt and family and keep them aware of [**last name (titles) 637**].
"
2980,"resp: pt rec'd on a/c 14/500/+8/40%. ett #8, retaped and secured @ 20 lip. bs are coarse bilaterally with occasional exp wheeze. suctioned for moderate amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's this shift (no aline). rsbi attempted with no spont resps. will continue full vent support.
"
2981,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 24/550/60%/10+. alarms on and functioniong. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with some coarse sounds noted. suctioned for copious amounts of bloody thick secretions. circuit changed to heated. [**last name (un) **]'s administered q4 alb/atr and [**last name (un) **] [**hospital1 **] with no adverse reactions.  am abg's 7.45/43/120/31.  no vent changes as noted by md. plan to continue to wean as tolerated.
"
2982,"resp: [**name (ni) 52**] pt on a/c 15/550/+5/40%. ett #7.5 retaped and secured @ 21 lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. see careview for rsbi, plan to continue full vent support.
"
2983,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick bloody secretions.  mdi's administered q4 alb/atr with no adverse reactions.  rsbi=155.  no further changes noted
"
2984,"resp:  [**name (ni) **] pt on [**name (ni) **] ps15/+5/50% alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning. suctioned x 3 small to moderate amount of  thick bloody/yellow tinged secretions.mdi's administered q4 hrs with no adverse reactions.  [**name (ni) 1017**]=85, sbt initiated.  not further changes noted.
"
2985,"resp: [**name (ni) 52**] pt on ac 550/15/5+/40%. ett retaped and rotated. bs are clear with diminished bases. suctioned for small amount of thick yellow to tan secretions. mdi's administed as ordered with no adverse reactions alb/atr. rsbi=136. plan to continue with present settings. family still to discuss cmo status.
"
2986,"resp: [**name (ni) 52**] pt on psv 10/10/50%. pt has air filled [**last name (un) **] trach secured @ 12.5 flange. 02 sats @ 100%. bs are clear with diminshed bases. suctioned for scant amount of white secretions mdi's administered alb/atr as ordered with no adverse reactions. vent changes to decrease fio2 to 40% and peep to 8. 02 sats remain @ 100%. plan: continue to wean as tolerated. no a-line.
"
2987,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 26/450/+10/50%.   alarms on and functioning. bs auscultated reveal bilateral diminished with some scattered rhonchi. suctioned for small amounts of  thick white secretions.  [**last name (un) **]'s administered q 4 hrs alb/atr with no adverse reactions. [**last name (un) **] given [**hospital1 **].  abg's drawn with notable vent changes (see careview) am abg's 7.41/45/104/30. present vent settings; a/c 20/45/10+/50%.  bedside abdominal ultrasound scheduled for today.
"
2988,"resp: pt rec'd on a/c 450/12/+8/40%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral coarseness in upper lobes with diminished bases. suctioned for small amounts of thick yellow. mdi's ordered and administered q6 hrs atr with no adverse reactions. rsbi=170. placed on psv 15/8/40% obtaining vt's 500's.  will continue to wean as tolerated.
"
2989,"resp: pt rec'd on psv 12/5/40%. pt has #8 portex trach. bs are clear and suction for small amounts of white secretions. mdi's administered alb/atr with out any adverse reactions. rsbi=60. pt has daily nif performed and t/c trials initiated and to continue today. pt has tendency to be anxious although with coaxing settles out. will continue to wean as tolerated.
"
2990,"1900-0700

   pt admitted from home for elective asa desenseitization to be followed by cardiac cath with stent placement. pt has significant hx: cad, mi [**67**], s/p rcs/pda, htn, hyperlipidemia, hypercholerolemia, menieres disease, ?copd, etoh, cocaine hx, + smoker.

neuro: pt awake,alert, oriented, follows all commands well. limited weight bearing and unsteady gait on r knee. dos not use assistive devices at home. pt non compliant with cardiac regiment at home ex-diet, lifestyle.

resp: nc 2l on, resp easy and regular with clear bs/diminished at bases. no cough noted. o2sat stable.

cv: nsr without ectopy, alarms on. hr 90-60, sbp 100-165, restarted on po meds. afebrile. asa desensitization completed without adverse reactions. nahco3^@75cc/hr. pt c/o of cp at 2315, ho at bedside 3 sl nitro q 5 minutes given with no relief, pain 7 out of 10, radiating to neck and back. denies sob/skin warm/dry. ekg completed showing st elevation in v1,v2,v3.  cardiac fellow to examine pt. nitroglycerine drip ^ titrating prn, heparin drip @ 750 units^ ptt 48.3. integrilin started at 0130. morphine givenx 3. pt finally became cp free. cpk:43.0. skin dry/intact, palpable pulses noted. pt awaiting cath this am. pt kept on bedrest.

gi/gu: abd round soft + bs, voids clear yellow urine via urinal.

iv: piv x2.

plan: cardiac cath, supportive cardiac care.
"
2991,"resp: pt on 2 lpm n/c and maintaining good sats @ 98%. bs reveal occasional wheeze. nebs adminisered q6 hrs alb/atr with no adverse reaction. will continue to monitor and treat.
"
2992,"resp: pt remains on psv 15/5/60%. placed on 50% t/c for nearly 4 hrs and tolerated well. periods of desaturation with ^ fio2. on psv 15/5/60 noc. bs auscultated to reveal bilateral coarse sounds. suctioned for small amounts of tan thick secretions. pt is [** 554**] and awake. no abg's rsbi=>200. mdi's administered q4hr alb with no adverse reactions. will continue t/c trials as tolerated.
"
2993,"resp: [**name (ni) 52**] pt on a/c 14/500/10+/40%. suctioned for scant amount of thin white secretions. mdi's administered as ordered with no adverse reactions. no changes noc or rsbi due to ^ peep. plan to wean as tolerated. abg 7.42/34/77/23
"
2994,"resp: [**name (ni) 52**] pt on psv 12/8/40%. ett 7.5, 23 @ lip.  bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. this am secretions appear to be slightly green. mdi's ordered alb q6 hrsprn and administed with no adverse reactions. pt had anxiety episodes noc and antivan administered. rsbi=54. pt weaned to psv 8/5/40%. vt's 350/ve's [**6-20**],rr 22 with additional abg pending. will continue to wean with mechanic's in am.
"
2995,"resp: [**name (ni) 52**] pt on a/c/14/500/10+/70%. ett 7.5, 20 @ teeth. bs are clear with diminished bases. mdi's ordered 4p alb and administered with no adverse reactions. suctioned for scant clear thin secretions. vent changes/abg's (see careview) am abg 7.35/38/101/22 on  a/c 14/500/10/70%. no rsbi due to ^ peep. will continue with present vent settings.
"
2996,"resp: pt rec'd on a/c 14/450/+8/40%. ett #7, retaped and secured 20 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small to moderate amounts of thick white secretions. mdi's administered q 4hrs alb/atr with no adverse reactions. no a line/abg's. rsbi=110.
"
2997,"resp: pt ordered for nebs of alb/atr. bs are diminished bilaterally. no adverse reactions following neb. will continue to follow.
"
2998,"nursing admission note:
   this 28 year old female was admitted from pacu @ 2045 c/o dr [**last name (stitle) 513**]. s/p craniotomy for clipping of opthalmic artery aneurysm.  patient had been extubated in pacu just prior to transfer to sicu and had stable respiratory status through noc on 4l o2 via n/c.
   neuro checks done q1h, pt not displaying any neuro deficit on exam, see neuro assessment flow sheet, also no evidence of drift or facial droop. c/o headache, neck incision pain and general discomfort x2, fentanyl 25mcg ivp given with good effect and no adverse reaction. craniotomy incision dressing dry and intact. left femoral artery sheath remains in place and transduced.
   taking sips of h20 and ice chips po, tolerating well with no nausea. diuresing well.
"
2999,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv10/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  cuff pressure@ 21cmh20.  ett taped and secured.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for small to moderate thick yellow secretions.  improvement noted after suctioning.  mdi's administered q4 hrs of albuterol with no adverse reactions.  rsbi=21, although no sbt initiated.  pt is scheduled for trach today. 02 sats remain in ^ 90's. no further changes noted.
"
3000,"respiratory care
pt remains intubated (#7.5 ett 23@lip) and on vent support. vent changes were simv to psv due to spont breathing and increase in ps from 5 to 8 due to rr >35. lung sounds were course t/o. suctioned for scant amounts of thk yellow secretions. mdi's given with no adverse reactions. last abg was borderline normal. care plan is to continue to wean and ? of extubation tomorrow or friday. will continue to follow pt.
"
3001,"resp: [**name (ni) 52**] pt on a/c 12/450/+8/50%. ett #7.5 21 @ lip. bs are slightly coarse with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered atr as ordered with no adverse reactions. no abg's, attempted rsbi=no spont resps. pt becomes aggitated with decrease in sedation. will re attempt rsbi with plans of possible extubation this am.
"
3002,"resp: [**name (ni) 52**] pt on a/c 12/450/+8/60%. bs are slightly coarse suctioning for small amounts of thick light yellow secretions. mdi's administered atr with no adverse reactions. pt desaturates when sedation is light. abg 7.41/40/59/26. fio2 ^ 70%, peep 12 to maintain sats of 96%. rsbi >150.
"
3003,"resp: [**name (ni) 52**] pt on a/c 15/600/15+/50%. ett #8. bs are coarse bilaterally. suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt has frequent coughing episodes when awake. no rsbi due to ^ peep. am abg 7.44/42/76/29. plan to wean as tolerated.
"
3004,"resp: [**name (ni) 52**] pt on a/c 10/600/10+/40%. pt has #8 shiley trach. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. no abg's this shift. 02 sats @ 97%. mdi's administered as ordered with no adverse reactions. rsbi=^peep. will continue with present vent settings.
"
3005,"resp: [**name (ni) 52**] pt on a/c 14/450/50%/10+. ett #7.5 taped @ 20 teeth. bs reveal bilateral crackles, and suctioning for small to moderate amounts of yellow (bile looking) secetions. bloody secretions from oral cavity. mdi's ordered and administered alb/atr with no adverse reactions. no abg's this shift (no a-line) or rsbi performed due to ^ peep. will continue with present settings.
"
3006,"resp: [**name (ni) 52**] pt on psv 15/10/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. changed out heated wire circuit, and inner cannula. suctioning copious amounts of bloody secretions. [**name (ni) **]'s administerd q4 hrs alb/atr no adverse reactions. vt's 400-500, rr 15-18. no vent changes noc.
"
3007,"resp:  [**name (ni) 52**] pt on psv 15/10/50%. alarms on and functioning. ambu/syringe @ hob. spare inner cannula in rm. 8.0 shiley trach. vt's 400-500, rr 17-24. trach care done, inner cannula changed. changed out heated wire vent circuit due to excessive blood (fluid) in tubing. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of old (brown) blood. slight improvement from yesterday. [**name (ni) **]'s administered q 4 alb/atr with no adverse reactions. no vent changes noc, no abg's. will continue vent support.
"
3008,"resp: [**name (ni) 52**] pt on a/c 10/600/10+/40%. pt is trached with #8 shiley. bs are coarse bilaterally and suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. no rsbi=^peep. no changes or abg's this shift. plans for rehab.continue with present settings.
"
3009,"resp: [**name (ni) 52**] pt on psv 16/6/40%. ett #7.5, 21 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned moderate amounts of thick yellow secretions. mdi's administered q4 hrs with no adverse reactions. no abg's this shift. rsbi=108. weaned to psv 12/5/40%. plan to continue to wean as tolerated.
"
3010,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 16/10+/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  attempted to wean ps to 14 and pt did not tolerate ^rr. difficult wean, becomes aggitated with lighten sedation. will continue to wean as appropriate. no further changes noted.
"
3011,"resp: [**name (ni) 52**] pt on pcv 27/dp22/+5/50%. ett 8, taped @ 25 and pulled out to 23 as [**name8 (md) 76**] md/xray. bs are slighly coarse/occasional exp. wheeze. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=155. am abg 7.42/47/74/32. pt will be scheduled for trach when condition improves. plan: wean vent as tolerated.
"
3012,"resp: [**name (ni) 52**] pt on pcv. bs are coarse to clear and suctioning for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=145. am abg 7.36/47/90/28. plan: wean to a/c as tolerated.
"
3013,"resp: pt rec'd on a/c 500/20/+12/30%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. ett #7.5, retaped and secured @ 25 lip. no changes this shift. am abg 7.45/37/141/27. will continue full vent support.

"
3014,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 12/10/40%. alarms on and functioning. ambu/syringe @ hob.  bs ausculatated reveal bilateral aeration with diminished bases.  mdi's administered q4 hrs alb/[**last name (lf) **], [**first name3 (lf) **] [**hospital1 **] with no adverse reactions. suctioned for moderate to copious amounts of thick yellow secretions. continue to wean as tolerated. am abg's 7.46/46/134/34.  no further changes noted.
"
3015,"[**2130-5-14**] ""b"" nsg progress note:

cvs:  tmax 102.7-tylenol given, down to 99.4 po. hr=92-114 sr with rare pvc's and pac's noted. iv mgso4 4gm given, kcl 20meq iv given. iv ns + 20meq kcl at 75cc/h. pulses present.

neuro:  a&ox3. mae. no deficits noted.

pain:  using pca mso4 appropriately with good pain relief noted. pain is in sternum when turning or coughing and deep breathing [**5-7**] reduced to [**2-6**] with pain med. no adverse reactions noted.

resp:  o2 4l nc. sats=95-98%, doing is 500-700. coughing and deep breathing well, small amts white sputum noted. lung sounds clear.

gu:  u/o=25-50cc/h given 2 boluses of 500cc iv lr per resident.

gi:  taking ice chips and sips of milk shakes.  water still causing some coughing.  +bs.

skin:  dsg on sternum intact with no drainage noted. 3 jp's draining serosanguinous. left heel red and sore,up on pillow.

plan:  antibx as ordered. increase diet today. continue weaning iv levophed.  encourage is, and deep breathing and coughing. tylenol for temp as needed.
"
3016,"7p-7a
neuro: alert, oriented x3. speech clear. mae with equal strength, follows commands.

cv: remains sr 60-70 with occasional pac's. sbp 110-130. a-wires capture and pace, set at a-demand 60; v-wires do not work, polarity changed. palpable distal pulses to extremities. svo2 >65; ci> 2.19. no gtts. started po metoprolol with good effect, no adverse reactions.

resp : ls clear, diminished at bases. 02sats>96% /2l nc. uses is to 750-800, coughs and deep breathes.

gi/gu: abd soft, not distended. +bowel sounds. tolerating po well. indwelling cath draining clear yellow urine to gravity, sufficient amts.

endo: riss continues as well as metformin.

plan: continue to monitor cv, continue pulmonary toilet. continue to advance diet and activity as tolerated. ?transfer to [**hospital ward name **] 2.
"
3017,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 12/500/40%/+8/ps20. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal coarse bs which improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rotated/taped and secured ett tube @ 21 lip.  rsbi= 120, no sbt initiated. no vent changes noted
.
"
3018,"resp:  [**name (ni) 52**] pt on [**last name (un) **] on a/c 14/500/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal clear apecies, with slight coarse bs in bases.  suctioned x2 for small-moderate amounts of thick yellow secretions.  mdi's administered q4 hrs with no adverse reactions.  rsbi=52.  no further changes noted.
"
3019,"7am-7pm update
neuro: pt alert and orienated x 3. cooperative. mae and able to follow commands. pt continues on respiradone.

cv: pt remains in nsr/st, rare pvc noted this am. hr 110-90's. sbp 150-100's. map 60-80. lopressor increased to 50 mg [**hospital1 **] -> tolerating. epicaridal wires dc'd this afternoon. k, inonized cal and mg replaced frequently. pt recieved 5 mg coumadin this evening (inr 1.1 this am) and started on heparin gtt at 500 u/hr (no bolus) due to clot in atrium (per dr. [**last name (stitle) **]).

resp: ls coarse. pt cotinues on 5 l nc. o2 sats 93-96%. pt with strong non productive cough. pt using is 500-750. cpt done. pt slighly wheezing afternoon after chair -> bed -> treated with med neb

gi/gu: pt with + bs. no stool. + flatus. tolerting cardiac diet. able to swallow pills without difficulty. foley to gravity draining clear yellow urine -> pt with large uo (autodiuresing) pt stated on lasix this afternoon-> diuresing well -> -> -> chasing lytes.

comofort/activity: pt oob to chair x 2 today with 2 person assist. pt receiving percocts for pain

plan: pulm toliet, monitor lytes, contines on heparin gtt, monitor coags, monitor qtc (d/t adverse reaction of resperidone -> pronlonged qt)
"
3020,"resp: [**name (ni) 52**] pt on [**last name (un) **] psv 10/8/50%. alarms on and functioning. ambu/syringe @ hob. transferred from ccu.  bs auscultated reveal bilateral ins/exp wheeze. mdi's administered q6 alb/atr with no adverse reactions. improvement noticed. rsbi=73. no abg's.
"
3021,"update
o: resp status: attempts to wean sedation to extubate unsuccessful d/t pt agitation/biting ett. propofol changed to precedex by 1700 & pt although tremulous & anxious calmer than while on propofol. suctioned q3-4h for sm amts tan secretions.lavaged w no appreciable change in amt of secretions.

cv status: hemodynamics stable subseq to iab dc.plan pa line dc subseq to vent wean.distal pulses dp's palp bilat and pt's+ w doppler.

skin: hives noted over trunk and thigh area after vancomycin nearly finished, ho notified-> benadryl given w rash receding w/in 20-30 mins. antibx changed to kefzol and pharm notified of pt drug allergy.
temp ^ w adverse reaction to vanco& ho notified. tylenol 1300mg pr given.

neuro status: as noted above pt poorly tol propofol wean,req versed and reinstituting propofol gtt until precedex cleared by pharmacy. pt opens eyes intermittently to voice, shaking arms intermittently. reinforced to pt the need for soft restraint until ett out,pt nodding but continues to have freq hand movement and tremors.pt denies pain upon questioning


endocrine: remains on low dose insulin gtt for glucose control.
a/p: attempt wean to extubate-> cpap w ps as tol while on precedex.cont to monitor glucoses and titrate per protocol.
"
3022,"resp: [**name (ni) 52**] pt on [**last name (un) **] psb 10/10/50%.  ambu/syringe @ hob.  bs ausculatated reveal bilateral coarse bs which clear with suctioning. suctioned moderage to large amounts of thick whitish/yellowish secretions for oral and ett.  mdi's administered alb/atr/ser/[**hospital1 **] with no adverse reactions. pt tends to drop sats, 02 probe better positioned on pts forehead.  no distress is noted noc, with no changes.
"
3023,"resp: [**name (ni) 52**] pt on a/c 26/470/12/40%. ett #7 taped @ 24 lip. bs are clear bilaterally. suctioned for scant amount of white secretions. mdi's administered as ordred alb/atr with no adverse reactions. vent changes (see careview) rsbi=41. am abg 7.40/35/71/22. will continue to wean as tolerated.
"
3024,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/+5/40%.  alarms on and functioning.
ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases.  suctioned x2 scant to small amounts of whitish secretions.  mdi's administered q4 of albuterol with no adverse reactions.  rsbi=42 02 sats remain @ 100% with no further changes noted.
"
3025,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 14/600/50/+10.  ambu/syringe @ hob.  bs auscultated reveal bilaterl coarse sounds with clear with suctioning.  suctioned x3 small to moderate thick yellowish secretions.  mdi's administered q4hr combivent/servent/flovent [**hospital1 **] with no adverse reactions.  vent changes as follows:  rate ^ to 16, peep ^ 12, fio2 ^ 60% resulting in improved abg. no further changes noted.  rsbi performed this morning results equal 47, rr 20.
"
3026,"resp: [**name (ni) 52**] pt on a/c 26/470/+8/40%. ett #7.0 taped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered atr as ordered with no adverse reactions. rsbi=61 with am abg's pending (see carview for results) plan to continue on present settings.
"
3027,"resp0: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/450/1.0/5+.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished bases. suctioned for small amounts of thick yellow secretions. mdi's 2p [**last name (un) **] [**hospital1 **]/4p combivent q4 hrs with no adverse reactions. vent changes reflect abg's (see careview). present settings a/c 20/350/50%/5+. am abg's 7.41/37/211/24. no further changes noted.
"
3028,"7p-7a: full assessment in flow sheet.

neuro: alert to person. pt was more confuse, mumble words, very tired earlier in evening. slept most of night. pt is  ""feeling better, more alert, clearer words, no pain"". mae - strong bilaterally. perl - [** **]. follow all commands. restraints hands - pt attempt to remove nc and ng tube. explain to pt the importand of medical equipments and why restraints need to be on.

cv: st 116-27 without ectopy. lopressor 10 mg pt tid - no adverse reaction, no change in bp. bp 110-130/56-62. warm, dry, no edema. heparin drip on, continue to monitor ptt, pulses, and bleeding precaution.

resp: clear in upper lobes then progress to coarse throughout - nasotracheal suction, chest pt and deep breathing and cough was done to assist pt (q 4 hr and prn). pt rr increase to 40-50 for short period of time then return to 20-40 after respiratory toileting. sao2- 98-100 at 5 l nc. thick/tenacious yellow sputum was suction.

gu/gi: soft distended abd. slight tender on left side. +bs x4 normal to hyper active. large amount of gas and stool. brown, loose, negative guiac. rectal bag intact. ng - tolerate tf (goal 60), +placement, minimal residual.

int: skin intact.

plan: respiratory toileting, bleeding precaution, gu/gi monitor.
"
3029,"resp: [**name (ni) 52**] pt on psv 5/5/40%. alarms on and functioning.  ett#8.0, taped @ 22 lip. ambu/syringe @ hob.  bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb/atr as ordered with no adverse reactions. vent changes to ^ ps to 10 due to ^ rr. am abg 7.41/53/104/35. rsbi=173.
"
3030,"resp: [**name (ni) 52**] pt po intubated ett 7.0 23 2 lip on a/c 18/500/5+/50%. bs are clear bilaterally. suctioned for small amount of brownish thin secretions. mdi's administered as ordered alb with no adverse reactions. intubation attempted fiberopticly but unsuccessful then intubated by direct larygoscopy and aspirated. abg 7.45/35/85/26. decreased fio2 to 40%. plan to extubate this am under direct supervision by anesthesia.
"
3031,"resp: [**name (ni) 52**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. am abg 7.23/42/229/25 with rsbi=28. pt continues on cvvhd. plan:continue to wean as tolerated.

"
3032,"pt update:

neuro: pt sedated. arouses to voice. mae on the bed. withdraws to painful stimuli. propofol weaned once precedex started @1300, and pt at comfortable level of sedation. pupils 3mm and reactive bilaterally. pt denies pain. ivig started @ 1400. no adverse reactions. rate advanced to 240cc/hr.

cv: hr 70-90s. nsr. no ectopy. sbp hypertensive in 190-200's in am. sbp max 210 @ 1200. treated with 10mg lasix and 15mg total hydralzine. htn continued until precedex given @ 0.7mcg/kg/hr. sbp came down to 120-140s where it remained through out rest of shift. ppp.

resp: attempt at ac early in shift. failed due to level of wob and increasing hr and bp. pt put back on cpap c/ ps. fio2 40, 5 and 5, 785 at 19. ls coarse with slight i/e wheeze. sxn'd for thick tan secretions.

gi: tf @ 20 via og tube. +bs. no bm.

gu: foley draining adequate amounts clear, yellow urine.

endo: iss.

plan: monitor for sbp htn. monitor infusion of ivig for fever, signs of adverse effect, etc.
"
3033,"resp: [**name (ni) 52**] pt on a/c 12/500/+5/40%. ett 7.5 rotated, retaped and secured @ 21 lip. bs are coarse to clear with suctioning. suctioned for small amounts of bloody/tinged secretions to tan by morning. mdi's administered as ordered alb/atr with no adverse reactions. no fever noc or changes. am abg 7.54/44/180/39. rsbi=86. plan: wean to psv as tolerated.
"
3034,"resp: pt rec'd on a/c 10/500/+5/50%. pt has #8 portex trach. bs are clear bilaterally with a few scattered crackles in bases. mdi's administered as ordered alb/atr/qvar with no adverse reactions. multiple abg's (see careview) with vent changes to ^ rr to 18, then 20 presently. cvvhd initiated noc and remains in am. am abg 7.34/42/104/24. no rsbi due to hemodyamic/no resps. plan: continue present mode of support.
"
3035,"resp: [**name (ni) 52**] pt on a/c 24/500/5+/50%. pt has #8 portex trach. bs are coarse to clear and suctioning small to moderate amounts of tan/bloody tinged secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. am abg 7.36/46/114/27. no changes noc. pt remains on cvvhd. no rsbi due to hemodynamic issues/no resps. plan: continue to wean as tolerated
"
3036,"resp: [**name (ni) 52**] pt on a/c 14/550/+5/40%. ett #8.0, rotated, retaped, and secured.  bs are coarse bilaterally and suctioned for small to moderate amounts of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. [**name (ni) 1017**]=82. no abg's or changes this shift. 02 sats @ 100%.  possible family meeting today to discuss cmo status?
"
3037,"resp:  [**name (ni) 52**] pt on a/c 16/600/10+/60%. bs are coarse bilaterally. suctioned for thick amounts of tan to yellow secretions. mdi's administered as ordered with no adverse reactions. weaned fio2 to 50%. am abg 7.42/25/125/17. no rsbi due to ^ peep. will continue to wean as tolerated.
"
3038,"addendum
back from or 1615. s/p exploration of mediastinum, drainage of pericardial effusion, and washout. received pt on propofol and vasopressin, levo added, and epi started [**name8 (md) 76**] md [**last name (titles) 10381**]. levo and vasopressin weaned to off [**name8 (md) 76**] md [**last name (titles) 10381**]. hct 21.9, 2 units of prbcs ordered and given, no adverse reactions noted. k 5.8, treated with 10units regular iv and 1 amp of d50 [**name8 (md) 76**] md [**last name (titles) 10381**], repeat 5.6, md [**doctor last name 10381**] aware, no new orders. pa 50s/30s. cvp 20. svo2 56-65. ci >2 via thermodilution. insulin gtt restarted for bs 214. see flowsheet for assessments and further details.

plan: hold heparin. hold vanco, level in am. wean epi as pt tolerates. monitor labs every 6 hours [**name8 (md) 76**] md [**name6 (md) 10381**] and md [**last name (titles) **].
"
3039,"resp: [**name (ni) 52**] pt on psv 12/14/50%. pt has #8 portex trach. bs are diminished with noted aeration. suctioned for small amounts of white secretions. mdi's administered of alb with no adverse reactions. pt had episode of desaturation then placed on a/c with fio2 @ 100% then titrated down. am abg 7.46/45/141/33 then weaned to psv 12/14/50%. plan to wean as tolerated. no rsbi=^ peep
"
3040,"resp: [**name (ni) 52**] pt on psv 22/10/70%. pt has #8 [**last name (un) **] air filled cuff, secured @ 12 flange. bs are coarse bilaterally and suctioned small amounts of greenish secretions. copious secretions of bile suctioned from nares/oral cavity. mdi's administered alb/atr with no adverse reactions. following rotation of pt in prone position, ett migrated to 8 with notable cuff leak. tube advanced to 12 with immediate improvement and no cuff leak. am abg 7.44/38/79/27 (following prone positioning). no changes noc. plan to continue present settings/wean when appropriate.
"
3041,"resp: [**name (ni) 52**] pt on psv 18.5/40%. pt has #8 trach with occasional positional leak. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's. o2 sats @ 98%. [**name (ni) 1017**]=141. plan to wean as tolerated.

"
3042,"resp: rec;d pt on a/c 22/500/10+/40%. ett #8, taped @ 24 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow to white secretions. insp ^ to .9/i:e 1:2.0 am abg 7.40/45/74/29. mdi's administered alb/atr with no adverse reactions.  no rsbi due to ^ peep. no further changes noted. pt remains on rotating bed. plan: wean as tolerated.
"
3043,"7a-7p
neuro: propofol decreased, pt able to mae on commnds, lower extremeties weaker than upper. pt nodded head yes/no to questions. perrla. medicated prn w/ dilaudid iv for incisional pain.

cv: hr 80-90s sr w/ occasional pacs and rare pvcs. in and of afib, at 0815 pt in afib, md [**doctor last name **] aware, amio bolus 150mg iv, converted to sr w/ pacs. again at 1345 pt in afib, md [**doctor last name **] aware, amio 150mg iv bolus and gtt increased to 1mg/min. at present time pt in sr w/ rare pac. see flowsheet. pt transfused w/ 1 unit of prbcs no adverse reactions, repeat hct 27-26, md [**doctor last name **] aware, no new orders. sbp 90-100s/. milrinone weaned to off as [**name8 (md) 76**] md [**last name (titles) **]. svo2 >60s. ci>2 by fick. levophed weaned to 0.06mcg/kg/min. epi gtt continues at 0.02mcg/kg/min, vasopressin continues at 3units/hr. pa 30/20s. cvp 14-18. see flowheet for details. k taken at 1500 as [**name8 (md) 76**] md order, k 5.8, md [**doctor last name **] aware, kayexeleate given as per order. repeat k due at 1900 [**name8 (md) 76**] md [**last name (titles) **]. dopplerable bilat at/pt.

resp: ls clear/diminished. cpap [**5-22**] w/ acceptable abg ~3 hours. after 3 hours pt rr >35, pt placed back on cmv rate 12, 5 peep, fio2 40%, see flowsheet. sats 100%. ct no airleak, draining dark serosang small amts. see flowsheet for further details.

gi/gu: abd obese soft, hypoactive bs. ogt +placement draining bilious drainage. no tf today per team, ? to start tomorrow. foley draining clear yellow 15-30cc/hr. no crrt today per renal. most likely tomorrow per renal. lasix 40mg ivp tid given as ordered.

endo: insulin gtt per protocol.

skin: see flowsheet.

social: [**name (ni) 1976**] (wife) visited pt today ~ 2hous. updated w/ poc.

plan: monitor henodynamics. monitor resp. status. wean levophed as pttolerates. pain control. ? crrt tomorrow. monitor k.
"
3044,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are clear to coarse and suctioned for small amount of bloody tinged thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.34/44/156/25. rsbi=57. plan; possible trip to or today, although nothing confirmed.
"
3045,"resp: pt rec'd on a/c 15/500/+5/40%. ett 8 taped @ 22 lip. bs are coarse and suctioned for moderate amounts of thick tan to yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. am abg 7.50/39/120/31. rsbi=166. plan: wean as tolerated
"
3046,"resp: [**name (ni) 52**] pt on psv 5/5/40%. ett 7.5 taped @ 21 lip. bs are clear with scant amount of suctioning. mdis administered as ordered alb/atr with no adverse reactions. no abg's this shift. rsbi=52. plan is to extubate this am following [**name (ni) **].
"
3047,"resp: [**name (ni) 52**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no abg's this shift. pt had episode of desating to 88, then increased fio2 to 50%. 02 sats this am @ 98%, then decreased fio2 back to 40%. rsbi=26. plan to continue to wean as tolerated.cvvhd discontinued noc.
"
3048,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett 7.5, taped @ 23 lip. bs are coarse bilaterally and suctioning small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift 02 sats @ 100 %. rsbi=43. plan to trach/peg today.
"
3049,"resp: pt rec'd on mmv 10/500/10/5+/40%. ett 7.5. taped @ 21 lip. bs are coarse to clear with diminished bases. suctioned for small amounts of bloody tinged/tan thick secretions. mdi's administered alb/atr with no adverse reactions. pt remains to become aggitated when not sedated with ^ bpto 190. no vent changes noc. am abg 7.48/50/137/38. rsbi=52. plan to wean as tolerated.
"
3050,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.44/56/142/39. rsbi=107. no change noc. [**name (ni) **] trip pending. family in discussing transfer to [**hospital1 1771**] & women today.
"
3051,"resp: [**name (ni) 52**] pt on a/c 14/600/+5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for copious amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=127. no abg's 02 sats remain @ 100%. plan to continue to wean as tolerated on psv.
"
3052,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett #7.5, taped @ 23 lip. bs are coarse to clear and suctioned for moderate amounts of thick tan/yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. am abg 7.50/36/122/29. rsbi=71. plan is to trach/peg today.
"
3053,"resp: pt rec'd on a/c 15/600/+5/40%. pt has #8 portex trach is vent dependent. bs are coarse bilaterally and suctioned for moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. attempted to wean to psv and pt did not tolerated became tachy with ^ wob immediately. rsbi=110. no aline or abgs. 02 sats @ 100%. plan to continue to wean to psv as tolerated.
"
3054,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett 7.5, taped  @ 23 lip. bs are coarse bilaterally and suctioning for moderate to copious thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes this shift. am abg 7.49/34/81/27 with a rsbi of 65. plan: family meeting today to discuss cmo status?
"
3055,"resp: [**name (ni) 52**] pt on 35% t/c t/c with humidification. bs are coarse to clear with spc. suctioned x1 for thick white secretions. mdi's administered alb/atr with no adverse reactions. inner cannula changed. 02 sats @ 100%. will continue to follow.
"
3056,"resp: rec'd on psv 10/5/40%. ett #8.0 taped @ 26 lip. bs are coarse to clear and suctioned for small amounts of thick bloody tinged secretions. mdi's administered as ordered alb/(atr d/c'd)with no adverse reactions. no changes noc or abg's. rsbi=38. family meeting to discuss trach? will continue to wean ps as tolerated.
"
3057,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 12/8/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with some coarse sounds noted throughout.  suctioned x3 for small amounts of white thick secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=70, no sbt initiated with ^ rr to ^ 30's and decrease in mean to 2.  02 sats remain @ 98% noc with no further changes noted.
"
3058,"day shift update
neuro: pt not moving extremeties at beginning of shift, pt on fentanyl gtt at 100mcg/hr. pa [**last name (un) 9952**] aware. fentanyl gtt turned off, approximately 1 hour after turning off fentanyl pt mae, not following commands. pt grimacing w/ any touch abd. team aware, general surgery consulted. see gi part of note for details. left pupil slightly larger than right, though both react briskly to light.

cv: hr 90-110s afib rare pvcs. mg 2gm iv for ectopy. sbp labile, hypotensive, pa [**doctor last name **] aware, neo gtt started as per pa. pt received 3 units of prbcs, no adverse reactions. see flowsheet for details of extremeties and pulses.

resp: ls coarse. unable to get pleth at times. acceptable abgs on cmv rate 24, 5 peep. fio2 40%. suctioned for thick pale yellow. see flowsheet.

gi/gu: abd slightly round, soft, grimacing w/ any type of touching abd. +visible blood w/ loose bm, pa [**doctor last name **] aware. +hemmorroids, surgery team aware. at present time pt in or, for exploratory lap. urine output dropped w/ hypotension, pa [**doctor last name **] aware. see flowsheet for details.

skin: see flowsheet. draining serous fluid out of open areas.

endo: riss.

social: daughter updated w/ poc.

plan: ?mri once abd. issues resolved. pt in or at present time. monitor hemodynamics. monitor resp. status.
"
3059,"7p-7a
neuro: pt lightly sedated on propofol 10-15mcg/kg/[** **]. moves all extremeties weakly, followed commands (wiggled toes on command), perrla. morphine 2mg ivp prn for pain shown by grimace scale and by pt nodding head when asked if in pain.

cv: hr 80-90s 1st degree avb pr 0.25. rare pac noted. mg 2.5, k 4.6, no repletion needed. sbp labile 86-130s (130 while turning in bed), neo gtt as high as 2.0mcg/kg/[**name8 (md) **], md [**doctor last name 1118**] aware at [**2173**] of sbp 86/ while on 2.0mcg/kg/[**year (4 digits) **] of neo, 1 unit of prbcs ordered and given as ordered, followed by 20mg of ivp lasix. md [**doctor last name 1118**] aware of increased temp, ok to transfuse [**name8 (md) 76**] md. tylenol 650mg pr given, see carevue for details. no adverse reactions. [**md number(3) 7143**]/20s. cvp 13-16. ci>2.2 thermodilution see carevue for details. svo2 60-69, see carevue. sternal and medistinal dsgs cdi. right groin iabp site cdi, no hematoma. + dopplerable pedal pulses.

resp: ls diminished. improved oxygenation after pt placed on simv [**name8 (md) 76**] md [**last name (titles) 1118**] (to rest overnoc). presently, on simv rate 14 (breathing [**2-3**] over rate at rest) tv 600 fio2 60% ps 8 peep 12, see carevue for details of abgs and vent settings.

gi/gu: abd softly distended. hypoactive bs. foley draining 33-280cc/hr, increased u/o after lasix given at 2230, see carevue for details. creatinine 1.4 this am.

id: receiving post-op vanco doses. wbc 12.2. temp 101-100.3, bc and uc sent on day day shift. no secretions via ett yet to send a sputum cx. tylenol 650mg pr prn.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. closely monitor urine output. wean vent as pt tolerates.
"
3060,"resp: pt rec'd on 35% t/c. pt has ""#7 portex fen. trach. inner cannula changed. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow/bloody tinged secretions. pt has a strong cough and is able to expectorate secretions. mdi's administered alb/atr with no adverse reactions. no changes. 02 sats @ 100%. will continue to monitor
"
3061,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are coarse to clear and suctioning for small amounts of bloody tinged thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/65/131/41.pt following commands.  rsbi=54. family meeting to discuss possibility of trach? will continue to wean as tolerated.
"
3062,"resp: pt on 50% cam. bs auscultated reveal bilateral i/e wheeze which improve following tx administered of sd hhn of 2.5 mg albuterol/ns. no adverse reactions noted. pt is on droplet precautions pending results of pcp/tb tests.
"
3063,"1500-2300 npn
see carevue for subjective/objective data.
neuro:  intermittently making eye contact, intermittently squeezing l hand to command.  no movement r arm/hand noted.  no attempts to speak around ett.

cv/pulm:  mp=afib, isolated pvc noted.  remains on neo currently at 0.15mcg/kg/min to maintain map>75.  attempted to wean neo however map dropped to 60.  l rad a-line intact with sharp waveform.  l multi-lumen central line intact.  prbc's infused without evidence of adverse reaction; rpt hct due between 2400-0100.  hands, feet edematous--elevated on pillows as much as possible.  remains vented on ps12 (increased to 12 from 10 for rr 40's), 5peep, 40%.  suctioned q4h for sm amts thick yel sec via ett.  bs clear, diminished bil.

gi/gu:  abd drain in place.  stat lock applied by radiology rn; site cleaned with ns and dsd applied by writer.  abd round, soft, bowel sounds present.  anuric (receives hemodialysis).

id/endo/integ:  tmax 99.2 r.  lactate cont to rise (md aware). sliding scale insulin coverage for fingersticks.  waffle boots r+r'd q2h.  multiple ecchymotic areas noted, unchanged.  skin care rn in, aquacell applied to coccyx, adaptic to r leg.

psychosocial/plan:  wife in to visit.  emotional support given to pt and fam.  plan is for ct of head/torso in am with contract followed by hemodialysis after ct due to contrast.  rpt hct.  maintain vent support.  cont with current nursing, medical regime.
"
3064,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  remains sedated with fentanyl at 15mcg/hr and versed at 1mg/hr.  spontaneous movement of arms noted, no movements of legs noted.  no attempts to speak or communicate; does not open eyes.

cv/pulm:  mp=afib, isolated pvc noted.  remained on vasopressin until 1530 when vasopressin off.  remained off until 1700 when bp dropping  to 68/41, remainins 68-72/42.  vasopressin restarted, dr. [**first name (stitle) **] notified.  prbc' infusing at this time; will re-try to dc vasopressin once prbc's have infused.  prbc's infusing without evidence of adverse reactions thus far.  l tlc, l a-line unchanged.  remains vented on ps was on [**4-5**] until traveled to ct scan then placed on a rate for ct.  upon return placed back on [**4-5**] but pt not tolerating [**4-5**], rr increased to 40's-->placed on [**11-5**] with rr improved to 20's.  bs coarse, diminished bil.  ct of chest and abdomen done; results pending.

gi/gu:  abd soft, non-tender, bowel sounds hypoactive.  tol tf at goal rate of 60ml/hr via ogt.  tol baricat pre-ct; now stooling liquid golden stool via mushroom catheter and occasionally oozing around mushroom.  u/o 20-40ml/hr.

id/endo/integ:  afebrile.  sliding scale coverage for fingersticks.  skin continues to weep requiring soft-sorb changes q2h-->arms, legs, back and buttocks.  multiple open areas noted, multiple skin tears noted--see carevue.

psychosocial/plan:  fam in to visit.  no decisions made by family re: re-intubation of pt if she is extubated.  encouraged fam to make these decisions at this time/prior to extubation planned for am.  emotional support given to pt and fam.  plan is [**month/day (1) **]'d vent support, npo after mn for ? extubation in am.  complete prbc's and re-check hct.  monitor vs, i+o, breath sounds.  [**month/day (1) **] with q2h skin care, current nursing/medical regime.  pt is dnr at this time.
"
3065,"resp: pt rec'd on psv 15/5/30%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of bloody tinged thick secretions. mdi's administered q 4 alb with no adverse reactions. pt had ^ in rr to 38 due to anxiety, ativan administered with good affect. rsbi=143, no abg's. attempted to wean psv but did not tolerate. will continue to wean appropriately.

"
3066,"nursing update:
   2nd unit of prbc's tranfused without adverse reaction.  hypertensive early noc >180, not responding to lopressor, lasix, capoten and atenolol.  pt c/o pain not relieved by mos4. dilaudid 1mg ivp given with good effect on comfort status and bp.
   placed on air mattress. large amount of serosang dng from left groin and abdominal incision.
pt remains alert and oriented when roused, though sleeping more comfortably on dilaudid.
"
3067,"2200-0700

received pt from [**hospital ward name 54**] 7 for meropenem desensitization. pt has bc x2 with gram negative rods and requiring meropenem for iv abx coverage.  pt awake, alert, orientedx3. follows commands well. moves upper ext well, lower ext bka bilaterally. speech clear and pt appropriate. no confusion noted. no neuro deficits.

resp: resp easy and regular without difficulty. no sob noted. o2 sat remain stable. lungs clear/diminished at the bases bilaterally.

cv:nsr without ectopy noted. hr 70-80s, sbp 130-150, low grade temps noted. denies pain at this time. meropenem desensitization started at 0245am. pt tolerating well. no adverse reactions. piv x1 to larm 20g intact.

gi/gu: pt on [**doctor first name 602**] diet. abd flat soft + bs, no bm noted. denies nausea. [**name (ni) **] pt. r arm av fistula not yet matured for use, +thrill/bruit. pt last received hd [**12-4**].

endo: riss.

plan: pt to finish meropenem desensitization and transfer back to [**wardname 1699**]-bed being held for pt.
"
3068,"resp: pt remains on psv 10/5/40%. bs are diminished bilaterally. suctioned for small amounts of thick tan secretions. mdi's administered q4 alb with no adverse reactions. am abg's 7.45/43/111/31. rsbi=148. no changes noc.
"
3069,"resp: [**name (ni) **] pt on [**name (ni) **] psv 5/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal noted aeration with slight i/wheeze on ls. suctioned for small amounts of thick yellow secretions mdi's administered q4 hrs alb/atr with no adverse reactions. abg's 7.41/55/136/36 rsbi=23.
"
3070,"resp: [**name (ni) 52**] pt on simv 10/600/5/+5/40%.  ambu/syringe @ hob.  pt has lg cuff leak, although tv's remain in 500's.  also noted secretions around trach site.  pt 02 sats decreased a few times during the noc.  bs auscultated reveal coarse bs bilateral with clear with suctioning.  suctioned x 4/5 times for bloody tinged thick secretions.  pt appears uncomfortable, rn aware.  mdi's administered q4 alb with no adverse reactions.  vent changes as follows:  rr ^ from 10, to 12, then 14, peep ^ 7, fio2^ 50%.  no further changes noted.
"
3071,"resp: [**name (ni) 52**] pt on a/c 12/400/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse to diminished.suctioning small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes or abg's this shift. plan to continue full vent support.
"
3072,"respiratory care note:
     patient remains trached with a #8.0 portex and on full vent support.  no changes have been made this shift.  bs are coarse throughout.  sx for small amounts of tan thick secretions via trach.  no rsbi this am due to fio2 of 60%.  patient remained afebrile.  mdi's administered as ordered, including 300mg of tobramycin at ~0200.  no adverse reactions noted.  spo2 remains 95-98%.  plan is to continue with current course of therapy.
"
3073,"resp: pt rec'd on psv 12/12/40%. bs are coarse with occasional wheeze noted. mdi's administered q4 hrs alb/atr with no adverse reactions. suctioned for small amounts of thick secretions. no vent changes this shift. am abg 7.49/37/122/25. will contine to wean appropriately.
"
3074,"resp: [**name (ni) 52**] pt on a/c 16/500/10+/40%. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered alb.atr with no adverse reactions. am abg 7.47/42/143/31. no rsbi due to ^ peep. noted occasional [**name (ni) 1999**] leak which is positional. will continue full vent support.
"
3075,"resp: [**name (ni) 52**] pt on a/c 12/400/10+/60%. alarms on and functioning. ambu/syringe @ hob. pt has #8portex trach. bs are relatively clear with some occasional wheeze noted. suctioned for small thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/59/115/41 then decreased fio2 to 59%. no rsbi due to ^ peep. will continue full vent support.
"
3076,"resp: pt administered 300 mg tobramycin @ 2:00 with no adverse reactions.
"
3077,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/+5 40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small amounts of thick whitish secretions.  pt became tachy once during the noc, lavaged, ambu, suctioned for small thk whitish amount, but no further episodes during the noc.  mdi's administered q4 of alb with no adverse reactions.  rsbi=38.  no further changes noted.
"
3078,"resp: [**name (ni) 516**] pt on psv 10/5/40%. pt has #7 portex trach. inner cannula changed. bs reveal noted aeration with diminished bases.suctioned for small amounts of thick tan/yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/30/104/19. rsbi=96. plan: wean as tolerated, initiate dialysis?
"
3079,"resp: pt rec'd on psv 16/10/50%. ett 8.0 19 @ lip. bs are coarse bilaterally and suctioning for moderate to copious thick yellow secretions. mdi's administered q4 alb with no adverse reactions. no changes noc. am abg 7.41/41/123/27. no rsbi due to ^ peep and procedure today. pt is being trached in am.
"
3080,"admission
pt admitted from or at 1305 s/p avr tissue and mv repair. uneventful or per anesthesia. ozzy from ct upon arrival from or. np [**name6 (md) **] and md [**doctor last name 816**] aware, protamine 50mg iv given as ordered. peep increased as [**name8 (md) **] np see fowsheet for details. 1 unit of prbcs given as ordered, no adverse reactions. pt requiring multi fluid boluses for svos 48-50s.epi gtt started as ordered. going by fick for co/ci, see flowsheet, pt w/ hx of tricuspid regurgitation.

neuro: pt sedated, perrla. no indication of pain. body temp 34.9-35 on arrival, bair hugger applied.

cv: hr 80. apacing. underlying 40s sb. sbp labile. goal sbp 90-110. see flowsheet for details, on and off neo and ntg gtts. [**md number(3) 1227**]/15-20s. cvp 5-11. requiring multi fluid boluses for low pad and cvp. np [**doctor last name 307**] aware. +dopplerable pedal pulses.

resp: ls clear diminished bases. sats >96%. presently orally intubated on simv mode rate 12, not breathing over, 5 peep, 5ps. plan to wake and wean as tolerates.

gi/gu: abd obese soft, absent bs. ogt +placement, draining bilious drainage.foley draining clear yellow urine 45-100cc/hr.

endo: gtt started per protocol, see flowsheet.

plan:monitor hemodynamics. monitor resp. status. follow fick q2 hours. allegy to latex. monitor ct drainage.
"
3081,"resp: pt rec'd on psv 5/10+/40%. ett 7.5, rotated, taped and secured @ 23 lip. bs are clear bilaterally. suctioned for small amounts of yellow thick secretions. mdi's administered as ordered atrovent with no adverse reactions. no abg's this shift. rsbi=47. weaned peep to 5. plan to continue wean with possible extubation in am.
"
3082,"resp: [**name (ni) 516**] pt on psv 10/5/40%. pt has #7 portex trach. bs are clear with diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.32/36/120/19. rsbi=43. plan: continue wean as tolerated with possible t/c trials.


"
3083,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #7 portex trach. bs are slightly coarse which clear with suctioning/diminished bases. suctioned for small amounts of bloody secretions due to recent trach. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/31/123/19. rsbi=97. plan: continue to wean as tolerated.
"
3084,"resp: pt on 3 lpm n/c and ordered for nebs alb/atr q6 hrs prn. administered alb/atr with no adverse reactions. will continue to follow.
"
3085,"resp: [**name (ni) 516**] pt on a/c 25/400/12+/60%. bs are diminished with crackles in bases bilaterally. suctioning for small to moderate amounts of thick tan/yellow secretions. mdi's administered alb with no adverse reactions. no changes noc. am abg 7.21/47/75/20. no rsbi due to ^ peep. plan: wean as tolerated.
"
3086,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #7 portex trach. bs are slightly coarse to clear. suctioned for small amounts of bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt wob ^ with declining abg's and ^ bp then placed on a/c (see careview for settings)with improved am abg 7.38/32/111/20. rsbi=97 but d/c due to ^bp to 180. plan:wean back to psv as tolerated.
"
3087,"resp: [**name (ni) 52**] pt on psv 10/5/40%. ett#8 retaped and secured @ 26 lip. bs are coarse to clear and suctioned for small amoutns of blood thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt had noted ^ in wob then increased ps to 15. vt's 400-500/ve 11/rr 25. rsbi=83. pt remains on ps 15. plan to wean ps as tolerated.
"
3088,"resp:  [**name (ni) 52**] pt on a/c 12/500/+8/50%. ett 7.0 taped @ 22 lip. bs are clear with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered of combivent with no adverse reactions.  abg 7.36/75/84/44.no rsbi due to or procedure today. no changes noc pt scheduled for trach/peg today?
"
3089,"resp: [**name (ni) 52**] pt on a/c 12/500/40%/+8. pt has #8 [**last name (un) **] air filled cuff which is secured @ 14 flange. bs are coarse to clear and suctioning for moderate amounts of thick bloody secretions which lighten in am. sputum sample obtained and sent. mdi's administered of combivent/ovar as ordered with no adverse reactions. rsbi=147. pt has coughing episodes causing desaturation at times. attempted psv but pt did not tolerate. plan maintain present settings.
"
3090,"resp: pt rec'd on a/c 14/450/+5/40%. pt has #8 portex trach. bs reveal ls clear with rs noted sub-q/crackles. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.50/51/92/41. rsbi=200. plan to wean as tolerated.
"
3091,"addendum
back from or at 1345 s/p exploratory of right axillary artery and repair dissection bovine patch. right hand cool, +palpable right radial, +ulnar and brachial via doppler. see flowsheet. svo2 dropped to 48, np [**doctor last name 330**] aware, 1 unit of prbcs given as ordered, no adverse reactions. ok for sbp 120s [**name8 (md) 76**] np [**doctor last name 330**]. fluid bolus for low urine output and low svo2, improving svo2 to 55-60. also epi gtt increased to 0.03mcg/kg/[**name6 (md) **] [**name8 (md) 76**] np. [**name (ni) **] (hcp) spoke to rn and updated w/ poc. mg 2gm given for ventricular ectopy. epicardial wires attached, not checked due to ectopy and tachycardia.  ptt >150, np [**doctor last name 330**] aware, no new orders. np[**md number(3) 732**] of act 170, no new orders. continues on epi, insulin, propofol, on and off ntg. see flowsheet for details.
"
3092,"resp: [**name (ni) 52**] pt on psv 10/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for copious amounts of thick bloody secretions/plugs. mdi' administered alb/atr with no adverse reactions. rsbi=58. pt is to be discharged today, although possibility of bronch this am.
"
3093,"condition update
d: see carevue flowsheet for specifics
 patient afebrile. dose of 2 million pcn g given this am at 0900 without any adverse reactions. pt was then bronched at 1015. second dose of 4 million pcn given at 1400 also given without any adverse reaction. thoracic team aware and transfer orders written. awaiting bed on floor.
 patient is a/ox3 and restarted on po diet.
 medicated with dilaudid 4mg po x2 with good effect.
 2 ct and 1 [**last name (un) **] remain intact. without any leaks. left lung with diminished breathsounds. 2l nc with o2 sats 98-100%.
plan:
 transfer out to floor when bed avail.
 notify h.o. with any changes
"
3094,"pt update

n: pt sedated on propofol. will open eyes and respond to stimuli. mae on bed. perla. fentanyl gtt for pain control.

cv: nsr, no ectopy. hr 90s. sbp 120s/80s. can get tachy to 130s and hypertensive to 200/90s when receiving treatment/vent changes/etc. repleted with 40kcl. pt received 1 unit prcs at 1700 with no adverse reaction.

resp: pt intubated. unable to wean from cpap ps fio2 .40, ps 18, peep 5. ls clear bilaterally.

gi: +bs. tf increase to goal of 40cc/hr. no stool.

gu: foley draining clear, amber urine. lasix gtt discontinued. uo ~50cc/hr.

endo: iss for control of blood sugars.

plan: attempt to wean from vent. monitor hemodynamics. replete electrolytes prn. monitor for s/s bleeding.
"
3095,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex trach, some ozzing form trach site. bs are coarse/diminished bases bilaterally. suctioned for copious amounts of thick yellow secretions until this am then became bloody. rn aware. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. rsbi=52. plan:wean as tolerated.
"
3096,"respiratory care note
pt received on ac as noted. bs essentially clear with good aeration. mdi's given q4 with no adverse reaction. ett repostioned and retaped without incident. bronchoscopy done - pt suctioned for large amts thick, yellow secretions. bal of rul sent to lab. plan to continue on current settings at this time.
"
3097,"micu npn 7a-3p

52 y.o. female s/p pcn desensitization for treatment of neurosyphillis.

neuro: alert and oriented x3. independent with adls.
resp: ls clear on room air.
cardiac: bp 100's/60's hr 80's nsr. no cardiac complaints offered.
gi: abd soft, nt, +bs. tolerating house diet.
gu: voiding clear yellow urine.
id: afebrile. tolerating oiv pcn q4hrs without s/s adverse reaction.
access: single lumen picc placed in left antecub. cxr confirmed; picc working well. pt to receive iv pcn for 2 weeks.

pt is called out to floor awaiting bed.
"
3098,"resp: pt rec'd on 35% t/c with humidification. pt has #7 portex. bs are coarse to clear and suctioned for small to moderate amounts of thick white to yellow secretions more towards morning. mdi's administered via trach alb/atr with no adverse reactions. pt has spc and is able to expectorate sputum.
"
3099,"npn
pt recieved from the er s/p 2 week history of headache, nausea, vomiting found [**5-29**] at home by friend lethargic. pt's daughter called by pt's friend and decided to call 911. pt taken to [**hospital 4223**] [**hospital 506**] hospital where a cxr and cat scan showed lung mass (l upper chest opacity) and ct head with l frontal mass with 5mml to r shift and hemnmorhagic l cerebellar mass causing tonsillar herniation. pt medflighted to [**hospital1 3**] for further eval/rx.
neuro deficit/pt disoriented to year will often respond ""[**2161**]"".
otherwise perrla 3mm each, mae with equal strength, no hand drift noted. tongue midline, smile symmetrical, no seizure activity. neuro sx = headache initially [**7-1**]. mri with and w/o contrast done. loading dose of dilantin 1000mg ordered in ew was given in icu. pt states allergy to steroids is increased hr, decadron given in ew without any adverse reaction and repeated x 1 in icu per dr [**last name (stitle) **]. pharmacy aware.
pain/as above [**7-1**] generalized h/a treated with dilaudid 0.5 mg ivp which decreased h/a pain to 3 then down to 1.
fluid deficit/pt c/o being thirsty, urine concentrated yellow, oral mucosa dry. pt recieved ns with kcl 40 meq at 250 cc/hr in the ew (1 liter). then iv changed to d5ns with 20meq kcl at 80ml/hr. pt is npo with exception of taking meds.
hypokalemic/k repleted in the ew as added to main iv for k 3.1. serum k level pending.
o2 sat 93%. at 12mn pt's o2 sat was 93% added 02 at 3lnp and sats improved to 97-98%.
icu prophylactics/h2blocker started, compression boots applied, sc heparin started.
psychosocial/pt,s sister [**name (ni) 2168**] in to see pt and with pt signed on as [**hospital **] healthcare proxy, form in chart. [**name (ni) 29**] brother has his phd and works with oncology research. pt has 2 young adult children who were in to visit. pt's family very concerned with recent developments in pt's health and decided to stay in hotel in [**location (un) 496**]. pt has hx of bipolar disease, anxiety disorder and depression. see [**month (only) **] for psych meds. pt is pleasant, calm and cooperative. she did ask for her xanax but neurosurg resident dr [**last name (stitle) **] did not want pt to take xanax. pain med as documented above has made pt comfortable and no further c/o anxiety after pain med given.
plan:nvs q1hr, notify neurosurg with changes.
emotional support for pt and her family.
monitor serum k's and replete as needed.
needs social work consult.


"
3100,"resp: [**name (ni) 52**] pt on psv 15/5/40%. ett #8.0 retaped @ 26 lip. bs are clear in apecies with diminshed bases/crackles. suctioned for small amount of thin bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. no vent changes noc. vt's 500's/ve 10. rsbi=66. rec'g rbc unit. plan remain on present settings and to wean as tolerated.
"
3101,"resp: [**name (ni) 52**] pt on a/c 16/500/5+/40%. ett 8.0, rotated, retaped and secured @ 22 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged/yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no-aline/no abg's this shift. no rsbi-or procedure this am.
"
3102,"resp: [**name (ni) 52**] pt on psv 12/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered combivent with no adverse reactions. no abg's 02 sats @ 99%. [**name (ni) 1017**]=124. plan to d/c today to rehab.
"
3103,"resp: pt rec'd on a/c 16/500/+5/40%. ett 8/0 rotated, retaped and secured @ 22 lip. bs are clear to coarse and suctioned for small to moderate amounts of thick bloody tinged/yellow secretions. mdi's administered combivent/alb as ordered with no adverse reactions. vent changes to ^ rr to 18. rsbi attempted but no spont resps. am abg 7.42/54/112/36. plan to wean as tolerated.
"
3104,"resp: pt rec'd on psv 5/5/40%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are coarse bilaterally and suctioned for small to moderate amounts of thick bloody tinged secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt placed on a/c (see abg's in careview) a/c 18/500/+5/40%. am abg 7.37/33/138/20/-4. no further changes. rsbi=190. plan: wean as tolerated.
"
3105,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are basically clear bilaterally. suctioned for scant to small amounts of bloody tinged thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes noc. am abg 7.35/38/131/22. rsbi=61. pt to or today for hip surgery.
"
3106,"resp: [**name (ni) 52**] pt on a/c 16/500/+5/40%. ett 7.5 taped @ 21 lip. bs are basically clear and suctioned for small amount of bloody tinged secretions. sample obtained and sent with results pending. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.44/37/154/26. rsbi=>200. weaned to psv 15/5/40% and pt tolerating. will continue to wean as tolerates.
"
3107,"resp: [**name (ni) 52**] pt on psv 10/12/60%. pt has #8 portex trach. inner cannula changed. bs are coarse bilaterally with diminished bases. suctioning for moderate to copious amounts of thick tan/yellow secretions, sample sent. mdi's administered as ordered alb/atr/qvar with no adverse reactions. abg's (see careview) no rsbi due to ^ peep.  am abg 7.42/58/68/39. plan: continue with t/c trials as tolerates.
"
3108,"resp: [**name (ni) 52**] pt on 40% cam, then ^ to 60% due to decreasing sat's. nebs ordered and administered q6 hrs alb/atr with no adverse reactions. will continue to treat.
"
3109,"nursing progress note

events: pt to [**hospital ward name **] for ercp, procedure performed under    anesthesia supervision, tolerated well, no adverse reaction. per gi team, no stones in cbd, + presence of sludge. sphincterotomy performed, pt doing well at present. febrile this morning, tmax 102.8, given tylenol for comfort, temp slowly improved, currently down to 99.1.

neuro: a+ox3, mae, normal strength. c/o diffuse achiness d/t being in bed, occas c/o ha and mild epigastric/ruq pain. given dilaudid prn w/ good effect.

resp: ls clear, dimin w/ intermittent fine crackles to r base posteriorly. pt given i/s instruction, o2 sats low 90-91% on room air, 2l nc o2 intact, sats 95-100%.

cv: bp stable, extrem warm, pulses intact. for most of shift hr nsr, rate 80s; note few episodes lasting anywhere from 5-10 minutes of sinus tachycardia w/ rate holding in the 120s. does not appear to correlate w/ any stimulation, increased pain, etc.  all episodes self limiting, hr returning to baseline w/ no intervention.  pt's home dose lopressor po restarted this am.

gi: belly soft/mildly distended. bs present. +flatus. denies nausea. remains npo post procedure.

gu: foley patent clear amber/icteric urine, qs.

endo: maintenance ivf per orders, glucose levels stable.

social: daughter [**name (ni) **] in for visit, updated on pt's status.

a/p: 54 yo female w/ known gall stones s/p ercp today. procedure uneventful, see report for findings.  abd pain minimal, remains npo. febrile this am, much improved this aft.  remains in icu for close obs, likely will require cholecystectomy in near future.
"
3110,"resp: pt has #8 portex trach with pmv in place. pt is on 50% t/[**hospital1 **] are diminished bilaterally and suctioned for small amounts of white thick secretions. mdi's administered via trach/ambu with no adverse reactions. will continue to monitor.
"
3111,"readmit
pt readmitted at 0645 from [**hospital ward name 54**] 6, unresponsive, intubuted, left pleural ct placed on [**hospital ward name 54**] 6. bs 30s at 0600, treated on [**hospital ward name 54**] 6. to cvicu hypotensive on 3mcg of neo. levophed gtt added, also vasopressin added as ordered. see flowsheet for details. neo gtt weaned to off as per team. echo done at bedside at 0730. fem aline placed at 0715. pa catheter inserted at 0915. see flowsheet for details.

neuro: pt mae on arrival, though not following commands, sedated on propofol gtt. pupils 6mm, left sluggish, right nr. np [**doctor last name **] aware. propofol off at 1100 to assess abd [**name8 (md) 76**] np [**doctor last name **]. at 1130, pt restless, mae, not following commands, grimacing at baseline, hard to assess abd d/t baseline grimacing. np [**doctor last name **] at bedside, ok to restart propofol [**name8 (md) 76**] np.

cv: hr 50-70s sr rare pvc noted. hypotensive on arrival. sbp 80s on neo gtt at 3mcg/kg/min. levophed gtt added as ordered. also pitressin started as ordered. see flowsheet for details. pa catheter placed at bedside. wedge pressure 22. svo2 70s-80s. [**md number(3) 10822**]/15-20s. cvp 8-14. ci>2 via thermodilution. co 4.2-4.8. 2 units ffp given as ordered and 2 units of prbcs given as ordered. no adverse reactions noted. multi-lumen rij dc'd and tip sent for culture,dc'd without incident. sternum uneven, team aware. pt in or at present time for ? sternal washout/ ? explor. lap.

resp: ls coarse throughout. bronch done at bedside, scant amt of secretions. lactate [**10-30**]. csurg team aware. see flowsheet for abg results, ph 7.22 on arrival, 2 amps of bicarb iv given as ordered. repeat ph 7.35. np [**doctor last name **] updated throughout shift of abgs and lactate. fluid boluses given as [**name8 (md) 76**] np, total of 1.5lns.

gi/gu: abd soft, no bs. ogt draining bilious brown scant amts. bmx2 large liquid brown, c.diff sent. + ob stool. general surgery consulted. lfts elevated. coag elevated. foley inserted, amber clear urine sent. ua and uc sent as ordered.

endo: 1/2amp of d50 at 0800 for decreasing bs. followed bs q1 hr. see flowsheet.

id: bc from fem aline and [**location (un) **] left subclavian. hypothermic. temp 92.2-93.4, see flowsheet. np [**doctor last name **] aware. uc sent. bronch specimen sent. zosyn and flagyl given before or. vanco given to anesthesia, to be given in or.

social: family updated by md.

plan: pt in or (at present time) for sternal washout and ? exploratory laparotomy to assess abd. monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. full code.
"
3112,"resp: [**name (ni) 52**] pt on psv 10/5/50%. pt has #8 portex trach. bs are coarse to clear with diminished bases. suctioned for moderate amounts of thick yellow secretions. inner cannula clear. mdi's administered as ordered alb/atr/qvar with no adverse reactions. vt's 500/rr 27 with 02 sats in 90's. a-line removed this am. rsbi=51. plan: continue with t/c trails as tolerated.
"
3113,"resp: [**name (ni) 52**] pt on t/c with hi-flow @ 60%. 02 sats @ 95%. bs are coarse bilaterally and suctioning for copious amounts of thick yellow secretions frequently. mdi's administered alb/atr/ovar as ordered with no adverse reactions. pt remained on t/c until 02:00. no distress was noted, 02 sats in 90's rr 18-20, although pt was noticably more lethargic. abg revealed ^ co2 with ph7.2 then placed on vent psv 10/8/50%. improvement noted pt more awake. co2 @ 62. ph 7.39. rsbi=52. plan: continue with frequent suctioning and t/c trials.
"
3114,"resp: [**name (ni) 52**] pt on a/c 14/500/5+/40%. bs are coarse to clear with suctioning. secretions initially bloody tinged then more white towards morning. mdi's administered alb/atr as ordered with no adverse reactions. abg's (see careview) within normal range on a/c. weaned to psv 10/5/40% in am with abg's pending. rsbi=123. still remains tachy
"
3115,"resp: [**name (ni) 52**] pt on a/c 35/450/16+/60%. ett 7.5 taped @ 23 lip. bs are clear and suctioned for none/white secretions. mdi's administered alb/atr with no adverse reactions. abg 7.15/48/74/18. [**name (ni) **] changes to ^ peep to 18. bicarb initiated again. plan: meeting to discuss cmo status. continue full [**name (ni) **] support.
"
3116,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 16/600/+5/10/40%. alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned copious bloody secretions. mdi's administered q4 of combivent with no adverse reactions.  rsbi=90.  no futher changes noted.
"
3117,"11p-0700
pt admitted from or at 2145 [**2186-8-24**], ( s/p aicd/ddd permanent pacer placed [**2186-8-24**] am, hypotension while on floor, back to or). see admission history for details.

neuro: pt sedated first on propofol, propofol weaned off and fentanyl 50mcg/hr and versed 1mg/hr gtts started d/t hypotension 88-90s/. opens eyes on verbal command, moves extremeties with hands on care, hx of right arm w/ steel rod placement. perrla. no facial grimacing noted.

cv: ddd permanent pacer hr 80-120s (120s while dopamine infusing). v paced, varying w/ own intrinsic and a paced beats. dopamine changed, secondary to hr, to neo gtt for sbp 90-100s. labile bp. goal 90-100s sbp. see carevue for details. cvp 5-8. + palpable pedal pulses. received 1 unit of prbcs, no adverse reactions. post hct 27. hct from ct 17.2, pa [**doctor last name 739**] aware. trauma line to left groin bleeding when received from or, pa [**doctor last name 739**] at bedside, stitched, no further bleeding. k repleted, order to replete k <4.0.

resp:ls clear. orally intubated, suctioned for scant blood tinged. sats >96% on fio2 40% rte 14 simv, see carevue for details.  left ct intact, no air leak, no crepitus, draining sang. minimal amts, see carevue.

gi/gu: abd soft, +bs. ogt + placement to intermittent wall suction, scant amt of blood via ogt after suctioning pt, pa [**name (ni) 739**] aware, no new orders at present. once bp stabilized, lasix 40mg ivp given. foley draining clear yellow urine adequate amts. see carevue.

endo: insulin gtt started for fs 150s, see carevue.

social: no contact from family this shift.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent as pt tolerates. monitor ct drainage. keep pt comfortable.
"
3118,"resp: [**name (ni) 52**] pt on h/f @ 50%. bs auscultated reveal bilateral coarse sounds. nasal trumpet in place. hhn alb/atr administered q 4 hrs with no adverse reactions. pt on cpap 16 with 2 lpm 02 bleed in noc.
"
3119,"resp:  [**name (ni) 52**] pt on [**last name (un) 993**] a/c 10/500/40%/+10.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral diminished breath sounds.  suctioned x3 small to moderate amounts of thick yellowish secretions.  mdi's administered q4 combivent with no adverse reactions.  no rsbi performed due to ^peep.  02 sats remain in ^ 90's @ 97-99%.  no further changes noted.
"
3120,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett 8.0 rotated, retaped @ 27 lip. bs are clear with diminished bases. scant amounts suctioned. mdi's administered as ordered alb/atr with no adverse reactions. [**name (ni) 520**] changes to decrease peep x1 increments and presently @ 14. am abg 7.47/43/79/28. no rsbi due to ^ peep. plan:continue to wean peep as tolerated/appropriate. presently on full [**name (ni) **] support.
"
3121,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett #8, rotated, retaped @ 27 lip. bite block in place. bs are coarse bilaterally and suctioning for copious amounts of thick yellow /brownish plugs. mdi's administered as ordered alb/atr with no adverse reactions. no rsbi due to^ peep. am. abg 7.34/43/103/24. plan: maintain full [**name (ni) **] support.
"
3122,"7a-7p
neuro: received pt sedated on fentanyl and versed gtts. weaned versed gtts to off. pt mae on command (spoken in french by translator), nodding appropriately to questions. fentanyl gtt wean to off to attempt cpap ps on ventilator. perrla. sleepy at present time.

cv: hr 80-90s sr rare pvc. sbp labile. aline overshooting/fling in aline waveform. nibp ~20-30points lower [**name6 (md) **] aline, md [**name6 (md) 859**] and md [**doctor last name 1357**] aware, go by nibp to titrate gtts [**name8 (md) **] md [**name6 (md) 859**] and md [**last name (titles) 1357**]. at present time on ntg to keep goal sbp 120-140. hct 25 this am, 1 unit of prbcs infused w/out adverse reactions, repeat hct 28, md [**doctor last name 859**] aware. ci [**2-20**] via thermodilution. [**md number(3) 5420**]/15-20. cvp 9-12. see flowsheet for details. 3+ generalized anasarca. +palpable pedal pulses.

resp: ls coarse, diminished bases. sats 100%. cxr done this am. attempted cpap/ps x2 unsuccessful d/t pt sleepy. will attempt when pt more awake. see flowsheet for abg/vent settings. ct to water seal, draining serosang. drainage, no airleak, no crepitus.

gi/gu: abd softly distended. hypoactive bs. ngt to suction draining bilious drainage. foley draining 80-400cc/hr of clear yellow urine. received 20mg of lasix ivp as ordered after blood transfusion. another dose of lasix 20mg x1 on hold for now [**name8 (md) **] md [**doctor last name 859**] since pt already 2.6 liters negative since midnoc. will need more lasix on pt's u/o starts to decrease [**name8 (md) **] md [**last name (titles) 859**].

endo: no coverage needed 90-100s.

social: friends into visit.

plan: monitor hemodynamics. monitor resp.status. monitor output. bp control by following cuff pressure. diurese. wean vent to cpap/ps.




"
3123,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett #8 rotated, retaped @ 27 lip. bs are clear/diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. new a-line inserted. am abg 7.36/45/78/26. plan was to decrease peep slowly, although with pao2 @ 78 peep remains @ 16. no rsbi=^ peep. plan: maintain full [**name (ni) **] support.
"
3124,"resp: [**name (ni) 516**] pt on a/c 34/380/12+/70%. ett 7.0 retaped, rotated and secured @ 20 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. fio2 weaned to 60%. am abg pending.no rsbi due to ^ peep/fio2. plan: wean as tolerated.
"
3125,"resp: [**name (ni) 516**] pt intubated ett 7.0 taped @26 lip transfer from sicu via or. vent settings a/c 26/600/10/40%.  bs are clear bilaterally with diminished bases. sputum sample obtained and sent. suctioned for small amounts of thick yellow/tan secretions. cvvhd initiated.  mdi""s administered as ordered alb with no adverse reactions. am abg 7.33/37/119/20. pt had episode of desaturation following arrival from or, vent changes to ^peep/fio2 to 60%,then titrated back down to present settings. no rsbi due to ^ peep. no further changes noted. plan: wean as tolerated.
"
3126,"resp: pt rec'd on psv 8/5+/25%. pt has a #7 portex trach. bs are coarse bileratally and suctioned for small amounts of white secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt had episodes of aggitation, trying to get oob at times, with rr to 40's. placed on a/c 14/450/+5/25% in morning to control/reduce rr with immediate improvement.  will wean back to psv when pt calms. rsbi=72. no abg's this shift, 02 sats @ 99%.
"
3127,"resp: [**name (ni) 516**] pt on a/c 22/600/12+/40%. bs are clear with dminished bases and suctioned for small amount of white thick secretions. mdi's administered as ordered alb with no adverse reactions. no changes this shift. am abg 7.42/40/103/27. no rsbi due to ^ peep.  plan: maintain full vent support. or on monday.
"
3128,"resp: [**name (ni) 516**] pt on psv 8/5/35%. pt has #7 portex trach. bs are coarse to clear and suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. titrated fio2 down to 25% and ps to 6. 02 sats @ 99%. pt tolerated presents noc with no distress noted. rsbi=90. continue to wean with t/c trials as tolerated.
"
3129,"resp: [**name (ni) 516**] pt on a/c 20/700/17+100%. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered with no adverse reactions. pt having episodes of desats with ^ bp, ^ hr. pt is dnr. pt expired @ 2:34 this am.
"
3130,"resp: [**name (ni) 516**] pt on psv 8/5/25%. pt has #8 portex. bs are coarse with decrease in aeration on ls. mucomyst/alb instilled as well as mdi's administered alb/atr with no adverse reactions. some green secretions oozing around trach site. bs reveal end exp. wheezing following administration of mucomyst. suctioned for small amounts of thick white/yellow secretions. episode of desaturation with ^ in ps & peep. weaned back to present settings in am. 02 sats @ 97% with adequate tv's. plan continue wean and attempt t/c trials if tolerates.
"
3131,"resp: pt rec'd on 40% f/t. alb/atr ud administered q6 hr with no adverse reactions. bs are coarse to clear. will continue to follow.
"
3132,"resp:  [**name (ni) **] pt on psv 12/5/40%. pt has #7 portex trach. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered atr as ordered with not adverse reactions.  rsbi=52. plan: pt is being screened for rehab. continue to wean as tolerated.
"
3133,"0700-1900  micu progress note


77 yo male admitted on [**6-28**] from home w/ 2 day history of confusion.  pt was intially admitted to cc-7 but acutely became more lethargic.  lp was done at that time on the floor which showed wbc >2300.  pt was treated for probable viral menigitis.  pt was intubated yesterday briefly for mri.  mri showed no acute bleed or mass.  pt had eeg today, results pending. pmh per care-vue.  pt started on ivig at 5pm, no adverse reaction

allergy: antihistamines

[**name (ni) 57**]  pt remains sleepy and lethargic, but arrousable to gentle stimulation.  pt unable to follow commands, and can be very impulsive and attempts to climb oob.  pt is at risk for falls and needs close monitoring.   grasps strong.  pt appears to be having pain when attmpting to [**last name (lf) **], [**first name3 (lf) 93**] monitor.  speech garbled and pt refuses to answer questions at times.  pt knows his wife and son, but unaware who his daughter was when she was visiting.

c/v-  remains in afib, rate controlled 80-120 with occas pvc's.  pt has no edema.  b/p 130-140/60-80.

resp-  respiratory pattern irregular at time, w/ short periods of apnea <5secs noted.  pt has weak and ineffective cough noted.  sat's have remained 94-96% on ra.  rr 12-24.  lungs coarse and diminshed.  mouth is very dry secondary to mouth breathing, mouth care provided.

g/[**name (ni) **]  pt on po lactulose for increased [**last name (un) **] level, no bm noted today.  remains npo, ngt in place for meds.  abd soft, +bs.

g/u-foley patent..u/o 50-250cc/hr  clear yellow.

endocrine-  remains on insullin gtt, fs q1hr..see care vue

[**name (ni) **]  pt's wife, son and daughter into visit and updated by pcp.  [**name10 (nameis) **] also provide update on poc.  family appropriate with queations.

i/[**name (ni) **]  pt will need labs drawn on tues [**7-4**] to be sent to the state lab for eee,and [**location 3989**].

plan-
continue to monitor mental status
state labs to be sent out tues am
? start tf in am

"
3134,"resp: [**name (ni) 516**] pt on psv 15/10/50%. ett #8, rotated, and retaped @ 26 lip. bs are clear/diminished bases bilaterally. sucioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.50/32/118/26. vent changes to decrease ps to 12, peep to 8. plan: wean as tolerated. rsbi to be done in am following pt tolerating decrease in peep
"
3135,"resp: pt rec'd on psv 5/5/40%. ett 8.0 taped @ 26 lip. bs are coarse to clear and suctioned for small to moderate white/yellow thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/43/148/30. rsbi=47. plan:trach/peg
"
3136,"resp: transferred from micu with incident, intubated with #7.5 ett, taped @ 21 lip. bs are clear on rs, diminished bases on ls. suctioned for small to moderate thick tan secretions. a-line in place. mdi's administered alb/atr with no adverse reactions. pt scheduled for radiation tx this am. plan to continue on present settings.
"
3137,"resp: pt rec'd on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear and suctioning for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.50/30/176/24. rsbi=55. possible t/c trials today?
"
3138,"resp: [**name (ni) 516**] pt on a/c 26/350/5+/50%. ett 7.5 taped @ 24 lip. bs are coarse and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. pt had episode of desaturation then peep ^ to 10. am abg  7.36/38/66/22. fio2 ^ to 60%. radiation treatment today. no further changes notes. no rsbi=peep
"
3139,"resp: [**name (ni) 516**] pt on psv 8/5/40%. ett 7.5, retaped and secured @ 21 lip. bs are coarse to clear and suctioning small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no abg's 02 sats @ 100%. vt 300's ve 7. rsbi=76. plan to continue diuresing with extubation on [**12-28**].
"
3140,"resp: mdi's administered of combivent as ordered without any adverse reactions.
"
3141,"resp: pt rec;d on psv 10/5/40%. ett 7.5, rotated, retaped and secured @ 25 lip. bs are clear with occasional coarse sounds. suctioned for small amount of tan secretions. mdi administered as ordered atr with no adverse reactions. am abg 7.37/46/135/28. rsbi=22. pt remains on cvvhd. plan to maintain present settings.
"
3142,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett #7.5, 21 @ lip. bs are coarse to clear and suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. pt had episode of ^ wob, then increased ps/peep temporarialy (see careview) and weaned to psv 5/5 this am. rsbi=90. plan is to extubate in am.
"
3143,"npn 0700-1900
events: weaned ntg to off, no c/o sob. weaned o2 to 2lnc. chemo regime started in [**hospital unit name 142**]. plt tx w/bump 16->39
neuro: afebrile, oob, amb in room, gait steady. med for back pain w/relief w/2-4mg dilaudid iv.
resp: ls:poor aeration t/o, exp wheezes t/o. denies sob. pre chemo hydration begun w/bicarb gtt @ 75cc/hr and mesna @42cc/hr, monitoring for sob, desaturation, may need lasix prn.
cv: b/p 160s/80s, cont w/2+edema. double lumen picc for access and 1perpheral 20guage iv added for chemo administration. plt transfusiom
gi: abd soft, distended, no bm today. refused lactulose as stated he moved bowels yesterday. pt w/fair appetite,eating most of food from trays.
gu: voiding clr yellow urine in urinal, now on chemo precautions.
plan: cytoxan administration tonight by oncology rn, monitor for s/s chf, adverse reactions.

"
3144,"11p-7a
neuro: pt alert and oriented, mae, follows commands, perrla. medicated w/ toradol, tylenol po, and dilaudid 0.25mg ivp prn for c/o incisional pain.

cv: apacing most of shift, d/t sbp 80s w/ intrinsic rate of 60s. hr at present 65 sr, no ectopy, sbp 96/44 w/neo gtt at 1.25mcg/kg/min. [**md number(3) 2282**]/10s, cvp 5-8, ci > 2 by thermodilution. epicardial wires attached and intact, see carevue. right radial aline dampened, going by femoral aline for bp readings. received 1 unit of prbcs for hct 25 as ordered,no adverse reactions, repeat hct 30. +palpable pulses.

resp: ls clear diminished. sats >94% on 2lnc. rr wnl. encouraged coughing and deep breathing.

gi/gu: abd soft, hypoactive bs. foley draining adequate amts of clear light yellow urine, see carevue.

endo: received pt w/ fs 48, 1/2amp of d50 given iv. gtt restarted for fs>200, see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean neo as pt tolerates. follow intake and output, treat as appropriate.
"
3145,"code status;dnr/dni

allergies;nkda

access;two piv one on each hand

cvs;a-fib on coumadin hr 80-110 frequent pvc's nbp 110-130/50-70 extremities are edematous pedal pulses are palpable.iv fluid d/cd at am.transfused one unit of prbc today without any adverse reactions.lytes and crit repeated,please see careview for results.metoprolol was d/cd after am dose.

resp;breathing efforts are normal rr 16-28 ls are clear spo2 100% on room air.

neuro;alert and oriented x 3 follows all commands moves all extrimities.medicated with versed 0.5 mg/iv and fentanyl 25 mg/iv for procedure at 1600 and pt is sleeping now.

gi;upper endoscopy done verbally reported as no active bleeding.still has active [**last name (un) **] emptied 150 ml from bag since am.ng tube to be pulled out and feed can be started as [**name8 (md) 21**] md.abdomen soft distended with positive bs.on pantoprozole iv.

gu; diuresed with 20 mg lasix prior and 20 mg/iv after blood transfusion.

skin;redness at back and haematoma on lt side of his thighs positioned q4h.

id;afebrile not on any antibiotics

endo;fs 270,s fixed dose d/cd and updated the sliding scale

social;daughter called and updated

plan;?to restart metoprolol
monitor vital signs
repeat crit /transfusions if remains low
n/g to pull out and restart feed when pt is awake
? call out
"
3146,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett 7.5, taped @ 24 lip. bs are coarse to clear and suctioning moderate to copious thick yellow/greenish secretions. mdi's administered as ordered combivent with no adverse reactions. am abg 7.48/40/99/31. rsbi=46. no changes noc. plan to wean as tolerated.
"
3147,"resp: [**name (ni) 516**] pt on psv 10/8/50%. ett #8, taped @ 20 lip. bs are coarse to clear and suctioned for small to moderate yellow/tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.45/49/93/35. vent changes to decrease peep to 5. rsbi=92. plan to continue wean as tolerated.
"
3148,"resp: [**name (ni) 516**] pt on a/c 26/550/+8/40%. ett 8.0 rotated and retaped @ 23 lip. bs are coarse to clear and suctioning moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt remains with ^ temp. attempted rsbi=132. no aline. 02 sats @ 94%. plan: wean as tolerated.
"
3149,"11p-7a
neuro: received pt on propofol, weaned to off, mae, follows commands, perrla. see carevue for details. nodded yes when asked if in pain, medicated w/ morphine 2mg ivp prn.

cv: hr 80-90s sr rare pacs, mg 2gm repleted. epicardial wires turned off d/t inappropriate spiking. following cuff pressures, aline waveform inaccurate, see carevue. sbp 100s-130s, after propofol weaned to off, sbp by cuff increasing 140-150s ntg restarted, see carevue. [**md number(3) 1227**]/17-20s, cvp 8-15, ci>2, see carevue for filling pressures. + dopplerable bilat pt, absent right dp unchanged from previous shift.

resp: ls clear. orally intubated, weaned from cpap 10/5-> [**6-16**] at 0600 w/ acceptable abgs, though still sleepy. see carevue for abgs and vent changes. sats 99-100%. rr 20s. tv 300s.

gi/gu: abd soft, absent bs. +placement of ogt, draining bilious drainage scant amts. low u/o 5-15cc/hr, pa [**doctor last name **] aware, albumin 500ccx2, additional 1l fluid bolus w/ no improvement. 1 unit of prbcs given, no adverse reactions, lasix 20mg ivp after blood increasing u/o >100cc/hr, see carevue.

endo: gtt per protocol.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. plan to extubate this morning. ?deline.

"
3150,"respiratory care:

pt remain orally intubated & sedated on spontaneous ventilation. we weaned ips this morning after early am abg. rsbi done ~89. bs are dim bil. mdi's adm as ordered with no adverse reactions. we are sxtn for small amt of thick whitish secretions, some orally, cough present. plan: wan as tolerate, ?sbt and continue present icu monitoring. will follow.

"
3151,"resp: [**name (ni) 516**] pt on psv 10/8/50%. ett #8 retaped, rotated and secured @ 22 lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no abg's noc. 02 sats @ 96%. rsbi=175. plan to continue to wean as tolerated.
"
3152,"resp: [**name (ni) 516**] pt on a/c 22/550/+10/40%. bs are clear with diminished rs base. suctioned for small amount of thick secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. pt remains on fentanyl/midaz. am abg 7.47/36/119/27. rsbi=no resps. plan: pending ip assessment, possible or for sent placement?
"
3153,"resp: [**name (ni) 516**] pt on psv 12/10/60%. bs are coarse to clear and suctioning for copious thick bloody/rusty plugs/secretions. sample sent. several vent changes due to pt aggitation and desaturation/^ wob (see careview for changes) mdi's administered (see carview for dosage/drug) with no adverse reactions. present settings;psv 20/12/50% with am abg 7.45/52/82/37.  no rsbi due to ^ peep/or procedure. plan: or for trach today.
"
3154,"resp: [**name (ni) 516**] pt on psv 12/10/50%. ett 8.0 taped @ 20 lip. bs are coarse to clear. suctioned for small to moderate tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt desating to 80's then increased peep to 14, weaned to 12. am abg 7.43/38/78/26. no rsbi due to ^ peep.  will continue to wean as tolerated.
"
3155,"resp: pt rec'd on a/c 12/450/5+/75%. bs are clear bilaterally. suctioned for small amounts of tan secretions and moderate amount x1 bloody clots from oral cavity. mdi's administered alb/atr with no adverse reactions. colistin neb tx given. pt continues to have ^ hr, ^ wob with rr to 40's. peep ^ to 15 with ^ sedation for noted improvement.no rsbi=^fio2/peep. fio2 weaned to 60%. plan to continue wean as tolerated.
"
3156,"resp: [**name (ni) 516**] pt on psv 12/14+/50%. ett 8.0 taped @ 20 lip.  bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.42/38/73/25. rsbi=^peep. will continue to wean as tolerated.
"
3157,"resp: [**name (ni) 516**] pt on a/c 28/500/+8/40%. ett # 8.0 retaped @ 23 lip. bs are clear/diminished bilaterally with poor chest rise. suctioned for small amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.29/47/121/24. rsbi=178. plan: maintain present support.
"
3158,"resp: [**name (ni) 516**] pt on 50% t/c and tolerated well this shift. bs are coarse to clear with suctioning. suctioned for small amounts of thick yellow secretions. mdi's administered via t/c with spacer alb/atr with no adverse reactions. pt remains anxious at times. will continue with t/c trials as toelrated.
"
3159,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, retaped and secured @ 20 lip. bs are clear with diminished bases. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered of atrovent with no adverse reactions. vent changes to decrease ps to [**10-17**]/and presently on 5 which reflect abg's (see careview) presently on ps [**2124-5-14**] %. am abg 7.44/37/113/26. will attempt [**month/day/year **] in am. plan is to wean to extubate today.
"
3160,"resp: [**name (ni) 516**] pt on a/c 22/550/14+/50%. pt has #8 portex trach with some bloody oozing from trach site. suctioned for minimal secrections. bs are clear with diminished bases. mdi's administered alb/atr with no adverse reactions.  am abg 7.49/39/91/31, no rsbi due to ^ peep. plan: wean as tolerated.
"
3161,"resp: [**name (ni) 516**] pt on psv 14/12+/50%. bs are coarse to clear and suctioned for small amount of secretions. pt has #8 portex trach. mdi's administered alb/atr/qvar with no adverse reactions. periods of desaturation to 80's and fio2 ^ to 60%. abg's (see careview). am abg on 50% 7.46/43/69/32. fio2 ^ back to 60%. no rsbi due to ^ peep. plan to continue to wean as tolerated.
"
3162,"resp: [**name (ni) 516**] pt on psv 10/5/50%. pt has #8 portex trach. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered combivent/alb prn as ordered with no adverse reactions. pt has episodes of anxiousness with ^ wob to 30's. rsbi=91. plan to wean as tolerate and initiate t/c trials.
"
3163,"resp: [**name (ni) 516**] pt on mmv 500/6/10/5/40%. ett 7.5, taped @ 25 lip. bs are coarse to clear. suctioned for moderate amounts of secretions. mdi's administered alb/atr with no adverse reactions. vt's 500-600 with ve's [**5-31**]. c02^ then placed on a/c 18/500/+5/40%. am abg 7.45/52/67/37. fio2 ^ to 50%. additional abg pending. plan to wean to psv as tolerated.
"
3164,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett #7.5, 25 lip. bs are coarse to clear and suctioned for small to moderate amounts of thin/frothy white secretions. mdi's administered as ordered alb/atr with no adverse reactions. vt's 400-500, ve's 6. 02 sats @ 100. abg 7.36/60/125/35. rsbi=31. plan to continue to wean as tolerated.
"
3165,"admission
pt admitted from or at 1600, s/p thrombectomy aortobifem limb thrombectomy and stent, vein graft thrombectomy, fasciotomy to right leg, see fhp for details of or and pmh.

neuro: received sedated on propofol. pupils equal sluggish.

cv: hr 80s. fluid bolus for hypotension w/ results. received 2 unit prbcs for hct 21.7. no adverse reaction noted. sbp labile 80s-110s. cvp 7-11. +dopplerable right pt, +dopplerable right popliteal. see flowsheet for details. left aka dsg cdi.

resp: ls coarse. peep increased to 8 [**name8 (md) **] np for sat abg 89%, rate decreased to 12. hard to obtain sats at times (poor wavefrom). see flowsheet for vent changes and abgs.

gi/gu: abd soft hypoactive bs. ogt +placement, not draining any secretions. foley draining [**location (un) **] urine, 20-45cc/hr, see flowsheet. np [**doctor last name **] aware.

endo: fs 120 no coverage.

plan: monitor hemodyanamics. monitor resp. status. start fentanyl gtt when bp improves. bicarb gtt x 1 liter for kidney protection as ordered. keep sedated. ? to go back to or tomorrow.
"
3166,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5 taped @ 23 lip. bs are clear bilaterally and suctioned for scant amount of secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no changes noc. pt is awake and alert and only remains intubated noc due to difficult airway/stent procedure po. rsbi=25. plan"": extubate this am with anesthesia present.
"
3167,"resp: pt has #8 portex trach and is on 50% t/c. bs are coarse to clear and suctioning moderate amounts of thick yellow to white secretions. mdi's administered via trach of combivent with no adverse reactions. no abg's this shift. 02 sats @ 98%.
"
3168,"7a-7p
neuro: received pt on propofol and fentanyl gtts. daily wake- up done per csurg team. with propofol off x 1/2 hour, pt awoke moving upper extremeties, agitated, not following commands, resedated. csurg and vascular teams aware. perrla. medicated w/ fentanyl gtt for pain, propofol weaned off, midaz gtt started as ordered.

cv: hr 80-90s sr w/ bbb, w/ occasional-> freq. ventricular bigeminy, np [**doctor last name 307**] aware. lytes checked q 4-6hours. i ca++ repleted as ordered. sbp 100s-120s. left radial aline sharp and intact. right ac arterial sheath transduced and w/ sharp waveform. sheath to stay in today per vascular. cvp 8-14. plavix and asa given as ordered for recent stent placements. see flowsheet for assessment of pulses. + dopplerable right pt/dt. right leg warm to touch. left amp dsg changed, staples intact, oozing small amts of serosang, to keep dry sterile dsg over, not to constrict left amp per vascualar. staples from right leg fasciotomy sites removed by vascular, large amts of sang. drainage, np [**doctor last name **] aware, hct sent. hct resulted to be 20. np [**doctor last name **] aware, 2 units of prbcs given as ordered, no adverse reactions. repeat hct 24.8, np [**doctor last name 307**] aware, no new orders at present time.  see flowsheet for details.

resp: ls coarse diminished at bases. sats >94%. tolerating cpap 10 peep, 12ps. rr 12-18. acceptable abgs. see flowsheet for details of vent changes and abgs.

gi/gu: abd soft absent to hypoactive bs. ogt +placement, draining greesnish clear. foley draining amber to clear yellow dark urine. on bicarb gtt for protection of kidneys and ck >30,000. np [**doctor last name 307**] aware of all labs throughout day. bicarb gtt off at 1745 [**name8 (md) **] np. continue maintenance fluid ns 250cc/hr as [**name8 (md) **] np. pt received lasix 20mg ivp btw blood, increasing u/o >100cc/hr.

endo: insulin gtt per protocol.

skin: see flowsheet.

plan: monitor hemodynamics. monitor resp. status. goal cvp ~12. next labs due [**2096**] [**name8 (md) **] np [**doctor last name 307**]. follow ck. monitor u/o.


"
3169,"resp: [**name (ni) 516**] pt on a/c 12/500/+8/50%. bs are coarse bilaterally and suctioning for moderate amounts of thick bloody tinged yellow secretions. hr remains tachy with increased close to 140 and rr in ^ 30's. combivent administered as ordered with no adverse reactions. no changes noc.am abg 7.37/35/89/21. plan: continue full vent support
"
3170,"resp: pt remains on a/c on 18/550/+5/50%. bs are coarse to clear and suctioning for moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reaction. no changes or [** **]'s this shift. rsbi=136. plan to wean to psv as tolerated.
"
3171,"resp: [**name (ni) 516**] pt on psv 5/5/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift 02 sats @ 100%. rsbi=82. plan to wean as tolerated, trach discussion?
"
3172,"resp: pt on 2 lpm nc. nebs alb/atr given with no adverse reactions. will continue to follow.
"
3173,"npn 7a-7p
events: pt was acutely agitated and combative this am. pt climbing oob and swinging fists at this rn. pt was unable to re-orient and calm down. dr. [**last name (stitle) 3215**] to bedside. pt medicated with 2.5mg iv haldol with good effect. pt nnoted to have ?able previous reaction to haldol, but family does not know what this reaction was. there was no adverse reaction today when this dose was given and it actuallly had a good effect. later this afternoon pt appeared to be more wheezy and with labored breaths. abg wnl, atrovent nebs given w/o effect. pt given 10mg iv lasix with good effect.

neuro: pt has slept in naps since this mornings events, but remains only oriented to person and his family. when told that he is the hospital he states ""i know"". no c/o pain. pt remains in bilateral soft wrist restraints for safety.

cv: dilt gtt weaned off. hr 60s-80s in afib. bp 100s-130s/60s-80s. pt has difficult to palpate pulses. pt on standing po loressor.

resp: sats> 96% on 4.0l nc. abg wnl. ls with exp wheezes in bilateral upper lobes, crackles over right base. pt on standing nebs. rr 16-20s.

gi/gu: abd is softly distended, +bs. pt is ordered heart healthy diet, but has refused all meals today. pt takes his pills well. u/o adequate, foley draining clear yellow urine.

skin: rue more swollen than left with small bruised area below armpit. dr. [**last name (stitle) 3216**] made aware and will cont to monitor. r arm elevated with pillows.

id: pt has been afebrile. pt covered on ceftaz and vacno, also tamiflu.

social: [**name (ni) 4**] wife and three daughters int to visit today and updated by dr [**last name (stitle) 3216**] and this rn.

plan: cont to monitor resp status, prn lasix/nebs.
      monitor ms, prn haldol for acute confusion and pt now on standing olanzapine at night.


"
3174,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett #7.5 retaped and secured @ 22 lip. bs are clear with diminished bases. suctioned for small amounts white thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.52/30/146/25. rsbi=75. no changes noc. will continue with present settings.
"
3175,"resp:  [**name (ni) 516**] pt on a/c 22/600/10+/60%. pt has #8 portex trach. bs are clear with diminished bases. suctioned for small amounts of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. weaned vent settings to present psv 10/5/50% (see careview for changes) rsbi=55. am abg 7.48/44/98/34 on psv. plan: continue to wean with possible t/c trials today.
"
3176,"resp: [**name (ni) 516**] pt on a/c 12/500/+5/40%. ett 7.5, 21 @ lip. bs are clear bilaterally. suctioned for no/scant clear secretions. mdi's atrovent administered with no adverse reactions. am abg 7.45/34/189/24. rsbi=34 plan: wean as tolerated.
"
3177,"resp: pt rec'd on psv 15/5/50%.  pt has #8 portex trach. bs are coarse bilaterally with decreased bs in l base. suctioned for large amounts of white frothy thick secretions. mdi's administered alb/atr with no adverse reactions. pt had large bm with immediate episodes of desaturation to low 80's and ^ wob with rr to 40's and hr >120. placed on a/c (md aware) with positive results then weaned back to psv. rn repositoned pt around 5:30 and pt once again had episodes of desats to 80's along with ^ wob to 40's and remains tachy.requiring to be placed back on a/c to rest. no rsbi due to above issues. pt is extremely sensitive to any movement/repositioning. plan is to wean back to psv when pt recovers.
"
3178,"resp: [**name (ni) 516**] pt on psv 10/5/40%/ ett #7.5, taped @ 23 lip. bs are coarse bilaterally and suctioning moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/45/80/32. rsbi=82. plan to extubate this am following cuff leak.
"
3179,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, 23 @ lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered of alb with no adverse reactions. vent changes to decrease ps to 10. vt'd 400's, ve's 10. no abg's this shift with rsbi=116. bal negative. will continue to wean as tolerated.
"
3180,"resp:  rec'dpt on a/c14/600/+5/40%. ett 8.0, rotated, retaped and secured @ 26 lip. bs are coarse bilaterally and suctioning for copious amounts of thick yellow secretions qhr. mdi's administered alb/atr as ordered with no adverse reactions.  abg's 7.48/40/104/31. rsbi=hemodynamic unstability. hr continues to be tachy with ^ bp. pt has no gag. no changes this shift. plan is to wean to psv, although questionable with 6 hr & bp.
"
3181,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett #7, rotated and retaped @ 20 lip. bs are coarse to clear and suctioning for moderate amounts of thick yellow secretions. mdi's administed as ordered alb/atr wtih no adverse reactions. pt had ^ wob with declining abgs then placed on a/c 18/400/+5/50% with immediate improvement noted. rsbi attempted for 184 although pt reacted with ^ bp to 180. am abg 7.38/48/95/29. plan: attempt to wean back to psv as tolerated.
"
3182,"resp:  pt has #8 portex trach and is on 40% t/c with humidification. bs are coarse bilaerally and pt able to expectorate secretions.  ud of tobramycin administered in line trach (door is to be closed while treatment is being administered and masks worn up to 1 hr following tx) with no adverse reactions. water bottle filled and drain placed in line. will continue to follow.
"
3183,"resp care
pt given neb tx. bs course with diffuse exp. wheezes that clear after neb tx and with producitive coughs. no adverse reactions.
"
3184,"resp: [**name (ni) 516**] pt on a/c 16/500/+5/40%. bs are clear bilaterally. suctioned for scant amounts of white secretions. mdi's administered atr as ordered with no adverse reactions. am abg 7.44/30/185/21. decreased rate to 12. rsbi=75. no further changes noted. continue on present settings.
"
3185,"resp: [**name (ni) 516**] pt [**name (ni) **] #8 ett @ 24 lip. xray confirmed placement. bs are clear with diminished bs. suctioned for small amounts of thick yellow/white secretion (large amounts of oral secretions) mdi's administered as ordered alb/atr with no adverse reactions. multiple abg's see careview. pt had vats left attempted;left open thoracotomy with decortication with a bronch. settings a/c 22/600/12/100% post op and weaned fio2 to 60%, peep to 10. no rsbi due to ^ peep.  am abg 7.50/43/105/35. plan to continue to wean.
"
3186,"resp: [**name (ni) 516**] pt on a/c 18/400/+5/50%. ett 7.0. taped @ 20 lip. bs reveal bilateral exp wheeze with improvement following mdi's. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. no changes noc. am abg 7.37/49/92/29. rsbi=177. plan: continue full vent support. trach expected next week.
"
3187,"nursing progress note 1900-0700
*full code

*access: 22g r wrist piv

*nkda

** please see admit note/fhp for admit info and hx.

neuro: pt had difficulty sleeping, given 2.5mg ambien x2 w/ little effect.  no c/o pain or discomfort overnight.  moves self in bed, turning on own.  may require assist to ambulate to commode when she eventually has to go.

cardiac:  sb w/o ectopy, hr 42-57, sbp 92-134, remains off dopamine.  cardiac consult w/ interpreter assist, stated they don't feel this is a cardiac issue.  hr of 50's is her baseline per patient.  cardiac feels she may have dropped pressure d/t vagal stimulation caused by pain from diverticulitis.  lactate last evening was 2.2 from 2.6.  awaiting am labs for hct and lytes.

resp:  o2sat 93-97 on ra, rr 12-21, ls clear, no c/o difficulty breathing or sob.

gi/gu:  tolerating reg heart healthy diet, +bs, no stool this shift, started on bowel regimen (has commode @ bedside, c.diff cx if pt stools), abd soft/non-tender.  urine out foley yellow/clear, 20-100cc/hr.

id:  afebrile. flagyl and cipro for diverticulitis w/ no signs of adverse reactions.  iv site wnl, skin intact.

psychosocial:  had friend visit in evening, received a few phone calls as well.  is looking forward to getting out of icu and getting disconnected from monitor.  request that foley be taken out, but this nurse explained that we need to closely monitor her urine output in the event that her bp drops.

dispo:  cont to monitor bp (restart dopamine gtt if required), awaiting am labs, assist pt to commode when bowel regimen begins to work, cont med regimen and abx, cont icu care @ this time.  possibly a call out to floor today.
"
3188,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 24 lip. bs are coarse bilaerally and suctioning for moderate amounts of thick yellow/greenish looking secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg 7.48/49/141/38. rsbi=46. no changes noc. plan: or/trach/peg vs cmo. family still undecisive.
"
3189,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 23 lip. bs are coarse bilaterally and suctioning for moderate amounts of thick tan/yellow and occasional plug.  mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. 02 sats @ 98%. rsbi=64. plan: family still unable to make decision on code status/or/trach/peg. family meeting again scheduled for today to discuss.
"
3190,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 19 lip. bs are coarse and suctioning thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.50/32/186/26. rsbi=75. maintain support.
"
3191,"resp: [**name (ni) 516**] pt on psv 5/5/40%.  ett 7.0 taped @ 24 lip. bs are coarse to clear and suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt has periods of anxiousness and lifting head off pillow. sedation administered. rsbi=162.  no changes noc. plan: family meeting to discuss trach/or?
"
3192,"resp: [**name (ni) 516**] pt on a/c 20/500/+5/50%. bs are coarse to clear and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.34/38/187/21. rsbi=30. weaned to psv 10/5/50% tolerating well with adequate tv's/ve's. cvvhd discontinued. plan: continue to wean as tolerated.
"
3193,"resp: [**name (ni) 516**] pt on a/c 14/400/+5/40%. pt has #7 portex trach. bs are clear bilaterally and suctioned for some bloody tinged due to new trach. scant white secretions in am. mdi's administered alb/atr with no adverse reactions. abg's (see careview) rsbi=52. weaned to psv 8/5/30% with additional abg's pending. plan: continue with wean to possbile t/c trials if tolerates
"
3194,"resp: [**name (ni) 516**] pt on a/c 22/500/10+/40%. ett 8.0 taped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for thick tan/yellow secretions. large amounts of oral secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift or vent changes. no rsbi due to ^ peep and or procedure today. pt expected to transfer to sicu following or.
"
3195,"resp: [**name (ni) 516**] pt on psv 18/5/45%. pt has #8 portext trach. bs are clear with occasional crackle and suctioned for small amounts of white thick secretions. mdi's administered alb/atr with no adverse reactions. no changes noc or abg's. rsbi=100. plan is possible d/c to rehab this am.
"
3196,"respiratory care note
pt received on psv 18/5 as noted. bs clear bilaterally and diminished in the bases. pt suctioned for small amts thick, tan secretions. ps weaned throughout the morning from 18 to 14. pt tolerated well with vt ranges 405-431 and rr 28-31. mdi's given a/o without any adverse reactions. plan to transfer pt to [**hospital **] rehab at [**hospital1 1589**] this afternoon.
"
3197,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett 7.5, taped @ 21 lip. bs are coarse bilaterally and suctioning for small amounts of white/yellow thick secretions. mdi's admimistered as ordered with no adverse reactions. no changes noc or rsbi performed due to or procedure today (trach). am abg pending, see carevue.
"
3198,"resp: pt rec'd on a/c 22/500/+5/50%. ett 7.5 taped @ 22 lip. bs are clear with diminished bases. suctioned for basically none. mdi's administered of alb/atr with no adverse reactions. pt remains on cvvhd=no rsbi. am abg 7.38/31/173/19. vent changes to decrease rr to 20. plan: wean as tolerated.
"
3199,"resp: pt rec'd on psv 11/5/50%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate to copious amounts of bloody thick secretions. mdi's administered alb/atr with no adverse reactions. pt has episodes of ^ wob with rr to 40. ps ^ to 15 and sedation administered with noted improvement. abg 7.41/35/112/23. rsbi=64. pt weaned back to psv 11. plan: continue to wean as tolerated.
"
3200,"resp: [**name (ni) 516**] pt on a/c 22/500/+5/40%.  ett 8.0 taped @ 24 lip. bs are diminished bilaerally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=51. weaned to psv 5/5/40%. vt's 400-500, rr 26, 02 sats @ 99%. plan: additional abg/sbt with extubation expected today.
"
3201,"resp: [**name (ni) 516**] pt on psv 8/5/40%. ett 8.0 taped @ 24 lip. bs are clear to diminished. suctioned for small/mod tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. weaned ps to 5/peep 5. rsbi=73. plan: wean to extubated this am. niv possible if pt begins to fail.
"
3202,"resp: [**name (ni) 516**] pt on a/c 24/400/+10/60%. ett 7.5, taped @ 20 lip. bs reveal bilateral clear apecies with diminished bases.suctioned for small amounts of yellow to tan thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes noc.  noted improvement in am abg's 7.45/66/73/47. no rsbi due to ^ peep/^fio2. plan: maintain present support.
"
3203,"resp: [**name (ni) 516**] pt on psv 5/10+/40%.  ett 7.0 taped @ 24 lip. bs are diminished bilaterally and suctioned for small to moderate [**name (ni) 1444**] tinged/plugs/secretions. mdi's administered alb/atr as orderd with no adverse reactions. no abg's this shift 02 sats @ 98%. no rsbu due to ^ peep. plan: family meeting to discuss cmo/trach/peg/or?
"
3204,"resp:  [**name (ni) 516**] pt on a/c 14/550/+5/40%. pt has #8 portex trach. suctioned for small to moderate amounts of tan to white thick secretions. mdi's administered as ordered of atr with no adverse reactions. no abg's or changes this shift. rsbi=no resps but will attempt again in am. plan to wean as tolerated.
"
3205,"resp: pt rec'd on a/c 10/550/+5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioned for small amounts of thick bloody secretions. mdi's administered as ordered atrovent with no adverse reactions. multiple vent changes (see careview) am abg 7.42/33/181/22. rr decreased to 14. no rsbi due to or procedure today. pt to be peg.
"
3206,"resp: pt rec'd on a/c 14/550/+5/40%. pt has #8 portex trach. inner cannula changed.  bs are coarse to clear. suctioned for scant to small amounts of thick tan secretions. mdi's administered as ordered of atrovent with no adverse reactions. no vent changes noc or abg's. rsbi=121. continue plans for placement in rehab. plan to wean to psv as tolerated.
"
3207,"resp: [**name (ni) 516**] pt on psv 12/10/60%. pt has #8 portex trach. bs are coarse to clear. suctioning for copious bloody secretions, pt developed epitaxis noc and subsided this am. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.46/35/112/26. vent changes to decrease ps to 10/peep to 8/fio2 to 50%. rsbi=61. plan to continue to wean as tolerated.
"
3208,"resp: [**name (ni) 516**] pt on 50% t/c. pt has #8 portex trach. pt began to desat then ambu/suctioned [**name (ni) 2160**] amounts of thick brown plugs. 02 sats 90-91%. nebs of albuterol administered x1, then mdi's combivent with no adverse reactions. pt is begin d/c to rehab this am.
"
3209,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has # 8 portex trach. bs are coarse and suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. pt placed on t/c trial around 3:00 @ 50% with humidification. cuff inflated. 02 sats @ 96%, rr 28 and tolerating well. will continue to monitor/assess.
"
3210,"resp: [**name (ni) 516**] pt on a/c 22/500/+14/40%.  ett #8, taped a@ 25 lip. bs are coarese bilaerally and suctioned moderate amounts of thick yellow/tan secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg pending. plan: pt scheduled for or for trach/peg this am. no rsbi=^peep.
"
3211,"resp: [**name (ni) 516**] pt on psv 12/10/50%. bs are basically clear with some scattered crackles with diminished bases. suctioned for scant amount of clear secretions. mdi's administered alb as ordered with no adverse reactions. am abg 7.41/42/102/28. no rsbi due to amount of peep. check leak is noted today. pt remains positive,and may continue with lasix today. no further changes noted. maintain present settings.
"
3212,"cvs;hr 80-100 a-fib no ectopy abp 100-120/40-70 on vasopressin 1.2 u/hr anasarca pedal pulses are doppled,extrimities are warm,left toes are dusky.hct 27.5 @ 2100 one unit prbc transfused without any any adverse reactions.for access a-line and pa line remains intact.recieving regular dose of albumin q6h.

neuro;sedated with fentanyl 50 mcg/hr,pt is comfortable,nodding head and appropriate with answering.not moving extrimities.

resp;recieved on cmv 40/400/20/5 no vent changes over night,saturation probe is not sensing well frequent abg was done to confirm o2 sats,po2 >130.ls are coarse throughout,required occasional suction for thin whitish secretions.

gi;abdominal dressing was done by surgen yesterday with jp in place,connected to wall suction draining serous drain please carevue for details,getting tpn for nutrition.no bowel movement at this shift.

gu;draining adequate amounts of amber color urine via foley catheter.

skin;anasarca,multiple skin breakdown and oozing from extrimities.sacral dressing intact,positioned and back care given as needed.lower extrimities are warm positive pedal pulses.

id;core temperature 38.2,on antibiotics vanco/flagyl/levaquin

social;no contact from family at this shift.

plan;abdominal wound closure--add on, consent taken over phone by surgen and filed.
type and screen send yesterday
pain management,monitor lytes,replete lytes as needed
continue albumin
update with pt and family.
"
3213,"resp: pt rec'd on 40% cam. nebs administered of mucomyst 3 cc's and albuterol with no adverse reactions. also ns nebulizer x1. bs are coarse bilaterally. will continue to follow.
"
3214,"resp: [**name (ni) 516**] pt on psv 10/5/40% @ start of shift then pt ^ wob and ^ rr and bp. increased ps back to 15 and pt tolerated well. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow secretions. mdi's administered alb with no adverse reactions. am abg 7.50/37/124/30. rsbi=87. plan: wean ps as tolerated.
"
3215,"resp: [**name (ni) 516**] pt on a/c 24/450/5+/50%. bs are basically clear with some occasional coarseness. suctioned for small amounts of thick yellow/tan secretions. mdi's administered as ordered alb/[**name (ni) **] with no adverse reactions. no changes noc or abg's. pt had some episodes of ^ wob when [**name (ni) **] light. rsbi=173. plan: continue present mode of support.

"
3216,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett 8.0 retaped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. rsbi=62. no abg's this shift. plan: pt scheduled for trach today.
"
3217,"resp: [**name (ni) 516**] pt on a/c 24/450/+8/50%. ett #7.5, rotated, retaped and secured @ 23 lip. bs are coarse to clear with exp wheeze noted at start of shift and suctioning for moderate to copious amounts of thick yellow secretions. mdi's administered as ordered alb/[**name (ni) **] with no adverse reactions. no abg's this shift/no a-line. 02 sats @ 99%. rsbi=134. plan: wean as tolerated.
"
3218,"resp: [**name (ni) 516**] pt on 24/450/+8/50%. ett 7.5 taped @ 23 lip. bs are coarse to clear bilaterally. suctioned for moderate amounts of thick yellow secretions which seems to be an improvement over yesterday, although continues to have fever.mdi's administered alb/[**name (ni) **] with no adverse reactions. no changes noc. am abg 7.44/40/97/28. rsbi=152. plan;wean as tolerated.
"
3219,"pt came to micu from [**wardname 665**] for merepenem desensitization  because of multiple allergy around [**2090**].completed desensitization without any complication. c/o ?

neuro:ox3. calm &cooperative

id: frequent uti now with e-coli. no signs of adverse reactions to merepenem.

cardio: nsr,vss.am lab pending. heparin drip per protocol. ptt qd.

resp: ls cta.

gi: abd soft. bowel sounds present. fsbs as noted.

gu:voids,minimal pain upon urination.clear yellow urine.

pain: severe left flank pain. pain mgt improved after multiple pain med adustments as noted.

plan ? c/o to floor today.
"
3220,"nursing progress note.
pls see carevue for specifics.
care of pt 1500-1900hrs.

resp:
trache 8.0 patent.  vent settings pressure support 18/10 50%.  tolerating well.  chest occasionally coarse.  few secretions.  trache care attended.

neuro:
awake and alert.  sat up in chair.  interactive with family.  denying pain.  answering questions by nodding.  in good spirits.  minimal movement left hand persists.  purposful with right hand.

cv:
afib continues.  pt pink, warm.  gross edema to legs.  diuresing well with lasix administered on prior shift.  weaning phenylephrine.  goal map >65mmhg sbp 100mmhg per csru pa.  1 unit prbc complete without adverse reaction.  repeat hct sent.

gigu:
abdomen large, soft.  minimal stool.  foley patent.

id:
antibiotics commenced.  tmax 100.1f this afternoon.

psychsoc:
multiple visitors.  questions addressed.

plan:
continue to monitor.  wean phenylephrine as able within given parameters.
follow hct.
continue discharge planning.


"
3221,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has #7 portex trach. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats maintained @ 98% with adequate tv's. rsbi=20. plan: continue wean/sbt with possible t/c trials.
"
3222,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #8 portex trach. bs are slightly coarse/diminished ls. suctioned for small/moderate amounts of white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's noc. rsbi=68. plan: wean as tolerated with possible t/c trials.
"
3223,"resp: pt rec'd on psv 15/5/40%. ett 7.5 taped @ 21 lip. bs are clear in apecies with diminished bases. suctioned for small amounts of white/pale yellow secretions. mdi's administered of alb with no adverse reactions no changes noc. am abg 7.48/35/104/27. rsbi=102. plan: wean as tolerated.
"
3224,"resp: [**name (ni) 516**] pt on psv 15/10+/60%. pt has #8 portex trach. bs are coarse to clear and suctioning small to moderate amounts of thick brown/plugs secretions.mdi's administered as ordered combivent/alb prn with no adverse reactions. no rsbi due to ^ peep. am abg 7.50/37/182/30. vent changes to decrease ps to 10, fio2 to 50%. plan to continue to wean as tolerated.
"
3225,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are clear to coarse bilaterally. suctioned for small amount of tan thick secretions. mdi's administered combivent q4 hrs with no adverse reactions. rr ^ to 30's then ^ psv to 10. tv's 500-600. no abg's this shift. rsbi=44. plan to wean as tolerated.
"
3226,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear. suctioned small amounts of thick yellow secretions. mdi's administered q4 hrs combiven with no adverse reactions. pt became ^ wob with rr to 30's then increased psv to 10. am abg 7.46/41/153/30
rsbi=49. plan to wean ps as tolerated.
"
3227,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, taped @ 20 lip. bs are clear with diminished bases. suctioned for small amount of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. rsbi=51. am abg pending. plan: continue to wean ps as tolerated.
"
3228,"resp: pt rec'd on psv 5/5/70%. pt has #8 portex trach. bs are clear with slight coarse bases which clear with suctioning. suctioned for small amounts of thick bloody tinged, then tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt fio2 wean to 50%. am abg 7.48/29/78 with 02 sats of 99%. rsbi=38. continue to wean as tolerated/possible t/c trials?
"
3229,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear and suctioned for clear to yellow thick secretions. mdi's administered as order alb/atr with tobramycin nebs. no adverse reactions noted. pt has episodes of desaturations to 80's then increased fio2 back to 50% resulting in saturations >94%.  am abt 7.44/31/83/22. rsbi=19. plan to continue to wean as tolerated and attempt t/c trials again today.
"
3230,"resp: [**name (ni) 516**] pt on psv 8/10+/60%.  ett 8.0 retaped @ 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions as well as large amounts of oral secretions. mdi's administered alb/atr as ordered with no adverse reactions. trip to ct scheduled for this am. no rsbi due to ^ peep. 02 sats @ 97%. plan to trach/peg this tuesday. plan: maintain present settings.
"
3231,"resp: pt rec'd on simv 14/500/14/+5/40%.  pt has #8 [**last name (un) **] air filled cuff trach, secured @ 14cm flange. bs are coarse bilaterally and [**last name (un) 7273**] thick white to yellow secretions. some improvement following suctioning. mdi's of combivent administered as ordered with no adverse reactions. no changes noc. rsbi=86. plan to continue with t/c trials as tolerated.
"
3232,"resp: pt rec'd on a/c 16/500/+5/40%. bs are coarse bilaterally and suctioned for small amount of tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's or aline. 02 sats @ 100%. rsbi=no resps. plan to continue to wean to psv as tolerated.
"
3233,"resp: [**name (ni) 516**] pt on a/c 24/300/10+/40%. bs are coarse and suctioned for small to moderate amounts of bloody tinged thick secretions to tan. no changes noc. mdi's administered alb with no adverse reactions. 02 sats @ 98% tonight. am abg 7.45/43/83/31. no rsbi due to ^ peep. will continue full vent support.
"
3234,"resp: [**name (ni) 516**] pt on a/c 16/500/10+/60%. bs are coarse to clear. suctioned for moderate amounts of thick bloody to tannish secretions. mdi's administered of alb with no adverse reactions. 02 sats continue to fluctuate with turning and light sedation. weaned to psv 16/10/60%. placed on 100% temporarily when pt turned. am abg 7.45/42/84/30. plan to wean as tolerated. discussion of trach?
"
3235,"resp: [**name (ni) 516**] pt on a/c 24/650/+14/60%. ett 7.5 taped @ 22 lip. bs are diminished bilaterally with minimal suctioning. mdi's administered as ordered comb/[**last name (un) **] with no adverse reactions. abg 7.36/42/80/25. no rsbi due to ^ peep. plan to wean as tolerates.
"
3236,"npn 7a-7p


#2 remains on nasal prongs cpap 5, 28-32%. rr 60-80's. ls =
and clear, sx'd x 1 for small yellow from nares. receiving
28cc prbc's in 2 aliquots today for fio2 requirement, sao2
drifting, paleness, and hct 27 (retic 1.9). is infusing w/o
adverse reaction. to receive lasix between infusions.
monitor.

#3 tf at 150cc/k/d, tolerating gavage feeds w/o spits, girth
steady, + bowel sounds, is voiding. gaining wt on 30cal pe.
monitor.

#5 maintaining temp in air isolette while swaddled. is very
alert with cares, settling well. skin intact. is pale-pink.
likes to suck on pacifier. con't present interventions.

#8 mom called and was updated on infat's status as well as
plans to transfuse. mom will call again for update later on.
visits every other day and held for 1hr yesterday. con't to
teach/support.


"
3237,"resp: [**name (ni) 516**] pt on psv 8/12/60%. pt has #8 portex trach. bs are coarse to clear and suctioning moderate amounts of thick bloody tinged to tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. cuff pressures @ 22 cmh20. vent changes to decrease ps to 10, then 8, fio2 to 50%, then 40%. rsbi=38. am abg 7.39/43/169/27. icp's continue to fluctuate noc. no further changes noted. plan:continue to wean as tolerates.
"
3238,"resp: pt rec'd on a/c 16/500/40%/5+. bs are coarse bilaterally.suctioned for small to moderate amounts of thick tan secreitons, sample sent.  mdi's administered alb/atr with no adverse reactions. no abg's 02 sats remain at 100%. vent circut changed to heated. rsbi=150. plan to wean to psv as tolerated.
"
3239,"resp: [**name (ni) 516**] pt on a/c 20/600/+15/70%. ett 7.0, taped @ 23 lip. bs reveal bilateral clear apecies with diminished ls base. suctioned moderate amounts of thick bloody tinged secretions. mdi's administered as ordered alb/ovar with no adverse reactions. pt continues to demonstrate abdominal desynchronous breathing. improved abg's oxygenation then weaned fio2 to 50%. am abg 7.34/35/91/20. no rsbi due to ^ peep. plan: continue wean as tolerated.
"
3240,"resp: [**name (ni) 516**] pt on psv 10/10/60%. ett 7.5 rotated, retaped and secured @ 22 lip. **note** ett was cut back.  bs are coarse bilaterally and suctioned for moderate-copious amounts of thick yellow/white secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. no changes noc. am abg 7.24/47/76/26. no rsbi due to ^ peep. plan: continue to wean as tolerated
"
3241,"resp: [**name (ni) 516**] pt on simv 18/550/5/+5/40%. ett # 7.5 taped @ 21 lip. bs are clear with diminished bases. suctioned for scant amount of clear thin secretions. mdi's administered combivent/alb with no adverse reactions. abg 7.42/37/97/25. no changes noc. rsbi=no resps. plan: wean as tolerated.
"
3242,"resp: [**name (ni) 516**] pt on simv 14/550/5/5/50%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are clear with diminished bases. suctioned minimal to no secretions. mdi's administered combivent/alb as ordered with no adverse reactions. am abg 7.30/50/137/26. vent changes to ^ r to 18, decrease fio2 to 40%. no rsbi due to hemndynamic instability. plan is to wean as tolerated.
"
3243,"7a-7p
neuro: pt sedated and paralyzed on fentanyl,midaz,and fentanyl gtts. pupils 3mm sluggish, equal.

cv: hr 60s sr w/ rare pvcs. as day progressed, hr 56-58 junctional pa [**doctor last name 87**] aware, no new orders. pt has epicardial wires v wires only, pacer not checked d/t ventricular ectopy. 1 episode of 25 beat run of vt self limiting, mg 2gm given. sbp 90s-100s. levophed gtt weaned to off. epi gtt continues at 0.02mcg/kg/min. vasopressin continues at 2.4units/hr. [**md number(3) 7566**]/30s. cvp 15-20. ci>2 by fick, team aware. at beginning of shift svo2 58-59, md [**doctor last name 859**] aware, 1 unit of prbcs infused as ordered, no adverse reactions. svo2 >60 after 1 unit of prbc. chest remains open w/ wound vac in place, draining serosang small amts. 4+ pitting edema. +dopplerable pedal pulses.

resp: ls clear diminished. sats 100%. continues on cmv mode rate 16, not breathing over vent, fio2 40% peep5. see carevue for abgs and vent settings. pa [**doctor last name 87**] aware of abg at~ 1700, no new orders.

gi/gu: abd softly distended. tf on hold at present time d/t high residuals, [**name8 (md) **] md [**last name (titles) 859**]. hypoactive faint bs. ogt to lcs/g tube to gravity draining bilious drainage, pa [**doctor last name 87**] aware. foley draining 5-10cc/hr of clear yellow urine. cvvhdf clotted x1, renal fellow aware and increased replacement fluid to 2000cc/hr. pt negative 1100cc since midnoc thus far. goal -100cc/hr as pt tolerates.see flowsheet for details.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. cvvhdf goal -100cc/hr as pt tolerates. monitor hr.


"
3244,"7a-7p
neuro: pt able to respond to stimuli throughout shift with responses to voice at times. goal to keep pt sedated.  pt thrashing arms and legs at times. pt currently on midaz and fentanyl with periods of midaz boluses in between [**name8 (md) **] np [**doctor last name 307**].  perrla sluggish in am and more brisk in afternoon.  pt able to mae's when more awake. no temp at this time and pt continuing on iv vanco.

cv: hr- sr/st with frequent pac's/pvc's 90's-120's at beginning of shift. at 1200, hr 80's with pac's. amiodarone drip contiuing at 1mg/min as ordered. placed on asynch 96 via epicardial wires in order keep pt out of a-fib [**name8 (md) **] np [**doctor last name 307**]. right radial a-line dampened and bleeding at site at 0900. np at bedside with several attempts to place a-line at another site. at 1030, left fem placed with positive fling. weaning drips (neo, levophed, vasopressin) according to fem map >60 [**name8 (md) **] np. electrolytes monitored and wnl throughout shift. see flow sheet for pulses. svo2 50's-60's with co [**4-8**]. ci above 2 per thermodilution. see flow sheet. np [**doctor last name 307**] aware. pt given multi-fluid boluses and hespan given as ordered. pa's 30's/20's and cvp 16-20. pt with hct of 21 at 1400. np [**doctor last name 307**] aware and pt transfused 2 units of prbc's with no adverse reactions. repeat hct pending.

resp: ls-coarse in am. cta/dim at bases in afternoon. pt given mdi's per respiratory. pt suctioned as needed with small amounts of thick white sputum. pt on cmv mode, rate 16, 5 peep, 650 tidal volume, and 60 fio2. abg's drawn in am with respiratory acidosis. resolved with settings on vent increased to 20 and peep increased to 8. abg rechecked and vent rate increased to rate of 24. resolving respiratoy acidosis. lactic acid 2.4 but resolving and 1.6 when rechecked after fluid given.  see flow sheet for abg's and flow sheet changes. np[**md number(3) 94**] throughout the shift. sats 93-96%. chest tube draining minimal amounts of serosang with no air leak.

gi/gu: abd soft with absent/hypoactive bs. pt with ng tube draining bilious/clear.  foley intact draining minimal amounts of urine 10-40cc/hr. np [**doctor last name **] aware. after fluid and blood given, pt given 20mg iv lasix with still minimal amount of urine output.

endo: pt continuing on insulin drip per protocol.

skin: see flow sheet. skin intact.

plan: keep pt hemodynamically stable with goal bp map >60 and titrate drips. pain control. monitor blood sugars and insulin protocol. monitor abg's. monitor urine output.
"
3245,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett 38.0 retaped, rotated and secured @ 24 lip. bs are diminished in bases with noted aeration in apecies. suctioned for small amount of white/tannish secretions.circuit changed to heated wire circuit. mdi's administered alb/atr with no adverse reactions. noted ^ in wob, then placed back on a/c 18/550/5+/40%. am abg 7.41/41/145/27. plan to continue to wean to psv as tolerated.
"
3246,"resp: [**name (ni) 516**] pt on psv 15/5/35%. ett #8, retaped, rotated and secured @ 24 lip.  bs are coarse bilaterally and suctioned for moderate amounts of thick yellow to tannish secretions. pt placed on a/c 12/400/5+/35% to rest noc. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=116. plan to continue to wean to psv.  no plans for pt to have trach, although may consider?
"
3247,"resp: [**name (ni) 516**] pt on psv 8/15+/50%. bs are diminished and suctioning for small to moderate amounts of thick bloody tinged to yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt continues to be desychronous with vent and had ^ wob episode then placed on a/c to rest noc. noticeable improvement noted and weand back to psv this am. pending abg to follow. plan: continue to wean as tolerated, possible dialysis? following renal consult.
"
3248,"resp: [**name (ni) 516**] pt on psv 12/8/50%. ett 7.4 taped @ 24 lip. bs are coarse to clear bilaerally and suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered comb/alb with no adverse reactions. abg 7.45/47/86/34. rsbi=62. weaned psv to [**11-11**]+ plan to continue wean as tolerated, extubate?
"
3249,"resp: [**name (ni) 516**] pt on psv 5/5/40%. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow/greenish secretions. changed to heated wire circuit. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. rsbi=53. am abg 7.45/42/85/30. family meeting today to cmo?
"
3250,"npn 7p-7a (please also see carevue flownotes for objective data)

dx: neutropenia; fuo

49f admitted for neutropenia, fevers; pt went to clinic, received injection, initally felt her s/s were adverse reaction (per family...);
pt became hypotensive, started on levophed; started on several iv abx, required several electrolyte iv replacements; also received 1 unit prbc's;

at approx 12a, went to ct for abd/chest, drank bari-cat w/out difficulty; at end of ct pt c/o not being able to breath; icu resident paged to come down, also to bring lasix; pt returned to [**wardname **]4 w/out event; continued develop resp distress w/ audible rales, lasix/morphine/ativan received, pt finally became more comfortable w/ respirations, especially after mask ventilation applied;

pt received bedside u/s at approx 04:00, team looking to see if pt had perf'd gallbladder, found to be intact; (at approx. c/w md stated pt had pna and untreated strip recently; [**8-4**] bld cx's grew [**4-19**] bacteria in chains:)

team/ w. c/s input decided since pt's lactate now 3+, up from 1+ in er, that pt needed vigorous fluid resucuitation, and that pt would need to be intubated to prevent pulm edema/resp distress;

pt intubated at approx 05:00, started on versed/fent gtt for sedation, started on [**2-/2095**], not adequate, as of 07:00, on [**3-/2110**];
iv hydration restarted; a-line attemped left wrist, not accessed;

plan:
1) iv abx as ordered (likely to be consolidated at rounds)
2) iv hydration
3) update family prn
4) levophed to maintain b/p
5) pt states we can give information to her mother, as well as husband
"
3251,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5 found @ 27 then retaped and pulled back to 24 as per xray. bs are coarse to clear and suctioning moderate amounts to small thick yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.45/40/144/29. rsbi=82. family mmeeting today for cmo status.
"
3252,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5, rotated, retaped and secured @ 24 lip. bs reveal ls clear with rs noted exp wheezes. suctioned for moderate amounts of thick greenish secretions. mdi's initiated and administered alb/atr as ordered with no adverse reactions.  bs in am noted exp wheezes on rs and diminished ls. am abg 7.45/40/104/29. rsbi 50. no changes noc. pt has cooling blanket/temp 101. plan: continue wean as tolerates
"
3253,"resp: [**name (ni) 516**] pt on psv 10/5/50%.  ett 6.5, taped @ 20 lip. bs are coarse bilaterally. suctioned for moderate to copious yellow to green plugs this am. mdi's administered alb/atr with no adverse reactions. 02 sats @ 98%. vt's 400. rsbi=70. pt spiking temp of 102. sbt scheduled for this am, question extubation with onset of temp and ^ hr to 120's. am abg pending.
"
3254,"resp: [**name (ni) 516**] pt on a/c 20/450/+8/40%. ett 7.5 taped @ 24 lip. bs are diminished bilaterally and suctioned for small amount of white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. plan: pt is to be trach/peg today.
"
3255,"7p-7a
neuro: pt attempts to open eyes w/ stimuli, perrla, random movements of hands and toes, not to command. medicated prn w/ morphine for pain noted by pt's grimacing.

cv: hr 100-110s. st. sbp >90 while on levo gtt. weaning levo gtt as pt tolerates, goal map>65 per vascular team, see carevue. cvp 12-14. lopressor held d/t levophed and hypotension, md bridges aware. k 5.4-5.3, md bridges aware, k gtt stopped from cvvhd.  received 2 units of prbcs, no adverse reactions. fingers and toes dusky. + palpable pulses.

resp: ls coarse. orally intubated, ps decreased to 18, w/ acceptable abgs, see carevue. rr 20s. tv 500-600 on cpap [**6-22**], fio2 50%. see carevue for further details. sats 94-100%, poor waveform at times. ct w/ no-> scant serosang drainage, flushed as ordered.

gi/gu: abd firmly distended, hypoactive bs. tf nutren renal at goal of 10cc/hr, w/ minimal residuals. flexiseal intact, draining loose brown stool. foley draining 8-15cc/hr of clear yellow urine. cvvhdf running pt even as pt's bp tolerates. see carevue for details.

endo: per pt's scale.

social: wife and son into visit at beginning of shift. vascular md [**doctor last name 2261**] spoke to son [**name (ni) 351**] re: pt and ct results.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean levophed to off, then start to remove fluid via cvvhdf slowly. skin care. keep pt comfortable.
"
3256,"resp: [**name (ni) 516**] pt on psv 10/5/40%. bs are coarse to clear. suctioned for moderate amount of thick yellow/tan secretions in am. pt is nasally intubated in r nare. noted audible cuff leak. pt has episodes of decreased ve and placed on mmv then returned to psv in am. mdi's administered alb with no adverse reactions. no further changes noted. rsbi=48. plan to monitor and extubate when appropriate.
"
3257,"resp:  [**name (ni) 516**] pt on psv 10/5/40%. ett 7.5, rotated, retaped and secured @ 23 lip. bs are coarse bilaterally. changed circuit out to heated wire which improved secretions, although still suctioning a moderate amount of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.46/39/115/29.  rsbi=99. plan to continue on present settings.
"
3258,"resp> pt rec'd on psv 10/5/40%. pt has #8 portex trach. bs are coarse and suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes or abg's this shift. 02 [** **] @ 100%. rsbi=43. plan to continue to wean as tolerated.
"
3259,"7a-7p
neuro: received pt on nimbex/fentanyl/midaz gtts. nimbex gtt dc'd as per csurg team this am. continuing fentanyl/midaz gtts for sedation while intubated. pt opens eyes to name, perrla, mae, follows commands.

cv: hr 70-90s sr no ectopy. sbp labile. weaned levo gtt to off, see flowsheet. received 1 unit of prbcs as ordered, no adverse reactions. repeat hct 29.9. cvp 9-12. new tlc placed to left subclavian. old right subclavian tip sent for culture. +[** **] left pt/ absent left dp, md [**doctor last name 420**] aware, not new. +[**doctor last name **] right pedal pulses.

resp: ls clear / coarse at bases. sats 94-98%. pt orally intubated on cmv rate 27, breathing 0-5 over set rate, peep weaned from 12 to 10. fio2 increased to 50% w/ pao2 70s, after right ct placement, repeat abgs showing pao2 120s, fio2 weaned back to 40%, md [**doctor last name **] aware. see flowsheet for abgs/vent changes. nasal tampon to right nare intact. suctioning small amts of blood tinged secretions from back of throat. new right pneumo, ct placed by md [**doctor last name **], scant amt of serosang drainage, no air leak, no crepitus. bronch done this am, large mucus plugs seen to left bronchus, suctioned and specimens sent [**name8 (md) **] md [**last name (titles) **].

gi/gu: abd soft, hypoactive bs. no bm. +placement of ogt, draining brownish/bilious. tpn as ordered. foley draining 30-100cc/hr of clear yellow.

endo: no gtt started d/t bs 90s-120s.

skin: see flowsheet.

id: fungal cultures sent. tmax 99.3 po. antibiotics as ordered.

plan: monitor hemodynamics. monitor resp. status. wean vent as pt tolerates. comfort/pain control.
"
3260,"nicu npn addendum:
prbc transfusion started but after 15 min site leaking, enough to redden band-aid. was removed and iv restarted in left foot. is infusing well, no complications at site or adverse reactions observed during transfusion so far.
"
3261,"npn


34 [**4-24**] week infant admitted to nicu warmer. infant pale but
active and responsive. vs stable. bp mean 40; sat 97%
d-stick 73. cbc and bx sent. crit 17.5->received 15cc's/kg
of prbc's over 4 hours without adverse reactions. will
recheck crit in 6 hours. infant very active, resting
comfortably between cares, sucks well on binki, vital signs
unchanged. blood culture pending. no antibiotics given.
erythromicin and vitamin k given as ordered. parents in and
spoke with nnp at bedside. infant currently resting
comfortably in room air with sat of 100%. nnp placed dluvc
infusing d10w at 60cc's/kg. piv heplocked.

see flowseet for further details.


"
3262,"npn:


2. infant remains on nco2 200cc flow, 30% fio2. rrs-40s-60s.
ls clear and equal, ic/sc rtxns noted upon exam. infant
remains on [** **] as ordered, no spells thus far. cont
towean fio2 as tolerated.

3. wgt-2070g, up 20g. tf remain @ 150cc/kg/d of bm30 with
promod. infant tolerating ng feeds well over 1hr. no attempt
to po feed made. abd benign, no spits, min aspirates. vdg
and stooling adaquate amts, stool heme neg. cont to monitor
wgt gain and feeding tolerance.

4. [**known lastname **] remains swaddled in an oac, temps remain stable.
alert and active with cares. bringing hands to face,
fontanels remain soft and flat. hep b vaccine administered
to infant this pm, no adverse reactions noted. consent
prsent in chart. cont to [**doctor last name 730**] dev needs.

5. mom and [**name (ni) 3809**] in tonight, updated @ bedside on infants
condition. mom independently participating in cares, held
infant x 1hr. asking appropriate questions. cont to update
and educate as needed.


"
3263,"nursing note days

7 hyperbilirubinemia
11 infant with potential sepsis

#1 resp: hfov, map 14, dp 19. no vent changes today, 2 abgs
done, see flowsheet. fio2 60-75%. baby gram done at 1530,
see [** 96**] note, keeping baby positioned w/ right side up. ls
course, large airleak. suctioned for mod cloudy secretions
in ett, and large tan and blood tinged from mouth and nose.
con't to monitor, check next abg at 2100.

#2 fen: tf 100cc/k/d, no basing fluids on current weight of
812g. recieving tpn d30, il, and dopamine in d12.5 by picc.
1/2 ns w/ hep running in radial art line. piv in right arm
hep locked. ds 60&56. uo: 1.7cc/k/hr for 12hrs. no stool.
abd full, soft, no bs (?hypoactive). ng repogle to low
intermittent suction, draining ~2cc of dark green bilious
aspirate per 12hrs. con't to monitor closely.

#4 g&d/pain&stress: alert and active, agitated easily w/
noise and bright lights. recieved fentanyl ~q3hrs, responded
well. maintaining stable temps nested in sheepsking w/ tight
boundries on servo controlled warmer. under tent for noise
controll. con't to support dev needs. due for 30day hus
thurs.

#5 family: mom in to visit today for ~1hr. asking
appropriate questions, talked to and touched baby. very
[**name2 (ni) **]. con't to support and update as needed. planning to
come in for family meeting at 3pm tomorrow and to kangaroo
sibling.

#8 cv: no murmor heard this shift. infant pale, pink, hr
140-190s. cbc checked at 0900. plt count 98, hct 33.6.
transfused 1st alequot of 20cc/k [**name2 (ni) 4103**]; 8cc over 4hrs,
completed at 1900. no adverse reactions, vitals checked per
protocol. due for next 8cc tonight. infant on dopamine drip
(60mg/50cc d12.5); required 6-7mcg/k/m this shift to keep
maps 32-36. con't to monitor and support.

#11 sepsis: cbc and cx sent at 0900. culture pending. see
flowsheet for cbc results. infant started on vanco and gent
iv, first doses given this am. con't to monitor for signs of
infection and administer meds per orders, check levels w/
3rd doses.

revisions to pathway:

  7 hyperbilirubinemia; d/c'd
  11 infant with potential sepsis; added
    start date: [**2149-3-4**]

"
3264,"7am-7pm


2. received infant in nasal cannula 200cc flow in room air.
resp rate stable as per flow sheet. breath sounds clear and
equal. o2 sats 92-100%. infant currently receiving
transfusion of prbc's for symptomatic anemia. tol procedure
well. no adverse reactions noted at this time.
14.intermittent murmur audible. color pale, mottled at
times. mild to mod intercostal/subcostal retractions noted.
stable at this time receiving prbc's.
cont to monitor per protocol.
3. no contact with [**name2 (ni) 26**] this shift. md spoke with [**name2 (ni) 26**]
re: transfusion procedure.
4. tf 140cc/kg/day. pe26 with promod. tol well. small spits,
min aspirates. abd full, active bowel sounds. voiding qs see
flow sheet. no stool x2 days. abd girth stable.
tol full feeds.
cont per plan.
6. in open crib cobedding with sibling. maintaining temp.
swaddled with boundries. sucks on pacifier
intermittently.wakes for feeds.
tol handling and minor stress with current stress
precautions.
cont plan.




"
3265,"respiratory care note
pt remains on imv 22/5 x 20 .21-.35fio2.  bbs ess clear with audible leak.  sx'd for scant pale yellow secretions.  2nd dose of 4.4cc survanta administered per protocol with subsequent wean of fio2 from .35 to .24fio2.  well tolerated with no adverse reaction.  comfortable rr 40-60s.  post intubation cxr this morning c/w rds and slightly high tube.  will continue to follow and wean as tolerated.
"
3266,"respiratory care note
pt remains on simv 27/7 x 28 .57-.70 fio2.  bbs coarse and diminished throughout.  sx'g for mod amts of cloudy secretions.  2puffs combivent given via mdi at 8a and 4p  - no adverse reaction.  rr 28-40s.  vts around [**9-20**] (spont [**1-10**]).  occ [**month/day (3) 182**] req increased fio2.  will cont to follow.
"
3267,"respiratory care note
pt remains on imv 23/6 x 18 .40-.55.  bbs coarse w/crackles and positional leak around the tube.  sx'd for mod amt of cloudy thick white secretions.  1pm [** **] held due to tachycardia, given at 5pm.  pt started on dornase alpha (pulmozyme via minineb) 1.25mg [**hospital1 **], given at 5pm, well tolerated w/no adverse reaction.  oral ett resecured ~8.5 @ lip. 5pm cbg (drawn prior to [**hospital1 **]/neb):  7.38/62/25/38/+7, no [**hospital1 **] changes made.  continues on caffeine.  occ [**hospital1 182**], usually self resolved.  comfortable rr 35-50s.  nard.  will continue to follow and wean as tolerated.
                                  [**first name4 (namepattern1) 2693**] [**last name (namepattern1) 2694**], rrt
"
3268,"pca progress note 3-11p


fen: feeding plan changed by order of feeding team consult.
tf: min 80cc/kg/d of neosure22 q3 hours. pt [**name (ni) 2563**] full
bottles+ at both feeds this shift. pt remains on reflux
percautions. pt mottles throughout with cares. abd is
benign; soft w/ +bs. v/s qs. infant is active to eat feeding
time, appears to stress and tire toward end of feeds,
becoming tachypnic and arching frequently, often until
bottle is removed. please refer to pt's chart for additional
fen data. continue to monitor and support feeding plan,
while encouraging all po feeds as tolerated.

dev:
  pt's temp remains stable while swaddled in [**name (ni) 133**]. axillary
temps have been inacurate due to pt sitting in swing with
arms uncovered. rectal temps are stable. pt woke for 1st
feed, and needed to be woken for 2nd. she is [**name (ni) **] and very
active with cares. activly sucks on pacifier for comfort
when waking. loves to be cuddled and held. continue to
encourage and support developmental milestones.

par: no  contact with [**name2 (ni) **] by this pca so far this shift.

sepsis:
  day 30 of 42 of oxicillin. no temp noted.  broviac line is
patent. no issues. plan to continue meds as ordered and
monitor for s&sx of toxicity or adverse reactions.


"
3269,"nursing status/progress note 7a-7p


#2 infant now under double photo tx w/yeye and genital
protection in place. to check a bili later this afternoon
along with cbc and lytes (last k 3.1). rec'd 2nd of 3 doses
immunoglobulin this am w/o adverse reactions, 3rd dose to be
given again in am. infant is jaundiced with pink mucosa.
further plan as per bili/lab results this afternoon. con't
to monitor.

#3 piv hl'd this am, and is bottling enf 20 well on a
""demand"" schedule. is voiding, and has been stooling
frequently. monitor intake on oral feeds.

#4 no parental contact so far this shift, but reportedly
parents are very involved. family meeting planned for 4pm
this afternoon. will con't to update and support.

#5 infant remains under photo tx on ""off"" warmer and is
maintaining temp well. is on all enteral feeds, bili level
has been decreasing and are con't to monitor. is very active
and alert with cares, is waking for feeds and settling well
afterward. will con't present interventions at this time.




"
3270,"npn 7a-7p


#1 tf at 140cc/k/d, bottling ~[**1-30**] volume but sometimes takes
all. has some head-bobbing and retractions when bottling and
when getting tired during feed. ngt in place. increased cals
to 34 of bm/neosure. voiding and [**month/day (2) **], circ site w/o
bleeding/oozing. on nitrofurantoin for hydronephrosis. no
adverse reactions noted so far. con't to monitor wt, check
lytes in am.

#2 [**month/day (2) **] took care plan (for play-time/positioning) home
with some discharge info. has been sleeping comfortably b/t
activities, wakes for feeds, bottles eagerly but gets a bit
tired. likes to suck on pacifier and sit in swing. will
receive eip when discharged.

#3 [**month/day (2) **] disappointed that [**month/day (2) **] would not be discharged,
but today they completed most of discharge teaching and
[**month/day (2) **] will have renal u/s and vcug at tch tomorrow prior to
discharge so out-patient app'ts have been cancelled. will
try to arrange for urology (dr. [**last name (stitle) 5004**] to see [**last name (stitle) **] on
friday when [**last name (stitle) 26**] bring [**last name (stitle) **] in to tch for cardiology
app't with dr. [**last name (stitle) 4998**]. vna will visit home tomorrow at 3pm,
as [**last name (stitle) **] will be discharge as early as possible in am.
([**location (un) **] home infusion will drop off equipment at house
today). mom states she is comfortable with passing ngt (and
she demonstrated on friday). discharge medication dosing and
administration was reviewed and return demonstrated
(needless syringes given).
-circ done, passed hearing screen, passed car seat test, and
synagis given. con't to support/review teaching.

#4 [**location (un) 345**] has murmur, hr 140-160's, is pale-pink (mottled at
times). hct 44/retic 2.7. observing for s&s of chf. is on
lasix, kcl, and digoxin. will be followed by dr. [**last name (stitle) 4998**] at
tch (app't fri [**2-25**] 10:30 am). con't to monitor.



"
3271,"nursing notes:


#1fen:tf-[**month (only) **]to 140cc/k/d. npo throughout this shift r/t
bilious asp. 1-2cc dark green asp. w/each care thus far this
shift. dr.[**first name (stitle) 612**] aware. kub this am w/o no neumotosis noted.
?malrotation,blockage? infant going to tch this pm for upper
gi series. abd.soft,mottled, hypoactive bs. voiding,no stool
noted thus far this shift. no spits today. ivf tpn d14w@
4.7cc/hr and lipids @.6cc/hr. dstick-108.g19-19.5. sepsis
eval.sent w/lytes this pm. results pending.a;?malrotation,
nec watch?mec.blockage?p;continue npo and closely monitor.
tx.to tch at this time for upper gi.
#2g/d;[**first name (stitle) **],active,and irritable throughout shift. comfort
measures given w/good response noted- positioning on abd,
pacificer,containment w/iv bag.nested in lambswool
w/bendybumper for boundaries. maew. mild temp.instability
97.5 this pm-?sepsis. remains in isolette and temp.adjusted.
[**first name (stitle) **]'s eod, no [**first name (stitle) **] today r/t current gi issues.
a;irritable r/t npo?sepsis?p;continue to monitor sepsis w/u
results. continue temp.monitoring and assess and support g/d
milestones. [**first name (stitle) **] tomorrow if stable.
#3parenting;[**first name (stitle) **]/grandparents at [**first name (stitle) **] this pm. asking
many appropriate questions. appropriately concerned r/[**initials (namepattern4) **]
[**known lastname 827**] and gi issues. update given and plan discussed
w/family by md. [**last name (titles) 190**],ot at [**last name (titles) **] coaching [**last name (titles) **] on ways
to get involved w/cares. [**last name (titles) 143**] demonstrated good hands on
skills with infants. a;involved,very loving towards infants.
mom continues to be slightly hands off with babies.
encourage soft speaking. support and encouragement of cares
given to mom.p;continue to support and educate. facilitate
touch of babies with moms comfort level. [**last name (titles) 8**] to [**first name9 (namepattern2) **]
[**known lastname 827**] tomorrow if stable.
#4cv;hr150-170's. pale,mottled. tx.today w/1alloquate-10cc
prbc. no adverse reaction noted. second alloquate due tonite
post gi procedure at tch.hx. of intermittant murmur. cbc
sent tonite r/t r/o sepsis.results pending. b/p stable means
30-40's(see flow sheet).a;anemia,sepsis?p;continue to
closely monitor. f/u cbc result


"
3272,"respiratory care note
pt continues on imv 24/6 x 21 .21-.33fio2.  rate had been weaned from 23 secondary to early am cbg.  pt had major desat to 20s requiring manual bagging to get sats up.  pip increased at this time to 24 with good effect.  fio2 weaned as low as r/a -continued labile sats despite increased pip, however now mostly self resolved and has dipped as low as 50bpm, and come back up on her own.  cxr, which was unremarkable had a sltly high ett but [**name8 (md) 90**] rn some tension was applied during cxr.  bbs coarse, but clearer after sxn.  sx'd frequently for small to mod cloudy white secretions.  1 puff combivent given at noon via mdi/spacer with no adverse reaction.  rr 30-50.  will monitor closely and will repeat a blood gas if worsening desats continue.
"
3273,"npn 1900-0700

16 heme

fen:  cw 2245g (down 60g).  infant npo for pneumotosis by
kub & bloody stools.  tf 140cc/kg/day via [**known lastname **]: pnd10 +
il.  prn piv hl l hand.  abd remains distended, firm, occ
soft loops, active bs.  ag= 29-30cm.  kubs done 2200 & 0300;
[**name8 (md) 90**] [**name8 (md) 1**] somewhat unchanged, bowel somewhat less distended at
0300 film.  repogle to cont lws.  scant amt cloudy/bilious
secretions in [**last name (un) **] trap (~1cc).  voiding qs, lg stools with
each diaper change.  stools rusty in color, mucousy, with
some blood streaks present; heme positive.  [**last name (un) 1**] aware.  ds=
96, 84.  lytes sent: 138/3.2/99/31.

dev:  temps stable while nested on open warmer.
active/lethargic with cares.  occ wakes crying btwn.
settles with pacifier. [**last name (un) 383**].  mae.

par:  mom in to visit at [**2148**].  updated at bedside by this
rn.  asking approp questions, approp concerned.  discussed
possibility of transfer to tch for study.  consents to be
obtained if needed, with interpreter.  [**year (4 digits) 143**] called at 2400
for update.  continue to support and update [**year (4 digits) **] as
needed.

bili:  recent bili 11.8/7.9.  infant with hx of elevated
direct bili.  actigal d/c'd yesterday due to npo status.  pt
may be transfered to tch for omega study, [**name8 (md) 90**] [**name8 (md) 1**].  continue
to monitor.

a/b's:  rec'd infant in ra.  infant placed in nc at 2400 for
freq drifts/spells; nc 100%, 60cc.  infant able to wean to
20cc at end of shift.  rr 30-50s, ls c/=, mild ic/sc
retractions.  2 spells thus far this shift.  required stim
and bbo2 for resolvement.  total of 4 spells in 24hrs.
continue to monitor.

id:  infant on zosyn tid for nec.  med admin as ordered.
cbc repeated at 0400; results pending.  temps stable.
infant active/lethargic with cares.  continue to monitor for
s/s sepsis.

heme:  infant transfused total 2 alloquots prbcs overnoc
(10cc/kg x2) for hct 25.7.  consent signed in chart.  no
adverse reactions noted.  soft murmur auscultated.  hr
150-160s, infant pink, mod gen edema.  bp stable 78/40 (53).


revisions to pathway:

  16 heme; added
    start date: [**2156-3-30**]

"
3274,"npn 1900-0700


resp:  infant in nasal [**doctor last name **] cpap 5, fio2 37-49%.  ls
clear/=, mild sc retractions.  rr 20-40s.  sxn'd mouth x1
for moderate amt clear secretions.  occ drifts, no spells
thus far this shift.  pt on iv [**doctor last name 775**] [**hospital1 **].  continue to
monitor.

fen:  cw 2185g (up 85g).  pt remains npo.  tf 130cc/k/day.
picc l ac patent and infusing pn d10 + il.  piv r hand
hep-locked.  repogle to cont lws.  4.2cc clear secretions
aspirated at 2100; discarded.  tube irrigated with 2cc
sterile h20 (asp entire volume back).  suction canister
changed at 2100 due to not maintaining proper suction.
repogle now appears to be draining secretions adequately.
abd soft, [**hospital1 **], round.  no loops, active bs.  ag stable,
27cm.  8hr uo= 3.0cc/k/hr, no stool thus far this shift, pt
is passing gas.  surgery fellow from tch in to consult.  no
plans for repeat kub as yet.  2 aloquots prbcs transfused
overnoc (20cc/k) for hct of 28.4.  consent present in chart.
 tolerated transfusion well, no adverse reactions.

par:  dad called x1 thus far this shift.  updated by this
rn.  asking [**hospital1 **] questions.  provided much support by this
rn.  continue to update and support as needed.

dev:  temps remain boarderline low; 97.8ax swaddled with
t-shirt, 2top blankets, hat.  [**hospital1 1**] aware.  a/a, irritable
with cares.  settles well with sucrose pacifier.  slept well
tonight in btwn cares.  moves hands to face.  [**last name (lf) 383**], [**first name3 (lf) 57**].

sepsis:  pt now day 3 of 14 with abx clinda and zosyn.  meds
admin as ordered.  temps boarderline low, will monitor
closely.  bc negative.  stool cultures: fecal culture
negative, campylobacter culture negative, prelim results of
viral culture negative.  will monitor for s/s sepsis
closely.


"
3275,"nicu nursing note 7p-7a


2.resp= o/remains intubated on hfov map 9, amp 15.  fio2
30-38%.  bscoarse, diminished bilaterally.  occas drifts in
o2sats to low- mid 80's. sxn'd small cloudy secretions via
ett.  orally sxn'd for mod thick cloudy secretions.  cbg
obtained 7.25, 44, 35, 20, -8.  no changes made.  cont on
vit a.  a/stable on hfov with current settings.  p/cont to
monitor for resp distress.

3.fen= o/bw= 717g current wgt= 711g (+34).  cont on tf=
160cc/kg/d.  enteral feeds @ 70cc/kg/d of bm 20 gavaged q3h
over 30min.  ivf @ 90cc/kg/d of pnd12 + lipids via central
picc in rarm.  received prbs via lfootpiv, infused without
difficulty.  no adverse reaction noted. abd benign, soft.
no loops.  + bowel sounds.  ag= stable.  uo= 4.8cc/kg/h x
12h.  having liquid yellow stools, heme(-).  a/tol feeds.
p/cont to monitor fen status.  plan to check lytes in with
next cares.

4.g&d= o/temp stable nested in servo isolette.  alert and
active. maew. afof.  a/aga. p/cont to support g&d needs.

5.[** **]= o/mom and dad visited for 2100 cares.  updated by
this rn and [** 7**].  p/cont to support and educate.


"
3276,"nursing progress note


#1. o: infant remains on hifi ventalation on unchanged
settings of map 7, delta p 14. fio2 overnight has been
29-32%. brief o2 sat drifts noted overnight. no bradycardia
noted thus far. ett suctioned for sm/mod white. breath
sounds are coarse and equal. ic/sc retractions noted. cbg
7.25-50-44-23--5. no changes made. last dose of indocin
given tonight.  a: stable on current settings. p: continue
to monitor resp status.

#2. o: infant transfused 2nd aloquot of 20cc/k transfusion
of prbc's tonight. no adverse reactions noted. last dose of
indocin given. no murmur heard tonight. infant [** 211**] and well
perfused. bp stable. a: s/p transfusion and indocin
treatment. p: continue to monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d of d6.5pn and
il's infusing well via dluvc line. infant npo. abd soft and
flat with active bowel sounds. no loops. no meconium thus
far. infant voiding 3.8cc/k/hr today. d/s 219-226. wgt is up
41gms tonight to 450gms. a: npo. p: continue to monitor fen
status. check elec's on sunday morning.

#5. o: infant remains in heated isolette with stable temp.
he is alert and active with cares. maew. sucking on fingers
intermittently. a: aga. p: continue to assess and support
developmental needs.

#6. o: mom called x1 for brief update. apologized for not
showing up at 1600. she stated she will be in today. a:
involved mother. p: continue to inform and support.

#8. o: infant remains under single phototherapy. eye shieds
in place. a: hyperbili. p: continue to inform and support.


"
3277,"nursing progress note


#1. o: infant remains on ampicillin and gentamicin for
sepsis. today is day [**10-30**]. cultures remain negative. a:
sepsis. p: continue with treatment.

#2. o: infant remains on prong cpap 5. fio2 has been 27-26%.
(27-30% while prone position). rr 40's-50's. breath sounds
are clear and equal. mild/mod ic/sc retractions noted. no
spells. remains on caffiene. a: stable. p: continue to
monitor resp status.

#3. o: infant completed 2nd aloquot of prbc's this evening.
lasix given. infant received total of 20cc/k of prbc's. no
adverse reactions noted during transfusion. infant pink and
well perfused. soft murmur heard. a: low hct. p: continue to
monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d. currently d9pn
and il's infusing well via picc at 120cc/k/d. feeds of bm
are at 30cc/k/d. no spits or aspirates. ag stable. abd
remains full and soft. no loops. active bowel sounds. d/ss
125. no stools. voiding 5.9cc/k/hr. wgt is up 10gms tonight
to 1025gms. a: advancing on feeds. p: continue to advance
feeds 10cc/k/[**hospital1 **] as tolerated. a.m. elec's pending.

#6. o: infant remains in servo control isolette with stable
temp. he is alert and active with cares. maew. otherwise
sleeping well. hc remains unchanged at 24cm's. a: aga. p:
continue to assess and support developmental needs. ?hus
today.

#7. no contact from [**name2 (ni) 4**] this shift.

#9. o: rebound bili sent this a.m. awaiting results.


"
3278,"social work
met with mother during her visit to the nicu [**4-15**]. states that she is slowly beginning to feel better after her c/section and subsequent adverse reaction to a blood transfusion. mom thrilled with the health of her newborn twins. asking appropriate questions re: visiting etc. mom has good support from her [**month/day (4) 4**] with whom she lives and she is currently uncertain about and open to fob's involvement with babies. mom had some ins. questions and requested [**first name4 (namepattern1) 330**] [**last name (namepattern1) 331**]-[**doctor last name 156**], lsw, community resource specialist speak with her. ms. [**doctor last name 332**] planned to do so this am. also provided info re: reduced parking.
mom aware that she will feel teary and emotional about her planned d/c today. encouraged her to call unit to maintain sense of connection. denied other questions/concerns at this time. overall mother appears to be slowly adjusting to her premature delivery and nicu environment. mom aware that i will continue to follow. please call with questions/cocnerns. thank-you.
"
3279,"nursing notes:


#2resp;
  o:[**known lastname 932**] remains in nc 30-40%fio2, 200ccflow to maintain
02sat's>92%. rr40-60's. lungs cta. sc/ic retx. 4bradys
w/apnea noted thus far this shift. 2requiring bb02!
dr.[**last name (stitle) 962**] aware. remains on caffiene, diuril,kcl. cbc
w/diff and blood cx. done this am r/t bradys. no shift in
cbc noted. blood cx.results pending. hct-23.6! [**known lastname 932**]
currently w/blood transfusion in progress. (see flow sheet).
no adverse reactions noted thus far. vss. 35cc to infuse of
prbc over 4hrs. [**known lastname **] aware per dr.[**last name (stitle) 962**]. a;inc. resp
effort, inc. apnea/bradys r/t anemia? no sepsis noted today.
p:monitor. observe transfusion.
#2fen;
  o:tf=140cc/k/d. bm26w/pm. 54ccq4hrs. po feeding qshift, bf
when mom at bedside. [**known lastname 932**] [**last name (namepattern1) 62**]. 45 cc w/nuk nipple this
pm. occasional periods of discoordination noted. active and
interested when po feeding. all other feeds gavaged over
40min. no spits, no evidence of reflux noted thus far this
shift. remains on reglan/zantac and reflux precautions
maintained. abd.soft,[**last name (namepattern1) 211**],no loops. voiding, no stool this
shift. last stool, noted last nite.a;stable, working on po
feeding.p;continue current feeding plan.
#3g/d;
  o:[**last name (namepattern1) 3**],active,and appropriate w/cares. occasionally
waking for feeds. stable temps in open crib.dressed,
swaddled,and positioned with [**last name (un) 58**] bumper. maew w/mild
hypertonia noted. ot involved. [**last name (un) **].sucks on pacificer at
times.a;agap;continue to assess and support g/d milestones.
#4parents:
  o:dr.[**last name (stitle) 328**] called mom this am w/update. no furthur
contact noted this shift.p;continue to educate and support.



"
3280,"npn 0700-1900
heme: infant born with known rh-isoimmunization. ivig given at 1230 today. infusion given over 4hrs and completed at 1630. no adverse reactions. vitals signs done as ordered, see flowsheet. no plan for further ivig infusion at this time. plan to check q4hr biliirubin levels. see attending note for further details.

bili: infant continues on triple phototherapy since 0800 today with eye shields in place. bili levels checked q4hrs this shift. bili presently 5.5/0.3, down from 6.5/0.3.
p: continue to monitor closely for hyperbilirubinemia.


**please refer to attending's notes above for details.
"
3281,"npn 0700-1900
heme: infant born with known rh-isoimmunization. ivig given at 1230 today. infusion given over 4hrs and completed at 1630. no adverse reactions. vitals signs done as ordered, see flowsheet. no plan for further ivig infusion at this time. plan to check q4hr biliirubin levels. see attending note for further details.

bili: infant continues on triple phototherapy since 0800 today with eye shields in place. bili levels checked q4hrs this shift. bili presently 5.5/0.3, down from 6.5/0.3.
p: continue to monitor closely for hyperbilirubinemia.


**please refer to attending's notes above for details.
"
3282,"npn 7a-7p


resp: infant in ra. lscl/=. mild scr. rr=30's-50's. 02 sats
>95%. no spells. continue to monitor resp status.

cv: infant is pink and well perfused. no murmur noted.
hr=130's-150's. bp is stable. continue to monitor cv.

fen: bw1835. new wt=1730gms -105gms. tf 80cc/kg/d ivf of d10
infusing via piv. site patent. rh hl. alos patent to flush.
abd is soft, flat with +bs. no stool yet. ag is 22cm. no
loops. ds=70. uop for 8hrs=4.9cc/kg/hr. conitnue to monitor
fen.

sepsis: infant continues on amp/gent for 48hr r/o. bc pndg.
continue to monitor for s/sx of infx.

g/d: infant is nested on sheepskin on radient warmer. temps
stable. a/a with cares. brings hands to face. sleeps well
inbetween. afsf. maew. continue to monitor dev.

[** 2**]: dad in with family member x1. updated at bedside.
mom resting in house. continue to update and support
[** **].

hyperbilirubinemia: infant is under triple phototherapy, eye
shields in place. high bili levels from previuous. sent bili
level at 2400 results pending. are now checking levels q6hrs
not q4hrs. may change with results. infant was treated today
for ivig, no adverse reaction occurred. continue to monitor
for s/sx of hyperbili.


"
3283,"progress note 7p-7a


fen: tf [** 145**] 120cc/k enfamil ar all po. waking to eat q/ 4
hrs. intake over last 24 hrs=175cc/k. abdomen soft and
benign. voiding/no stools so far this shift. no spit noted.
will continue to monitor feeding tolerance and progression.

dev: temps stable swaddled in [** 13**]. active and [** 29**] w/
cares. comforted by pacifer. will continue to support
developemental needs.

a's and b's: day [**1-3**]. no spells noted so far this shift.
will continue to monitor closely.

tachy: hr and bp wnl. continues on propanilol q. 8hrs.
tolerating well with no adverse reactions noted so far. will
continue to monitor closely.


"
3284,"respiratory care note
pt continues on simv 23/6 x 22 .50fio2.  bbs slightly coarse.  sx'd ett tube for small amts of cloudy white secretions. nares sx'd for thick yellow secretions.  comfortable rr 30-50s.  good vts;  5-7ccs.  2p combivent given as ordered w/no adverse reaction. no spells and nard.  will continue to follow - wean fio2 as tolerated.
"
3285,"nursing note 1900-0700


resp: recieved in simv 26/6 x29bpm. abg at 0200 was
7.45/44/54/32/5. breath rate weened to 27. fio2 55-70%,
increased slightly w/ [** **] ween. ls course/crackly but has
good aeration. sats v. [**known lastname **]. rr 27-50, rides [**known lastname **] often.
lasix given x1. stable on current settings, con't to
monitor. check [**known lastname 1380**] gas this am.

fen: weight 936, up 1gram. tf 100cc/k/d of pn d18 w/hep and
il. npo. ds109. abd soft and full, no loops. girth up 3cm to
20.5. bs active. uo: 4.7cc/k/hr x12hrs. no stools. con't w/
current plan.

cv: soft murmor heard w/ all cares. pulses normal, brisk cap
refil, hyperactive precordium. hr 150-180s. recieved
dopamine drip at 5mcg throughout night, turned off at 6am.
keeping maps 32-38. given 10cc/k prbc transfusion w/ lasix
x1 at 8pm for hct of 34 yesterday. also given 15cc/k
platelet transfusion at 6am after plt count dropped from 88
to 66 o/n. no adverse reactions noted, vitals assessed per
protocol. [**known lastname **] out currently 0.8cc. stable at this time, bp
means 30-36. con't to monitor closely and check bps q 15min.


parenting: no contact w/ [**name2 (ni) **] so far this shift. [**name2 (ni) 18**]
spoke w/ [**name2 (ni) **] yesterday evening to give update on
[**name2 (ni) 168**]'s condition. con't to support and update as needed.

bili: [**name2 (ni) **] pink. last bili level checked on [**2152-4-25**].
recieving phenobarbitol for increased direct bili. con't to
monitor for jaundice and check bili levels per orders.

r/o sepsis: [**date range **] remains w/out signs of infection at this
time.  temps stable, alert and active. continues on gent and
oxacillin iv. con't to monitor closely.


"
3286,"npn 1900-0700


resp/heme:  infant on nasal prong cpap 7, fio2 29-35%, incr
with cares.  ls c/=, ic/sc retractions.  rr 20-50s.  sxn po
x1 thus far this shift, no secretions noted.  2 spells noted
thus far this shift.  total of 11 spells in 24hrs.  infant
transfused 1 alloquot directed donor prbcs; 12.5ml over
4hrs.  no adverse reactions noted.  consent signed in chart.
 lasix given x1 after transfusion complete.  pt on caffeine
and vit a.  continue to monitor.

fen:  cw 830g (down 5g).  tf 140cc/kg/day.  ef currently at
60cc/kg/day bm/sc20.  non-cent picc patent and infusing
pnd10 + il at 80cc/kg/day.  prn piv rl; hl.  appears to be
tolerating pg feeds well.  no spits, max asp 1.2cc; benign,
refed.  abd full, soft, soft loops noted x1, hyperactive to
active bs.  ag= 20-21cm.  8hr uo= 5cc/kg/hr, trace mec
stools noted qdiaper change.

dev:  temps stable while nested in servo isolette.  a/a with
cares, sleeps well btwn.  likes pacifier, moves hands to
face.  [**last name (lf) 457**], [**first name3 (lf) 83**].  pt planned for repeat hus today; hx of
nml hus.

par:  mom called x1 thus far this shift.  updated by this
rn.  asking approp questions.  plans to be in to visit
today.  continue to update and support parents as needed.


"
3287,"npn 1900-0700

8 potential for sepsis

resp:  [**name (ni) **] pt on conv vent settings 21/6, r 19.  0200 abg
was 7.24/40/42/18/-9, therefore decreased pip by 1 to
current settings 20/6, r 19.  0600 cbg 7.25/43/36/20/-9.
fio2 21-38%, mostly in 30s since last setting change.  rr
30-50s, sc/ic retractions.  ls wheezy/sl diminished.  air
leak noted thru ett.  sxn x1 sm amt cloudy via ett/oral.  1
spell tonight.  hr to 68, o2 sat 81% after cares.  mild stim
and incr o2 required to resolve.  cont to monitor resp
status.

fen:  cw 965g (up 3g).  pt remains npo.  tf 120cc/kg/d.
dluvc infusing pn d12.5.  repogle to gravity; 0.1cc clear
asp.  abd soft, hypoactive bs, no loops.  ag 21-22cm.  12hr
uo= 4.5cc/k/hr, no stool this shift.  lytes drawn:
143/4.0/117/15.  triglycerides: 165.  glucose=140.

dev:  maintaining temps nested in servo isolette.  pt is
a/a.  irritable with cares; settles with hand containment
and decr stim.  moves hands to face, sucks on thumb.  r & l
feet edematous/bruised (r>l).  excoriated area on abdomen
improved; bacitracin applied.  repeat hus today.

social: mom in most of noc tonight (2200-0100; 0400-0630).
updated at bedside by this rn and nnp.  asking appropriate
questions.  appeared loving/affectionate to nb.  plans to be
in later today to participate in cares.

bili:  single phototx restarted at 0600 for rebound bili
5.3/0.2 (up from 3.4/0.2).  eye mask in place.  pt ruddy, no
stool this shift.  cont to monitor.

cv:  infant transfused tonight.  9cc prbcs transfused over
4hrs.  pt tol well; no adverse reactions.  bp means 30-50s.
hr 130-150s.  no murmur auscultated; s/p 1 course indocin.
palmar pulses absent.  pt ruddy.  total blood out since
transfusion tonight: 1.2cc.





revisions to pathway:

  8 potential for sepsis; resolved

"
3288,"npn 1900-0700


resp:  infant remains on conv [** **] settings 18/5, r 18.  abg
2200: 7.23/46/105/20/-8; no changes made.  fio2 27-35%, incr
with cares.  ls coarse, sxn'd q3-4h thick cloudy secretions
via ett, small po and nares.  no bradys thus far this shift.
 caffeine held tonight for tachycardia.  pt continues on vit
a.  continue to monitor.

fen:  cw 852g (up 92g).  feeds restarted at 0100 at
100cc/k/day pe24.  picc infusing d10 ns + 0.5u hep/cc at
1.5cc/hr.  no spits, min asp.  abd full, soft.  ag noted to
be incr at 2200 (20.5cm with soft loops).  [** 41**] aware.  ag
now back to baseline at 18cm without loops.  uo improving.
8hr uo= 9.2cc/k/hr.  no stool thus far this shift.  lytes
sent 2200: 123/5.1/96/18.  na improving (up from 118 on
days).  lytes to be resent at 0500.  ds= 89.

par:  mom called x2 thus far this shift and in to visit with
dad at 2300.  updated at bedside by this rn, [** 41**] [**doctor last name **], and
md [**last name (titles) **].   mom expressed her concerns to this rn.  very
emotional and worried about her daughter.  much support
provided.  anxious to hear hus results this am.  continue to
support and update as needed.

dev:  temps stable while nested in servo isolette.  a/a with
cares, irritable at times btwn.  settles with hand
containment and pacifier.  moves hands to face.  anterior
font appears slightly full.  [**last name (titles) 41**] aware.  hus to be done in
am.  continue to monitor.

cv:  loud murmur auscultated.  pt tachycardic this shift,
170-190s (occ to 200s).  team aware.  caffeine therefore
held at 2100.  bp means stable (37-56).  most recent cuff
74/44 (56).  pt transfused 2nd aloquot (8cc) prbcs at 2330
over 4hrs.  consent signed in chart.  no adverse reactions
noted.  post-hct to be sent later today.  continue to
monitor cv status.


"
3289,"nicu admit: pls see dr.[**name (ni) 179**] detailed note reviewing both mom and [**name2 (ni) 700**] history. to nicu for ivig transfusion s/p platelet count of 29 last eve.  1cc of whole blood collected for platelet antigen genotyping. hl placed in infants r foot. 30cc of ivig infused over 4hrs as ordered. frequent vs monitoring done. infant without any evidence of an adverse reaction. fed 1-2oz of similac20 q 4hrs with ease. wet diapers x 2, no stool passed. mom and dad in to visit. reviewed plan for son. platelet count to be resent ~ 0700.
"
3290,"npn 1900-0700


sepsis:  infant now day 4 of minimum 7 day course iv abx amp
and gent.  meds to be admin as ordered.  infant continues to
have foul odor.  repeat cbc dol 1 with left shift; bc
negative.  cbc to be repeated later today.  lp planned.
continue to monitor for s/s sepsis.

resp:  intubated on hifi settings map 6, delta p 14.  delta
p weaned x2 overnoc according to abgs.  most recent abg
0300: 7.34/44/56/25/-2 (decr from amp 16 to 14 at this
time).  fio2 23-33%.  ls coarse bilat.  sxn'd mod-lg white
via ett & po.  ic/sc retractions.  no bradys thus far this
shift, occ drifts.  pt is on vit a.  continue to monitor.

fen:  bw 605g  cw 555g (up 5g).  pt npo.  tf 170cc/kg/day:
uac: sterile h20 + 7.7meq naace + 0.5uhep/cc; dluvc: pnd10
(70cc/kg/day) + d10w + 0.5uhep/cc.  ds stable, 63, 92.  abd
soft, flat, bs unappreciated.  ag= 14.5cm.  ngt pulled by
pt, not replaced at this time due to npo status.  12hr uo=
5.9cc/kg/hr, no stool this shift.  q6h lytes, most recent
0400: 145/3.2/112/22/14.  bun: 35, creat: 0.8, mg: 3.2.

dev:  infant nested on servo warmer with water pillow,
sheepskin, tent.  ear muffs provided for comfort with noise.
 fentanyl given prn x1 thus far this shift for unsettled
aggitation, with good effect.  infant can become aggitated
at times, usually settles well with hand containment or decr
stim.  aquaphor applied [**hospital1 56**] as ordered, skin intact.  eyes
fused bilat, rt eye appears to be opening slightly.

par:  parents in to visit for early part of shift
(~[**2171**]-2400).  updated at bedside by this rn.  asking approp
questions.  dad participated in temp taking and diaper
change.  continue to update and support parents as needed.

cv:  loud murmur ausculated.  pda by echo.  1st course
indocin started yesterday.  2nd dose given at 2330.  [**location (un) **]
pulses absent, good cap refill.  ruddy, wp.  hr 140-170s,
uac means 28-41.  cuff 72/44 (50).  infant transfused
overnoc prbcs (20cc/kg total).  consent signed in chart.  no
adverse reactions noted with 1st alloquot.


"
3291,"nsg note 0700-[**2041**]


resp:infant received in nasal prong cpap-6, 21% fio2. cpap
decreased to 5 at 0930, infant tolerated well. placed in
room air at 1430. bilateral lung sounds clear and equal with
good aeration. respiratory rate 20-50's. saturations
99-100%. mild subcostal retractions. no spells. p:continue
to assess and support respiratory status.

c/v:infant's heart rate 120-140's, nsr. no murmur
auscultated. pink and well perfused. received second aliquot
of prbc's, 14 ml, over four hours. tolerated tranfusion
well, no adverse reactions. bp's stable 60/29 (40).
p:continue to assess and support cardiovascular status.
repeat hct lab.

f/n:infant on total fluids of 80cc/kg/day. npo. tpn @
80cc/kg/day via double lumen uvl, primary port @4.8cc/hr.
d/s stable-76. abdomen benign, +bowel sounds. girth stable
at 22.5cm. voiding, small mec smear. p:continue to assess
and support nutritional status.

dev:infant maintaining temperatures, nested on servo warmer.
appropriate for gestational age. alert and active for care
times, sleeping well between. comforts with boundaries.
sucking on pacifier well. p:continue to assess and support
growth and development.

par:mom called this morning. dad in for a visit. asking
appropriate questions. discussed respiratory status and plan
for second aliquot of prbc's. very loving with [**known lastname **].
p:continue to support and update parents.

id:infant continues on ampicillin and gentamycin for a 48
hour rule out. blood cultures pending. no signs/symptoms of
sepsis. temperature's stable, active and alert, stable
respiratory status. p:continue to monitor for signs of
infection.


"
3292,"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



"
3293,"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**]

"
3294,"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**]



"
3295,"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**]

"
3296,"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**]"
3297,"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**]
"
3298,"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.



"
3299,"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



"
3300,"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**]
"
3301,"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**]



"
3302,"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**]
"
3303,"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**]

"
3304,"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**]"
3305,"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**]"
3306,"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



"
3307,"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**]
"
3308,"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**]
"
3309,"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**]
"
3310,"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**]"
3311,"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**]
"
3312,"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**]"
3313,"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**]"
3314,"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**]"
3315,"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.



"
3316,"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.



"
3317,"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 **]
"
3318,"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).



"
3319,"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**]
"
3320,"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**].



"
3321,"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**]"
3322,"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**]



"
3323,"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**]

"
3324,"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 **].



"
3325,"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**]"
3326,"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**]"
3327,"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.



"
3328,"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**]



"
3329,"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**]
"
3330,"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) **]"
3331,"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**]"
3332,"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**]"
3333,"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



"
3334,"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**]"
3335,"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



"
3336,"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**]
"
3337,"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**]

"
3338,"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.
"
3339,"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.
"
3340,"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.
"
3341,"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
"
3342,"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.
"
3343,"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.
"
3344,"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 ------
"
3345,"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 adverse reactions.
   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.
"
3346,"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.
"
3347,"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.
"
3348,"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.
"
3349,"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.
"
3350,"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:
"
3351,"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.
"
3352,"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.
"
3353,"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.
"
3354,"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.
"
3355,"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.
"
3356,"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.
"
3357,"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:
"
3358,"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**]
"
3359,"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 ------
"
3360,"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.
"
3361,"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.
"
3362,"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.
"
3363,"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.
"
3364,"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.
"
3365,"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.
"
3366,"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:
"
3367,"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
"
3368,"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.
"
3369,"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
"
3370,"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:
"
3371,"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
"
3372,"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:
"
3373,"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.
"
3374,"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 ------
"
3375,"title:
   respiratory care: atrovent nebs administered  @ 4:00 . bs are clear
   bilaterally in apecies with diminished bases. no adverse reactions
   following tx.
"
3376,"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.
"
3377,"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
"
3378,"[**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.
"
3379,"[**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.
"
3380,"[**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
"
3381,"[**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
"
3382,"[**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
"
3383,"[**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.
"
3384,"[**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.
"
3385,"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
"
3386,"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:
"
3387,"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.
"
3388,"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.
"
3389,"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:
"
3390,"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
"
3391,"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
"
3392,"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
"
3393,"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
"
3394,"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
"
3395,"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.
"
3396,"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.
"
3397,"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
"
3398,"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.
"
3399,"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
"
3400,"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
"
3401,"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.
"
3402,"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
"
3403,"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.
"
3404,"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.
"
3405,"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.
"
3406,"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.
"
3407,"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.
"
3408,":
   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.
"
3409,"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:
"
3410,"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:
"
3411,"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.
"
3412,"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.
"
3413,"title:
   respiratory care: alb/atr nebs administered as ordered q 6hrs with no
   adverse reactions. bs are coarse bilaterally.
"
3414,"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
"
3415,"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
"
3416,"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
"
3417,"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
"
3418,"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.
"
3419,"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 ------
"
3420,"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:
"
3421,"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.
"
3422,"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.
"
3423,"[**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.

"
3424,"[**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.




"
3425,"[**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.

"
3426,"[**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.



"
3427,"[**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.

"
3428,"[**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.



"
3429,"[**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)

"
3430,"[**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.




"
3431,"[**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)

"
3432,"[**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)

"
3433,"[**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)

"
3434,"[**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.



"
3435,"[**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.


"
3436,"[**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.


"
3437,"[**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)

"
3438,"[**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.

"
3439,"[**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.



"
3440,"[**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)

"
3441,"[**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.



"
3442,"[**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.



"
3443,"[**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.


"
3444,"[**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)

"
3445,"[**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)

"
3446,"[**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)

"
3447,"[**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.

"
3448,"[**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)

"
3449,"[**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.

"
3450,"[**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.


"
3451,"[**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.

"
3452,"[**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.






"
3453,"[**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)

"
3454,"[**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.

"
3455,"[**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.

"
3456,"[**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.


"
3457,"[**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.


"
3458,"[**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)

"
3459,"[**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.









"
3460,"[**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.

"
3461,"[**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.

"
3462,"[**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.


"
3463,"[**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.

"
3464,"[**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.

"
3465,"[**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)

"
3466,"[**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.

"
3467,"[**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)


"
3468,"[**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.


"
3469,"[**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.


"
3470,"[**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.

"
3471,"[**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.

"
3472,"[**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.



"
3473,"[**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.



"
3474,"[**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.


"
3475,"[**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.


"
3476,"[**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.


"
3477,"[**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.



"
3478,"[**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)

"
3479,"[**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.

"
3480,"[**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**].


"
3481,"[**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.



"
3482,"[**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)

"
3483,"[**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**].


"
3484,"[**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)


"
3485,"[**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.


"
3486,"[**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**].


"
3487,"[**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.



"
3488,"[**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.



"
3489,"[**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.



"
3490,"[**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)

"
3491,"[**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.



"
3492,"[**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


"
3493,"[**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.


"
3494,"[**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.

"
3495,"[**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.


"
3496,"[**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)

"
3497,"[**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.



"
3498,"[**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  21 year old man with
 reason for this examination:
  r/o inj
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: eez sat [**2185-1-29**] 12:58 am
  aorta ok. tiny, non-linear focus of decreased attenuation in posterior spleen,
  less than 1cm deep, too small to characterize by ct, but cannot exclude a
  small laceration. no perisplenic hematoma is present. no free fluid in abdomen
  or pelvis. no free air.
 ______________________________________________________________________________
                                 final report *abnormal!
 indication:    motor vehicle accident.

 technique: helically acquired axial images were obtained of the abdomen and
 pelvis from the lung bases to the pubic symphysis with 150 cc of optiray
 contrast.  there were no adverse reactions to contrast administration.
 multiplanar reformations were made.

 ct chest with contrast: the aorta is well opacified demonstrating no
 extravasation or contour abnormality. there is no aortic dissection or para
 aortic hematoma. age appropriate thymus tissue and a small pretracheal lymph
 node are present. evaluation of the lung parenchyma is limited due to
 respiratory motion but there are no gross consolidations or pulmonary
 contusions.  there is no pneumothorax. no rib fractures are seen.  there are
 no pleural or pericardial effusions.

 ct abdomen with contrast:  no hepatic lacerations or parahepatic hematoma is
 present.  there is no hematoma adjacent to the spleen but there is a tiny
 focal area of decreased attenuation along the posterior splenic border. no rib
 fractures are seen in this region.  there is no perisplenic hematoma. the area
 of decreased attenuation is too small to accurately characterize by ct, but
 overall depth is less than 1 cm.  the kidneys enhance symmetrically without
 evidence of obstruction or injury.  the adrenal glands, duodenum, pancreas and
 gallbladder are unremarkable.  intra abdominal loops are normal. there is no
 free air or free fluid within the abdomen or pelvis.

 ct pelvis with contrast: distal ureters are unremarkable. the bladder contains
 a foley catheter but is otherwise unremarkable. there is no free fluid in the
 pelvis or pelvic or inguinal lymphadenopathy.

 no fractures are seen.

 multiplanar reconstructions: coronal and sagittal reformats show no evidence
 of traumatic aortic injury.

                                                             (over)

 [**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report *abnormal!
 (cont)
 impression:
 1) no evidence of aortic injury.
 2) tiny focus of decreased attenuation in the posterior spleen, too small to
 characterize on ct.  there is no adjacent hematoma. overall depth of the area
 of decreased attenuation is less than 1 cm. a tiny laceration cannot be
 excluded.


"
3499,"[**2198-2-14**] 8:31 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8085**]
 ct 150cc nonionic contrast
 reason: s/p fall, trauma, r/o internal injuries, abdominal distension
 field of view: 36 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with s/p fall
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  status post 20 foot fall.

 ct abdomen and pelvis with contrast:

 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 abdomen with iv contrast: there is no basilar pneumothorax. there is a
 small left lower lobe contusion vs atelectasis. no pleural or pericardial
 effusions are present. no hepatic or splenic lacerations are seen. the
 kidneys, pancreas, gallbladder, and stomach are unremarkable. there  is motion
 throughout portions of the scan, limiting evaluation somewhat. there is no
 free fluid in the abdomen or evidence of free intra- abdoimnal air. the bowel
 is unremarkable.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable. there is no free fluid in the pelvis.subcutaneous contusion
 is see in the right buttock region

 osseous structures:  bilateral nonunionized apophyses are present adjacent to
 the posterior acetabular rim. no acute fractures are seen.

 impression:   no evidence of acute intra-abdominal injury.  no fractures seen.


"
3500,"[**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  59 year old man with
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications: trauma.

 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.  there were no adverse reactions to contrast administration.
 additional delay sequences of the superior mediastium and liver/spleen were
 acquired.

 ct of the chest with iv contrast: on the initial sequence, there is fluid
 density anterior to the distal ascending aorta.  on the delayed scan with a
 breath hold, this is not seen.  there is a small retrosternal hematoma, but
 the fat adjacent to the aorta is unremarkable. there is no evidence of
 extravasation of iv contrast from the aorta. on the reconstructed images, the
 aortic contours are smooth. there is no evidence of disssection.  there are
 areas of calcification in the aortic arch, and in the left subclavian artery.
 no pneumothorax is seen.  no focal pulmonary consolidations or contusions are
 seen.  there are no pleural or pericardial effusions.  no pathologically
 enlarged axillary, hilar, or mediastinal lymph nodes are seen.  no rib
 fractures are seen.  visualized portions of the clavicles and scapula appear
 intact.

 ct of the abdomen with iv contrast:  the liver and spleen are intact without
 focal laceration or adjacent hematoma.  the adrenal glands, pancreas, and
 kidneys show no evidence of acute traumatic injury.  there is no free
 intraabdominal air.  there is no free fluid within the abdomen or in the
 mesentery.  bowel loops are all normal in course and caliber.  the abdominal
 aorta is unremarkable.

 ct of the pelvis with iv contrast: the bladder contains a foley catheter with
 internal air.  there is no free fluid in the pelvis.  distal bowel is normal.

 bone windows: there is a comminuted fracture of the proximal right femur.
 within the proximal femoral diaphysis, there are three major fragments, one of
 which is anterior, the other lateral, and the final one is medial.  the
 lateral fragment is contiguous with the greater trochanter, femoral neck, and
 head. the anterior fragment is small and extends superiorly to the level of
 the femoral neck, where there is a small anterior cortical defect within the
 femoral neck, but no full thickness femoral neck fracture.  the smallest
 fragment is the medial fragment, which is highly comminuted, and it consists
 mostly of an avulsed lesser trochanter.  the left proximal femur is intact.
                                                             (over)

 [**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 osseous structures of the pelvis appear intact.  no spinal fractures are seen.
 note is made of a likely healed left 11th rib fracture laterally. there is
 extensive costal cartilage calcinosis.

 ct reconstructions:  coronal and sagittal reformations show a normal aortic
 contour.

 impression:
 1.  no aortic extravasation, periaortic hematoma, or dissection.
 2.  no evidence of acute traumatic intraabdominal injury.
 3.  comminuted fracture of the proximal right femur as described above.


"
3501,"[**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  68 year old man pod#3 s/p r colectomy now with increasing o2 requirement,
  hypoxia, and tachycardia
 reason for this examination:
  evaluate for pulmonary embolism
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: oxygen requirement.  evaluate for pulmonary embolism.

 technique: axial images of the chest were aquired helically from the lung
 bases through 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 angiography of the pulmonary vessels.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:

 ct chest with iv contrast:  the pulmonary vasculature is well opacified and
 demonstrates no intraluminal filling defects suggestive of pulmonary emboli.
 there is extensive collapse/consolidation in both lower lobes. small bilateral
 pleural effusions are present. portions of the right lower lobe consolidation
 are more patchy, raising suspicion for pneumonia.  there is an additional
 dense consolidation in the dependent portion of the right upper lobe which is
 suspicious for aspiration or pneumonia.  there is fluid within the esophagus.
 numerous small mediastinal lymph nodes are seen which do not meet size
 criteria for pathological enlargement by ct scan. no pathologically enlarged
 axillar or hilar nodes are seen.  osseous structures are unremarkable. limited
 evaluation of upper abdominal structures shows possible fluid adjacent to the
 liver and a cystic structure immediately under the left hemidiaphragm which is
 not fully evaluated.

 ct reconstructions: multiplanar reformations show no evidence of pulmonary
 embolism.

 impression:
 1) no evidence of pulmonary embolism.

 2) bilateral pleural effusions with extensive consolidation in both lower
 lobes and the right upper lobe from aspiration or pneumonia.

 3) fluid filled esophagus. further evaluation with barium esophagram may be
 performed to evaluate for achalasia, stricture, or possible reflux.

 results were discussed with the surgical team at the time of interpretation.

                                                             (over)

 [**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)










"
3502,"[**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
     66 year old man with persistent fevers, increasing abdominal pain, s/p
  ex-lap. also decreasing hematocrit.
 reason for this examination:
  evaluate for abscess/intra-abdominal infection, as well as source of bleeding.
  with po and iv contrast.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  fevers, increasing abdominal pain after exploratory laparotomy,
 decreasing hematocrit.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 findings:  comparison is made to the prior torso ct from [**12-28**] and the
 gallbladder ultrasound from [**2119-1-6**].

 ct of the abdomen with iv contrast:  there are moderate-sized bilateral
 pleural effusions with associated bibasilar atelectasis.  again identified is
 a likely cyst within the right posterior hepatic lobe inferiorly (segment vi).
 there is stable intrahepatic biliary ductal dilatation.  the gallbladder
 contains calcified stones and asymmetrical areas of wall thickening consistent
 with the previously seen adenomyomatosis.  the common bile duct remains
 prominent extending into the duodenum.  there is no stranding around the
 gallbladder.  the pancreas is unremarkable.  the adrenal glands and kidneys
 are unchanged.  within the posterior aspect of the spleen is a wedge-shaped
 focal area of decreased attenuation, which likely reprents an infarct.  the
 spleen has progressively enlarged over the past two ct scans, now measuring
 over 13 cm. the appearance of the stomach is unchanged. there is no evidence
 of bowel obstruction.

 ct of the pelvis with iv contrast:  again, there is a small amount of fluid in
 the pelvis, but no loculated pockets with enhancing rims or internal air to
 indicate an abscess.  multiple cecal diverticula are seen.  the appendix is
 visualized, and is filled with oral contrast, and normal.  again, there is a
 suggestion of cecal, and transverse colonic wall thickening.  again, these
 segments are not fully distended, limiting evaluation.  there is some ascites
 in the right inguinal fat-containing hernia.

 osseous structures:  no suspicious lytic or sclerotic lesions are present.

 impression:
                                                             (over)

 [**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 1) no definite intraabdominal abscess.  moderate bilateral pleural effusions
 with associated bibasilar atelectasis.
 2) progressive splenic enlargment compared to [**2118-12-28**] and [**2118-12-16**]. the spleen
 now measures over 13cm. findings are suspicous for possible lymphoma in the
 absence of other etiologies for splenic enlargement.

 results were discussed with dr. [**last name (stitle) 4478**] at 9:55 pm on [**2119-1-8**].

"
3503,"[**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old woman with s/p intramural hemmorage in sigmoid
 reason for this examination:
  s/p intramural hemmorage in sigmoid-?resolved
 ______________________________________________________________________________
                                 final report
 indications:  status post intramural hemorrhage in sigmoid colon.  evaluate
 for resolution.

 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.  non-ionic contrast was used secondary to the patient's
 asthma history.  there were no adverse reactions to contrast administration.

 findings:  comparison is made with the study from [**2158-12-7**].

 ct of the abdomen with iv contrast:  no focal lung lesions are identified.
 there are no pleural or pericardial effusions.  no focal liver lesions are
 identified.  the spleen contains several punctate calcifications, likely
 calcified granulomas.  the adrenal glands, pancreas, stomach, and
 intraabdominal loops of small bowel are unremarkable.  there is a single focus
 of decreased attenuation in the lower pole of the left kidney which likely
 represents a simple cyst, and is unchanged in appearance since the prior
 study.  the kidneys otherwise enhance symmetrically without evidence of focal
 mass or obstruction.  there is no ascites or pathological mesenteric or
 retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast:  there has been marked reduction in the
 previously seen sigmoidal wall thickening.  extensive diverticular disease and
 likely muscular hypertrophy in the sigmoid colon, but there is no evidence of
 surrounding stranding to indicate acute diverticulitis.  the previously seen
 small amount of free fluid in the pelvis has also resolved. distal ureters and
 bladder are unremarkable.  there is no pathological pelvic lymphadenopathy.

 a small sclerotic focus is seen in the superior pubic ramus, which is likely a
 bone island.  additional sclerotic foci are seen in lower-thoracic vertebral
 bodies, which are also likely bone islands.  no suspicious lytic lesions are
 identified.

 impression:
 1) marked improvement in the previously seen sigmoidal wall thickening, and
 resolution of free fluid in the pelvis.  extensive diverticular disease is
 present, but there is no evidence of acute diverticulitis.

 2) tiny left renal cyst.

 3) multiple splenic granulomas.
                                                             (over)

 [**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)



"
3504,"[**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  66 year old man with h/o gallstone/necrotizing pancreatitis and multiple
  drainage procedures
 reason for this examination:
  pancreatic protocol - renewed pancreatitis?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  history of necrotizing/gallstone pancreatitis.  evaluate for
 acute pancreatitis.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 comparison:  [**2107-2-10**] abdominal ct scan.

 findings:

 ct of the abdomen with iv contrast:  there are small bilateral pleural
 effusions, left greater than right, with associated compressive atelectasis of
 both lower lobes.  no focal liver lesions are identified.  the spleen, adrenal
 glands, kidneys, and stomach are unremarkable.  again seen are two drainage
 catheters in the region of the pancreas and a jejunostomy tube.  located
 immediately below the catheters are fluid pockets with internal air.  these
 appear slightly smaller than on the previous study.  only the head of the
 pancreas enhances. the degree of inflammatory change surrounding the pancreas
 has not changed appreciably. the fluid pocket adjacent to the tip of the
 pancreas extending inferiorly is unchanged.  the degree of abdominal
 stranding/fluid is unchanged.

 ct of the pelvis with iv contrast:  the distal ureters and bladder are
 unremarkable.  the bladder contains a foley catheter and internal air.  no
 sigmoid bowel wall thickening.  no pathologically enlarged inguinal or pelvic
 lymph nodes are seen.

 osseous structures are unchanged, again showing diffuse degenerative changes.

 impression:
 peripancreatic fluid collections with internal air slightly smaller adjacent
 to the two drainage catheters.  the degree of inflammatory stranding around
 the pancreas and in the abdomen has not changed significantly. only the
 pancreatic head enhances.

                                                             (over)

 [**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)


"
3505,"[**2146-12-28**] 7:12 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8484**]
 ct 100cc non ionic contrast
 reason: trauma
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with mva
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  trauma.

 technique:  axial images of the abdomen and pelvis were acquired helically
 from the lung bases through the pubic symphysis with 150 cc optiray contrast.
 there were no adverse reactions to contrast administration.

 findings:

 ct of the abdomen w/iv contrast:  there is a small focal area of consolidation
 in the right lower lobe, medial basal segment.  no pleural or pericardial
 effusions are seen.  there is periportal edema, consistent with vigorous fluid
 resuscitation.  the liver is intact without evidence of laceration.  the
 spleen appears intact.  the adrenal glands, kidneys, pancreas, and duodenum
 are all unremarkable.  the gallbladder is normal.  there is a general lack of
 intra-abdominal fat, limiting sensitivity for mesenteric injury.  there is no
 free fluid in the abdomen.  no free air is seen.

 ct of the pelvis w/iv contrast:  the bladder contains a foley catheter and
 air.  sigmoid colon and rectum are unremarkable.  there is no free fluid in
 the pelvis.

 no pelvic fractures are seen.  note is made of a densely sclerotic area in the
 left femoral neck, which likely represents a bone island.  there is a
 diminutive first right lumbar rib.  no rib fractures are seen.

 impression:

 1. no evidence of acute traumatic intra-abdominal injury.
 2. likely diminutive right first lumbar rib. no acute fracture.


"
3506,"[**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  62 year old woman with hx of bladder cancer with resection of tumor and
  retroperitoneal disection as well as chemotherapy.
 reason for this examination:
  pt with hx of bladder cancer with resection of right kidney and ureter as well
  as retroperitoneal dissection and has received chemotherapy now needs  ct of
  torso for staging.
 ______________________________________________________________________________
                                 final report
 indication:  renal cancer, status post resection of right kidney, ureter, and
 retroperitoneal dissection.

 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.

 comparison:  comparison is only able to be made to the study from [**2171-10-28**].  the more recent torso ct from [**2171-12-9**] is not available
 secondary to pacs malfunction.

 ct of the chest with iv contrast:  there are no pathologically enlarged
 axillary, hilar, or mediastinal lymph nodes.  there are no pleural or
 pericardial effusions.  again identified are multiple bilateral pulmonary
 nodules.  one previously seen nodule in the right lung base laterally is not
 visualized on the current study, but the largest nodule, in the left lung
 base, has increased in size.  the bronchi remain patent to the subsegmental
 levels.  the heart and great vessels is unremarkable.

 ct of the abdomen with iv contrast:  there has been marked progression of the
 patient's multiple hepatic masses.  there is some local biliary ductal
 dilatation adjacent to one of the masses in the right lobe.  surgical clips
 are seen in the right renal fossa from prior nephrectomy.  no soft tissue
 density suggestive of disease recurrence is present in this area.  there is a
 slight prominence of the first and second portion of the duodenum, but the
 bowel is not fully opacified, limiting evaluation.  the pancreas and adrenal
 glands, along with the spleen, and stomach are unremarkable.  the left kidney
 enhances uniformly.  there is no filling defect in the left renal pelvis or
 ureter.  no pathologically enlarged mesenteric or retroperitoneal lymph nodes
 are seen.  the descending aorta is calcified.  there is no ascites.

 ct of the pelvis with iv contrast:  the appearance of the cystic structure in
 the right adnexa is unchanged.  again seen is stranding in the presacral fat,
 likely post operative in nature, which is unchanged since [**2171-10-28**].
 the distal left ureter is unremarkable, with a normal appearing left ureteral
 jet.  the bladder is within normal limits.  there is no free fluid in the
 pelvis or pathological inguinal or pelvic lymphadenopathy, although multiple
                                                             (over)

 [**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 small pelvic nodes are seen which do not meet size criteria for pathological
 enlargement by ct scan.  the sigmoid colon and rectum are unremarkable.

 no new suspicious lytic or sclerotic osseous lesions are identified.

 impression:  progression of multiple intrahepatic masses, some of which are
 associated with localized biliary ductal dilatation.  no ascites.  enlargement
 of pulmonary nodule in left lung base.  findings all consistent with
 progression of disease.

"
3507,"[**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   42 year old man with pod#10 s/p ex-lap, small bowel resection x4, found to
  have celiac sprue, t-cell lymphoma on path, now w/ temps post-op, and new pus
  draining from ex-lap wound.
 reason for this examination:
  evaluate for perforations, fluid collections, wound infection.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: celiac  sprue, multiple small bowel resections, now with post
 operative fevers, pus draining from exploratory laparotomy wound.  evaluate
 for intraabdominal abscess or perforation.

 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 contrast.  there were no adverse reactions to contrast
 administration.

 findings:  comparison is made to the study from [**2150-3-2**].

 ct abdomen with iv contrast: again seen is a rounded 4 mm nodule in the right
 lower lobe which is unchanged in appearance.  there is bibasilar atelectasis.
 no focal consolidations suggestive of pneumonia are present.  no focal hepatic
 lesions or splenic lesions are seen.  the pancreas and gallbladder are normal
 in appearance.  both adrenal glands and kidneys are unremarkable.  multiple
 surgical suture lines are seen throughout the small bowel.  there are multiple
 dilated small bowel loops, and enlarged mesenteric lymph nodes.  the
 appearance is unchanged since [**2150-3-2**]. there is no free intraperitoneal
 air. again seen is a heterogeneous area of attenuation in the anterior
 abdominal wall in between the rectus muscles, which measures 13 x 22 mm on
 today's study.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable.  again seen is a small amount of fluid adjacent to the
 sigmoid mesocolon which is slightly smaller than on the previous study.  no
 new intrapelvic abscess is present.  there is no pathologic inguinal or pelvic
 lymphadenopathy.

 impression: no new focal intraabdominal abscess.  stable appearance of
 multiple small bowel resections, with dilated small bowel loops and mesenteric
 lymphadenopathy.

                                                             (over)

 [**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

"
3508,"[**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  32 year old woman with ard and pancreatitis s/p multiple medication overdose
 reason for this examination:
  please check pancreas for necorsis by pancreatitis protocol and evaluate lungs
  for ards
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  multiple medication overdose, with pancreatitis and acute
 respiratory distress.

 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 patient's debility.  there were no adverse reactions to
 contrast administration.

 findings:  reference is made to the portable ap chest x-ray from [**2167-2-16**].

 ct of the chest with iv contrast:  again seen are sternal wires.  the
 orogastric and post-pyloric feeding tubes in appropriate positions.  the
 endotracheal tube is present in satisfactory position.  there are extensive
 bilateral areas of ground-glass opacity and consolidation consistent with
 ards.  there are small bilateral pleural effusions.  no pericardial effusion
 is seen.  oral contrast is seen within the thoracic esophagus, suggestive of
 possible aspiration. there are multiple prominent mediastinal lymph nodes,
 which are likely reactive.

 ct of the abdomen with iv contrast:  no focal hepatic lesions are identified.
 the spleen, adrenal glands, kidneys, stomach, and intra-abdominal loops of
 small and large bowel are unremarkable.  the gallbladder is mildly distended,
 but there is no adjacent stranding to suggest acute cholecystitis.  the
 pancreas enhances symmetrically without adjacent fluid collection.  there is
 minimal stranding adjacent to the pancreatic tail, consistent with the
 patient's known pancreatitis.  there is no ascites or pathological mesenteric
 or retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast: the appendix, distal ureters, sigmoid
 colon, and rectum are within normal limits.  there is a small amount of free
 fluid within the pouch of [**location (un) **].  the bladder contains a foley catheter.
 there is no pathological inguinal or pelvic lymphadenopathy.

 no suspicious lytic or sclerotic osseous lesions are identified.

 impression:
                                                             (over)

 [**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 1)  stranding adjacent to the tail of the pancreas consistent with patient's
 known pancreatitis.  no peripancreatic fluid collection or hematoma or
 abnormal pancreatic perfusion.

 2)  ards.


"
3509,"[**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  60 year old man with
 reason for this examination:
  fu aortic dissection and last week 4 d sx sob, chest pain radiating to back
 ______________________________________________________________________________
                                 final report
 indications: followup of aortic dissection. chest pain radiating to back.

 technique: contiguous axial images of the chest and abdomen were acquired
 helically from the lung apices through the proximal common iliac vessels,
 before and after administration of 150 cc of optiray contrast, secondary to
 the rapid bolus injection rate required for ct angiography of the aorta. there
 were no adverse reactions to contrast administration. coronal reformations
 were made.

 findings: comparison is made to the chest cta from [**2178-11-3**].

 ct chest with iv contrast:  again seen are changes from repair of a prior
 aortic dissection, with graft material extending from the aortic root to the
 proximal aortic arch. no extravasation is seen.  previously seen small amount
 of contrast in the false lumen and aortic arch is no longer present. the
 origins of the brachiocephalic, left common carotid, and subclavian arteries
 are all patent. no contrast is seen in the false lumen, until the dome of the
 right hemidiaphragm. there is a tiny circular area of contrast present which
 is not continuous with either the true lumen or the more inferiorly mixing
 contrast within the false lumen. there is symmetrical opacification of the
 true and false lumens by the level of the aortic hiatus in the diaphragm. the
 true lumen perfuses the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left renal artery is fed by both
 the true and false lumens.  the dissection flap extends into both common iliac
 vessels for a longer extent into the left than into the right. there is no
 peri-aortic hematoma or evidence of active extravasation. there are no pleural
 or pericardial effusions. emphysematous changes are seen in the lungs. again
 identified is a small, ill defined right middle lobe nodule which is unchanged
 in appearance. bibasilar atelectasis is seen.  no pathologically enlarged,
 axillary, hilar, or mediastinal lymph nodes are seen.

 ct abdomen with iv contrast: limited evaluation with only one phase of
 contrast shows no focal hepatic or splenic lesions. multiple bilateral renal
 cysts are present which are unchanged in appearance. visualized portions of
 intra-abdominal bowel loops are unremarkable.  the adrenal glands are normal.
 ct reconstructions: coronal reformats show a stable appearance of the aortic
 disection, without definite evidence of leak.

 impression:

 1. status post surgical repair of prior type a dissection. overall, appearance
                                                             (over)

 [**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 is unchanged compared to [**2178-11-3**].  the previously seen small amount of
 contrast in the false lumen in the aortic arch is no longer present.  the true
 lumen supplies the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left kidney is supplied from
 both the false and true lumen. there is a small rounded contrast pocket within
 the false lumen located slightly above the site of mixing, but this is not
 definitely connectable to either the true lumen, or to the mixing contrast.



"
3510,"[**2129-10-30**] 1:23 pm
 cta head w&w/o c & recons; ct 150cc nonionic contrast           clip # [**clip number (radiology) 85922**]
 reason: ? bleed and emboli
 admitting diagnosis: pulmonary edema,dm
  contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   74 year old man with history of somnolence, now w/ acute delta ma, lethargy

 reason for this examination:
  ? bleed and emboli
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 indication:  acute mental status changes.  history of endocarditis.  evaluate
 for embolus or stroke.

 technique:  axial images of the brain were acquired before and after
 administration of 150 cc of optiray contrast.  nonionic contrast was used
 secondary to the rapid bolus infusion rate required for ct angiography.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:  comparison is made to the study from [**2129-10-16**].  again
 identified is an old left frontal lobe infarct.  there is no acute intra- or
 extra-axial hemorrhage, hydrocephalus, or shift of normally midline
 structures.  no areas of abnormal enhancement are present to suggest septic
 emboli.  there is no evidence of impending herniation.

 both internal carotid arteries are visualized.  there is moderate stenosis of
 the distal cervical portion of the right internal carotid artery, likely due
 to atherosclerotic disease, albeit this is a somewhat unusual locale.
 atherosclerosis seems more likely than dissection, as the vessel shows mural
 calcifications, and there is a history of diabetes as well. note is made of
 moderately stenotic left cavernous carotid artery.  the middle cerebral
 arteries to the level of the bifurcation, anterior communicating artery, and
 anterior cerebral arteries are unremarkable.  both vertebral arteries are
 patent.  the basilar artery is slightly small, but demonstrates good flow, and
 fills both posterior cerebral arteries, the proximal portions of which are
 normal.

 impression:  remote infarct of left frontal lobe.  atherosclerotic stenoses
 as noted above.


"
3511,"[**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  55 year old woman with
 reason for this examination:
  55 yo female.  change in bowel habits.  unable to do colonoscopy secondary to
  adverse reactions to sedations.  request ct colonography to screen for colon
  ca.
 ______________________________________________________________________________
                                 final report
 indication:  recent change in bowel habits, unable to tolerate conventional
 colonoscopy secondary to adverse reaction to conscious sedation.  assess for
 colon cancer.

 technique:  contiguous axial images were obtained from the lung bases to the
 pubic symphysis after insufflation of intrarectal air in the prone and supine
 positions.  iv contrast was not administered.

 comparison:  ct abdomen/pelvis of [**2180-9-28**].

 ct colonography:  no suspicious lesions are seen.  there is no evidence of
 polyps, masses, strictures, or inflammatory disease.  there is a small amount
 of fluid within the cecum, descending colon and sigmoid which displaces with
 repositioning.  there is minimal retained fecal matter.

 ct of abdomen w/o iv contrast:  the imaged portions of the lung bases again
 show a 1-2 mm noncalcified nodule of the peripheral right lower lobe.  the
 liver, spleen, pancreas, adrenal glands, kidneys, and unopacified loops of
 small bowel are unremarkable.  there is no free air, free fluid, or
 lymphadenopathy.  the patient has had a previous cholecystectomy.

 ct of pelvis w/o iv contrast:  the rectum, urinary bladder and adnexal regions
 are unremarkable.  there is no free air, free fluid, or lymphadenopathy.

 bone windows:  there are no suspicious osseous lesions.

 multiplanar reformatted images and full endoluminal navigation performed in
 the antegrade and retrograde direction confirm and aid in the above findings.

 conclusion:
 1)  no significant polyp or mass identified (greater than 1 cm).  please note
 that the sensitivity of ct colonography for polyps greater than 1 cm is
 85-90%.  the sensitivity for polyps 6-9 mm is about 60-70%.  flat lesions may
 be missed with ct colonography.

 2)  stable 1-2 mm noncalcified nodule within the right lower lobe, likely
 representing a benign granuloma.  in the absence of any known primary
 malignancies, no further follow up is needed.

                                                             (over)

 [**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
                                 final report
 (cont)

"
3512,"[**2113-7-18**] 7:48 am
 lumbar puncture                                                 clip # [**clip number (radiology) 42757**]
 reason: please do lumbar puncture, not cervical - ? cns infection
 admitting diagnosis: weakness
 ********************************* cpt codes ********************************
 * [**numeric identifier 2678**] lumbar spinal puncture          [**numeric identifier 2679**] fluoro guid for spine diag/the   *
 ****************************************************************************
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  78 year old man with waxing/[**doctor last name 561**] mental status - ? cns infection, unable to
  obtain lp.
 reason for this examination:
  please do lumbar puncture, not cervical - ? cns infection; please also note the
  patient should receive no benzos for sedation given prior adverse reactions.
 ______________________________________________________________________________
                                 final report
 indication:  78-year-old male patient with waxing and [**doctor last name 561**] mental status
 changes.  evaluate for cns infection.  referring service unable to obtain
 bedside lumbar puncture.

 radiologist:  drs. [**first name8 (namepattern2) 4228**] [**last name (namepattern1) 33771**] and [**first name8 (namepattern2) **] [**last name (namepattern1) 722**], the attending
 neuroradiologist, was present and supervising throughout the procedure.

 procedure and findings:  the risks and benefits of the procedure were
 discussed with the patient through a portuguese interpreter.  written informed
 consent was obtained.  a preprocedure timeout was performed using two patient
 identifiers.

 the patient was brought to the fluoroscopy suite and placed on the
 angiographic table in prone position.  the lower back was prepped and draped
 in the usual sterile fashion.  using fluoroscopic guidance in ap and lateral
 planes, a suitable location for lumbar puncture was identified at the l2-3
 level.  approximately 10 cc of 1% lidocaine was used for local anesthesia.
 using fluoroscopic guidance, a 22 gauge spinal needle was used to access the
 lumbar subarachnoid space at the l2-3 level.  approximately 12 cc (four tubes,
 2 cc, 3 cc, 3 cc and 4 cc) of clear cerebrospinal fluid was removed and
 submitted to the laboratory for requested diagnostic test.  the patient
 tolerated the procedure well without immediate complications.

 impression:  technically successful fluoroscopic guided lumbar puncture.  csf
 samples sent for laboratory analysis.

"
3513,"[**name (ni) 257**] pt on [**last name (un) 33**] a/c 12/550/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small amount of white thick secretions. mdi's administered q4 atr with no adverse reactions. 02 sats @ 99%. cuff pressure @ 21 cm h20.  rsbi performed but no spont resp.  plan is to wean to psv then possibly extubate. no further changes noted.
"
3514,"ccu (sicu border) nursing transfer accept note 7p-7a

64 yo male with pmh af, imi, ptca, cva x2(no residuals observed), asthma, lung ca, cabg x2 [**6-1**], chf, htn, bladder ca, mild copd, tia's, and mvr admditted to [**hospital1 2**] [**10-10**] with abd angina, diagnosed with mesenteric ischemia. pt underwent [**name (ni) 3549**] [**10-11**] of sma, developed sbo and later had ileocecectomy [**10-14**]. post-op course c/b chf/pneumonia. pt with difficulty breathing, low sats and pao2 44 last [**hospital 3550**] transferred to sicu service for closer resp monitoring/ ?cpap.

all: ativan, librium---adverse reactions

neuro: arrived alert, oriented x3, cooperative and pleasant. following commands appropriately. moving all extremities.

cv: hr 80-90's afib/vpaced. occ pvc's noted. bp 97-120/60's. denies chest pain/palpitations. ck neg x2 thus far. inr 2.7 yest. given 1mg coumadin x1, to be dosed per day.

pulm: ls bilateral crackles [**2-2**] way up. rr 20-30's. o2 sats 88-100% on 100% nrb. unable to speak full sentences but able to speak several words at a time. pt [**name (ni) 865**] rapidly to low 80's without o2 and takes a while to return to 90's. received lasix on floor prior to transfer, no further lasix given.

gi/gu: abd soft, +bs x4. abd incision with staples c/d/i. no drainage noted. pt with sips h20 and crackers only r/t desat without o2. no stool this shift. foley draining 20-30cc/hr clear amber/yellow urine. ho notified of low u/o, no intervention at this time.

id: afebrile. wbc yest 16.4. started on cipro and clinda for pneumonia.

endo: 11p fs 11. no coverage per ss.

social: wife called and updated by resident. other family members called also.

access: left dl picc. one port not flushing.

plan: observe resp status, cpap if needed. con't abx for pneumonia. diet as tolerated. full code. communication with family.
"
3515,"resp: [**name (ni) 257**] pt on simv 14/500/+5/50%.  ett 7.5 retaped and secured  20@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of bloody, clots secretions. mdi's administered q4 with no adverse reactions. am abg 7.39/42/69/26. fio2 increased to 60%. plan trip today to or for debridment.
"
3516,"resp:  pt continues to be mechanically ventilated on psv 15/+5/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve following suctioning. suctioned for small amount of thick white secretions. mdi's administed q 4hrs atr with no adverse reactions.  rsbi=117, plan to keep pt on psv and wean as tolerated.  no further changes
"
3517,"continuation of previous note.
cv:  patient originally with low grade temp,  now afebrile.  patient on multiple cardiac medications thoughout the day with various adverse and not adverse reactions.  patient currently on esmolol for rate control, norepi for bp management, heparin, insulin and currently versed.  patient with poor [** **] pt on right foot and no dp on right foot.  [**name (ni) **] pt and dp on left foot.

resp: no vent changes made this shift, patient overbreathing on vent, with adequate oxygenation and good gases.  patient with minimal amounts of ett secreations.

gi:  patient started on insulin gtt for elevated blood sugars with multiple foul smelling bloody stools.

gu:  patient with patent foley voiding minimal amounts of urine.  please see flowsheets for all other information.  thank you
"
3518,"7p-7a
neuro: pt opens eyes, does not follow commands, does not [**name8 (md) 506**] rn in room, does not move any extremeties. perrla. morphine 2mg ivp given for pain shown by increase in bp.

cv: hr 80-90s in and out of afib. at present 80s sr no ectopy, lytes repleted prn. sbp labile, see carevue, on and off neo. at present time sbp 102, on 0.5mcg/kg/min. picc to right arm patent and [**name8 (md) 235**]. left radial arm [**name8 (md) 235**] reddened. dopplerable pedal pulses. generalized anasarca. bilat upper extremties oozy moderate amts of serous fluid. sternal sutures cdi, covered w/ gauze and abd. binder [**name8 (md) 235**] to sternal area. received 1 unit of prbcs, no adverse reactions, repeat hct 28.

resp: ls clear- coarse, diminished bases. sats >98%. rr 25-35. trial of cpap rr increased to 40's. on cmv rate 10, fio2 40% peep 5, see carevue for abgs. suctioned for small amts of thick yellow secretions via ett.

gi/gu: abd soft, round, hypoactive bs. tf residual at 0030 250cc, given back to pt, tf on hold, pa [**doctor last name **] aware. dophoff +placement. foley [**doctor last name 3447**] adequate amts of clear yellow urine.

skin: stg 2 2cm round to coccyx area, duoderm on and [**doctor last name 235**]. see carevue for further details.

endo: riss.

plan: monitor hemodynamcis. monitor pulmonary status. follow labs and treat as appropriate. pain control. monitor neuro status.
"
3519,"resp: [**name (ni) 257**] pt on psv 10/5/50%. bs are clear bilaterally with diminished bases. suctioned for scant to small amounts of thick tan secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's or changes this shift. rsbi=54. plan to wean to extubate today.
"
3520,"resp: [**name (ni) 257**] pt on psv 18/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. continued periods of extreme aggitation with rr into 60's. ativan given to calm with results. peep ^ to 8 abg's 7.43/35/104/24. rsbi=164. will continue to wean appropriately.
"
3521,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 20/5/50%. alarms on and functioning. ambu/syringe @ hob. portex #7 with spare inner cannula in room. cp @ 23 cmh20. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.39/36/133/23. rsbi=127. terminated with ^ rr to 40's. will continue to wean appropriately.
"
3522,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c14/550/+5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellowish secretions. mdi's administered q4 combivent with no adverse reactions. vent changes: psv 12/5/35%, abg's drawn (careview)ps ^ 15, fio2^40% abg 7.39/42/99/26. rsbi=40, ps decreasd to 10. will continue to wean for possible extubation.  ett retaped and secured @ 22 lip. no further changes noted.
"
3523,"[**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  71 year old woman with pancreatic cancer s/p ex-lap with bx of periduodenal
  nodule, chole, [**last name (un) **], choledochojejunostomy, and gastrojejunostomy
 reason for this examination:
  for oncology staging
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 ct chest with contrast

 comparison:  none.  correlation is made with cta abdomen of [**2143-8-14**].

 technique:  multiple axial ct images were obtained through the chest following
 the administration of 75 cc of omnipaque iv contrast.  sagittal and coronal
 reconstructions were obtained.  no adverse reactions were reported.

 indication:  71-year-old female with pancreatic cancer, status post
 exploratory laparotomy with biopsy of peri-duodenal nodule, cholecystectomy,
 roux-en-y procedure, choledochojejunostomy, and gastrojejunostomy.  exam is
 done for oncology staging.

 findings:  right picc terminates at the superior atriocaval junction.  no
 supraclavicular, mediastinal, hilar, or retrocrural lymphadenopathy.  small
 right hilar lymph node measures 8 mm on short axis and does not meet criteria
 for pathologic enlargement by size.  scattered left hilar pulmonary calcified
 granulomas.  heart size is within normal limits without pericardial effusion.
 the thoracic aorta is normal in caliber without dissection or aneurysmal
 dilatation.  branches of the aortic arch are normal.  pulmonary trunk is
 within normal limits by size.  no central pulmonary thromboembolic disease is
 identified.  thyroid gland demonstrates homogeneous attenuation without focal
 lesions.

 there is a 4-mm nodule in the middle lobe and a 3-mm nodule in the subpleural
 right lower lobe (2:36).  no pulmonary mass is identified.  bilateral basilar
 subsegmental atelectasis.  small bilateral pleural effusions.  no
 pneumothorax.

 abdomen:  pneumobilia is likely related to recent changes of reported
 choledochojejunostomy. hypodensity in the gallbladder fossa with intrinsic air
 is compatible with surgicel packing although an abscess would have a similar
 appearance.  stable 0.9 x 1.3 cm hypodensity in the right hepatic lobe
 (segment vii).  small perihepatic and perisplenic ascites.  colonic
 diverticulosis without diverticulitis involving the visible splenic flexure.
 there is patchy fluid surrounding the splenic flexure, which may be due to
 post-surgical change.

 bones and soft tissues:  no acute fracture or destructive osseous process.
                                                             (over)

 [**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 multilevel degenerative disc disease.  advanced degenerative changes of the
 right and moderate degenerative changes of the left acromioclavicular joint.
 degenerative arthrosis of both humeral heads.  there is a calcific structure
 along the greater tuberosity of the left humerus which may relate to calcific
 tendinosis.  no acute fracture or destructive osseous process.

 impression:
 1.  indeterminate right middle lobe and lower lobe pulmonary nodules.  in a
 patient with history of prior malignancy, unenhanced ct chest is recommended
 in three months to monitor growth pattern and malignant potential.
 2.  no intrathoracic lymphadenopathy.
 3.  pneumobilia, abdominal ascites and pericolonic fluid involving the splenic
 flexure are likely related to recent surgery. hypoattenuation in gallbladder
 fossa with intrinsic air is compatible with surgicel packing, however an
 abscess would have a similar appearance and cannot be excluded.
 4.  scattered colonic diverticulosis.

"
3524,"resp: [**name (ni) 257**] pt on psv 15/8/40%. bs reveal noted aeration with sub q bilaterally. suctioned for moderate amounts of thick yellow secretions, copious thick clear from oral cavity. mdi's administered alb/atr with no adverse reactions. pt 02 sats to 80's with ^ wob then placed on simv (see carview). attempted rsbi but no resps. sedation lightened and plan is to change settings to psv.
"
3525,"resp: pt rec'd on simv 20/450/10/+5/40%. ett #7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration and sub q noted on ls and up front of chest. suctioned for small amounts of thick yellow/whitish secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions. am abg 7.44/47/95/33. rsbi=no spont resps. plan to attempt wean to psv today as tolerated.
"
3526,"resp: pt rec'd on simv 20/400/20/+5/50%. bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions with a few plugs. mdi's administered q4 hrs alb/atr with no adverse reactions. attempted to wean to psv this am and pt ^ wob,^rr to 38+ with vt's @ 200, so returned to simv. abg's 7.37/56/116/34. vent changes to  decrease fio2 to 40%, increase vt to 450. no further changes noted.
"
3527,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] 10/8/40%. alarms on and functioning. ambu/syringe @ hob.  cp @ 20, trach #8 portex. bs auscultated reveal bilateral clear sounds. suction for small amount of thick yellow. mdi's administered q4 hrs combivent with no adverse reactions. plan to continue t/c trials as pt tolerates.  am abg's 7.36/42/100/25. rsbi=56.  will continue to wean appropriately.
"
3528,"resp: [**name (ni) 257**] pt on psv 12/8/50%. #8 portex with positional [**name (ni) **] at times. bs are coarse bilaterally. suctioned small amounts of thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt still very anxious with rr 6 to 40's.  no abg's or vent changes this shift. vt's 300's
"
3529,"resp: rec'd on psv 8/5/40%. portex #8, ^ cuff pressures md aware. bs reveal bilateral aeration, chest tubes sealed. suctioned for moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. pt had episodes of ^ wob/rr. increased psv to 10, peep to 8 with vt's 300's, 02 sats 98%. no abg's.
"
3530,"resp: pt remains on pcv dp20/r20/+5/40%. bs are coarse with small amounts of thick yellow secretions suctioned. no changes or abg's noc. 02 sats @100%. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. will continue full vent support
"
3531,"resp: [**name (ni) 257**] pt on simv 20/450/+5/40%. alarms on and functioning. ett 7.5, 23 @ lip. bs are diminished bilaterally. ls chest tube in place. mdi's administered q4 hrs with no adverse reactions. abg's 7.39/49/98/29. rsbi=126. placed pt on psv 15/8/40%. vt's 400/ve's 6/rr 18/02 sats @99% with am abg to follow. no further change noted.
"
3532,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/+8/60%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal ls coarse, rs diminished with some aeration noted in apecies. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.40/44/144/28. decreased fio2 to 50%. rsbi=16. plans to wean to possible extubate this am.
"
3533,"resp:  [**name (ni) 257**] pt on [**last name (un) **] a/c 20/500/40%/+8.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal rs clear apecies with ls coarse, diminished bases. 02 sats ^ 90's, 98%.  suctioned for small to moderate amounts of thick yellowish secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=153. no further changes noted
"
3534,"resp: [**name (ni) 257**] pt on a/c 12/500/+5/40%. bs are slightly coarse. suctioned for moderate amounts of tan-yellow thick secretions. mdi's administered as ordered of atr with adverse reactions. am abg 7.41/39/104/26. plan is for possible extubation today.
"
3535,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 15/5/40%. bs are clean bilaterally with diminished bases. mdi's administered q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions. spare trach, ambu in room. no abg's. t/c trials to continue today as tolerated.
"
3536,"resp: [**name (ni) 257**] pt on psv 22/10/50%. bs are coarse bilaterally. suctioned for small amounts of thick secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.43/47/148/32. vent changes; decreased ps to 20/fio2 to 40%. will continue to wean appropriately.
"
3537,"resp: [**name (ni) 257**] pt on a/c 26/350/12+/40%. pt is trached #8 [**last name (un) 3338**]. alarms on and functioniong. ambu/syringe @ hob. bs are coarse with noted improvement following suctioning. suctioned for moderate amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=no sponts. am abg 7.33/38/80/21. no changes noc.
"
3538,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  a+ox3.  speech clear.  mae ad lib.  med per [**month (only) **] with morphine for face/head/neck pain while double lumen balloon in place--pain tolerable with morphine however pt has not been pain free with balloon in place.

cv/pulm:  mp=vpaced with freq pvc's noted.  bp 140's-160's/40's-60's.  heparin titrated according to sliding scale/ptt's.  transtracheal 02 catheter in place at 1liter cont.  breath sounds clear upper lobes, crackles lower lobes.  bumex 1mg iv given with brisk diuresis, breath sounds clear/coarse after bumex.  at 1630 return of bibasilar crackles noted--team aware, no intervention at this time.  doe noted; no sob at rest.  [**first name8 (namepattern2) 3568**] [**last name (namepattern1) 3569**] in to see pt from outpatient pt; attempted to remove transtracheal catheter over wire for stripping; unable to remove.  several attempts following humidified air over next 4 hours unsuccessful.  dr. [**last name (stitle) 3570**] in to see pt, catheter removed over wire, cleaned and reapplied by dr. [**last name (stitle) 3570**]. sm amts mucous and old blood noted on catheter prior to cleaning.  o2 sats mid 90's throughout day, airway intact throughout day.  pt remains with double lumen balloon in r nares, scheduled for embolicectomy [**2131-5-18**] ? time.  vit k given both po and iv in addition to one unit ffp to correct inr in preparation for procedure in am.  one unie prbc's given for hct 27.3 with increase in hct to 32.0.  no adverse reactions noted with prbc, ffp or vit k iv.

gi/gu:  tol po's--does have some difficulty swallowing.  abd soft, non-tender, bowel sounds present.  no flatus, no bm.  voiding clear yel urine; [**name8 (md) 20**] md foley inserted following void--25ml residual obtained.  foley left in place, draining clear yel urine at this time.

id/integ:  tmax 99.1 po.  remains on cefazolin.  skin intact.  old scarring noted from r mastectomy.

psychosocial/plan:  husband in to visit.  emotional support given to pt and fam.  plan is to cont to titrate heparin according to sliding scale/ptt, npo after midnight for embolectomy in am, cont to follow labs, monitor i+o, assess for signs of bleeding, monitor airway/cont 02 sat monitoring.  cont with current nursing/medical regime.
"
3539,"resp: [**name (ni) 257**] pt on a/c 26/350/+12/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. abg' 7.31/46/78/24. vent changes to increase rr to 28, fio2 to 50%. am xray and additonal abg's pending. no further changes noted.
"
3540,"respiratory care note
pt received on ac as noted with no changes this shift. bs are slightly decreased, but clear bilaterally. pt suctioned for no secretions. mdi's given q4 - pt tolerated well with no adverse reactions. plan to continue on current settings at this time.
"
3541,"resp: [**name (ni) 257**] pt on nrb. hhn administered of xopenex 0.63 as ordered with no adverse reactions. pt placed back on niv @ 4:00 psv 15/5/60%. fio2 ^ to 60% due to 02 sats in low 80's. abg pending. will continue to monitor progress to wean.
"
3542,"resp: pt rec'd on a/c 14/400/+5/50%.bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q 4 hrs [** **] with no adverse reactions. no abg's. rsbi=>200. plan is to attempt wean today as tolerated.
"
3543,"resp: pt remains on a/c. bs are coarse with occasional wheezing. mdi's administered q4hrs [** 892**] with no adverse reactions. suctioned for moderate amounts of thick tan secretions.  will continue full vent support.
"
3544,"resp: pt remains vented on a/c 18/400/+10/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4h [** 892**] with no adverse reactions. plan to wean to psv as tolerated.
"
3545,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration in apecies with diminished lll noted.  mdi's administered q4 hrs combivent with no adverse reactions. episodes of desaturation during the noc, fio2 increased to 60%. 02 sats 95-97%.  rsbi=69. pt scheduled for trache today [**3-31**]. no further changes noted.
"
3546,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex. bs are clear in apecies with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. no abg's and rsbi=72. will continue with t/c trials.
"
3547,"resp: [**name (ni) 257**] pt on psv 12/8/50%. ett #7, 26 @ lip. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. suctioned for small amounts of yellow to white thick secretions. mdi's administered alb/atr with no adverse reactions. vt's 500-600, ve's [**11-22**], 02 sats @ 98%. [**month/year (2) **]=80. plan to wean to extubate this am.
"
3548,"respiratory care note:
     received patient on ac as noted in carevue.  ett is secured and patent.  no changes have been made this shift.  for specific settings please refer to carevue.  bs are coarse throughout with occasional wheezes noted on the left side.  sx for small amounts of tan thick secretions, blood tinged at the beginning of the shift.  no rsbi this am due to increased fio2 and peep settings (.60 fio2 and 10 peep).  patient remained afebrile this shift.  mdi's administered as ordered with no adverse reactions noted.  spo2 remains 94-95%.  plan is to maintain current therapy and wean fio2 and peep as tolerated.
"
3549,"resp: [**name (ni) 257**] pt on psv 12/8/40%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioning scant amounts. mdi's administered as ordered alb/atr with no adverse reactions. vt's 500-700, rr 20's to 30's when aggitated.  no changes this shift.
"
3550,"resp: [**name (ni) 257**] pt on 50% t/c. pt removed t/c and 02 sats to 60's with ^ rr. place on [**last name (un) 33**] psv 5/5/40% to rest noc. suctioned for moderate amounts of thick yellow secretions. mdi's administerd q4 hrs alb/atr with no adverse reactions.am abg 7.38/57/132/35. will place on 50% t/c in am.
"
3551,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/5/50%. alarms on and functioning.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  rsbi=168. 02 sats remain in ^ 90's @ 97%.  no further changes noted.
"
3552,"resp: pt rec'd on psv 5/5/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. pt had some episodes of anxiety. 02 sats @ 99% with rr 18. vt 400. rsbi=37. plan to continue with t/c trials.  will continue to wean.
"
3553,"resp:  [**name (ni) 257**] pt on psv 15/5/35%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned for small to moderate amounts of thick tannish secretions.  mdi's administered q4 alb/atr with no adverse reactions. pt rested noc on a/c 12/350/+5/35% where he remains. will return to psv this am.  no further changes noted.
"
3554,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 24/380/+8/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of greenish thick secretions. mdi's administered q4 alb/atr with no adverse reactions. no further changes noted.
"
3555,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate-copious amounts of yellow and some bloody tinged secretions.  mdi's administered q4 hrs with no adverse reactions. no further changes noted.
"
3556,"resp: [**name (ni) 257**] pt on a/c 14/700/+8/50%. ett 7.5, 26@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse with diminished bases. suctioned for small amounts of thick secretions.  mdi's administered as ordered with no adverse reactions.  no changes or abg's noc. md ask to hold off on [**name (ni) 817**] and to attempt around 10:00am due to pt's past hemodynamic instability.  plan to lighten sedation, attempt [**name (ni) **] then wean as tolerated.
"
3557,"resp: rec'd on psv 15/5/40%. bs are coarse bilaterally. suctioned for copious amounts of thick bloody secretions with large clot under tongue. pt has open cuts on tongue and md aware. mdi's administered q 4 hrs alb/atr with no adverse reactions. rsbi=101. will continue with present support.
"
3558,"resp:  [**name (ni) 257**] pt on 16/400/5/40%. bs auscultated reveal ls clear with diminished rll. suctioned for small amounts of yellow thick secretions, sample sent. mdi's administered alb/atr with no adverse reactions. vent changes to decrease r to 14, fio2 to 30%. am abg 7.47/43/109/32.  rsbi attempted with no resps results. will attempt again on day shift.
"
3559,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 15/+12/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick bloody tinged secretions due to new trach.  mdi's given q4 hrs alb with no adverse reactions. vt's 600/ve 16-19, rr 28. pt has tachy periods with ^ rr in ^ 30's at times.   no rsbi due to ^ peep. no a-line for abg's presently, but expect new a-line started today. 02 sats @ 97%. no further changes noted.
"
3560,"respiratory: pt remains intubated on psv 8/8/50%. ett retaped and secured @ 21 lip. bs are diminished with some crackles noted in bases. suctioned for copious amounts of thick yellow secretions and oral secretions. mdi's administered q4 hrs alb with no adverse reactions. vt's 500-600/ve 9/rr 17. rsbi=29. around 5:00 pt self extubated even though pt was restrained. pt was placed on nrb with sats @ 99%. wife was called and informed. will continue to monitor and will re-intubate if necessary.
"
3561,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 20/5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal diminished rll with aeration noted on ls/slightly coarss/occasional wheeze.  suctioned for moderate amounts of thick yellow/bloody secretions, as well as out of oral cavity.  mdi's administered q4 alb/atr with no adverse reactions. pt became ^ sob, vent settings changed to a/c 20/400/+5/35%. abg's this am 7.37/51/99/31.  maintain settings with no further changes noted.
"
3562,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv8/5/50%.alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal clear apecies with diminished bases. suctioned for small amounts of white thick secretions. mdi's administered q6 combivent with no adverse reactions. trip to mri without incident, results negative. am abg's 7.36/48/107/28. vent changes to decrease ps to 5 and fio2 to 40%. will continue to wean appropriately.
"
3563,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 28/500/12+/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 alb with no adverse reactions. vent changes reflect abg's. am abg's 7.45/45/109/29. no further changes noted.
"
3564,"7a-7p
neuro: pt alert, disoriented to time and place. perrla. mae. medicated w/ one darvocet po for c/o incisional pain.

cv: hr 60-70s sr no ectopy noted. epicardial wires secured and attached, see carevue for details, no paced beats noted. sbp >100. a- line [**name6 (md) **] [**name8 (md) 20**] md [**last name (titles) 132**]. pressure dsg applied. 2 units of prbcs given as ordered for low hct. no adverse reactions w/ blood transfusions. extra dose of lasix 20mg given iv secondary to extra volume today. hct after prbcs 31.

resp: ls clear/ rales at bases. sats greater than 97% on 4l nc. breathing regular, not labored. chest tubes [**name6 (md) **] by md [**last name (titles) 132**]. pressure dsg intact.  cxr done.

gi/gu: abd round distended. +bs. no bm. groin area swollen w/ ecchymosis. md [**doctor last name 132**] aware. no new orders. foley draining yellow -> [**location (un) 138**], decreased u/o in afternoon- extra dose of lasix given increasing u/o. see carevue for details.

endo: fs 176-198, covered by csru protocol. md [**doctor last name 132**] changed protocol to pt's own scale to cover fs.

plan: monitor resp. status. pulmonary toilet. replete electrolyes as needed. ? transfer to floor.


"
3565,"nursing (0700-1900)
todays events- right ij line dc'd by resident

a&ox3. dilaudid for abd. surgical pain with no adverse reactions, previous night experienced hallucinations. oob to chair tolerated well, no futher complaints of pain.

periods of sinus tachycardia otherwise cv signs wnl.  afebrile.

abdominal incision tender upon palpation, open to air, no drainage, jt.

nasal cannula 2l, independent incentive spirometery (1250ml) and cough deep breathe.

abdomen soft and distended. ngt dc'd by surgery, previously clws with moderate amounts bilious drainage. tolerating jt trophic feeds.  bg treated with 2units riss.

diuresing, urine potassium level-wnl; p.m. level pending.

pt. tolerated 6 hrs. in chair today.  stood and walked back to bed with max assist, but tolerated well.

patient and family met with surgery to discuss results of tumor debulking.

plan of [**hospital 5826**] transfer to floor (bed), continue diuresing goal is -3l, continue activity oob to chair as tolerated, pain management, skin care, keep family informed of plan of care.

[**first name8 (namepattern2) 5827**] [**last name (namepattern1) 5828**] bc student nurse

"
3566,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex trach. bs are diminished bilaterally. suctioned for small to moderate amounts of thick white/yellow secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. pt having ^ wob and ps ^ to 12. vt's 500's ve's [**6-4**]. am abg 7.48/45/141/34 and ps decreased back to 10. rsbi=90. plan to continue to wean ps as tolerated.
"
3567,"resp: [**name (ni) 257**] pt on psv 10/5/40%. bs are coarse bilaterally. suctioned for large amounts of thick white secretions. mdi's administered as ordered (see careview) with no adverse reactions. pt ^ rr to 30's and bp to 190, placed on a/c to rest. abg 7.47/40/146/30. rsbi=126. plan to wean to psv as tolerated.
"
3568,"resp;  [**name (ni) 257**] pt on [**last name (un) 33**] psv 5/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned for moderate-copious thick yellow secretions. mdi's administered q4 with no adverse reactions.  pt awake, not following commands. pt returned to a/c noc for ^ in rr, bp, hr. rsbi=65.  returne o psv this am. plan to possible extubate today.
"
3569,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+10/50%.  ambu/[**last name (un) 1299**] @ hob.  bs auscultated reveal bilater coarse sounds which clear with suctioning.  suctioned x3 small to moderate amounts of thick tan secretions.  also, had a substantial amount in oral cavity.  mdi's administered in line q4hrs (6 p) combivent with no adverse reactions.  rsbi performed = 19.4, then placed back on current settings.  no further changes are noted.

"
3570,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 14/600/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. re-taped and secured ett. mdi's administered q4 hrs alb/atr with no adverse reactions. pt is waking up. rsbi=68.  still not following commands.  will proceed to wean to psv trial in am.  no further changes noted.
"
3571,"resp: [**name (ni) 257**] pt on psv 10/10/50%.  ett # 7.5 taped @ 21 lip.bs are clear in apecies and diminished in bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. pt had periods of apnea, then placed on simv 14/500/10+/50% until 4:00 and returned to psv 10/10/50%. am abg 7.42/58/100/39. no further changes noted.
"
3572,"resp: pt placed back on mmv due to periods of apnea. psv 10/5/40% (see careview for mmv settings) bs are coarse to clear and suctioning for small to moderate amounts of thick white secretins. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=50. no abg's this shift. 02 sats @ 99%. adequate tv's/ve's.
"
3573,"resp: pt rec;d on a/c 20/500/+10/60%. ett #8.0 retaped and secured @ 26 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear apecies with diminished bases. mdi's administered q4 hrs alb/atr with no adverse reactions. no rsbi=^ peep. no abg's or changes this shift. will continue full vent support.
"
3574,"resp: [**name (ni) 257**] pt on mmv (psv 10/5/40%). ett 7.5, rotated, taped and secured @ 21 lip. bs are coarse to clear and suctioning for white to yellow thick secretions. mdi's administered as ordered alb/atr without adverse reactions. no abg's this shift. pt weaned back to psv 10/5/40% this am. results from abdominal ct unchanged. rsbi=95. plan: trach/peg? continue on present settings.
"
3575,"resp: pt remains intubated on a/c 16/500/+5/50%. bs are coarse bilaterally. suctioning for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs. combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. no vent changes this shift. am abg's 7.52/36/95/30. will continue full vent support.
"
3576,"resp: pt rec'd on psv 15.+5/50% bs are coarse to clear. suctioned for small amounts of white thick secretions. mdi's administered q4 hrs combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt had ^ wob with rr to ^ 30's, bp >200, increased ps to 20 with no affect. place pt on a/c 18/500/+5/50%. abg' 7.50/40/87/32. pt comfortable noc. attempted to wean to psv this am and pt bp went over 220 immediately, then placed back on a/c.will attempt wean to psv in am.
"
3577,"resp: [**name (ni) 257**] pt on psv 10/5/40%. ett 7.5 secured @ 21 lip. bs reveal slightly coarse to clear and suctioned for small amounts of secretions. mdi's administered alb/atr with no adverse reactions. pt having periods of apnea and placed on mmv for noc. rsbi=48. pt opening eyes to name. plan: wean to psv in am. no abg's this shift.
"
3578,"71 y/o female with cirrhosis,esrd,l leg fracture due to fall at home now in hypotension currently on dopamine gtt 2 mcg/kg/mt attempted to wean and d/c but drpopped to sbp 60-80 with map < 40.

events;crit stable today but low to 23,transfused 1 unit prbc without any adverse reactions.

cvs;hr 73-80 nsr no ectopy,abp 94-126/40-60 on dopamine gtt unable to wean off.cvp 10-12.post transfusion crit send please see carevue for lab results.pedal pulses are doppled.

access;rij and rt r a-line remains patent.lt av fistula positive for bruit and thrill.

neuro;looks more alert today answers all question appropriately but remains confused at times and trying to pull out invasive lines ,rt hand restrained for few hrs and released with reorientation.lt leg spilnted and able to move lower extrimities on bed and upper extrimites are able to move off the bed,no tremors or flaps noted today.

resp;ls are clear to dim at bases o2 sats are maintained 100% on room air,breathing efforts are normal.

gi;abdomen soft,positive bowel sounds tolerating diet,no n/v pantoprasole increased to bd,gi followed up not planning for any invasive procedures at this time. draining brown colored liquid stool via mushroom catheter which is positive for guaic.on bowel regimen.

gu;not dialysed since 5 days due to hypotension.please see carevue for lab values.

skin;multiple areas of bruises all over teh body due to fall rt upper extrimities has weeping areas and bleeding.lt leg is spilnted.positioned as needed for comfort.

id;afebrile,wbc 7.5 on zosyn and daptomycin(recieved only one dose/on hd days)on contact precautions for mrsa/vre.

endo;blood sugar > 200 sliding scale renewed and started on fixed dopse today.

social;daughter called and updated and will be coming later to visit her.

plan;follow crit bd,transfuse prn
maintain  map>60
reorientation and restraints as needed
fs q6h,calorie count till monday.
 pt for left leg.
"
3579,"[**2170-8-10**] ""b"" admission note:

80 yr old pt came to ed with diarrhea&vomiting for 4 days, 1 day of burning on urination. fever up to 105.0. u/a+ and 3 bld cults+,still has some nausea.

pmh:  htn,cva with no residual effect,anemia,niddm.quit smoking 40yrs ago.

allergy:  codeine-makes her ""crazy""

cvs:  afebrile. hr=58-75 nsr no ectopy since arrival, reportedly in afib in ed.  sbp=110-135 in left arm and 70-80 in right arm.  given 6l of fluid in ed and 1500cc lr iv bolus upon arrival when bp low.  hct=23.4 down from 30.2, given 2 units prbc's with no adverse reactions noted.  mg=1.6 given 2gm iv mgso4.

resp:  o2 3l nc, lung sounds clear, diminished at bases.  sats=98-100%.  no sob noted.

gu:  sent u/a this am.  given 3 antibiotics in ed. u/o=30-55cc/h

gi:  +bs, ate small amt supper that family brought in, she says she doesn't eat much because she doesn't like the diet restrictions. no stools.  rectal guaiac was - in ed.

neuro:  a&ox3, mae. speech clear and appropriate.  follows all commands.  screaming and crying whenever aline or iv lines were attempted to be inserted.

skin:  no open areas noted.  old brown bruises noted on both knees, shins, upper back, legs.

plan:  continue antibiotics, monitor vss and labs. [**hospital **] transfer to floor when bed available.

"
3580,"resp: [**name (ni) 257**] pt on a/c 22/500/+8/40%. bs are clear with diminished bases. suctioned for small amounts of white thicksecretions. mdi's administered alb/atr with no adverse reactions. no changes [**name (ni) **] or abg's pt remains on [**name (ni) 1858**].
"
3581,"7a-7p
neuro: pt alert and oriented following commands. mae. perrla. percocet for pain w/ good relief.

cv: hr 70-80s sr w/ occasional pacs, lopressor increased to 25mg [**hospital1 **], np [**doctor last name **] aware of pacs. sbp >90 , map >60, see carevue for details. +palpable pulses. introducer patent in rij, #20 rw patent and intact. epicardial wires intact, shut off secondary to inappropriate spiking, team aware on rounds. 1 unit of prbcs given in am, no adverse reactions.

resp: ls clear- diminished at bases, wheezy w/ activity, later in shift rales at bilat bases, np [**doctor last name **] aware. inhalers given. sats on 3lnc >94%. breathing unlabored. pt denies trouble breathing. no resp. distress noted. ct dc'd at bedside dsgs intact, cxr taken results pending. much encouragement needed for oob,coughing and deep breathing, and the use of is.

gi/gu: abd softly distended +bs, no bm. foley draining yellow urine, around 2pm u/[**name initial (md) **] decreasing, np [**doctor last name **] aware, labs sent to eval if pt needs increased dose of lasix, labs pending at present see carevue for details.

endo: insulin gtt weaned to off, po glyburide started and continuing riss.

social: family updated w/poc.

plan: monitor hemodynamics. monitor resp. status. aggressive pulmonary toilet. follow labs, including creatinine and glucose. increase activity and po intake as pt tolerates. ? transfer in am.
"
3582,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] simv 14/800/5/+5/40%.  alarms on and funtioning. ambu/syringe @ hob. cuff pressure @ 21.  bs auscultated reveal bilateral coarse sounds. suctioned x3 small to moderate amounts of thick pale yellow secretions.  mdi's administered q4 hrs with no adverse reactions.  vent changes to decrease rr to 12 vt to 650 to obtain improvement in abg.  rsbi=86, although no sbt initiated due to ^ in rr to 40's.  placed on psv [**2110-11-1**] where pt remains with 02 sats @ 100, rr 20-22 and not distress noted.  no further changes at this time.
"
3583,"resp: pt rec'd on 70% cam f/t. bs are coarse bilaterally with strong cough although pt unable to expectorate. nebs administered q6  hrs alb/atr with no adverse reactions. no nts this shift. will continue to follow.
"
3584,"resp: [**name (ni) 257**] pt on psv 5/5/50%. pt has #9 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs of atrovent with no adverse reactions. vent changes to decrease fio2 to 40%. am  abg 7.43/45/85/31. vt's 500, ve's 13, rr 22. rsbi=49. no further changes noted.
"
3585,"7a-7a
neuro: pt extubated at 11am, alert and oriented, following all commands. perrla. mae. morphine ivp and percocet prn for pain w/ fair relief.

cv: hr 80-100s sr/st, hr 100s st at beginning of shift, lopressor 12.5mg po started and digoxin 0.25mg started po bringing hr 80-90s sr. frequent pacs noted around 11am, mg 2 gm iv given, no ectopy noted since 12pm. sbp labile, as high as 120-130 while intubated and w/ activity, nipride as high as 1.2mcg, md [**doctor first name **] aware, at present 0.2mcg w/ bp 100/50. see carevue for details. ci [**3-20**], see carevue for filling pressures. cvp 10s. 1 unit of prbcs, no adverse reactions noted. +palpable pulses.

resp: ls clear, diminished bases- coarse. inhalers restarted. pt extubated at 11am, acidotic prior to extubation 7.29, 1 unit of prbcs given and 1 amp of bicarb as [**name8 (md) 20**] md [**last name (titles) **]. repeat ph 7.32. post abg 7.32/44/113/-3/24/98%, md [**doctor first name **] aware, no new orders. instructed how to use cough pillow and is. using is as high as 500-750cc. oob to chair.

gi/gu: abd softly distended, obese. +bs, no bm. ogt dc'd w/ extubation. tolerating clears. u/o low at beginning of shift, md [**doctor first name **] aware, blood given, lasix 20mg ivp started. foley draining adequate amt of yellow clear urine.

endo: insulin gtt restarted, as high as 9units/hr, at present at 2units/hr. see carevue for details of gtt.

social: many family members into see pt throughout day. spouse updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. follow labs including blood glucose. wean nipride as pt tolerates.


"
3586,"nursing update
   temp dropped 100-96.1.  hr stable nsr, no ectopy or arrythmias.  co/ci stable 6.45/3.52 @ 0400. pap's and cvp stable.
   plts 20 @ [**2141**], heparin stopped @ 2230 and 10-pack platelets tx @ 2300.  rec'd cmvig 3.2g @ 2330 - no adverse reactions.  hct 24.7 @ 2400, ho notified, recheck @ 0300 25.3. no new orders @ this time. continues to bleed from nasal to oral cavity.
   not retaining ca+, ica repleted with ca gluc 4g x4.  glucose rx per s/s, tolerating post-pyloric tf's well, green bile only draining per ngt.   stooling large amount loose green bile colored stool.
   abg's stable, weaned off nitrous oxide.

"
3587,"resp: rec;d pt on cam @ 100%. pt desating to 80's change to hi-flow with f/t. (see careview for changes in fio2) nasal trumpet inserted in l nare. suctioned for moderate amounts of bloody secretions. nebs ordered alb/atr and adminisered q6 hrs with no adverse reactions. will continue to follow.
"
3588,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 18/+5/30%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions.  pt gets anxious at times resulting in ^ rr, then settles down.  no resp distress noted. rsbi=200, no further changes noted.
"
3589,"7a-7p
neuro: pt [**last name (lf) **], [**first name3 (lf) **], follows all commands. right pupil 5mm sluggish, left 3mm briskly reactive to light. daughter [**name (ni) **] called re: eye gtts. np [**doctor last name **] aware. [**name8 (md) **] md following pt, opthamology called today so pt can be re-evaluated per daughter's request to review eye gtts and assess right eye. pt medicated w/ 1mg morphine sc for incisional pain, w/ relief.

cv: hr 60-70s sr. no ectopy qt 0.43. amio gtt dc'd and po amio started via ogt. sbp 100-130s. see carevue for filling pressures. ci>2. pa dc'd w/o incident. + palpable pulses. received 1 unit of prbcs, no adverse reactions. repeat hct 32. k+ repleted prn.

resp: ls scattered rhonchi-> clear diminished bases. sats 98-100%. orally intubuted. weaned vent to [**3-21**] 40% fio2, 7.50/36/80/4/29/95%, np [**doctor last name **] aware. plan to extubate in am, resumed 5/10ps fio2 50% at present, see carevue for abgs and vent settings. suctioned for small to moderate amts thin yellowish white via ett.

gi/gu: abd softly distended. +ogt placement. dophoff in stomach (clamped) [**name8 (md) 20**] np [**doctor last name **]. foley draining clear yellow urine lasix frequency decreased from tid to [**hospital1 **].np [**doctor last name **] aware of alkalotic abgs.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. awaiting eye re-consult. plan to extubate tomorrow am.


"
3590,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  pt remains alert but ? level of orientation.  moving r arm, r leg ad lib; no movement l arm or l leg noted.  mouthing words around trach, occasionally speaking in single word sentances, nodding ""yes"" and ""no"" appropiately.

cv/pulm:  mp=nsr, no ectopy noted.  vss.  one unit platelets given without evidence of adverse reactions.  repeat plt count done.  remains on trach collar at 50% cont with sats mid to high 90's.  bs coarse, diminished bil.  expectorating lg amts thick white sec; did suction this am for blood tinged mucous plug.

gi/gu:  remains on tf fs probalance at goal of 60ml/hr via peg.  peg dsg d+i.  one lg formed soft bm this am.  u/o qs q1-2h via foley.  abd round, soft, bowel sounds positive.

id/endo/integ:  afebrile.  pipercillin dc'd as platelet count dropping. remains on contact precautions for +mrsa, +vre.  sliding insulin coverage for fingerstick glucose [**name8 (md) 20**] md orders.  buttocks raw, pink--barrier cream applied, duoderms reapplied prn.  l heel black area x2 unchanged.  multiple ecchymotic areas noted on arms (not new).

labs:  k repleted with 40meq via peg.  one unit platelets given; rpt plat count 96.

psychosocial/plan:  fam in to visit.  emotional support given to pt and family.  plan is to return to rehab in am.  family aware and agrees to plan.  cont to monitor loc, mp, vs, 02 sats, maintain o2, tf, monitor i+o.  administer meds as ordered/continue to follow medical/nursing regime.   cont to provide emotional support to pt and family.  replete labs as ordered.  repeat labs in am.
"
3591,"resp: pt rec'd on [**last name (un) 33**] simv 18/750/+10/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished sounds with noted aeration in apecies.  mdi's administered q4 hrs combivent with no adverse reactions. rsbi=49, am abg's 7.39/35/160/22.  vent changes to simv 10/750/+5/5/50%.  no further change noted.
"
3592,"resp: [**name (ni) 257**] pt on a/c 22/400/80%/10+. bs are clear with diminished bases. mdi's ordered and administered alb/atr with no adverse reactions. multiple abg's and vent changes (see carview) pt presently on psv 5/5/40%. plan to wean to extubate this am. am abg pending.
"
3593,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 32/450/12+/50%.  alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral clear apecies with diminished bases. suction for  scant amounts of white secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.31/45/126/24.  no further changes noted.
"
3594,"resp: pt is [** **] with #6 cuffless trach on 35% t/c. bs are coarse bilaterally with diminished bases. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. no distresss noted. will continue to follow.
"
3595,"social work note:

new trauma pt on t-sicu.  pt is a 23 year old man who is s/p fall/jump from 5 stories.  he has some head bleeds and an l2 burst fx.  pt was intubated this morning when this sw visited initially but has been extubated this afternoon.

[**name (ni) 25**] girlfriend, [**name (ni) 6199**] (misidentified as his sister initially) and pt's [**last name (lf) 344**], [**first name3 (lf) **] and les, are visiting this afternoon.  this sw met with pt and then his [**first name3 (lf) 344**], and then his girlfriend.  girlfriend's cell # is [**telephone/fax (1) 6200**] and work # is [**telephone/fax (1) 6201**].  she will likely return to work on thursday.

pt is a student at [**university/college 6202**].  he lives in [**hospital1 **] with his girlfriend, [**name (ni) 6199**].  [**name2 (ni) **] has one more semester of college.  family reports that only recent stressor is that their cat is quite ill and will likely be put down.

when this sw met with pt, he was alert and oriented to self and knew that he was in a hospital.  he was polite and engaged easily.  he was talking ""ragtime"" at various points and seemed concerned about getting in trouble legally.  he encouraged this sw to talk with his girlfriend for further information.  pt reports remembering being on a roof and that the people he was with were not strong enough to keep him from doing something that he wanted to do.  he referred to what happened as a ""dream"" and made reference to ""external reality"" and the involvement of his ""ego"" and the effect that had on his ""short term memory"".  pt denies wanting to hurt himself.  he feels comforted by his [**name2 (ni) 344**] and girlfriend's presence.

pt's [**name2 (ni) 344**] seem mutually supportive and expressed relief that pt is not more injured.  they report that they have been told that pt took some mushrooms last night and that his girlfriend has more information.  they said that one of pt's grandmothers had schizophrenia but that pt has no psychiatric hx himself.  he was evaluated during grade school and was found to have above-average intelligence and borderline add.  [**name2 (ni) **] said that pt does not use drugs and treats his body like ""a temple"".

[**name (ni) 25**] girlfriend reports that to her knowledge pt has never been suicidal and is generally quite ""happy"".  she said that pt tried mushrooms yesterday for the first time and had an ""adverse reaction"".  the friends that pt was with did not seek assistance for him (seemingly because they feared getting in trouble) and pt got away from them and got up to rooftop prior to fall/jump.  he left her a voicemail prior to fall/jump begging for help.  [**name (ni) 25**] girlfriend said that he does not otherwise use drugs.  the police have been involved and pt's [**name (ni) 344**] will be in contact with them.  [**name (ni) 25**] girlfriend does not think that there will be legal implication for pt from this incident following her conversation with police.

[**name (ni) **] and girlfriend given contact information for this sw for support as needed.  family given written information for themselves about emotional reactions to traumatic experiences.  pt is being evaluated by psychiatry and this sw met with them briefly to share above
"
3596,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] simv 20/300/10/10+/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amounts of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions. sensitivity decreased to 8, pt tolerated well. no further changes noted.
"
3597,"resp: [**name (ni) 257**] pt on 35% t/c with #6 cuffless trach. ambu/syringe @ hob. bs are coarse bilaterally which clear with suctioning. suctioned for small to moderate amounts of thick white secretions. mdi's atrovent  administered via trach with no adverse reactions. water bottle filled/trap emptied. will continue to follow.
"
3598,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 10/320/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats @ 100%.  rsbi performed without adequate results.  no further changes noted.
"
3599,"resp: rec'd pt on psv 10/5/40%. pt has #8 portex trach. inner cannula clean. bs are coarse bilaterally. suctioned for small amount of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions. no aline, or abg's 02 sats @ 99%. rsbi=78. plan to wean as tolerated and continue planning for d/c to rehab.
"
3600,"resp: [**name (ni) 257**] pt on psv 10/5/50%. ett #8.0, 25 @ lip. bs are coarse to clear. suctioned for x1 bloody thick secretions, subsided in am. no changes noc. vt 400's ve's [**8-27**]. mdi's administered alb/atr with no adverse reactions. rsbi=41. plan to wean to sbt this am with possible extubation.
"
3601,"respiratory care
pt remains trached (#7.0 portex) with cuff inflated (3.5-4cc's of air) and positional [** **]. pt remains on a fio2 of 0.40 via trach mask. lung sounds were course t/o. suctioned for mod thk white. mdi's given with no adverse reactions. 1 prn dose of albuterol was given. last abg showed chronic resp acidosis with metabolic alk. care plan is to continue current therapy and to have pt remain off vent as long as tol. continue with trach care and suction as needed. will continue to follow pt.
"
3602,"7pm-7am([**2154-5-4**])

on full code

[**age over 90 148**]y/o female got admitted on [**2154-4-23**] in micu from ccu with c/o fatigue weaknes,increased abd girth,pedal edema and was found down at home.has pmh of cad,copd,htn,mi remains intubated since the day of admission.


cvs;hr-78-100 nsr,no ectopy.nibp-122-101/41-50 cvp-[**6-7**]. pedal pulses by doppler.

access: rij is patent.

resp;on vent,cmv-30/400/14/5,ls are dim at right side and coarse at left side.spo2-95-97,no vent changes are done at this shift.requires frequent oral sxn and et sxn were done minimally  and obtained small amt of thick white sxn.


neuro;not on any sedation, remains sleepy throughout but follows verbal commands by making facial expressions,no limb movements are noted.
received ivig last evening beginning at 1830,no adverse reactions noted on completion of infusion.

gi;abd soft and mildly distened with positive bs,tf@ goal with very minimal residual.small amt semi-formed stool passed at this shift.

gu;u/o-20-40 and nil  at 22hr informed ho,advised not to give fluid bolus since pt remains on + balance.urine is concentrated with sediment.

skin;temp-98.5,noted echymosis on right hand,has abrations on b/l elbows,duoderm in situ.

social: family visited last evening and were updated by this rn.

plan:monitor resp status,watch spo2,frequent oral sxn,observe muscle strength.watch u/o.


"
3603,"resp: pt rec'd on psv 15/10/40%. ett #8, 25 @ lip. bs are coarse to clear and suctioning for small to moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt continues to have periods of apnea, then placed on a/c 12/600/10+40%. am abg 7.41/59/69/39. no rsbi=^peep.  plan to wean to psv as tolerated.
"
3604,"resp: [**name (ni) 257**] pt on psv 15/5/40%. pt has #8 portex trach. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administed q 4 hrs with no adverse reactions. vt's 300-400, ve's [**7-7**], with periods of low ve's. ps decreased to 10. rsbi=100. plan to continue with t/c trials. rehab planning continues.
"
3605,"resp:  [**name (ni) 257**] pt on psv 8/+10/40%. alarms on and functioning. ambu/syringe @ hob. ett 7.0, retaped and secured @ 20 lip. ett tube has been cut back.  bs are coarse bilaterally and suctioned for small amount of white thick secretions. mdi's administered atr q4 hrs with no adverse reactions. abg 7.34/55/105/31. vent changes to ^ peep to 10.  no rsbi due to ^ peep. will continue to moniter to wean as tolerated.
"
3606,"resp: [**name (ni) 257**] pt on pcv 30/pinsp 35/10+/40%/dp25. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. rr at times to 40, no changes this shift. am abg 7.40/29/89/19. will continue full [**name (ni) **] support.
"
3607,"resp: [**name (ni) 257**] pt on n/c @ 4lpm. bs auscultated reveal bilateral wheezing throughout lung fields. discussed continous tx with md and agreed. set up 3.0mg albuterol for 4 hrs continous neb. no adverse reactions and notable improvement. proceeded to administer alb/atr as ordered. pt feels better this am with no distress noted.  will continue to follow aggressively.

"
3608,"resp: [**name (ni) 257**] pt on psv 5/15+/40%. ett#7.5 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse with diminished bases. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb with no adverse reactions. abg's (see carview). pt rr in mid 30's with ^ wob noted. bicarb drip initiated. placed on pcv pinsp 35/10+/dp 25/r30/40% with abg 7.28/35/89/17. will continue present settings.
"
3609,"resp: [**name (ni) 257**] pt on psv 12/10/40%. ett #8, retaped, rotated and secured @ 22 lip. bs are coarse to clear. suctioned for moderate amounts of thick white/yellow thick secretions. mdi's alb/atr administered with no adverse reactions. ps weaned to 7 due to periods of apnea, abg 7.29/77/94/39. ps ^ to 12. additional abg pending. will continue to wean as tolerated.
"
3610,"resp: pt rec'd on a/c 16/350/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions, although it does initiate a cough reflex. abg 7.47/32/87/24, rsbi >200. will continue full vent support.
"
3611,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminished l base.  suctioned moderate amounts of thick white secretions. re-taped and secured ett @22 lip. mdi's administered q4 alb/atr with no adverse reactions. pt placed on a/c 12/600/+5/50% noc to rest,then placed back on psv setting this am.  no abg's. rsbi=47
"
3612,"resp: pt rec'd on psv 10/8/50%. bs are coarse bilaterally. suctioned for small-moderate thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg's 7.41/50/95/33, removed vd with abg pending. will continue to wean appropriately.
"
3613,"resp: pt rec'd on mmv 10/500/15/+5/40%. bs are clear with diminished bases. vt's 800-900, ve [**9-12**], rr 14, 02 sats @ 99%. suctioned for small amounts of thick yellow secretions. mdi's administered q4 alb with no adverse reactions. rsbi=60. will continue t/c trials.
"
3614,"resp: [**name (ni) 257**] pt on mmv 10/500/15/+5/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. vt's 700-900, ve 8-13l, rr 12-18.  rsbi=42. plan to continue with t/c trials as tolerated.
"
3615,"resp: [**name (ni) 257**] pt on psv 12/+5/40% (mmv) bs auscultated reveal bilateral clear sounds with slight coarse bases. suctioned for moderate amounts of white thick secretions. mdi's administered q4 hrs alb with no adverse reactions. no a-line. 02 sats @ 99%. vt's 400-500, ve's [**10-11**], rr 12-18. rsbi=21. plan to wean on t/c trials as tolerated.
"
3616,"resp: [**name (ni) 158**] pt on a/c 26/600/10+/40%. ett #8, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease tv to 550 and rate to 22. abg 7.46/34/79/25 with no further changes noted. will continue full vent support.
"
3617,"resp: [**name (ni) 158**] pt on a/c 32/500/12+/50%. ett #8, taped @ 22 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse and suctioned small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt is on rotating bed and pip's fluctuate with rs ^ tend to higher. no abg's or changes noc. will continue full vent support.
"
3618,"resp: [**name (ni) 158**] pt a/c 32/500/+10/40%. ett#8, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with occasional exp. wheeze. suctioned for copious amounts of thick tan secretions as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg' (see carview) and multiple vent changes. present settings a/c 22/600/10+/40%. no rsbi=^ peep. possible bronch today? will continue full vent support.
"
3619,"resp: pt rec'd on psv 15/+5/50%. bs auscultated reveal bilateral aeration. suctioned for moderate amounts of white thin secretions. pt has frequent episodes of coughing spells.  no mdi's administered due to adverse reactions of bronchospasms. no abg's a-line not working. pt schedule for or this am for trach insertion.  vt's 500, ve7-8l, o2 sats @ 99%.
"
3620,"s/p cabg
pt is a 71 year old male arrived from or s/p cabgx2. arrived on propofol, ntg, epi at 0.02mcg/kg/min. see carevue for details. continues to be cold. 1 unit of blood given, no adverse reactions noted. plan assess neuro status, monitor for bleeding, wean to extubate.
"
3621,"resp: pt rec'd on [**last name (un) 647**] psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds and suctioned for small amounts of tan/yellowish thick secretions. mdi's administered q4 [**last name (un) 741**] with adverse reactions. pt bronchospasms and complains of chest pain, rn aware as well as md. [**first name (titles) 742**] [**last name (titles) 741**], suggest try flovent to help with inflammation.  will continue full vent support. possible trip to ctscan today. no abg's. vt 500's ve 9-13l, rr 20, o2 sats 96-98%
"
3622,"resp: [**name (ni) 257**] pt on simv 20/600/10+/50%.  ett #7.5, 24 @ lip. bs are slightly coarse with diminished bases. suctioned for moderate to small amounts of bloody tinged secretions.  mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. vent changes to decrease peep to 5, am abg 7.40/40/125/26. rsbi greater than 200. plan to wean to psv as tolerated.
"
3623,"resp:  [**name (ni) **] pt on [**name (ni) **] pcv 35/peep +12/ 80% r 42 i/e 1:1. alarms on and functioning. ambu/syringe @ hob.  auscultated bs reveal bilateral clear apecies with diminished bases.  mdi's administered q4 hrs alb with no adverse reactions.  suctioned x4 copious amounts of bloody secretions/clots from oral cavity.  vent changes to accomodate improvement in abg's with ^ peep resulting in decrease in bp.  fi02 ^ 90%, driving pressure @35.  no further changes noted
"
3624,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 20/550/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies.  mdi's administered q4 alb with no adverse reactions. vent changes reflect am abg's (see careview). rsbi=67. plan to wean to extubate this am.
"
3625,"resp:  [**name (ni) **] pt on [**name (ni) **] pcv 35/rr 34/ 20+ itime .6 i:e 1:1.9 /90%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal ls clear apecies with diminished bases. rs coarse sounds.  suctioned x3 moderate amounts of thick bloody secretions/clots from oral cavity with improvement noted.  mdi's administered q4h alb with no adverse reactions. ett moved to ls taped and secured.  pt remains on present vents settings.  no changes.
"
3626,"resp: pt rec'd on psv 10/8/50%. bs auscultated reveal bilateral clear with diminished bases.ett 7.5, 22 @ lip. mdi's administered q 4 hrs combivent with no adverse reactions. suctioned for small amounts of thick yellow secretions. no vent changes noc. rsbi=46. plan to wean to extubate this am.
"
3627,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] pcv 31/+12/80%/r 42 i/e 1:1 ambu/syringe @ hob.  alarms on and functioning.  bs auscultated reveal bilateral clean apecies with some fine scattered crackles.  suctioned x2 small to moderate amount of thick bloody tinged secretions.  mdi's administered q4hr with no adverse reactions.  vent changes as follows: peep^ 15, bp dropped, decreased peep to 12 where it remains.  abg's still acidoic with poor pao2.  no further changes noted. no rsbi performed pt is paralized.
"
3628,"resp: pt trached #8 portex rec'd on [**last name (un) 33**] a/c 20/400/10+/40%, bs are clear bilaterally. suctioned for small amount of tan secretions. mdi's administered q4 combivent, no adverse reactions. vent changes to decrease peep to 8, then 5 with 02 sats @ 98% and tolerating well. rsbi=61. plan to wean to psv this am.
"
3629,"3p-7p
see carevue for vital signs and for full assessment. received 2 units of prbcs, no adverse reactions. temp 94-95.9 orally, np [**doctor last name **] aware. right groin [**doctor last name 2169**] culture sent. dophoff placed by np [**doctor last name **], awaiting cxr. see carevue for vent changes and abgs, np [**doctor last name **] aware of abgs, pco2 28-30, bicarb 19. plan: to go to ct tonight at 8pm. if needed, restarted neo gtt.
"
3630,"resp care
pt extubated tonight, present air leak. no adverse reactions. pt currently on nc 3lpm and sating 99. will continue to follow.
"
3631,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions.  mdi's administered q4 hrs alb with no adverse reactions.  02 sats remain in ^ 90's (96-99%).  attempted to lower the peep to 16, although pt did not tolerate.  increased rr to 35.  returned peep to 18 where it remains.  no further changes noted.
"
3632,"7a-7p
neuro: pt [** **] and oriented x2, knows pt is at [**hospital1 **] and knows self. [**hospital1 **]. follows commands. mae,weakly. denies pain when asked.

cv: hr 90s-100s. sr rare pvcs. sbp >100. map>60. +[**hospital1 **] pedal pulses.

resp: ls coarse. sats >93% on 5lnc. nebs x2. productive cough, not bringing up sputum. talc to ct by thoracic resident.

gi/gu: abd obese, hypoactive bs. dophoff placed, cxr done + in stomach [**name8 (md) 20**] md [**last name (titles) **]. tf started at 1600 as ordered, continue tpn [**name8 (md) 20**] md [**last name (titles) **]. foley draining greenish yellow urine (intensivist aware on rounds)- from dye. draining adequate amts.

endo: per own's scale.

id: afebrile. antibiotics changed- meropenem started, no adverse reactions noted. bc sent from central line, need peripheral.

plan: monitor hemodynamics. monitor resp. status. skin care.




"
3633,"condition update
d: please see carevue flowsheet for specifics
 pt running [**name (ni) 10073**] temps all day with tmax 100.4. hr 60-80 in nsr with occassional pac's noted this afternoon. nmed goal is to maintain sbp 100-150 this am pt required neo which was weaned to off for a couple of hours and then pt required labetolol gtt to be started. all solutions are mixed in ns per request of nsurg. mannitol was restarted with no adverse reactions after dosing, and glycerin po was d/c'd.
 pt's neuro status has waxed and waned throughout the day. at most alert moments will open eyes on command-at other times won't even open to sternal rub. perrla but does not track/attend. pt consistently has purposeful movement and normal strength in left extremeties. rue has no movement to withdraws slightly and moves on bed to pain.
 no vent changes made today. pt remains on simv 600x16 with 5peep and 5ips and 50%. thick tan to blood frothy secretions-sputum spec sent for culture. patient is not breathing over the vent rr 16 except when stimulated.
 wife in and spoke to dr. [**last name (stitle) 10074**] who had been updated by nmed and nsurg service. wife's nephew was present during visit and due to wife's expressive aphasia it was agreed with wife and nephew that he would be the contact person-phone # in chart. social worker also met with wife/nephew.
plan:
 neuro checks
 sbp 110-150
 dose mannitol according to serum osmolality
 notify h.o. with any change
"
3634,"7a-7p
neuro: pt alert and orientedx3. mae equally. perrla. intermittent twitching of left arm noted, pa [**doctor last name 372**] aware, no new orders. right eye droopy pt states ""has been like that for years"". perrla,smile symmetrical, mae equally.  morphine and percocets po for incisional pain, percocets po work better per pt. pt states is anxious at times,team aware.

cv: hr 70-110s. 110s at start of shift, lopressor started, received total of 10mgx2 ivp during shift. lopressor 50mg po started. sbp 110-140s. goal sbp<140 per pa [**doctor last name 372**]. ntg as high as 3mcg, pa [**doctor last name **] aware, captopril and hydralazine started, see med orders, captopril increased during day as per pa [**doctor last name 372**]. pt received 1 unit of prbcs no adverse reactions, repeat hct 27.2, pa [**name6 (md) 372**] and md [**doctor last name **] aware, no new orders. ci>2. svo2 57 when received pt pa [**name (ni) 372**] aware, recal'd, svo2 improved >60, see carevue. pa dc'd w/o incident. cordis flushes well though unable to draw blood from, pa [**doctor last name 372**] aware, ok to use per pa [**doctor last name 372**]. plavix started today 300mg loading dose today as ordered. epicardial wires intact, a side sense appropriately, do not capture appropriately. on vdemand 50, v wires sense and capture appropriately. lytes repleted prn. dopplerable pedal pulses.

resp: ls clear diminished bases. sats decreased on 6lnc to 91-93%, pa [**doctor last name 372**] aware, inhalers ordered. face tent and nc applied, see carevue for settings and sats. present sat 95% on face tent 50%, 4lnc. pt using is appropriately, 750cc. encouraged coughing and deep breathing. ct no air leak, draining 10-40cc/hr serosang drainage.

gi/gu: abd soft hypoactive bs. no bm. tolerating sips of clears. foley draining clear yellow urine, lasix 20mg ivp given this am, w/ minimal (1st hour only 140cc after lasix then tapered to 30cc/hr) results, pa [**doctor last name 372**] aware, additional lasix 40mg ivp given at approx. 1400 as ordered w/ improved results. see carevue for i+o's.

endo: insulin gtt as per protocol. fs 100-170s.

plan: monitor hemodynamcis. monitor resp. status. pulmonary hygeine. follow labs and treat as appropriate. wean ntg to keep sbp<140. pain control. increase diet and activity as pt tolerates.
"
3635,"resp: pt remains intubated on psv 10/+5/40% with no changes this shift. bs are coarse to clear. suctioned small amounts of tan/yellow thick secretions/moderate amounts of oral secretions. some seizure activity noted without incident. mdi's administered alb/[**last name (un) **] with no adverse reactions. abg 7.41/38/188/25. vt's 300-400, rr 20-24, ve7-8l. rsbi=93.
"
3636,"resp: [**name (ni) 257**] pt on psv 5/5/40%. ett 7.5 retaped, rotated and secured @ 25 lip. abg 7.46/45/126/33. placed back on a/c 12/500/5/40% to rest noc. bs are coarse bilaterally and suctioning frequently for copious yellow thick secretions. mdi's administered q4 atr with no adverse reactions. rsbi=68. plan to wean to psv in am.
"
3637,"resp: pt rec'd on a/c 12/500/+5/40%. bs are coarse bilaterally and suctioned frequently for copious thick yellow to tan secretions. mdi""s administered atr with no adverse reactions. rsbi =62. plan to wean to psv as tolerated. talk of possible trach? will continue to follow.
"
3638,"resp: pt rec'd on a/c 12/500/5+/40%. ett 7.5, 25 @ lip. bs are coarse bilaterally and suctioned for copious amounts of thick white secretions. mdi's administered atr as ordered with no adverse reactions. ps trials to continue as tolerated today. see careview for rsbi. no abgs this shift.
"
3639,"resp: rec'd on 50% t/c. bs are coarse bilaterally. suctioned for small amounts of [** **] yellow secretions. mdi's administered alb/atr via trach with spacer with no adverse reactions. pt remains on t/c. vent pulled.
"
3640,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 18/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs ascultated reveal bilateral coarse sound which improve with suctioning.  suctioned x3 small to moderate thick yellow secretions.  mdi's admininstered q4 hr alb with adverse reactions.  pt vomited early this morning.  02 sats remain in ^90's @ 96%.  rsbi=130. no further changes noted
"
3641,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 12/600/40%/+[**6-16**].  alarms on and functioning. ambu/syringe @ hob.  cuff pressure @ 21 cmh20. bs auscultated reveal bilateral diminished sounds.  092 sats @ 99%.  mdi's administered q4 hrs alb with no adverse reactions.  no rsbi performed, pt had no spontaneous breathing rate.  rsbi to be performed on day shift as rn to lighten up on sedation.  no further changes noted.
"
3642,"resp: [**name (ni) 158**] pt on pcv 38/r27/50%/0+. pt has #8 shiley trach with audible leak. bs are coarse bilaterally. suctioned for small amount of tan thick secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions. am abg 7.26/74/127/35. pt following commands this shift. remains on cvvhd. no rsbi, pt is vent dependent. no changes noted this shift. will continue with present therapy.
"
3643,"resp: pt rec'd on simv 10/500/+5/40%. bs are clear bilaterally. suctioned for small amounts of bloody tinged secretions due to new trach. mdi's administered q4 combivent with no adverse reactions. abg 7.49/44/171/34. vent changes to psv 18/5/40% with abg pending. rsbi=85. will continue to wean appropriately.
"
3644,"resp: [**name (ni) 158**] pt on a/c 22/340/60%/0+. pt has #8 shiley. audible leak noted. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white/tannish secretions. mdi's administered alb/atr as ordered with no adverse reactions. abg's (see careview) ph consistant 7.1. bicarb drip initiated for ^ in bicarb to 30's. pt placed on pcv (see careview for settings) no change. am abg pending. will continue with present mode of ventilation.
"
3645,"resp: pt rec'd on pcv 44/32/+0/55%. pt has #8 shiley trach with audible consistant leak. vt's 300-400. bs are coarse  to diminished at bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no [** 353**] due to vent dependency. no changes or abg noc. will continue with present settings.
"
3646,"resp: pt rec'd on pcv 38/27/50%. pt has #8 trach. bs are coarse bilaterally. suctioned for small rusty secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg's 7.27/72/120/35. no changes noc. pt is vent dependent so no rsbi.
"
3647,"7p-7a
neuro: pt sedated on propofol as high as 50mcg/kg/min. increased propofol secondary to pt awoken during am care, nodding appropriately, mae. perrla. fentanyl 50-100mcg iv as needed for pain control.

cv: hr 90s-110s vvi permanemt pacer. epicardial wires attached and in place. noted occasional pvcs. repleted electrolytes as needed. sbp 90-110s. nitro gtt off. milrinone gtt at 0.5mcg/kg/min as ordered. epinepherine gtt infusing at 0.02mcg/kg/min as ordered. ci >2. md [**doctor last name 840**] aware of hr and hct 26.5, 1 unit of prbcs ordered and given. no adverse reactions noted. cvp 7-11. received 500cc ns fluid bolus for cvp 7 and sbp 90s w/ maps 55-60 as [**name8 (md) 52**] md [**last name (titles) 840**], see carevue for details. pap 40s/20s. doppler pedal pulses. hands and feet cool to touch. pt w/ hx of raynauds.

resp: pt orally intubated. simv rate decreased to 8, and fio2 decreased to 40% secondary to po2 170s, and pco2 low 30s. see carevue for details. ls clear but diminished at the bases. sats 99-100%. suctioned for small amt of thick white.ct intact draining serosang drainage.

gi/gu: abd soft, absent bs. ogt +placement. foley draining clear yellow 45-100/hr. see carevue for details.

endo: on insulin gtt as high as 9units/hr, fs checked per protocol and insulin gtt maintained as per protocol.

plan: monitor hemodynamics. monitor respiratory status. monitor blood sugars.
"
3648,"resp: rec'd on pcv pinsp 44/32/0+/55%. pt has #8 shiley traach. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. audible trach leak noted. vt's 200's ve-[**8-9**]. 02 sats @ 98%. plan to have family meeting today to discuss cmo status. will continue with present settings.
"
3649,"resp: [**name (ni) 158**] pt on pcv pinsp 44/32/+0/55%. pt has #8 shiley trach with notable audible leak. bs are coarse bilaterally. suctioned for scant to small amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no changes noc. no abgs. plan to continue with present settings.
"
3650,"resp: pt presently on 4 lpm n/c. bs reveal bilateral wheezing, mostly due to fluid.  hhn given alb/atr x2  ud with no adverse reactions. no other changes noted.
"
3651,"resp: pt remains intubated on simv 14/500/+5/40%. bs reveal bilateral diminished sounds. suctioned for small-moderate amounts of secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.50/51/123/41. no changes noc. plan to trach/peg. will continue full vent support.
"
3652,"resp: pt rec'd on a/c 20/500/+8/50%. ett 7.5, 26 lip.bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. abg with pa02 75, ^ fio2 to 60%. am abg 7.47/36/153/27. no changes noc. will continue full vent support.
"
3653,"resp: pt rec'd on pcv pinsp 44/r32/+5/60%.  pt has #8 shiley trach with persistant positional leak. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tannish secretions. mdi's administered as ordered alb/atr with no adverse reactions. abgs with decrease in pao2, fio2 ^ to 70%. am abg 7.13/146/87/13. family meeting expected tomrrow. will continue present settings.
"
3654,"resp: pt rec'd on psv 16/5/40% (mmv 500/10) bs auscultated reveal bilateral clear sounds. suctioned for small amount of tan secretions. mdi' administered q4 combivent with no adverse reactions. rsbi=85. am abg' 7.44/50/81/35. ps decreased to 10. vt's 400's. will continue to wean appropriately.
"
3655,"resp: pt is  [** **] and vent dependent (see careview for settings) no changes this shift or abg's. bs are coarse which improve following suctioning. suctioned for small to moderate amounts of yellow to tannish thick secretions. mdi's administered as ordered with no adverse reactions. pt is able to suction oral cavity and prefers too. no rsbi due to vent dependency. 02 sats @ 100. will continue full vent support.
"
3656,"resp: [**name (ni) 158**] pt on pcv pinsp 44/5+/rr 32/60%. pt has #8 shiley trach. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg 7.17/156/69/60. no changes noc. will continue with present settings.
"
3657,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 14/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration. mdi's administered q4 hrs atrovent with no adverse reactions.  pt complains she can't take it anymore.  rsbi=92 am abg'd 7.37/53/100/32.  continue to wean to extubate.  no further changes noted.
"
3658,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bialteral wheezes with some fine scattered crackles. mdi's administered q4 hrs alb with no adverse reactions. suctioned for small amounts of thick yellowish secretions. pt's rr^ to 30, ^ ps to 10.  no further changes noted.
"
3659,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/+5/35%.  alarms on and functioning. bs ascultated reveal bialteral coarse sounds. suctioned for copious amounts fo bloody secretions as well as plugs. trach site [**name6 (md) **] [**name8 (md) 1290**], rn aware. trach care performed, changed dressings and tie. mdi's administered q4hrs with no adverse reactions.  rsbi=54.  no further changes noted.
"
3660,"pt given bronchodilators as ordered with no apparent adverse reactions, midnight tx withheld at rn request.
"
3661,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 7/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned moderate amounts of bloody tinged secretions.  mdi's administered q4 hrs alb with no adverse reactions.  am abg's 7.43/45/106/31. rsbi=174. continue to wean sedation. no further changes noted.
"
3662,"resp:  [**name (ni) 257**] pt on t/c then placed on [**last name (un) 33**] psv 10/5/40% to rest [**last name (un) **].  suctioned for moderate amounts of thick yellow secretions.  mdi's administered alb/atr with no adverse reactions.  pt placed back on t/c this am @ 6:00 am to proceed to wean.
"
3663,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] psv 12/5/60%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral notable wheeze, related to fluid issues.  mdi's administered q4hr os combivent with no adverse reactions. 02 sats @ 97%. rsbi=30, although rr^ to ^ 30's so no [**last name (un) 607**] initiated.  fi02 decreased to 50%.  no further changes noted.
"
3664,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+5/50%.  alarms on and functioning.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral crackles with slight exp. wheeze noted.  suctioned x 3 moderate to copious amounts of thick bloody tinged secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=40, although no [**last name (un) 607**] initiated since ^ rr to 40's.  02 sats remain in ^ 90's @ 97%.  no further changes noted.
"
3665,"resp: [**name (ni) 257**] pt on [**name (ni) **] ph28/pl14/th4.5/tl0.5/60%. ett #7.5, 23 lip.  bs have noted aeration with slight exp wheeze on rs. suctioned for copious amounts of thick bloody secretions, then tapered off towards end of shift. mdi's administered alb/atr q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions.  am [**hospital1 **] pending. pt sats fluctuating between 92-97%.

"
3666,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] psv 10/+5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for moderate amount of thick tan secretions. mdi's administered q4 hrs combivent with no adverse reactions.  cuff pressures @ 38, rsbi=80, rr ^ to 40's no [**last name (un) 607**] initiated.  no further changes noted.
"
3667,"micu nsg admission note
ms. [**known lastname 11491**] is a [**age over 90 **]yo [**hospital3 327**] resident who has been in her usual state of health until past few days when she states she has been ""falling alot"" at home.  multiple old bruises noted on torso, upper arms.  last evening pta she had 2 episoded of brb pr, came to [**hospital1 2**] er.  pmh significant for cad, cva with minimal residual effects, depression, asthma, gerd, diverticulosis by c-scope, paf, pvd, hemorrhoids, h/o falls, s/p appy, glaucoma and htn.  allerg->pcn (rash) and asa (rectal bleeding).  in er pt treated with fluids and prbc.  baseline hct=37; hct in er 29 range prior to prbc.  pt s/b surgery and gi in er.  tagged rbc scan done; results pending.  pt does have a daughter [**name (ni) 3095**] [**name (ni) 11492**] ([**telephone/fax (1) 11493**]) who is involved in her care, lives locally ([**location (un) 3163**]) and pt had a son who was a cardiologist but expired at age 38 due to mi.

current status:

see carevue for subjective/objective data.  pt arrived to icu via stretcher at 0330.  prbc #2 infusing upon arrival.  neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  vss.  mp=nsr, no vea noted.  bp 120's-130's/50's.  periph iv's x2.  prbc second unit hung in er infusing.  room air with coarse breath sounds bil.  no sob or doe noted.

gi/gu:  npo.  abd soft, tender but not tense.  no bm since arrival to icu.  three way foley placed with one attempt; irrigant port clamped.

id:  afebrile.  no abx at this time.

iv:  prbc completed with no adverse reactions noted.  ns 500ml bolus infusing to be followed by d5and [**12-10**] at 75ml/hr.  will rpt hct btw 0530-0600.

psychosocial:  pt sleeping once settled in room.  no visitors with pt.

plan:  monitor vs, hct, ? scope in am.
"
3668,"resp: pt rec'd on 4 lpm nc. ^ wob with sob. abg 7.32/78/92/42. re-intubated #8 ett, taped @21 lip as per previous intubation. cp @ 20 cmh20. vent settings; a/c 12/450/10+/40%.  bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.34/65/124/37. no a-line. no rsbi due to ^ peep. will continue full vent support
"
3669,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] simv12/600/5/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of bloody tinged thick secretions and some white.  mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=80.  placed pt on psv 15/5/50% and tolerating well, plan to continue to wean today with possible t/c trial. no further changes noted.
"
3670,"resp: [**name (ni) 257**] pt on psv 10/5/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi' administered q4 alb with no adverse reactions. am abg 7.43/41/137/28. rsbi=37. no further changes noted.
"
3671,"resp: [**name (ni) 158**] pt on psv 12/5/50%.positional trach [**name (ni) 156**]. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with diminished bases. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered with no adverse reactions. rsbi=82. plan to continue trach trials as tolerated.
"
3672,"resp: [**name (ni) 257**] pt on psv 10/10/40%. ett #8, 21 @ lip. bs are clear but diminished. suctioned for small amount of thick yellow secretions. mdi's administered q3-4 hrs alb/atr with no adverse reactions. am abg 7.37/60/110/36. no vent changes noc. rsbi=42. plan to wean to extubate this am.
"
3673,"resp: [**name (ni) 158**] pt on psv 12/5/50%. pt has #8 portex perc trach. inner cannula changed and was clear.alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick tannish secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=92. attempted abg, pt not cooperative.
"
3674,"resp: [**name (ni) 158**] pt on a/c 14/60/+5/50%. alarms on and functioning. ambu/syringe @ hob. suctioned for small-moderate amounts of tan thick secretions. mid's administered as ordered with no adverse reactions. pt has noted cuff [**name (ni) 156**]. rsbi=100. no changes or abg's this shift.
"
3675,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 14/500/35%.+5. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. abg's (see careview) fio2 ^ to 50% with abg pending. pt cardioverted tonight and stable. will continue full vent support.
"
3676,"resp: [**name (ni) 257**] pt on a/c 12/350/+5/30%. ett #7.5, 20@ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions as well as oral cavity. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg7.46/37/1741/27. rsbi=68. weaned pt to psv 12/8 for tv's 300-400, ve [**4-19**], rr 16. plan to continue to wean to possible extubation.
"
3677,"resp: [**name (ni) 257**] pt on a/c 10/350/+5/30%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick bloody secretions probably due to endo procedure yesterday.  mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.48/38/113/30. rsbi attempted but pt on sedation, results >200. no further changes noted.
"
3678,"resp: [**name (ni) 257**] pt on [**last name (un) 33**] a/c 24/550/+10/60%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20, ett # 7.5 retaped, secured and advanced 23 @ lip (found @ 21). bs auscultated reveal bilateral aeration with diminshed bases. suctioned x1 for none. mdi-s administered combivent q4 hrs/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see carview) am abg's 7.40/51/68/33. 02 sats @ 92%. pt remians on paralytic noc, but plan to d/c today. no vent changes. plan to continue full vent support.
"
3679,"resp: [**name (ni) 257**] pt on psv 12/12/40%. ett #7.5, retaped, rotated and secured @ 23 lip. bs are coarse to clear. suctioned for moderate amounts of thick white/yellow secretions. [**name (ni) **]'d administered alb/atr with no adverse reactions. am abg 7.36/74/115/44. rsbi=155. team to discuss possible extubation even though failed rsbi.
"
3680,"npn shift 1900-0700:

pt status quo. pt remains confused, agitated, restless, attempting to self-d/c medical deviced. restraints remain on for safety. neuro otherwise stable. pt conversant, able to verbalize needs though inappropate words at times due to confusion. ativan 2mg iv, ok's by ho, with temorary effect, approx 2 hrs. no adverse reactions. haldol 5mg iv given w/ less effect. fenatnyl patch changed. c/o discomfort. morphine 4mg iv given with good effect. weaned o2 to ra, tol well. coughing productively on command. st 120-140's w/ agitation. when calm, hr spontaneously decreases to 80-90's. no [** **] episodes. sbp 130-150's. autodiuresing, output > 2l. started on ns maintenance ivf at 100cc/hr. am hct 23.1, down from 26.7. some may be dilutional. awaiting prbc x1u. rectal bag off, 300cc [**location (un) 138**] stool. applied new rectal bag. afebrile, tmax 100.4 orally.
"
3681,"resp: [**name (ni) 257**] pt on 70% t/c. emergency equipment @ hob. pt has portex #9 trach. pt ^ wob, placed back on psv 10/8/40% to rest noc. bs are coarse bilaterally. suctioning tan thick secretions. mdi's administered atrovent with no adverse reactions. trach care performed/inner cannula replaced and site cleaned. am abg 7.44/39/96/27. rsbi=71. plan to continue with t/c trials in am.
"
3682,"resp: pt rec'd on psv 8/8/40%. et 7.5, 23 @ lip. bs are coarse to clear and suctioned for moderate amounts of thick white frothy secretions. [** **]'s administered alb/atr with no adverse reactions.vt's 300, ve's [**7-27**]. 02 sats @ 100%. no abg's this shift or changes. rsbi=120. plan to continue to wean as tolerated.
"
3683,"progress notes
neuro= received lethargic, easily arousable, folows commands, confused at times, oriented x2, moves all extremities spontaneously but weakly, complains of right hip/leg pain, h/o right hip replacement, medicated with ultram/mso4 with good result, assisted in turning.

cv= s1 s2 regular with rare apc's, palpable peripheral pulses x4, normal capillary refill to nailbeds, denies chest pains or palpitations, hr 96-118, nbp 120-134/40-76.  on lopressor dosage increased from 1.5 mg to 2.5 mg q6hrs iv.

pulm=received on nc 4lpm, clear bilat breath sounds diminished on the bases, she's an mouth breather and her sat's dropped to 80's when she's asleep, placed her on face tent at 40% with spo2 readings 92-97%. had occassional expiratory wheezes relieved after coughing. unproductiove cough. encouraged deep breathing and coughing, she's complaint.

gi= soft, slightly tender to deep palpation, normoactive bs x4, no bm, passed out foul smelling flatus x1, attempted to used bedpan x2 but no bm, on clear liquid diet, given ice chips and po cold water for now, nauseous x1, no vomiting so far.  no melena.

gu= foley cath draining dark clear yellow urine u/o= 30-45cc/hr.

skin=dry and intact, no bedsores, turned and position q2 and prn, skin and back care done.

iv= right arm hl intact. no signs of infiltration/infection noted.
     left hand pvl intact, infusing ivf + 60 meq kcl at 100cc/hr. site intact/ no redness/infiltration noted.

labs= last hematocrit at 8:30pm is 29, transfused another 1 unit prbc, no adverse reactions noted post-bt.  will check cbc later this am.
serum k+ at 8:30pm= 4.1.

code status= dnr/dni.

plan= continue with current therapy, pain management, monitor h/h and transfuse as indicated, monitor lytes and replete prn.
"
3684,"resp: pt rec'd on a/c 15/550/+8+50%. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. sucitoned frequently for moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. no changes this shift. rsbi=58. will continue full [** **] support.
"
3685,"resp: [**name (ni) 158**] pt on a/c 22/600/+5/50%. ett #8, 23 lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amount of bloody tinged secretions. mdi's administered q4 alb with no adverse reactions. pt is being r/o for tb. am abg pending. will continue will full vent support.
"
3686,"resp: [**name (ni) 158**] pt on a/c 15/550/+8/70%. ett #7.5, 24 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick tan secretions. mdi's alb/atr administered with no adverse reactions. [**name (ni) **] changes to decrease fio2 to 60%. abg 7.37/41/100/25. no further changes noted. will continue full [**name (ni) **] support.
"
3687,"resp: rec'd on psv 14/+5/40%. ett 7.5 taped @ 23 lip. bs are clear with diminished bases. suctioned for small amount of white secretions. mdi's administered atr as ordered with no adverse reactions. vt's 500's/ve's 11/rr 23. rsbi=90. am abg 7.40/34/147/22. plan to wean as tolerated. no changes this shift.
"
3688,"resp: [**name (ni) 158**] pt on a/c 30/400/18/50%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, retaped, and secured @ 25 lip. bs auscultated reveal bilateral clear apecies with diminished bases. suctioned for small amounts of white secretions. mdi's administered as ordered with no adverse reactions. abg's (see careview) vent changes to decrease peep to 16, rate to 28 with am abg pending. will continue to wean as appropriate.
"
3689,"resp: [**name (ni) 158**] pt on a/c 14/600/10+/50%. retaped tube ett 8.0 @ 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no aline/abg's noc. no changes or rsbi due to ^ peep. will continue full vent support.
"
3690,"resp: pt remains vented on psv 5/5/50%. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered q 4h alb with no adverse reactions. rsbi=68. am abg's pending. o2 sats @ 100%. plan to wean to t/c as tolerated.
"
3691,"resp: [**name (ni) 158**] pt on a/c 30/400/+20/60%. ett retaped by rn, then found at end of shift @ 23 lip, retaped, advance and secured @ 25 lip. bs are clear bilaterally, with diminished bases. suctioned for small to moderate amounts of bloody tinged to rusty plugs. abg 7.39/41/78/26.mdis administed as ordered alb/atr with no adverse reactions. pt had episodes of desaturation to 80's then ^ fio2 to 70%. no further changes noted. esophageal balloon in place. will continue to wean fio2 as tolerated.
"
3692,"resp: pt rec'd on psv 10/5/40%. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.46/29/103/21. rsbi=74. plan to possible trach today. will continue to wean appropriately.
"
3693,"resp: [**name (ni) 158**] pt on 40% t/c with humidification. 02 sats @ 99%. bs are coarse bilaterally and pt is able to expectorate secretions. mdi""s administered q4 hrs alb/atr with no adverse reactions. pt has #8 shiley trach with cuff deflated. no abg's or distress this shift. pt scheduled for pmv [**name (ni) **]. will continue to follow.
"
3694,"resp:  [**name (ni) 158**] pt on 7200 psv 5/+5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 for small amount of whitish secretions.  mdi's adminintered q4hrs with no adverse reactions.  rsbi performed this morning resulting @ 71.4 and sbt initiated.  02 sats remain in ^ 90's and rr @ 24.  no further changes noted.  possible extubation today, awaiting sons arrival at hospital.

"
3695,"resp: [**name (ni) 158**] pt on simv 10/600/12/+12/50%. ett#7.5, 25 lip.  bs reveal bilateral crackles. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs of atrovent with no adverse reactions. abg drawn; results 7.34/49/179/28. vent changes to decrease rr to 8, fio2 to 40%. no further changes noted.
"
3696,"resp:  [**name (ni) 158**] pt on a/c 14/550/+8/50%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan with green plugs. mdi's administered as ordered with no adverse reactions. no changes or abg's this shift. 02 sats @ 100%.
"
3697,"[**name (ni) 158**] pt on [**last name (un) 647**] psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration noted in apecies with diminished bases.  mdi's administered q4 hrs combivent with no adverse reactions.  abg's drawn with worsening acidosis, placed on simv 22/600/+5/5/50%.  am abg's 7.37/31/178/19 with no further changes noted.
"
3698,"resp: [**name (ni) 158**] pt on psv 10/10/40%. ett 8.0 retaped, rotated and secured @ 23 lip.  alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally.  suctioned for large amounts of thick bloody secretions/clots. heated wire circuit changed. mdi's administered alb/atr as ordered with no adverse reactions. vt's 700's with occasional drop in ve's to 3l then back up to 8-9l. no rsbi due to 6 peep. am abg 7.46/41/84/30. no changes noc. [**name (ni) 4812**] started.

"
3699,"resp: pt rec'd on a/c 14/550/50%/8+. bs are coarse bilaterally. suctioned moderate amounts of thick greenish secretions. mdi's administed as ordered with no adverse reactions (see careview) no abg's/no aline. weaned to psv but didn't tolerate and placed back on original a/c settings. rsbi=68.
"
3700,"resp: [**name (ni) 158**] pt on simv 8/500/12/+12/40%. ett #7.5 retaped and secured 25@lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions with occasional tannish plug. mdi's administered q4 atrovent with no adverse reactions. no changes or abg's this shift. no rsbi due to ^ peep. will continue full support.
"
3701,"resp: pt rec'd on 50% t/c. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. nebs alb/atr administered with no adverse reactions. no changes noc.
"
3702,"resp: [**name (ni) 158**] pt on a/c 12/500/+5/50%. [**last name (un) 3028**] #8 trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick tan secretions. mdi's administered q4 alb/atr with no adverse reactions. no changes or abg's this shift. plan to attempt to wean to psv today.
"
3703,"resp: [**name (ni) 158**] pt on psv 12/+5/40% then placed on a/c 14/450/+5/40% to rest noc. ett #7, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amounts of bloody secretions. mdi's administered as ordered of combivent/flovent with no adverse reactions. pt has a tendency to bite on tube. no abg's this shift. 02 sats @ 99%. plan to tap bilateral pleural effusions today. will continue full vent support.
"
3704,"resp: [**name (ni) 158**] pt on a/c 14/550/+10/60%. bs are coarse bilaterally. suctioned for thick greenish secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease peep to 8, fio2 to 50%. no a=line, 02 sats @ 99%.
"
3705,"resp: pt rec'd on psv 16/8/50%. ett retaped, rotated and secured. alarms on and functioning/ambu/[**e-mail address 4476**] are coarse bilaterally. suctioning for moderate amounts of thick tannish secretions. mdi's administered q 4 alb/atr with no adverse reactions. pt ordered for potassium iodide, after consulting pharmacy was advised not to administer down ett, just po. pt placed on a/c 20/500/+8/50% to rest [**e-mail address **]. am abg 7.47/30/182/22. decreased rate to 14, fio2 to 40%, peep+5. plan to wean back to psv today.
"
3706,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/500/50%/+5. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned a moderate amount of thick yellowish secretions. mdi's given q4 alb with no adverse reactions.  [**last name (un) 353**]=135, cuff pressure @ 22cmhc0 with no further changes noted.
"
3707,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi""s administered q4 combivent with no adverse reactions. rsbi=98, no am abg. plan to continue to wean as tolerated.
"
3708,"resp: pt remains intubated on psv 10/5/50%. alarms on and functioning. pt had periods of desating to 80's, increased vent setting temporarily then returned to present settings. bs auscultated reveal bilateral clears sounds, suctioned for small amount of tan thick secretions.  mdi's administered alb/atr q4hrs with no adverse reactions. abg's 7.45/30/116/21. rsbi=76. vt' 500's, ve 13l, rr 25. will continue to wean appropriately.
"
3709,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 12/550/40%/+5.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with some coarseness noted on ls, diminished bases bilaterally.  mdi's administered q 4hr combivent with no adverse reactions. suctioned x3 small amounts of thick white secretions.  sputum sample obtained this am.  rsbi=172 and no sbt initiated.  no further changes noted.  02 sats remain in ^ 90's.
"
3710,"resp: [**name (ni) 158**] pt on a.c 14/550/5+/60%. ett #8, 24 @ lip. alarms on and functioning. ambu/syringe 2 hob. bs are clear bilaterally in apecies with diminished bs on lll. xray shows improvement from prior. mdi's initiated and administered as ordered atr/alb with no adverse reactions. suctioned for small amount of thick white secretions. pt is still tachycardic and may require cardioversion??. vent changes noc (see carview) am abg 7.44/44/119/31 at present settings. no rsbi due to hemodynamic issues.
"
3711,"resp:  [**name (ni) 158**] pt on psv 12/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilteral aeration with a noted wheeze. mdi's administered q4 hrs combvient with no adverse reactions. suctioned for small amounts of bloody tinged secretions. am abg's 7.42/61/98/41.  no further changes noted.
"
3712,"micu npn
see carevue for subjective/objective data.  neuro:  unresponsive to verbal stimuli, withdraws to tactile/painful stimuli.  no attempts to communicate or speak around ett.  minimal movements of arms, hands noted; no leg movements noted.

cv/pulm:  vs labile.  dopa titrated to maintain map>60--overnoc dopa max 12mcg/kg/min, currently at 9mcg/kg/min with map 60-64.  swaned at 1900--pa catheter at 65cm, intermittently wedges with 1and [**1-7**] ml air. pa's 20's/10's with cvp 11 to 5.  pcwp 13-11.  initial co/ci low at 4.5/1/5.  dobutamine added at 2.5mcg with co/ci improved to 5.3/2.5.  sensitive to dopa-->bp drops rapidly during even brief interuptions of infusion (bag change), takes 15-30min to return to baseline.  mp=nsr with occ pvc's at beginning of shift, now no ectopy noted.  completed prbc's hanging at 1900, hung third unit prbc's (total of 4 units including prbc rec'd in er).  no adverse reactions noted with blood transfusions.  maintained on vent-->ac12x700x50%x5peep.  bs coarse with bibasilar crackles.  lasix 40mg iv given prior to last unit prbc's with good diuresis; continues to diurese.  sputum sent for c+s.
suctioned for scant thick light yel sec via ett.

gi/gu:  ogt-->lcs drng bilious material.  bs absent.  abd soft, non-tender.  u/o qs via foley with brisk diuresis following lasix.  no bm.

integ:  incision on upper back noted (cyst removed pta)--drng sm amts light yel drng.  dsd applied/changed.  coccyx pink with sm area ""rough"" but not open--duoderm applied.  no other open areas noted however heels pink--elevated off of bed as much as possible.

id:  tmax=100core.  bc, urine cultures sent in er; sputum culture sent in micu.  started on vanco and levo (per pharmacy levo needs id approval following initial dose).

psychosocial:  emotional support given to pt.  no visitors or [**name2 (ni) **] contact thus far this shift.
"
3713,"blood administration
pt given one unit of prbcs for hct of 22.7.  pt tolerating procedure well at this time, no adverse reactions.  rn to follow up by checking hct and obtaining new iv access.
"
3714,"resp: [**name (ni) 158**] pt on t/c and place back on [**last name (un) 647**] psv 5/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral areation noted. some fine crackles.  suctioned for small amounts of yellow thick secretions. mdi's administered q 4 hrs of combvient with not adverse reactions. md [**first name (titles) 1531**] [**last name (titles) 2435**] today.  place back on t/c this am. tv low 300's.
"
3715,"resp: [**name (ni) 158**] pt on a/c 18/550/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amounts of thick secretions. mdi's administered 2p atr with no adverse reactions. trip to ct without incident, with results pending. am abg 7.40/41/75/26 with no changes noc. rsbi=no resps. will continue full vent support.
"
3716,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 10/500/10+/50%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. mdi's administered q4 hrs [**last name (un) 741**] with no adverse reactions. no vent changes noc. plan trach/peg tomorrow.  no rsbi due to peep.  am abg's 7.53/34/148/29.  no further changes noted.
"
3717,"resp: [**name (ni) 158**] pt intubated via or ett 7.0 retaped and secured 19 @ lip. place on a/c 18/550/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered as ordered 2p atr with no adverse reactions. vent changes to decrease fio2 to 40%. am abg 7.28/41/107/20. no further changes noted. will continue full vent support.
"
3718,"resp: [**name (ni) 158**] pt on psv 10/8/40%. ett #8, 27 @ lip. bs are coarse to clear and suctioning moderate to copious amounts of thick rusty/plugs secretions. mdi's alb administered with no adverse reactions. am abg 7.48/37/76/28. rsbi=43. plan is to extubate in am.
"
3719,"resp: [**name (ni) 158**] pt on psv 10/8/40%. ett #8 taped @ 27 lip. bs are coarse to clear. suctioned for large amounts of rusty/plug thick secretions. mdi's administered as ordered alb with no adverse reactions. rsbi=31. am abg 7.46/37/80/27. plan to wean as tolerated.
"
3720,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett #7.5 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration with diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift or changes. rsbi=27.
"
3721,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett #7.5, retaped and secured @ 21 lip. alarms on and functioning. ambu/syringe @ hob. suctioned for small to moderate amounts of thick tan secretions as well as copious oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sat @ 100%. rsbi=28. no changes or abg's noc.
"
3722,"pmicu nursing progress note 7a-7p
review of systems

[**name (ni) 248**] pt is responsive to stimuli, both voice and pn. she still does not move her extremities, but opens her eyes inconsistently when asked. she was not given any medication for sedation today, both scheduled doses of valium were held due to hypotension.  she has cont to recieve 300 mcg/hr of fetanyl, the plan following evening rounds is to start to slowly wean the fetanyl. the pt is planned to have a pancreatic needle aspiration [**last name (lf) **], [**first name3 (lf) **] will cont. to need pn medication.

resp- ac 400/40%/18/5 peep.  has maintained sats btw 97-100% since the peep was decreased from 8to5.  ls coarse bilaterally, suct. scant amts of thick, white sputum.  ett rotated, 25 to lip.  significant amt of thick yellow drainage suctioned from nares. team aware.

cv- hr btw 102-122 today, b/c more tachycardic w/ inc temp.  no ectopy noted.  nbp 90's-102/40-60's. hypotension was tx w/ 1 u of prbc to inc. intravascular vol.  received 2 gm of ca today.

gi-  bs, present, stooling loose green stool per mush cath.  cont. to receive tpn, lipids have been added per dietary recommendations.  tf cont to be held due to severity of inflammation in pancreas, residuals have been < 20 cc on q 4 hr checks.

gu- 100 cc/u/o/hr, clr, yellow. 24 hr net body balance + 1114.3. given 1 l bolus of ns for dehydration per teams request.

heme/[**name (ni) 998**]  pt transfused w/ 1 u prbc to inc. intravascular vol. and for hct of 27.4.  prbc's infused without evidence of adverse reactions.  plan to dc insulin drip when last l of d5 finishes infusing.  sliding scale orders in chart for coverage.

id- febrile today w/ temp ranging from 100.5-101.7; pt received q 4 hr tylenol and remained on a cooling blanket. day # 10 of imipenim.
fungal isolators sent.

plan- social work met w/ pt's fiance and spoke w/ pt's sister today over the phone and a meeting is to held tomorrow with all members. please refer to note in chart.  cont to monitor resp, cv, fever status.  tomorrow ir is scheduled for a pancreatic needle aspiration.


"
3723,"12p-7p
pt readmitted from [**hospital ward name **] 2, ct draining bile ? anastomosis leak ([**11-14**] s/p esophagogastrostomy and jtube placement). pt went to ct prior to being transferred.

neuro: pt alert and orientedx3. mae. perrla. using dilaudid pca appropriately for pain management see carevue.

cv: hr 102-119 st no ectopy. sbp >90. see carevue. dopplerable pedal pulses. 2+ pitting edema to bilat ankles. porta cath to left cw patent and intact. #20 placed to rh, patent and intact.

resp: ls coarse throughout. face tent applied at 70%, desats to 91% on nc. sats on face tent >95%. rr wnl. ct intact, no air leak noted, see carevue for details of color. md [**doctor last name 6980**] in at bedside on arrival and aware of color and content, barium given down ngt in ct scan by md. [**first name (titles) 6981**] [**last name (titles) 4318**] in ct by md [**doctor last name 6980**] to declot ct to drain. no adverse reactions. ct w/ scant drainage after 1700, md [**doctor last name 6980**] aware.

gi/gu: abd soft, + bs. ngt to right nare, to lis draining bile, see carevue. no manipulation of ngt [**name8 (md) 52**] md [**last name (titles) 6980**]. j tube clamped [**name8 (md) 52**] md [**last name (titles) 6980**]. foley draining [**first name8 (namepattern2) 1074**] [**location (un) 206**] color urine. at 1600, lasix 20mg ivp given for decrease in u/o to 5cc for 1 hour. see carevue for details.

endo: covered per pt's own scale.

id: wbc 22-23. afebrile.

plan: monitor hemodynamics. pulmonary toilet. monitor temp. ? to or/ir tomorrow.
"
3724,"resp: pt rec'd on a/c 20/600/40%/5+. alarms on and functioning. ambu/[**e-mail address 5171**] #7 re-taped and secured @20 lip. cp @ 23 cmh20.  bs auscultated reveal bilateral coarse sounds with exp. wheeze noted. mdi's administered q 4 alb with no adverse reactions. suctioned for small- moderate amounts of tan secretions. am abg's 7.31/40/80/21. pt remains on cvvhd. will continue full vent support. no vent changes noc.
"
3725,"ccu progress note!  7a-7p
delayed transfusion reaction:
   pt began to feel uncomfortable around 930am, stating he was feeling 'awful'.  at 10am, team in to assess pt on rounds, pt feeling nauseous. droperidol 0.625mg given total of 3 times today w/ little effect. ekg done w/ no changes noted. labs sent, cks flat. pt sob resp rate 20-30s, laboured at times. ls clear, crackles to bases. tmax 100.4. st 1320-130s. milrinone gtt d/c'd d/t ?adverse reaction to drug. pt con't all afternoon w/ nauseous feeling and stating he felt awful. slept in naps most of afternoon. hematuria - u/a sent. unknown about why pt was feeling so awful.
  around 5pm, house staff notified by blood bank that pt recieved blood + for minor antigens that pt has antibodies for.(1 unit prbcs given [**2130-1-10**], checked via ccc and w/ 2 nurses and given over 4hrs - hung 10am-down 2pm. benedryl 25mg po and tylenol prior to transfusion.) blood bank stated that due to missmatch he may have a delayed transfusion reaction.  pt had temp of 100.4 today, nausea, resp distress and hematuria (signs of a transfusion reaction). labs sent. ivf d5w w/3amp naco3 @ 250cc/hr x 1l.


neuro: a+ox3 today. pleasant + cooperative. pt napped most of late morning/afternoon d/t feeling awful. moves self in bed.

cardiac: st 110-130s today. occ pvcs noted. integrillin d/c'd at 11am. post cath fluids stopped at 8am. milrinone d/c'd at noon. ekg showed no changes today. no c/o chest pain. rij swan intact, pad 28-32, pcwp 31->23. co 3.3->4.7, ci 2.2->3.1, svr [**2127**]->1200. dobutamine @ 15mcg/k/min, nitro @ 180mcg/min. for cath lab in am to fix lad, to recieve pre cath fluids tonite.

resp: ls clear, crackles to bases. rr 20-30s, o2 3l n/c. laboured breathing at times this afternoon. cxr unchanged. sats 94-100%.

gu: foley changed today d/t ?clotted catheter. u/a sent. con't w/ hematuria, pink urine w/ clots. poor u/o, noting decrease in u/o since ivf d/c'd at 8am. lasix gtt decreased to 5mg/hr. ns bolus given this afternoon w/ no results. currently recieving d5w w/ 3amps bicarb @ 250cc/hr x 1l to flush out patient (d/t transfusion reaction). last cr 2.6!

gi: abd soft, distented. bm this evening. nauseated most of day, droperidol given x 3 w/ little effect. took small amt dinner this evening since he has started to feel a bit better. npo at midnite for cath in am.


plan: monitor resp status d/t ^ivf. monitor for further delayed transfusion reactions. con't to monitor vs and do cardiac calcs q4h. npo @ midnite for am cath. start pre-cath ivf tonite.
"
3726,"resp: [**name (ni) 158**] pt on a/c 24/350/+10/40%. pt has #9 [**last name (un) 3028**] foam filled trach. alarms on and functioning.ambu/syringe @ hob. bs are coarse and suctioning small to moderate amounts of yellow to tannish thick secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's or changes noc. will continue full vent support.
"
3727,"7p-7a
neuro: at beginning of shift pt alert,sleepy, following all commands,mae,perrla, nodded yes when asked if wants ""breathing tube out"" able to move head forward. pt resedated after re-intubation, on propofol,perrla, mae to painful stimuli. no indictions of pain.

cv: hr 70-100s. >100 during episode of re-intubation. sr/st. sbp labile on and off neo and ntg. currently off of neo and ntg. sbp 110s. [**md number(3) 5118**]/15-20s. cvp 7-16. svo2 52-64, md bridges aware. ci>2 by fick, see carevue. low svo2 treated w/ fluid bolus x3 and 2 units of prbcs,no adverse reactions, see carevue. epicardial wires attached and on ademand backup, see carevue for settings. +palpable pedal pulses, verified w/ doppler.


resp: at beginning of shift, pt following commands, acceptable abgs on cpap 5/5, md bridges at bedside before extubation and aware of svo2 57-60 before extubation. ok to extubate, extubated at [**2095**], pt sats to 55, pt in resp. distress, pt oxygenation w/ ambu and oral airway w/ improved sats to 90%, anesthesia called stat and at bedside re-intubated 7.5 tube, see carevue for vent settings and changes. abg after re-intubation 7.21/62/108, md bridges aware, rate on vent increased to 18, w/ improved abg 7.32/48/106, md bridges aware. presently on cmv rate 18 tv  700, fio2 70% w/ acceptable abgs, see carevue for details. ls clear diminished at bases. sats 94-100% at present time. suctioned for scant amts of thick white.

gi/gu: abd soft, abesent bs. ngt replaced after extubation draining bilious to brownish drainage. foley draining 40-60cc/hr of clear yellow urine, see carevue.

endo: gtt per protocol.

social: daughter updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. once pt stabilizes, wean vent as pt tolerates.
"
3728,"ccu npn 7am - 7pm
s: ""  my anxiety level is so high.""
o:  cvs:  hr 60 -70 sr no vea noted.  bp 140/30 -40's.  continues on labetelol, hydralazine and norvasc.

resp.:  pt. c/o sob this morning. lungs were clear at the time and o2sat was 94 %.  o2 2lnp was placed and pt. is attributing this episode to anxiety and it resolved spontaneously.

g.u.:  creat. is up to 4.9.  u/o is minimal.  presently pt. is 500 cc's neg.  pt. was told that he probably would need some dialysis after the surgery.

g.i.:  pt.'s main complaint today was of nausea.  vomitted x1.  given zofran 4mg iv x2 with relief.  appetite has been poor.  pt. ate very little.  took medications sporadically throughout the day.

d.m.:  blood sugars continue to be high.  ss insulin was increased.  last sugar was 221.

i.d.:  pt. has remained afebrile.  needs to receive vanco in the o.r. tomorrow.  please send down.  continues on ceftriaxone.

mental status:  alert and oriented x3,  very anxious.  h.o. does not want pt. to have any antianxiety meds due to adverse reactions in the past.

a: nausea and vomitting, awaiting valve surgery tomorrow

p:  continue zofran for comfort, monitor blood sugars, monitor u/o, [**doctor first name 4**] tmr ? at 8am.
"
3729,"respiratory:  [**name (ni) 158**] pt on 7200 simb8/550/15/5/40.  alarms on and functioning.  ambu/syringe@ hob.  bs auscultated reveal bilateral diminished with a few coarse sounds. suctioned x2 small amount of thick yellowish secretions.  mdi's administered q4 with no adverse reactions. fio2 remains in ^ 90's with no futher changes noted.
"
3730,"resp: [**name (ni) 158**] pt on ac 24/350/10+/40%. #9 [**last name (un) 3028**] foam filled trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse which improve following suctioning. suctioned for small to moderate amounts of thick bloody tinged secretions. mdi's administered combivent as ordered with no adverse reactions. no abg's or changes noc. will continue full vent support.
"
3731,"nsicu npn
see carevue for subjective/objective data.  neuro:  confused to place and time.  does not attempt to answer questions or nod ""yes"" or ""no"" however does follow commands to ""squeeze my hand"" and ""move your toes"".  mae ad lib.

cv/pulm:  vss.  mp=nsr without vea noted.  face mask in place-->breath sounds coarse bil.  second unit prbc's infusing when accepted pt; remainder bag infused without adverse reactions noted.

gi/gu:  ogt for meds with effect.  fib in place, passing flatus.  bs positive.  no tube feedings at this time.  u/o qs via foley.  rec'd lasix 40mg iv after second unit prbc's at 0230 with good diuresis.

integ:  pink areas noted on both arms, torso.  no worsening or change in skin condition overnoc.  duoderm to coccyx intact.  skin dry.

id:  afebrile.  no change in abx overnoc.

endo:  no sliding scale insulin required at 2400; glucose pending this am.

psychosocial:  emotional support given to pt.  no visitors/[**name2 (ni) **] contact thus far this shift.
"
3732,"7a-7p
neuro: pt a+ox3, mae, perrla. oxycontin 10mg for chronic back pain, percocet prn for breakthrough pain.

cv: hr 50-60s sr/sb w/ occasional pvcs. sbp >120-140s.+palpable pulses. picc line in place and intact. 2 units of prbcs given this am w/o adverse reactions. lopressor dose held secondary to bradycardia as parameters are written.

resp: ls rhonchi to clear. sats > 97% on ra. rr wnl. oob to chair.
no c/o respiratory distress.

gi/gu: abd soft, no bm, +bs, +flatus. foley placed as ordered secondary to surgical recommendations to keep strict i+os. u/o as low as 10-30cc/hr after [**name6 (md) **] placed, md [**doctor last name 610**] aware, no new orders at present time.

endo: fs qid , requiring no coverage.

skin: see carevue.

plan: monitor hemodynamics. hct every 4 hours. monitor output. pain control. monitor respiratory status.
"
3733,"respiratory:  [**name (ni) 158**] pt on 7200 psv15/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x2 small amount of yellowish secretions. mdi's administered q 4 hrs of combivent with no adverse reactions.  sat's remain ^90's.  no further changes noted.
"
3734,"1900-0700
see carevue for assessment and vital signs.

neuro: a&o. perl. mae. following commands. sleepy due to analegesia but easily rousable.

cv: sr 70's. no ectopy noted. sbp 97-125. always >100 when awake.

resp: maintaining sats 94-100% on ra. encouraged to deep breathe. ls clear.

gu: foley draining adequate volumes of clear urine.

gi: good diet tolerated. ssi coverage. made npo from midnight for possible or today. lr @ 125mlsph.

skin: intact. pin sites to l leg clean.

pain: ketamine infusion continues @ 7.5mls/15mg/hr. no adverse reactions/effects noted. dilaudid pca (double strength) continues. 0.5mg/6min lock/5mghr tot. used less since ketamine infusion commenced. pt slept for long periods and pain reported to be better controlled. sharp intermittent l leg pain continues. 2am morphine sulphate sr 130mg held as pt resp rate 12-13, pt comfortable/sleeping and also npo.

id: t max 100.5. 650mg acetaminophen given with effect.

plan: remain npo for possible or for l leg orif.
      monitor neuro status while on ketamine/dilaudid.
      maintain traction to l leg.
      emotional/psychological support of pt.
"
3735,"resp: [**name (ni) 158**] pt on psv 18/+5/40%. [**last name (un) 3028**]#9 foam filled [**last name (un) **] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse and suctioned small to moderate amounts of thick yellow secretions. mdi's administered as ordered without adverse reactions. no abg's. will continue to monitor closely.
"
3736,"resp: [**name (ni) 158**] pt on a/c 12/450/5+/40%. pt has #9 [**last name (un) **] foam filled trach. bs reveal coarse sounds and suctioned for small amounts of thick white secretions. mdi's administered as ordered of combivent with no adverse reactions and some improvement noted. dr. [**last name (stitle) 1531**] not to drop peep below +5, so no rsbi performed. no abg's 02 sats @ 100%. will continue full vent support.
"
3737,"resp: [**name (ni) 158**] pt on a/c 35/500/+14/60%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. vt ^ to 550. am abg's 7.42/47/94/32. esophogeal balloon study to terminate today?. will continue full vent support.
"
3738,"resp: [**name (ni) 158**] pt on a/c 22/600/+10/50%. #7 [**last name (un) 3028**] trach. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds. suctioned for moderate amounts of thick tan secretions. mdi's administered q 4 alb/atr with no adverse reactions. nebulized tobra in line (filter used/removed) and tolerated well. rsbi=^ peep. abg's pending. will continue full vent support.
"
3739,"resp: [**name (ni) 158**] pt on psv 10/10/40%. bs auscultated reveal bilateral clear with diminished bases. suctioned for small to moderate amounts of bloody tinged secretions. mdi's administered q4 hrs alb with no adverse reactions. pt complains of ^ wob, and placed on a/c 18/360/+5/40. am abg's 7.48/32/151/25. will continue to wean appropriately.
"
3740,"nursing progress note for 7p-7a:
neuro: pt is a&ox3, mae, follows commands.
pain: epidural gtt in infusing at 2ml/hr with good pain control and no adverse reactions noted.(changed dose, see [**month (only) **])
cv: hr is nsr 60-70's, rare pac noted. sbp 90-100's with maps 55-65.
skin is warm and dry, color pink, ppp. pt asymtomatic. remains on neo gtt at .4-.6 mcg/kg/min. bp does drop when attempts made to decrease neo gtt. lr at 10 ml per hour, cvp at 5. no fluid [**name8 (md) 52**] md's.
resp: pt's sats dropped to 88% while on 4l/nc, changed to 50% face mask with sats now 92-96%. wean non-productive cough. uses is with encouragement. 2 rt pleural [**last name (un) **] ct's to 20 cm sx. low amt of drainage. small airleak, no crepitus. md aware. dressing cdi.
gu/gi: npo, bs absent.  foley to bsd with adequate hourly o/u.

s/p thoracotomy with wedge resection, bx, lobectomy, esophageal mass removal and repair to trachea.  plan to keep pt dry to prevent re-intubation and attempt to wean neo gtt to off. encourage is.
"
3741,"resp: [**name (ni) 158**] pt on a/c 14/600/10+/40%. ett 38, 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. no rsbi due to ^ peep am abg 7.40/48/165/31. vent changed to decrease peep to 5. no further changes noted. plan to wean as tolerated.
"
3742,"resp: [**name (ni) 158**] pt on 7200 psv5/+5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilat coarse/rhonchi that clear after sux.  suctioned x3 small-moderate amount of thick yellowish/green secretions.  mdi's administered q4 hr alb/atr with no adverse reactions.  rsbi performed = 78.1 and sbt initiated.  rr 25, 02 sats remain 96-98% with no disress.  no further changes noted.
"
3743,"resp:  [**name (ni) 158**] pt on 7200 psv 5/5/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds in apecies with diminished bases.  suctioned x3 small amounts of thick whitish/yellow secretions which tend to pool in the oral cavity.  mdi's administered [**3-4**] p albuterol with no adverse reactions.  no further changes noted.
"
3744,"resp: [**name (ni) 158**] pt on psv 15/+8/30%. pt has [**last name (un) **] (airfilled) trach secured 12 @ flange. bs are coarse bilaterally. suctioned for small amounts of yellow secretions. mdi's administered as ordered combivent with no adverse reactions. am abg 7.41/35/108/23. rsbi=71. no changes noc. plan to continue to wean as tolerated.
"
3745,"resp:  [**name (ni) **] pt on 7200 psv10/50%/+7.5.  ambu/syringe @ hob.  auscultated bs reveal bilat coarse, no wheeze noted.  suctioned small amount of thick yellow/whitish secretions.  mdi's administered in line alb/atr q4hrs.  pt sats remain 98-99% with no adverse reactions or distress noted.  ps ^ to 12 but all previous vent settings remain the same.  no further changes noted.
"
3746,"resp:  [**name (ni) **] pt on 7200 psv 5/+5/50%.  ambu/syringe @ hob.  bs ascultated reveal bilateral rhonchi which clear with suctioning.  suctioned x3 small amount of whitish/yellowish thick secretions. mdi's administered q4 hr alb with no adverse reactions.  no further changes noted.
"
3747,"resp: [**name (ni) 158**] pt on psv 15/8/30%. pt has #8 [**last name (un) 3028**] (air filled cuff) [**11-12**] @ flange. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions,x1 for plug. mdi's administered combivent as ordered with no adverse reactions. am abg 7.34/42/86/24. rsbi =82. plan to wean as tolerated.
"
3748,"resp:  [**name (ni) 158**] pt on psv 12/8+/30%. pt has #8 [**last name (un) 3028**] (air filled) trach 12.5 @ flange. bs are coarse bilaerally with diminished bases. mdi's administered combivent as ordered with no adverse reactions. suctioned for small to moderate amounts of thick yellow secretions. no changes noc. am abg 7.35/42/1204/24. rsbi=98.  plan to continue with t/c trials as tolerated. discussions on possible dialysis and plan for rehab.
"
3749,"12a-7a
pt is a 66 year old male readmitted from sinia w/ increased sob,
fever. s/p cabg x3 on [**2174-9-29**], wound dehiscence, trach on [**2174-11-4**]. vent dependent. wbc on readmit 42.

neuro: pt a+ox3, forgetful at times. mae. perrla. morphine 2mg iv prn.

cv: hr 90-110s st w/ rare pvcs. increased hr w/ aggitation. sbp 150, nitro gtt started keeping sbp 110-130 map >60. 1 unit of prbcs given for hct 26, no adverse reactions. + palpable pulses. left a line placed at bedside by dr. [**first name (stitle) **]. +csm. double port picc to left ac, flushing well.afebrile 96.4-98.0.

resp: ls coarse, diminished at bases. trach [**first name (stitle) 657**], fio2 50% on cmv mode rate 20 tv 600 peep 5. abgs drawn on admission, md [**doctor last name 2641**] aware. sats 99-100%. suctioning small thick yellow via trach.

gi/gu: abd soft slightly distended +bs. ngt patent and [**doctor last name 657**] from rehab. pt states foley was placed today. foley draining adequate amts of yellow urine. urine cx sent in er.

[**doctor last name **]: sternal wound open w/ wound vac dsg [**doctor last name 657**], last change on [**12-23**]. see carevue.

plan: monitor hemodynamics. pulmonary toilet. ? ct today. pending cultures. ? id consult.continue triple antibiotics.
"
3750,"resp:  [**name (ni) 158**] pt ond simv 18/750/5/5/50%.  alarms on and functioning. ambu/syringe @ hob. during positioning of pt, ett tube dislogged from trachea, stat anesthesia called to re-intubate.  size 8 ett taped and secured  24@lip. bs auscultated reveal bilateral clear with diminished bases. mdi's administered q4 alb with no adverse reactions. vent changes reflect abg's.  am abg's 7.47/33/130/26. rr decreased to 16 and fio2 to 40%. additional abg to follow. continue to wean appropiately.  no further changes noted.
"
3751,"7a-7a
neuro: pt a+ox3, mae, perrla. oxycontin 10mg scheduled [**hospital1 10**] for pain, and percocet for breakthrough pain for hx of chronic back pain.

cv: s/p mi w/ stent placement in [**month (only) **], hr 50-60s sb/sr w/ pvcs (lytes sent). sbp 130-150. ? endocarditis prior to this admission, picc in place and intact ( at home on continuous pcn gtt), given pcn q4 hours as ordered. received 2 units of prbcs this am, making total of 5 units thus far during this stay. 2 units of ffp given this shift also 1 unit of platelets. no adverse reactions.

resp: ls w/ faint rhonchi. non productive cough. sats greater than 95% on ra. denies sob. no resp. distress noted.

gi/gu: abd soft, +bs. 3 total bms during this 12 hours approx. 300-450cc each time of frank red w/ clots. gi study done w/ positive [**name8 (md) 8**], md [**doctor last name 610**] aware and gi team aware. at present plan to continue to monitor.  pt voiding, hard to assess color secondary to stool.

plan: continue to monitor hemodynamics. monitor resp. status. monitor labs. to get 2 more units of prbcs tonight. monitor gi status.

"
3752,"resp: [**name (ni) 158**] pt on psv 5/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for copious amounts of thin white secretions which then became bloody by early am. mdi's administed as ordered alb/atr with no adverse reactions. pt had ^ rr with decrease in sats and placed on psv 12/8/50%. vt 500-600, rr 19 and improvement noted. md notified and order placed. rsbi=84. plan to continue with wean and t/c trials as tolerated. no abg's this shift.
"
3753,"resp: [**name (ni) 158**] pt on psv 8/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small amounts of bloody tinged secretions due to trach insertion. mdi's administered as ordered alb/atr with no adverse reactions. abg 7.45/31/76/22. rsbi=73. [**name (ni) **] changes to decrease ps to 5. will continue to wean for trach collar trials.
"
3754,"resp: pt remains on psv 12/5/50%. vt's 600, ve's 8-9l, rr 14, 02 sats 100%. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr without adverse reactions. am abg's 7.42/47/168/32. rsbi=44. will continue to wean appropriately.
"
3755,"resp: [**name (ni) 158**] pt on a/c 12/550/5+/40%. ett#8 24@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered alb/atr as ordered with no adverse reactions. rsbi=81. pt placed on psv 10/5/40%. vt's 450's, ve 8, rr 16. am abg 7.51/50/183/41. ps decreased to 5 with additional abg. plan to wean to as tolerated to possible extubation this am.
"
3756,"resp: pt rec'd on psv 20/10/50%. pt has #7 [**last name (un) **] water filled trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. am abg 7.44/57/112/40%. no further changes noted.
"
3757,"resp: [**name (ni) 257**] pt on psv 5/5/35%. ett #7, retaped and secured @ 20 lip. bs reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg's (see carview) 7.52/27/106/23. rsbi=34.
"
3758,"resp:  pt remains on t/c with cuff deflated noc. minimal secretions. 02 sats in ^ 90's.  mdi's administered via t/c alb with no adverse reactions.  plan to get pt up to chair, and possible ambulate if tolerates.  pmv during the day.
"
3759,"resp:  pt remains on t/c noc tolerating well. mdi's administered via t/c with no adverse reactions.  02 sats in ^ 90's noc with minimal secretions. plan to ambulate today if tolerated. pmv during the day.
"
3760,"resp: [**name (ni) 257**] pt on a/c 14/600/50/+5. pt has #8 portex trach. alarms on and functioning. ambu/syringe 2 hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions, as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes or abgs this shift. rsbi= no resps. will continue full vent support.
"
3761,"7a-7p
neuro: a+ox2. mae. perrla. follows commands.

cv: hr 60-70s sr. converted to afib 100-110s at 1500 for approx. 15min, then converted back to nsr. sbp 100-130. weakly palpable dp/pt. 2+ generalized edema. aline positional, unable to draw blood from line, team aware. 1 unit of prbcs given, no adverse reactions noted.

resp: portex #7 trach site oozing w/blood. trach care done. trial on trach collar done, tolerated for 30 min., placed back on ventilator cpap. see carevue for details. ls clear. sats above 95%. suctioned for thick blood tinged secretions via trach. yellow thick secretions via [** **]. left sided pleural  effusion by xray, lasix ordered.
tolerated oob to chair x3hours.

gi/gu: abd soft, hypoactive bs. tf restarted at 20cc/hr. minimal residuals. bm x1 formed brown stool. foley draining adequate clear yellow urine.

skin: rash noted on back.team aware. cont. vanco.

plan: pulmonary toilet. rehab screening. diurese.
"
3762,"resp: [**name (ni) 257**] pt on a/c 12/360/10+/40%. #7 [**last name (un) 4254**] (water filled) trach. ambu/syringe @ hob. alarms on and functioning. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered, alb/atr/[**last name (un) **] with no adverse reactions. no rsbi due to ^ [**last name (un) **]. no changes or [**last name (un) **]'s this shift. will continue full vent support.
"
3763,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 12/400/100%/+5.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with slight crackles over r base.  suctioned for small amounts of white secretions. mdi's administered q4 hrs combivent with no adverse reactions. cuff pressure @ 23 mmhz.  rsbi=>200. present vent settings;a/c 14/400/+5/30% with am abg's;7.44/49/89/34.  no further changes noted.
"
3764,"resp:  [**name (ni) 257**] pt on 7200 psv 15/15+/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small-moderate amounts of thick yellowish secretions.  mdi's administered q4 hr alb/atr (6 p  ea) with no adverse reactions.  rsbi=108.6 and no sbt initiated.  pt scheduled to receive trach today.  no further changes noted.
"
3765,"resp: [**name (ni) 257**] pt on a/c 12/360/10+/40%. pt has a #7 [**last name (un) 4254**] water filled trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/light greenish secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. no changes or [**last name (un) **]'s this shift. no rsbi due to ^ [**last name (un) **]. will continue full vent support.
"
3766,"resp: pt rec'd on a/c 12/360/+10/40%. pt has [**initials (namepattern4) **] [**last name (namepattern4) 4254**] #7 water filled trach. bs are coarse bilaterally. suctioned for small-moderate amounts of white/yellow secretions. mdi
"" administered as ordered  with no  adverse reactions. no [**last name (namepattern4) **]'s or changes noc. will continue full vent support.
"
3767,"resp: [**name (ni) 257**] pt on a/c 14/600/5+/50%. pt has #8 portex trach in place. alarms on and functioning. ambu/syringe @ hob. bs are coarse to diminished bilaterally. suctioned small amounts of white to yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi= no resps. no changes or abg's this shift. will continue full vent support.
"
3768,"resp: [**name (ni) 257**] pt psv 5/5/40%. bs are clear bilaterally. suctioned for scant - small amounts of tan secretions. mdi's administered q4 hrs with no adverse reactions. last abg 7.42/45/117/30. plan to place on t/c trials today as tolerated.
"
3769,"resp: [**name (ni) 257**] pt on ffv psv 10/5/60%, then placed on 60% f/t for about 3 hrs. hhn administered alb/atr with no adverse reactions. bs are coarse with occasional exp wheeze noted. pt placed back on ffv psv 10/5/50% due to ^ wob. pt tolerating mask, 02 sats @ 100%. will continue to wean to f/t as tolerated.
"
3770,"resp: [**name (ni) 158**] pt on pcv 40/25/55%/0+. pt has shiley #8 trach with audible leak noted. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes this shift. vt's 400's/ve's9. no rsbi pt is vent dependent. abg's (see careview) co2's still consistantly >100. will continue with present vent settings.
"
3771,"resp: [**name (ni) 158**] pt on pcv pinsp 44/32/55%/0+. pt has # 8 shiley trach with audible cuff leak. bs are diminished bilaterally. sucitoned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's or changes this shift. no [**name (ni) **] due to vent dependent. plan to continue full vent support.
"
3772,"resp: [**name (ni) 257**] pt on a/c 12/360/+10/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of yellow secretions. mdi's administerd q4hrs alb/atr with no adverse reactions. vent changes to ^ rr to 20, fio2 to 50%. am abg 7.46/55/87/40. no further change noted.
"
3773,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 22/550/50%/+5. alarms on and functioning. ambu/syringe @ hob. ett #8.0, retaped and secured @ 26 lip. bs are coarse with diminised lll. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 alb/atr with no adverse reactions. abg's (see careview) which vent changes refect. am abg's 7.42/32/89/21 on ^ peep to 10.  will continue full vent support.
"
3774,"resp: [**name (ni) 158**] pt on psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob. ett retaped and secured @ 25 lip. vt's 600's/ rr 15. bs auscultated reveal bilateral clear apecies with some coarse sounds. suctoned for moderate amounts of thick white secretions. mdi's administered q4 alb/atr with no adverse reactions. some periods of decreased rr with drop in ve, suggested mmv during noc. plan to trach today @ 11 am. will continue vent support.
"
3775,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] 14/600/5/5+.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with coarse bases.  suctioned for moderate amounts of yellow secretions.  mdi's administered q4 hrs alb/atr 4 p with no adverse reactions. am abg's 7.42/36/110/24.
"
3776,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/500/10+/40%. alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick white secretions.  mdi's administered q4 hrs atr and [**last name (un) **] [**hospital1 10**] with no adverse reactions.  no rsbi due to ^ peep. am abg's pending.
"
3777,"resp:  [**name (ni) 158**] pt on (mmv) psv 10/7/40%. alarms on and functioning. ambu/syringe @ hob. 8.0 ett, taped and secured @ 25 lip. 23 cmh20 cp. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions. vt's 400-500's. plan to trach today. no abg's or changes noc. will continue support.
"
3778,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/600/50%/5+.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned moderate amounts of thick yellow secretions.  mdi's administered q4hrs alb/atr with no adverse reactions. no spont resp for rsbi. am abg's 7.38/36/140/22.  no further changes noted.

"
3779,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 18/600/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate to copious amounts of secretions tannish/white thick, as well as oral secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi-180. scheduled for trip to o/r today for additional wound graft.  no further changes noted.
"
3780,"resp: [**name (ni) 158**] pt on simv 10/600/15/+5/40%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20, ett @ 23 lip. bs auscultated reveal bilateral coarse sounds. suctioned for small amount of thick yellow secretions. mdi's administered q4hrs combivent/[**last name (un) **] [**hospital1 10**] with no adverse reactions. am abg's 7.44/37/116/26. no changes noc. 02 sats @ 97%. plan to continue full vent suppport.
"
3781,"resp: [**name (ni) 158**] pt n a/c 16/500/5+/50%. bs are clear with diminished bases. suctioned for scant amount of white secretions. [**name (ni) **]'s administered as ordered combivent with no adverse reactions. 02 sats @ 100%, fio2 titrated to 40%. no a-line. rsbi=63. plan to wean as tolerated.
"
3782,"resp: [**name (ni) 158**] pt on 40% t/c cool mist.  ambu/syringe/spare trach @ hob. bs auscultated reveal coarse bilateral sounds which clear after suctioning.  trach care performed x3, pt tends to plug up inner cannula.  sux x 3 for small to moderate thick bloody plugs/secretions.  mdi's administered q 4hrs alb/atr (4p) via air chamber through trach and pt tolerates well with no adverse reactions.  02 sats remain 99-100% with no distress.  no further changes noted. cuff remains deflated.
"
3783,"resp:  [**name (ni) 158**] pt on 7200 a/c 24/450/50%/+5.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse/rhonchi which clear with suctioning.  pt suctioned x3/4 for copious thick tan secretions/plugs.  [**name (ni) **]'s administered q4 alb/atr with no adverse reactions.  abg's drawn throughout the noc with improvement noted.  sputum sample obtained.  vent changes noted, rr @18 with abg's pending.  no further changes noted.  pt resting comfortably.
"
3784,"resp: [**name (ni) 158**] pt on a/c 14/550/5+/40%. ett #7, retaped and secured @ 23 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally and suctioned for small amount of white thin secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbt=71. attempted to place on psv although pt still sleepy. will wean in am to psv as tolerated to extubate today.
"
3785,"resp: [**name (ni) 158**] pt on psv 16/8/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/white thick secretions, as well as oral cavity. mdi's administered alb q4 with no adverse reactions. vt's 500-600, ve's 13-15, rr 24-27 with 02 sats @ 100%. no aline or abg's this shift. no changes noted.
"
3786,"resp: [**name (ni) 158**] pt on psv 16/8/50%. pt is trached #9 extra long portex. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white/clear secretions. mdi's administered q4 hrs alb with no adverse reactions. vt 500-600, ve [**11-4**], rr 18-25. rsbi=100. no abgs (no aline).
"
3787,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 24/450/+5/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. ett rotated re-taped and secured. suctioned small to moderate amounts of tannish secretions. mdi's administered q4 alb with no adverse reactions.  rsbi=110, ^ hr to 107/rr an exihibted atrial fib rsbi terminated.  am abg's 7.29/43/98/22.  no further changes noted.
"
3788,"micu npn

see carevue for subjective/objective data.  neuro:  initially sedated with propofol/morphine while intubated.  propofol off at 1140--pt moving in bed, semi-awake prior to shutting propofol off.  pt awake within 10min of propofol off, able to hold head off pillow, nodding ""yes"" and ""no"" appropiately, mouthing words around ett.  mae ad lib before and after extubated.  once extubated pt speaking clearly, continues to mae ad lib.  a+ox3.

cv/pulm:  vss per carevue.  hct 23 down from 25 this am--two units prbc ordered.  first unit infused without adverse reactions, second unit currently infusing without adverse reactions thus far.  serial hcts q4h.  k=3.4, currently being repleted with 20meq over 2hrs x2 for total of 40meq over 4hrs--(pt has only periph access).  iv d5lr with 20meq kcl at 125/hr except during prbc's then kvo'd.  afebrile.
pt intubated this am then rapidly weaned and extubated once propofol off.  placed on cmm at .40%; sats 100%.  pt continuously removing mask with sats remaining 99-100% even with o2 off.  pt agrees to keep mask near mouth and nose but not tight until this afternoon and has complied--currently on room air with sat 100%.  no sob or doe noted.  bs clear upper lobes, coarse lower lobes in am, clear bil this pm.  pt moving ad lib in bed (restless) and coughing without encouragement--thick/clear secretions, occ blood tinged.

gi/gu:  ngt removed this am when ett removed.  abd firm but not tense, sl tender, bs absent.  abd dsg d+i.  no flatus but pt does burp frequently.  u/o qs q1h via foley.  vaginal bleeding slowed this shift-->one pad q4h.  s/b ob/gyn this am and this [**name8 (md) 8972**] md spoke  with pt re: events of past 24hrs.  pt states comprehension of events.

integ:  intact.

id:  afebrile.  no change in abx.

psychosocial:  pt crying much of afternoon, restless, states ""i need to get my butt comfortable"".  pt stated concerns re: children at home. offered to call pts home but pt refused, stating she does not want to ""talk to anybody or see anybody"".  brother (? name) and son [**name (ni) 8973**] in to see pt--pt crying, moaning.  much emotional support given to pt and fam.  visitors left, attempted to assist pt with comfort and emotional needs.  med with ativan 1mg iv with little-->no effect.  remains on morphine at 1mg/hr cont.  will cont to provide emotional support and comfort measures.
"
3789,"resp: [**name (ni) 158**] pt on a/c 14/550/+5/40%. ett #7, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. suctioned for scant amounts of tanish/white secretions. mdi's initiated and administered alb/atr as ordered with no adverse reactions. rsbi=85. plan to wean to psv, then extubate this am.
"
3790,"resp: [**name (ni) 158**] pt on psv 5/5/40%. ett 7.5, taped @ 22 lip. bs are coarse to clear bilaterally and suctioned for moderate amounts of thick yellow to white secretions. mdi'd administered of alb as ordered with no adverse reactions. pt remains on sedation, when lightened is extremely aggitated. rsbi=36 no abg's/no a-line. vt's 400-500, 02 sats @ 99%. plan: wean to extubate today?
"
3791,"resp: pt rec'd on 14/600/+5/40%. bs are clear with occasional wheeze noted on ls. suctioned for small amount tan thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. ett #7.5. 25 lip. 02 sats @ 100%. am abg 7.37/46/108/28. rsbi=53. plan to possible psv today if tolerated.
"
3792,"resp: [**name (ni) 158**] pt on psv 8/5/40%. ett #7.5, taped @ 22 lip. bs are coarse bilaterally and suctioning for copious amounts of thick white/yellow secretions.circuit changed to heated wire circuit. mdi's administered atr with no adverse reactions. no changes noc or abg's. rsbi=42. plan: wean as tolerated.
"
3793,"resp: pt rec'd on a/c 14/450/+8/40%. ett#7.5/23 lip. bs auscultated reveal notable improvement w/o wheeze, with clear apecies bilaterally. suctioned for small amount of thick secretions. sputum sample sent. mdi's administered q4 alb/atr with no adverse reactions. no abg's (no a-line). rsbi=200. no changes this shift
"
3794,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] simv 20/500/ps15/+10/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with i/wheeze noted. suctioned for moderate amounts of thick yellow/tannish secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. 02 sats @ 96% with no further changes noted.
"
3795,"resp: [**name (ni) 158**] pt on psv 12/5/40%. ett retaped and secured.bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=79. md [**first name (titles) 7856**] [**last name (titles) 2377**]. place pt on psv 5/0 for 30-45 min and pt ^ wob,^ sob with 02 desaturations to 80's. abg 7.18/78/96/31. [**last name (titles) 2377**] terminated.(see carview for multiple vent changes)pt place on 100% temporarily, then decreased to 50%. bs reveal bilateral crackles and suctioning copious amounts of thick white frothy secretions. lasix given with good effect. present settings. 18/500/+10/50%. additional abg's to follow.
"
3796,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 14/500/5/+5/40%. alarms on and functioning.  ambu/syrnge @ hob.  cuff pressure @ 21.  pt trached and peg today.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 small to moderate amounts of thick bloody tinged secretions.  mdi's administered q4 hrs alb with no adverse reactions.  02 sats @ 100%. no further changes noted.
"
3797,"7a-7p
neuro: pt sedated on [** **], as low as 10mcg/kg/min, following commands increased for ir procedure as high as 80mcg for comfort at present at 20mcg to keep pt comfortable. perrla. mae. nods no if asked in pain.

cv: hr 80s. sbp labile. 90-110s. keep map>60. received total thus far 4 units of [** 458**], 1 unit of plt, 2 units of prbcs, no adverse reactions. afebrile. ordered for cryoprecipiate and more plt, to be given. see carevue. cvp 12-20[**street address(1) 7840**] aware of cvp. to ir w/ monitor and rn see ir notes for vs, angio site cdi, w/ pressure dsg+ saline bag over site. palpable pedal pulses. no aline put in from micu team secondary to bleeding issues. to lie flat until 9pm.

resp: no aline. venous gases [**street address(1) 7841**] aware of all labs including 7.55 ph repeat when back from ir 7.48 on cpap 50%, 5peep/15ps. ls clear diminished at bases. sats >98%.

gi/gu: abd soft, but distended absent bs. ogt + placement, receiving lactulose as ordered. ogt draining brownish in color. mushroom cath in place ok [**name8 (md) 52**] md [**doctor last name 1055**] for blackish brown liquid stool. foley draining iteric urine minimal amts 10-15cc/hr md [**name6 (md) 1055**] [**street address(1) 7842**] aware.

labs: see carevue for details. k repleted w/ 60meq iv kcl, 3 separate  20meq bags over an hour [**street address(1) 7843**] updated w/ labs and u/o and angio site when back from ir.

plan: monitor hemodynamics. monitor resp.status. improve coags so tomorrow ? stent placement to hepatic/bile duct, ir unable to find source of bleeding. monitor angio site and pulses


"
3798,"resp: [**name (ni) 158**] pt on psv 12/8/40% ett 7.5/25 lip.bs are coarse bilaterally. suctioned for moderate to copious amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no abg's or changes this shift. rsbi=80. plan to continue to wean as tolerated

"
3799,"resp: [**name (ni) 158**] pt on simv 10/500/15/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of frothy yellow/white secretions.  mdi's administered as ordered with no adverse reactions. pt is vent dependent. no changes noc. plan to be discharged today to rehab.
"
3800,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 143/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned for moderate amounts of thick secretions. changed out dry circuit for heated one.  mdi's administered q4 hrs combivent with no adverse reactions.  exutbation still planned for monday [**5-25**].  no further changes noted.
"
3801,"resp: [**name (ni) 158**] pt on psv 10/10/40%. bs are coarse bilaterally which improvement with suctioning. suctioned for small amounts of thick yellow secretions. mdi's administered q4 [**name (ni) 741**]/[**last name (un) **] [**hospital1 10**] with no adverse reactions. vent changes to ^ ps back to 15 due to ^ in rr. will continue to wean appropriately.
"
3802,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/5/40%. alarms on and functioning. ambu/syringe @hob. bs auscultated reveal bilateral clear apecies with some fine scattered rales, diminished bases bilaterally.  mdi's administered q4 hrs combivent, with no adverse reactions. suctioned/lavarged x3 for moderate amounts of thick white secretions.  x-ray indicates bilateral pleural effusions, questionable tapping. plan to extubate this am.  am abg's 7.45/39/85/28.  no further changes noted.
"
3803,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. eet #8 taped and secured @ 24 lip, cuff pressure @20. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick white, pale yellow secretions.  mdi's administered with no adverse reactions. am abg;s 7.43/33/126/23. vt' 900/ve20's. rsbi=22. pt reacts anxiously to any stimuli.  plan to continue to wean appropriately.
"
3804,"resp: pt rec'd on psv 10/10/50%. bs are coarse bilaterally which improve following suctioning. suctioned for copious thick bloody secretions with some clots. mdi's administered q4 combivent with no adverse reactions. am abg's 7.37/38/111/23 with no changes noc. rsbi=75. will continue on psv and wean appropriately.
"
3805,"resp: [**name (ni) 158**] pt on a/c 14/700/+10/70%. bs reveal bilateral crackles with slight wheezing noted. mdi's administered q4 combivent with no adverse reactions. suctioned for small amounts of bloody tinged secreitons (new trach). abg 7.36/40/161/24, fio2 decreased to 60%. am abg's 7.36/37/98/22. no further changes noted. will continue to wean appropriately.
"
3806,"resp: [**name (ni) 158**] pt on a/c 14/450/+5/45%. bs are coarse bilaterally. [**name (ni) **] for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. pt expected to be d/c to rehab this am.
"
3807,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/460/+14/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with noted aeration in apecies. suctioned for small amount of tan thick secretions. mdi's administered q4 alb with no adverse reactions. fio2 decreased to 40%, with am abg's 7.28/58/115/28. no further changes noted.
"
3808,"resp: pt is on h/f02 @ 80% with 6 lpm n/c. bs are coarse bilaterally, pt able to expectorate some secretions. nebs administered q6 hrs atrovent ud with no adverse reactions. will continue to follow.
"
3809,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/280/+8/60%. alarms on and functioing. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of white secretions. mdi's administered x1 of alb with no adverse reactions. pt had episodes of desaturations to 70's and fio2 ^ temporarily to 100% then titrated down (see carview) to 50%. abg 7.47/49/127/37 with am abg pending. no further changes. will continue full vent support.
"
3810,"resp: [**name (ni) 158**] pt on a/c 16/280/+8/50%. alarms on and functioning. ambu/syringe @ hob. ett rotated and secured. bs are coarse bilaterally. suctioned for small to moderate amounts of white/pale yellow secretions. mdi's administered q4 alb with no adverse reactions. rsbi=no resps. plan to attempt rsbi to wean to psv.
"
3811,"resp:  [**name (ni) 158**] pt on 7200 simv 16/550/ps12/+5 40%.  ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned moderate to copious thick yellow secretons.  [**name (ni) **]'s administered q4 hr alb/atr with no adverse reactions.  no further changes noted
"
3812,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] simv 14/600/10+/5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminshed bases. suctioned for small amount of thick bloody tinged secretions.  mdi's administered q4 hrs combivent with no adverse reactions. rsbi=55. am abg's; 7.44/40/109/28 with no further changes noted.
"
3813,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c20/600/10+/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration noted in apecies with diminished bases. re-taped and secured ett. mdi's administered q4 hr alb with no adverse reactions. suctioned moderate amounts of tan secretions early in the [**last name (un) **] with pale yellow in am.  no vent changes [**last name (un) **]. am abg's 7.43/37/121/25.  no further changes noted.
"
3814,"resp: [**name (ni) 158**] pt on a/c 18/55/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and suctioned for small amounts of tan secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's or vent changes noc. pt is awaiting bed at rehab. will continue full vent support.
"
3815,"respiratory care
non-intubated bronchoscopy preformed on pt without apparent adverse reactions. 1% lidocaine used via atomizer followed by instilling 8cc of lidocaine at 2cc doses via bronchoscope. suctioned for moderate amounts of thick tan colored secreations. pt on 5 liters nasal cannula. sat's from 91%-94%.
"
3816,"resp: pt rec'd on psv 8/5/40%. pt has #8 portex trach. bs are coarse in upper lobes bilaterally and suctioned for small amounts of thick yellow secretions. mdi's as ordered alb/atr/[**last name (un) **] with no adverse reactions. abg 7.30/36/116/18 with rsbi=49. possible trach collar trials again today. vt400's ve 9l.
"
3817,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 18/550/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. notable leak at times, rn/md aware. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tan secretions. mdi's administed combivent with no adverse reactions.  no rsbi due to ^ peep or abg's no aline. 02sats to 96%. will attempt to wean as tolerated.
"
3818,"resp: pt rec'd on a/c 18/550/+8/60%. ett #7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick tannish secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift. will continue full vent support.
"
3819,"resp: [**name (ni) 158**] pt on a/c 18/550/+8/60%. ett #7.5, retaped, rotated and secured @ 23 lip. 02 sats 97-99%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions, copious oral secretions. mdi's administered as ordered with no adverse reactions. no abg's or changes this shift. plan to trach. will continue full vent support.
"
3820,"micu npn
see carevue for subjective/objective data.  neuro:  started on cisatracurium at 1mcg/kg/min as continues to overbreathe vent.  morphine 0.5mg/hr added when paralytic initiated.  remains on ativan 2mg/hr.  pupils remain 6mm, non-reactive.  no movements noted prior to initiation of paralytic.

cv:  remains on levo and neo per carevue.  vasopressin added at 0.04units/min.  bp remains labile--low of 70's/30's with map 50's to high of 110/60's with map 70's.  hr initially low 100's but by 0815 hr 170's--remained 160-170's until swan dc'd then hr immediately decreased to 120's.  remainder of day hr 110's-120's.  mp=st; only ectopy noted during swan removal.  currently levo at 20mcg/min, neo at 10mcg/kg/hr, vasopressin at 0.04units/min.  bicarb gtt on throughout morning then dc'd then restarted.  calcium chloride given per [**month (only) 5**]; calcium gluconate gtt started.  k repleted with 20meq x3 for k of 3.1--rpt lytes this pm. maintenance iv 500-700ml/hr until 1800 then decreased to 10ml/hr.  tylenol for temp of 100 (core); cooling blanked placed on for temp of 101.1 (core).  temp decreased to 99.1, blanket off.  tmax remainder of day=99.7 po (no longer using core temps as swan dc'd).  rec'd 2units ffp and 6units platetes--both ffp and platelets given without adverse reactions.

pulm:  remains vented.  multiple vent changes throughout day; currently on ac28x750x80%x10peep.  bs coarse.  attempted to obtain sputum for c+s; no secretions despite lavaging.  scant oral secretions.  abg's per carevue.  on bicarb gtt as noted above.  ct to 20mm suction until 1500 then placed to water seal.  drained only 5ml straw colored fluid this shift.

gi/gu:  ogt-->lis drng scant amts coffee ground secretions.  remains on protonix.  nothing given per ogt.  bs absent.  no bm.  remains anuric.  quinton cath placed at 1845 as anticipating need for cvvh--no cvvh planned at this time.  bladder pressure done x1-->17.

integ:  extremities cool, mottled (on three pressors).  no open areas noted.  does have scleral edema, generalized edema.

id:  tmax=101.1 core.  tylenol and cooling blanket as noted above.  ceftazadime and vanco added to regime however vanco not started yet as waiting for vanco level.  rocephin dc'd.

psychosocial:  brother, sister and sister-in-law in to visit--updated by [**name (ni) 1302**] on current status/prognosis/plan (potential for cvvh).  emotional support given to pt and family.
"
3821,"micu nsg admit note
mr. [**known lastname **] is a 51yo male adm to micu as trans from cc6 s/p laminectomy from [**2176-9-26**].  pmh significant for etoh use, iv drug use, psych hx (on meds), copd, smoker, htn, (+) for hepatitis c, multiple old ortho injuries due to ""bar bralls"".  per family no etoh or drug use since [**month (only) 1279**] of this year; [**name6 (md) 52**] trans rn pt adamantly denies etoh or drug use since [**month (only) **] of this year.   pt had fusion of l5 and s1.  post op pt noted to be restless but no mental status changes.  friday he had increasing mental status changes, placed on ativan.  over w/e he cont'd on ativan.  mon am he was transferred to medicine.  mon am he also developed hypotension with o2 sats 80's; anesthesia paged to floor, pt intubated, sent to micu.

overview of day:  upon arrival pt intubated, hr elevated 150's->180's. lopressor 5mg iv with no effect given be dr. [**last name (stitle) 4952**].  bp low but map's greater than 60 until early afternoon when map dropped to 50's.  placed on neo, titrated for map of 60.  by mid afternoon levo added to maintain map.  multiple ns bolus' given, d5w given, ffp given, prbc's hung.  swan'd, cooling blanket on pt.  tmax=108.0 orally and rectally. ice under axilla, in groin and under head/around head.  minimal u/o.  hr remains elevated, temp remains elevated.

current status:  see carevue for subjective/objective data.  neuro:  pupils 5-6mm, non-reactive.  did note slight grimace in response to brother calling pts name.  no arm or leg movements noted.

cv/pulm:  vs remain labile with neo at 7mcg/kg/min and levo at 3.2mcg/min.  initial swan readings ra 15, rv 35/11, pa 37/14, wedge 5. have attempted to wedge post insertion-->unable.  pcxr post insertion no pneumo, line in good position [**name8 (md) 52**] md.  pa at 52cm.  remains vented on cpap+ps 20/5, 100%, tv600.  bs coarse bil.  suctioned initially for copious amts thick/tenacious tan sputum both orally and via ett.  now no secretions when suctioned.  prbc's #1and #2 currently infusing; no adverse reactions noted.  tmax=108 both orally and rectally.  axilla, groin, head and neck packed in ice with cooling blanket on.  current temp=107.1 core.

gi/gu:  ogt placed by md-->lg amts coffee ground material obtained.  lavaged till clear, intermittently lavaged.  on protonix.  u/o scant; md's aware.  urine concentrated.

iv access:  swan placed, r groin triple lumen catheter and 20guage periph iv.

id:  tmax=108 po and rectally.  on rocephin, vanco, flagyl and levo.  bcx2 sent, urine for c+s sent.  unable to obtain sputum for c+s.

psychosocial:  sister and brothers in to visit.  emotional support given to pt and fam.  fam updated by md--aware of grave prognisis.  pt is full code.
"
3822,"resp: pt remains intubated on a/c 28/350/+5/40%. bs are slightly coarse with notable improvement from yesterday. suctioning small amounts of tan secretions. mdi's administered q4 alb with no adverse reactions. ve's 10l, 02 sats @ 99%. peep decreased from 10 to 5 this shift. rsbi attempted but no resps. am abg's 7.32/43/144/23. will continue full [** **] support.
"
3823,"resp: [**name (ni) 158**] pt on pcv pinsp 19/r18/+5/40%/dp 10. [**last name (un) 3028**] trach @8, 8 @ trach site. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amount of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. while performing trach care pt began to forceful cough and trach was disloged. re-inserted with 4cc sterile water for 30 cmh20 to seal, no cuff leak noted. x-ray reveals trach to be approx 2-3 cm above carina. md verified. vent changes to ^ pinsp to 22 with dp of 19. vt's 300-400. no further changes noted.
"
3824,"resp: [**name (ni) 158**] pt on a/c 20/500/10+/40%. ett 7.5, rotated, and secured @ 24 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow secretions. changed circuit to heated wire. mdi's administered as ordered with no adverse reactions. am abg 7.48/38/130/29. vent changes to decrease peep to 5 and rate to 16. rsbi attempted and bp ^ to 190 and terminated. plan: continue to wean as tolerated.
"
3825,"resp: pt presently on 5 lpm n/c maintaining 02 sats 94-96% and comfortable. nebs administered alb/atr with no adverse reactions. continue to monitor pt with bipap @ bedside when needed.
"
3826,"resp: [**name (ni) 158**] pt on ps 8/40%/0+.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. rsbi=47. pt presently on ps5/40%. 02 sats @97% rr 19. will continue to wean. possible t/c trial today.
"
3827,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] ac 18/600/13+/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases. mdi's administered q4 hrs combivent with no adverse reactions. suctioned small to moderated amounts of tannish thick secretions.  plan to lighten up on sedation and proceed to wean.  possible psv today? no rsbi performed due to level of peep. am abg's 7.47/33/118/25.
"
3828,"resp: [**name (ni) 158**] pt on pcv 18/12/dp 13/+5/40%. [**last name (un) 3028**] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white/yellow secretions. mdi's administered alb/atr with no adverse reactions. attempted psv although pt did not tolerated. no abg's rsbi=>200.
"
3829,"resp: [**name (ni) 158**] pt on a/c 22/550/10+/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amount of bloody secretions. mdi's administered q4 hrs alb with no adverse reactions. ett 7.5, 24 @ lip, 22 cp. pt had episode of desating, temporarily placed on 100%, then returned to 50%. [**name (ni) **] changes to decrease tv to 350 and ^ rr to 28. last abg 7.32/40/196/22. am abg pending. no further changes noted.
"
3830,"resp: pt intubated for impending respiratoy failure. bilaterally insp/exp wheezes with no improvement following nebs. ett #8 secured @ 22 lip. planced on a/c 18/500/+5/60%. mdi's administered alb/atr with no adverse reactions. abg 7.44/31/161/22. rsbi=54. wean rr to 14. plan maintain present settings.
"
3831,"resp: [**name (ni) 158**] pt on simv 6/400/15/5+/40%. ett 7.5 retaped, rotated and secured @ 23 lip.  bs are coarse with diminished bases. suctioned for small amounts of yellow/white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.45/37/123/27. rsbi=153. plan to continue to wean as tolerated.
"
3832,"resp: [**name (ni) 158**] pt on psv 10/5/40%.ett#8, 22 lip. bs are clear with diminished bases. suctioned for small amount of white secretions. mdi's administered q4 hrs combivent with no adverse reactions. abg's indicate uncompensated metabolic acidosis. am abg pending.
"
3833,"resp:  [**name (ni) 158**] pt on [**last name (un) **] a/c 12/450/10+/35%.  alarms on and functioning. ambu/syringe/spare trach @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x2 for small amount of  thick whitish/tan secretions. cuff pressure checked and noted positional leak.  mdi's administered q4 hrs of alb/atr with no adverse reactions. vent changes to psv 10/10/35% with 02 sats in ^ 90's. no rsbi performed ^ peep.  no further changes noted.
"
3834,"resp: pt rec'd on psv 15/5/40%. ett 7.5, 23 @ lip. bs reveal bilateral clear apecies with diminished bases, occasional coarseness noted. suctioned for small amounts of thick yellow and rusty plugs. pt circuit changed to  heated wire circuit. mdi's administered alb/atr with no adverse reactions. abg 7.41/43/94/28. pt ^ wob with rr's to 45 then placed on a/c 14/500/+5/40%. pt continues on cvvhd. plan to maintain present setting and monitor to wean back on psv when appropriate. rsbi=>200
"
3835,"resp: [**name (ni) 158**] pt on a/c 14/500/+5/40%. bs reveal noted aeration with some coarse sounds. suctioned for large amount of thick bloody tinged secretions with plugs toward end of shift. mdi's administered alb/atr with no adverse reactions. vbg's (see careview) which vent changes reflect. present settings a/c 8/400/+5/40%. rsbi=>200. family meeting to discuss cmo status. will continue full vent support. pt continues on cvvhd.
"
3836,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 14/+10/35%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick yellow secretions.  mdi's administered q4 hr of alb/atr with no adverse reactions.  cuff pressure @ 21 cmh20. 02 sats @ 98%.  no further changes noted.
"
3837,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/10/35%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suction x2 small amount of whitish/yellow thick secretions.  mdi's administered q4 alb/atr with no adverse reactions.  02 sats in ^ 90's.  no rsbi due to ^ peep.  no further changes noted.
"
3838,"resp: [**name (ni) 158**] pt on a/c 14/600/+5/30%. bs are coarse bilaterally which clear with suctioning. pt has strong cough/gag reflex.  suctioned for moderate to large amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. [**name (ni) **] changes to decrease rate to 10. no abg's pending. will continue to wean as tolerated.
"
3839,"resp: pt was extubated on [**3-29**] and placed on n/c @ 2 lpm. 02 saturation in 80's then ^ to 4 lpm.  ordered hhn ud atrovent q6 hrs and administered with no adverse reactions. pt is mouth breather so placed on humidified f/t @ 70% without n/c. 02 sats 95-97%. will continue to follow.
"
3840,"resp: pt rec'd on [**last name (un) 647**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. cp @ 22 cmh20. ett re=taped and secured @ 24 lip. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered combivent q4 hrs/[**last name (un) **] [**hospital1 10**] with no adverse reactions. vent changes to +5 with am abg's 7.40/43/157/28. plans to wean to extubate, although secretions still copious. continue vent support.
"
3841,"npn7a-7p
neuro: pt using voc board to com. needs. dozing on & off all day, but easily arousable. anxious in am. tx'd w/ repos. 1mg ativan & 50mcg of fentanyl w/ good effect.
resp: recent abg's per pt's baseline. cont. to monitor sats & abg's as ordered. sxn' prn.
cv: hypotensive to sbp 80's following 50mg lopressor via ngt. team aware. bp corrected w/out need for ivf bolus & ivgtt. afebrile. nsr hr 90-106. no ectopy noted. +doppler bilat le pulses, cool to touch cyanotic in appearance. +2 edema r>l. rece'd ivig over 41/2 hr w/out adverse reactions.
gi/gu: npo. nepro tf @ goal of 40cc/hr. +bs +bm soft brown. foley draining adequate urine clear & yellow in color.
integ: skin tears w/ tegaderm drsgs reapplied over face & cocyx. staples in tact over lami inc site. no drainage noted.
endo: bs wnl. no coverage required w/ riss.
plan: goal for i/o negative to help prepare for possible extubation [**7-8**]. monitor hct, abg's as needed.
"
3842,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 12/5/50%/ alarms on and functioning.  ambu/syringe @ hob. minimal leak tech for notable leak in cuff.  bs auscultated reveal rs clear with ls diminished bs.  mdi's administered q4 alb with no adverse reactions noted.  suctioned x3 small to moderate amount of thick bloody secretions.  vt returned 400-500/ve [**7-29**].  02 sats remain in ^ 90's.  rsbi= 115. no vent changes noted.
"
3843,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] psv 10/10/35%. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small amount of thick white secretions. mdi's administered q4 hrs with no adverse reactions. pt does continue to have periods of bronchospasms, but no resp distress noted.  rsbi=163.  decreased peep to 8.  no further changes noted.
"
3844,"resp: [**name (ni) 158**] pt on a/c 12/500/5+/60%. ett #7.5, 23 @ lip. bs auscultated reveal bilateral exp wheeze. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered alb q4 with no adverse reactions. am abg 7.35/37/89/33. rsbi=115. plan is to wean as tolerated and extubate if possible.
"
3845,"resp: [**name (ni) 158**] pt on psv 16/8/50%. pt is trached #8 portex. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. pt has periods of anxiety with ^ rr to 40's. rsbi=65. am abg 7.45/42/108/30.
"
3846,"resp:  [**name (ni) **] pt on [**name (ni) **] psv 10/5 50%. alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal increase in aeration with improvement noted.  suctioned small to moderate amounts of thick yellow secretions.  mdi's administered with no adverse reactions.  rsbi=58,sbt initiated.  pt [**name (ni) 6577**] 20minutes ^rr. ^bp, ^hr then returned pt to present settings of [**9-23**] where they remain.  no further changes noted.
"
3847,"resp: pt rec'd on a/c 30/380/16+/50%. bs are coarse bilaterally. suctioned for large amounts of bloody tinged thick secretions. ambu @ hob. mdi's administered as ordered alb/atr with no adverse reactions. no changes this shift. pt remains on cvvhd. no platetles given. no rsbi=^ peep. will continue with present mode of ventilation.
"
3848,"resp: [**name (ni) **] pt on a/c 30/380/15+/60%. ett 7.5, taped @ 23 lip. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of rusty/bloody tinged thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg's (see carview). vent changes to decrease peep to 14. am abhg 7.37/44/89/26. no rsbi due to ^ peep. pt remains on cvvhd. will contine to wean as tolerated.
"
3849,"resp: [**name (ni) **] pt on psv 10/5/40%. ett#8, retaped and secured @ 22 lip. bs are clear with diminished bases bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. rsbi=66. no changes this shift.family meeting today?  plan to wean as tolerated.
"
3850,"nursing note 7a-7p
neuro-sedated, when weaned off propofol pt is able to follow commands,and deny pain.  perrla.

cv- hr 60's, v-paced with frequent fusion of intermittant underlying a-fib.  pedal pulses l>r. rle cool, pale, md notified.  right groin angio site intact with bandaid.  us on ble's wnl.  bp's 120's 40's. right radial line zero'd and level'd.  cvp line zero'd and leveled. compression boots on, tol well.

resp- vented on assist control fi02 40% sat maintained at 100%. suct x3-scant thick clear, some blood tinged sputum noted.  lung sounds-rhonchi. see carevue for gases and lab results.

gi/gu- abd grossly distended, soft, nontender.  +bowel sounds.  rectal bag in place, maroon colored liquid stool noted.  scant amt from this shift.  foley patent-drg dk yellow clear urine. output is poor. < 150ccs this shift.  md is aware.  ng tube-cont low suction-bilious drg.

heme- mtemp 98.7ax. this shift.  this am temp 95, 96 po, intervened with bair hugger blanket, and fluid warmer.  temp is stable at this time.  pt received 6 units of prbc, 4 units of ffp and 1 unit of platelets, no adverse reactions noted.  hct previous to infusion was 19.5 post transfusion 26.4.  see carevue for more details. bc-still pending.

endo- propofol infusing at 40mcg/hour, insulin gtt infusing at 1.5units/hour.  last blood glucose at 1600 was 93.  pt was weaned off propofol twice this shift to assess for pain, denies pain and able to follow commands.

pt had an exploratory laparoscopy this am - bleed ruled out.  ct scan done at 1330 results- right groin, small hematoma found. rle us done- results wnl. left and right wrist iv's infiltrated, and dc'd.  l ac #18 wnl. right ij wnl. flagyl, levaquin, and vanco started secondary to ? sepsis.

assess- 83 yo w/acute lower gi bleed, s/p embolization; complicated by acute resp distress, intubation; s/p diagnostic lap. ? arf.

poc-will cont to attempt to wean 02, insulin and propofol gtt's. will cont to monitor hct & coags,stools,and urine output.

"
3851,"resp: pt remains intubated #8 ett, 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. no abg's this shift or vent changes. rsbi=36. plan to trach/peg today in or.
"
3852,"resp: pt remains mechanically vented on simv 16/650/+5/10/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated with mostly clears sounds, and occasional rs wheeze noted. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. suctioned minimal amounts of white secretions. am abg's 7.41/32/119/21. reduction in temp. will continue to wean appropriately. no further changes noted.
"
3853,"resp: pt rec'd p/o intubated ett #7.5, 19@ lip retaped and secured. bs reveal coarse sounds bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr with no adverse reactions. pt desated to 92, then ^ peep to 8, abg's 7.42/44/204/30. decreased peep to 5 with 02 sats 98%. rsbi=no spont resp. will continue full vent support.
"
3854,"resp: pt remains intubated/trached #8 portex. bs are coarse and suctioning moderate amounts of thick bloody tinged secretions. mdi administered q4 alb/atr with no adverse reactions. vent settings psv 5/5/50%. rsbi-43. no abg this shift.
"
3855,"resp: pt remains intubated on psv 10/5/30% with no changes noc. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. sputum sample obtained and sent. mdi's administered q4 hrs with no adverse reactions. pt remains on [** **]. possible trach this week. will continue on psv. no abg's, aline removed.
"
3856,"resp: [**name (ni) **] pt on psv 12/5/40%. ett#7.5 taped @ 25 lip. bs are clear with diminished bases. vent changes reflect abg's (see carview) suctioned for small amounts of yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.30/45/113/23. present settings psv 14/5/50%. vt's 350-400. plan to trach/peg in or today.
"
3857,"resp: [**name (ni) **] pt on a/c 20/600/+5/50%. bs are clear bilateral. suctioned for scant amounts of white secretions. mdi's combivent q4 with no adverse reactions. vent changes relfect abg's (see carveiw) pt remains paralized/sedated. present settings. a/c 12/550/+5/30% with am abg's 7.41/40/121/26. no further changes noted.
"
3858,"resp: [**name (ni) **] pt on psv 8/2/40%. #8 portex trach. bs are coarse bilaterally with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. no abg's this shift. rsbi=39. will continue to wean as tolerated.
"
3859,"resp:  [**name (ni) **] pt on [**last name (un) 205**] cpap/ps [**11-20**] 40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral mild coarse sounds which clear with suctioning.  suctioned x3 scant-small amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  ett re-taped & secured.  no distress noted. rsbi=32, sbt initiated and maintaining tv's 500-600, with 02 sats ^90's.  no further changes noted.
"
3860,"resp:  [**name (ni) **] pt on [**last name (un) 205**] ps 5/+5/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse bs which clear with suctioning.  suctioned x3 small amount of thick yellow secretions, and oral cavity. mdi's administered atr/alb q4 with no adverse reactions.  rsbi=26 and sbt initiated.  no further changes noted.

"
3861,"resp: [**name (ni) **] pt on 7200 psv 10/+5/40%.  alarms on and functioning.  amubu/syringe @ hob with spare trach.  bs auscultated reveal bilateral coarse apecies with diminished bases.  suctioned x3 small to moderated amoutn of tanish thick secretions. mdi's administered q4 combivient with no adverse reactions. pt's trach positional.  pt is out of bed sitting in chair.  rr at base line 30's increases when anxious.  rsbi=112.5 with no further changes noted.
"
3862,"resp:  [**name (ni) **] pt on [**last name (un) 205**] cpap/ps 12/10/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small amounts of thick yellow secretions, and oral cavity.  mdi's administered alb/atr 6p q4 hrs with no adverse reactions.  vent changes as follows; peep decreased to 8, where it remains.  rsbi performed =70.  no further changes noted.
"
3863,"resp care
pt remains on vent. changes made according to protocols. mdis given with good effect: decreased vent pressures.  no adverse reactions. will continue to mointor
"
3864,"resp: [**name (ni) 158**] pt on a/c 14/650/+5/40%. ett 7.5 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow to tannish secretions with some bloody tinged.  mdi's ordered alb/atr q4 and administered with no adverse reactions. large amounts of thick clear to white oral secretions as well. no aline, vbg's (see careview) vent changes to decrease vt to 550, ^ rr to 18. 02 sats @ 100% with am vbg  7.41/44/29. rsbi=70. no further changes noted, pt in/out of a-fib.
"
3865,"pt. completed asa desensitization protocol. last asa dose 2355. tol process well with no known adverse reactions at this time. slept well throughout the night being npo after midnight for ? cardiac cath today. one mod loose stool. voiding in commode.
plan cardiac cath today. ? plavix [**hospital1 **] vs. qd now pt. on asa. needs to be clarified. plavix was [**hospital1 **] at home and pt. got it [**hospital1 **] yesterday.
plan transfer to floor if needed. pt. stable. repeat k=3.8 not hemolized.
"
3866,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 10/550/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal diminished bases. mdi's administered q4 alb/atr with no adverse reactions. suctioned for small amounts of tan thick secretions. am abg's 7.32/47/111/25.rsbi attempted with no spont. resp. noted.  plan to wean sedation this am and place on psv when appropriate.
"
3867,"npn 7a-2p

events:  pt. restarted on heparin (at 800u/hr), sent to cath lab for cardiac cathertization at 1400.  pt. with transient hypotension and low u/o today.  c/o of cp x 1 resolving without intervention.

neuro:  a+o x 3.  pleasant and cooperative.  anxious about cath.  medicated x 1 w/ 1 tab vicodin for lower back pain; [**8-23**].  pt. takes vicodin at home per her report despite hx. stating she has morphine allergy.  pt. without adverse reactions and pain dissapated; 0/10.  pt. decribes that her pcp believes her to have sleep apnea with insomnia; takes ambien at home as well for sleep.

resp:  sat's maintained >95% on 4l nc.  + smoker 1/2-1 pack/ day.  ls- clear/ diminished bases.  productive cough.

cv:  team describing weekends' events as ischemia, not infarction d/t unstable angina.  cp x 1 with no other associated symptoms; denied sob.  of note, pt. reported cp when asked.  30 minutes prior to onset of cp, pt. received vicodin for back pain.  no further narcotics were administered as pt. stated that cp or ""pressure"" was resolving on own.  no nitrates administered.  sbp 90's (manually/ doppler).  ho called immediately.  pt. started on heparin prior to onset of cp as well at 800u/hr with no bolus.  pt. sent to cath lab at 1400 after consent obtained by pt. and son.  [**name (ni) **] at bedside.    hr 60's.  bp 90's.  ivf started prior to cath at 125cc/hr of ns with 500cc fb.

gi:  pt. encouraged to drink po's d/t poor u/o, then made npo for cath.  abd wound dressings done at 8am; packed with several yards of nu-gauze; wounds tunnel.  wounds with serosanginous output.  no bm.  + bs.

gu:  u/o minimal.  ivf started prior to cath.

id:  pt. receiving pcn and flagyl rtc.  afebrile.

plan-  s/p cath care, hct s/p cath with wbc.  check ptt on 800u at 6:30pm.
"
3868,"resp: pt rec'd on simv 18/500/12/+8/40%. ett 7.5, retaped, rotated and secured @ 23 lip. alarms on and functioning. ambu/syringe @ hob. bs reveal slightly coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. cuff pressure @ 20 with no notable [** **], foul odor still exists from oral cavity. no rsbi due to hemodynamic instability. no changed noc. will continue full vent support.
"
3869,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] psv 12/8/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear apecies with diminshed bases. suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs alb with no adverse reactions. ett @ 24 lip, cuff pressure 20. am abg's 7.43/47/73/32. rsbi=142. will continue to wean appropriately.
"
3870,"resp: pt on 40% hiflow. bs are clear. nebs administered q6 hrs alb/atr. plumicort [**hospital1 **] with no adverse reactions. will continue to follow and treat.
"
3871,"respiratory: [**name (ni) **] pt on 7200 psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse bs which improve with suctioning.  mdi's administered q4hr combivent with no adverse reactions.  suctioned x3 small to moderate amounts of thick yellowish secretions.  rsbi=117.6 no further changes noted.










































"
3872,"1900-0700

general: pt remains sedated with cont'd mechanical ventilation. prbc transfusion completed with no adverse reactions: repeat hct-30.8,wbc-16.5. no changes made to vent through night, o2sat 92-97%.

neuro: pt reamins sedated, eye twitching noted to painful stimuli. minimal to no movement of ext noted. pupils 3mm bilaterally with r-brisk and l-sluggish.

resp: pt remains orally intubated with # 8.0 ett 24cm @ lip line. vent settings remain ac tv 600, 70% 35, peep 20. mv-22.o2sat 92-97%. suctioned for scant thick blood tinged secretions. abg 4am: 7.24, 69, 60, 27, lactic acid-2.2. lungs on r-rhonchi,l-coarse through lung field. oral cavity with bleeding gums and sinusitus noted.

cv: nsr-s.tachycardia with rare pacs noted. max temp 99.8 orally, bp 120-165/50's. hr 90-110. cvp-[**9-23**]. generalized edema noted to ext. pulses to lower ext by doppler. triadayne bed in use with rotation and percussion. compressive boots/foot drop splints on.

gu/gi: abd firmly distended with + bs noted. liquid diarrhea noted, occult neg-fecal incont bag applied with double skin barrier. ogt to liws draining bilious fluid, irrigated for questionable internal bleeding-negative. foley catheter to bsd draining clear yellow urine. lasix given at 2300. pt -800 at this point for 24hrs. na-152, bun-79, cr-1.7,

endo: insulin drip remains titrated to bs. bs 120-150.

iv: r radial aline zeroed and calibrated with sharp waveform. l ij tlc intact with [**month/year (2) **] @ 5mg/hr, fentanyl@ 80mcg/hr, lr@ 10cc/hr, insulin@3u/hr, [**e-mail address 6573**]/hr.

plan: continue supportive measures. family meeting today.

                       [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
3873,"resp: pt remains intubated on psv 10/5/50%. bs are clear in apecies with diminished bases. sucitoned for small amounts of thick white secretions. (see careview for abg's) rsbi=55. mdi's administered q4 alb/atr with no adverse reactions.
"
3874,"npn 7a-7p

events-  abd ct done with gastrografin (not barocat), results pending, conts to stool (500 out this shift), transitioned to psv this afternoon, hct stable, wbc increasing again...

review of systems-

[**name (ni) **]  pt. nodding appropriately, eyes closed most of the shift, denying pain except x 1 when she was medicated with 2mg of mso4 w/ good effect.  family cautions use of versed/ ativan d/t adverse reactions to benzo's in the past- pt. reportedly becomes confused and disoriented.

resp-  received on a/c, transitioned to psv- will obtain evening abg.  ls- diminished throughout... sat's stable.  sx'd for thick white secretions.  would obtain sample if turns purulent- appears to be nasalpharyngeal ? sinusitis...

cv-  hr 80's-90's sometimes appears to be in nsr, others appears to be in aflutter- conts on amiodorone iv d/t poor tolerance of pos. bp stable via arterial line.  pm hct stable >32.  e-lytes repleted this am received 80meq of kcl, ca+ and mg+.  skin appears distressed and friable, oozing from extremeties.

gi-  abd conts to be firm and distended, tender to touch.  flexiseal device inserted and appears to be draining and containing stool well- 500cc output thus far.  no further go-lytely given today, would consider after ct results interpreted.  lactulose d/c'd as it could be causing increased flatus.

gu-  u/o adequate.  d5w changed to po 250cc q 4hours to save on input. tpn also adjusted to decrease sodium and improve e-lyte imbalance.  nutritionist recommending we not replete imbalance tom'row am as new bag of tpn should correct.

id-  afebrile.  off abx.  ? sinus drainage causing secretions.

[**name (ni) 4**]  husband and youngest dtr, [**name (ni) 169**] to visit and updated on plan of care.  also talked with dtr, [**name (ni) **] and plans to meet w/ fellow dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 5901**] tom'row to discuss timeline.
"
3875,"resp:  [**name (ni) **] pt on a/c 16/500/+5/50%. ett #7.5 found @ 24, retaped,pulled badk to 22 as charted @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small amounts of white secretions. mdi's administered as ordered atr/alb with no adverse reactions. am abg 7.41/41/147/27. no changes noc. rsbi=50. plan to wean to psv as tolerated.
"
3876,"resp: [**name (ni) **] pt on niv psv 14/4/50%. placed pt on 50% cam and tolerated well for 2-3 hrs then ^ wob with ^ co2. mdi's administered a/b/atr and hhn with no adverse reactions. bs are clear bilaterally. placed back on niv am abg 7.38/45/147/28. will attempt to wean as tolerated.
"
3877,"respiratory care
pt remains trached (#8.0 portex) with cuff inflated and no [** **] present. pt remains on fio2 0.35 via trach mask. lung sounds were course to clear and dim in the bases. suctioned for sm-mod thk yellow and once for small thin bloody secretions. nebs were given with no adverse reactions. no abg's were drawn during shift. care plan is to continue nebs as ordered and continue to suction prn. rehab screen started. will continue to follow pt.
"
3878,"resp: [**name (ni) **] pt on psv 12/5+/40% bs are coarse bilaterally. suctioning small to moderate amounts of thick white to yellow secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. rsbi=28. plan to continue to wean down psv, with possible t/c trials as tolerated.
"
3879,"resp: [**name (ni) **] pt on simv 24/550/ps5/+16/50%. ett 7.5, retaped and secured @ 23 lip as per xray correct placement, although being charted at 21. bs are diminished with noted aeration in apecies. suctioned for scant amounts of white/yellowis secretions. mdi's administered combivent as ordered with no adverse reactions. cuff pressure @ 25 cmh20. am abg 7.42/44/101/30. no vent changes noc. no rsbi due to ^ peep. possible ct trip today?
"
3880,"resp: [**name (ni) **] pt on [**last name (un) 205**] simv6/650/5/+5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4hrs combivent with no adverse reactions. weaning initiated with vent settings @ psv 10/5/40%. am abg's 7.40/36/102.23. plan to continue to wean then extubate this am.
"
3881,"resp: [**name (ni) **] pt on psv 15/10 and pt became hyertensive then placed on a/c 16/500/+10/50%. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi' administered q4 (seecarevew) no adverse reactions. am abg's 7.39/378/111/24. plan to wean to psv this am
"
3882,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 16/500/+10/40%. alarms on and functioing. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate-copious amounts of thick yellow secretions. cp @ 22 cmh20. mdi's administered q4 hrs combivent q4/flovent [**hospital1 **] with no adverse reactions. vent changes reflect abg's (see [**hospital1 673**]) am abg's 7.39/39/97/24 on a/c 16/5///+5/40%. plan to continue full vent support.
"
3883,"resp: pt ordered for nebs alb q2 hrs/atro q6 hrs. pt on 2.5 lpm n/c. bs auscultated reveal bilateral insp/exp wheeze which improve following tx. had one short episode of bronchospasm with cough. no adverse reactions following administration of meds. 02 sats @ 99%. md to change order to q3 hrs alb.  will continue to follow. see carview
"
3884,"resp: [**name (ni) **] pt on psv 15/5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for copious amounts of thick bloody secretions/plugs. inner cannula changed. mdi's administered with no adverse reactions. am abg 7.42/35/85/23. plan to change trach to [**initials (namepattern4) **] [**last name (namepattern4) **] today.
"
3885,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with diminished bases. suctioned for small to moderate amounts of thick bloody tinged plugs. mdis administered q 4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. most recent abg 7.36/38/92/22. rsbi=52. no changes noc.
"
3886,"ccu npn
see carevue for subjective/objective data.  neuro:  confused to place and time, is oriented to self/family.  mae ad lib although weakly.  speech clear.  re-oriented frequently.

cv/pulm:  bp 90's-120's/30's-40's.  mp=afib 70's-80's with occ->freq mf pvc's.  cycling cpk's and hct's.  second of three units prbc currently infusing.  no adverse reactions noted during first unit, no adverse reactions noted thus far second unit.  developed bibasilar crackles, lasix 20mg iv given at start of second unit prbc.  rpt hct at 0200 done. hct 22.1 up from 19.9 (but done with blood infusing on opposite arm).  hct reported to dr. [**last name (stitle) **], third unit prbc ordered upon completion of current unit.  pt on room air with sats consistently 99-100%.  no sob or doe noted.

gi/gu:  npo.  two melena stools, liquid, approx 50ml each.  starting to diurese from lasix.

integ:  impaired--ecchymotic area noted l hip--pt states he ""falls alot"".   ecchymotic areas also noted on abdomen.  no open areas noted.

psychosocial:  daughter is rn w/vna of [**location (un) **].  emotional support given to pt and daughter.  sleeping in long naps.
"
3887,"resp: pt rec'd on psv 15/5/50%. pt remains on cvvhd. bilateral coarse bs. suctioned/lavarged for copious amounts of thick bloody/brown plugs. mdi's administered as ordered without adverse reactions. am abg 7.39/43/117/27. no further changes noted.
"
3888,"resp: [**name (ni) **] pt on psv 5/5/40%. #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for large amounts of thick tan secretions. mdi's administered as ordered alb with no adverse reactions. rsbi=62. am abg's 7.40/31/94/20. plan is to continue on trach trials as tolerated.
"
3889,"resp: [**name (ni) **] pt on a/c 10/500/+8/40%. trach #8 portex.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds. suctioned small amounts of white secretions. mdi's administered q4 hrs 6p alb with no adverse reactions. rsbi=67. placed pt on psv 10/5+/40% obtaining vt's 400-500's, rr 15, ve 6l. no further changes noted.
"
3890,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] on a/c 550/15/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of white thick secretions. mdi's administered q4 hrs of alb with no adverse reactions.  ett re-taped @ secured 21 lip line. cuff pressure @ 21. 02 sats 93, increased fio2 to 60% fio2 97%.  rsbi=136, no further changes noted.
"
3891,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/600/+10/60%.  ambu/syringe @ hob.  bs auscultated reveal ls clear with rs diminished.  suctioned x 3 small amounts of thick yellow secretions.  mdi's administered q4 hr alb/atr with no adverse reactions.  rsbi=26 and no further changes noted.
"
3892,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 16/500/+5/60%. alarms on and functioning. ambu/syringe @ hob. ett 7.5 retaped and secured @ 22 lip. cp @ 23 cmh20. bs auscultated reveal bilateral rhonchi, suctioning copious amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions.vent changes to ^ rr to 21, decrease fio2 to 50%.  am abg's 7.35/44/102/25. rsbi=54. no further changes noc. plan to bronch today in am. will continue full vent support.
"
3893,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 14/350/+14/70%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral aeration in apecies with diminished bases.  mdi's administered q4hrs alb/atr with no adverse reactions.  fio2 ^ 90% due to desaturation in 80's.  abg's drawn (see careview) fio2 decreased to 70% were they remain. am abg's 7.29/69/88/35.  02 sats @ 97%.pt remains on ards protocol.
"
3894,"resp: [**name (ni) 158**] pt on a/c 21/500/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions, some improvement noted. mdi's administered q4 hrs. combvient with no adverse reactions. am abg's 7.40/45/96/29. rsbi attempted but no spont resps.  will continue full vent support.
"
3895,"resp: rec'd on psv 10/5/40%. bs reveal bilateral wheezing. suctioned for small amounts of thin white secretions. mdi's administered as ordered with no adverse reactions. vt's 450's, ve's 11, rr 22. am abg 7.42/37/105/25. rsbi=89. no further changes noted.
"
3896,"resp. care
pt. remains on mech vent. flipped from simv/ps to cpap/ps at 0500. pt. has a patent 7.0ett secured at 21 at the lip and is being sx for mod amts of bloody secr. b/s are dim with a few scat wheezes. mdis given with good effect and no adverse reactions. aeration was better bilat. post rx.plan is to wean as tol. and extubate.
"
3897,"0200-0700
neuro: pt alert and oriented to self and place, confused at times. perrla. mae weakly, stiff. medicated w/ fentanyl gtt at 25mcg/hr, appears to be comfortable, except w/ hands on care, continues to yell at staff w/ bathing turning and repositioning.

cv: hr 60-70 sr rare pac occasional pvcs. k infusing through ivf at 75cc/hr. mg to be repleted. sbp 130-140s. hct 22.3, 2 units of prbcs ordered, 1st unit up at 0500, infusing, no adverse reactions see carevue for vs. weak palpable pedal pulses. 4+ pitting edema to ble.

resp: ls clear diminished bases. sats >98% on 2 lnc. see carevue for abgs.

gi/gu: abd soft hypoactive bs. ileostomy stoma pink draining greenish stool scant amts. stoma care done at [**2106**], dsg changed at that time. tf at 30cc/hr presently, goal of 80cc/hr, no residual via jtube. g tube to gravity draining greenish bile. urine and irrigation draining aroung foley balloon, could feel balloon when palpating bottom of penis, pa [**doctor last name 486**] aware, attempted to place another cathether unsuccessful pa [**doctor last name 486**] aware, to keep foley out and urology to see in am per pa [**doctor last name 486**].

endo: no coverage needed.

skin: wound care per wound care orders. see carevue. penis and scrotum very edematous, pa [**doctor last name 486**] aware.

plan: monitor hemodynamics. one more unit of prbcs. monitor resp. status. stoma care. skin care. follow labs and treat as appropriate. urology to see pt to place foley cath.
"
3898,"resp: [**name (ni) 158**] pt on [**last name (un) 647**] a/c 26/500/+10/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered q4 hrs alb with no adverse reactions. no wheezes noted. am abg's 7.46/44/131/32. scheduled trip to or for repair of pelvis. no further changes noted.
"
3899,"resp: [**name (ni) 158**] pt on a/c 20/450/+8/100%. bs are slightly coarse, and suctioning small amounts of tan secretions, trach site clear. mdi's administered q4 hrs alb/atr with no adverse reactions. abg's (see careview) vent changes to ^ rr to 22, decrease fi02 to 60%. am abg pending. will continue to wean appropriately.
"
3900,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] ps5/+10/50%.  ambu/syringe @ hob.  auscultated bs reveal coarse bs on ls with diminished on rs.  suctioned thick copious yellow secretions x3 as well as from oral cavity.  mdi's adminishered q4 hrs alb/atr with no adverse reactions.  vent changes as follows: ac 16/600/40% @ [**2097**] with no further changes during noc.  rsbi=34.
"
3901,"resp: [**name (ni) **] pt on psv 10/5/40%. bs reveal bilateral wheezing. suctioned for small amounts of thin white secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=77. no changes or abg's this shift.
"
3902,"resp: pt rec'd on psv 25/8/60%. bs are coarse bilateraly with noted wheeze. mdi's administered q4 alb/atr with no adverse reactions. am abg 7.37/46/98/28. decreased ps to 20, tv 400's rr, 20, 02 sats 99%. will continue to wean as tolerated.
"
3903,"resp:  [**name (ni) 158**] pt on [**last name (un) 647**] a/c 15/550/60%/+5.  alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with diminished bases. 02 sats 93-96%.  suctioned small amounts of thick white secretions, clear from oral cavity. mdi's administered q4 hr alb with no adverse reactions. am abg's 7.26/40/108/19 with no changes.  family to discuss possible withdrawal of support.
"
3904,"resp:  [**name (ni) **] pt on [**last name (un) **] psv 20/10/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick whitish/yellow secretions,pooling secretions in oral cavity.  pt rr ^ to 30's and pt becoming tired, placed back on simv noc to rest. placed back on psv 20/10/40% this am. mdi's administered q4 hr combivent with no adverse reactions.  02sats ^90's no distress noted.  vent settings remain at present settings.
"
3905,"1600-1900
pt is a 70 year old female admitted s/p cabg x4, see admission h+p for details of history and details of events in or. oozy through chest tube on arrival, act 159,  np [**doctor last name **] and dr [**last name (stitle) 1348**] aware, protamine 50mg iv given,peep increased, labs sent, np [**doctor last name **] aware, plts ordered and given, no adverse reactions.

neuro: pt sedated on propofol gtt. perrla.

cv: received from or w/ hr sr 80-90s. epicardial wires work per anesthesia. ekg done. sbp 110-120s on ntg as high as 1.5, see carevue. goal sbp<130. ci>2. pa 20s/15, cvp 7-11. 1l of lr given and 468cc of plts given for volume. dopplerable pedal pulses. k repeted. np [**doctor last name **] aware of mg and phosphate, repeat phosphate sent.

resp: ls clear. see carevue and ccc for abgs and vent changes. presently on fio2 of 60%, rate 12,peep 10. sats 100%. ct draining sang. drainage on arrival 30-60cc q 15min, np [**name6 (md) **] and md [**doctor last name 1348**] aware, protamine and plts given, at present 10-20cc q15-30min.

gi/gu: abd soft absent bs. ogt +placement, draining bilious secretions. foley draining adequate amts of clear yellow urine.

endo: gtt started at 1845 for glucose 116.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. monitor for bleeding, once stable, wake and wean as pt tolerates.
"
3906,"resp: pt rec'd on a/c 22/400/40%/+5. bs are coarse with diminished bases. suctioned small amounts of thick/thin white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=no spont resp. no changes noc.  will continue full [** **] support.
"
3907,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 20/450/10+/50%. alarms on and functioning.ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of tan secretions, as well as oral cavity. mdi's combivent administered with no adverse reactions. will continue full vent support.
"
3908,"resp: [**name (ni) **] pt on a/c 12/400/5+/40%. pt has #8 portex trach. ambu/syringe @ hob. alarms on and functioning. bs are diminished with occasional wheeze noted. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. abg's (see careview) vent changes to ^ fio2 to 60% following abg. no [**last name (un) 125**] due to hemodynamic status. no further changes noted.
"
3909,"resp:  [**name (ni) **] pt on [**last name (un) 205**] pcv 22/+5/rr 18/50%/dp 17.  alarms on and functioning.  bs auscultated reveal bilateral diminished sounds. suctioned for small-moderate amounts of thick white secretions. mdi's administered q6 hrs combivent/flovent [**hospital1 **] with no adverse reactions. rsbi=124. no abg's drawn (no a-line) plans to transfer to rehab when bed available.
"
3910,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions with occasional plugging noted.  mdi's administered q4 hrs combivent with no adverse reactions.  no further changes noted.
"
3911,"resp: pt remains on aprv 34/8/2.7/0.3.40% with no changes noc. mdi's administered q4 hrs alb/atr with no adverse reactions. suctioned for small amount of white secretions. am abg 7.42/44/176/30. will continue support.
"
3912,"resp: rec'd on simv 16/400/5/5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe 2 hob. bs are diminished bilaerally with scattered occasional crackles. suctioned for scant amounts of secretions. mdi's administered as ordered ofcombivent with no adverse reactions. no changes this shift. no [** **] due to hemodynamic issues. pt 02 sats decrease to 80's as well as bp. will continue on present settings. see careview for abg's.
"
3913,"resp: pt remains intubated on aprv 34/8/2.7/0.3/40%. bs reveal bilateral aeration. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.48/32/169/25. no changes noc. [**month (only) **] initiate wean this am.
"
3914,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv 16/650/10+/5/60%.  ambu/syringe @ hob.  auscultated bs reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 moderate to copious amounts of thick yellow secretions.  mdi's administered of albuterol q4 hrs with no adverse reactions.  [**last name (un) **]=52.  no further changes noted.
"
3915,"micu npn
see carevue for subjective/objective data.  neuro:  alert to person, able to accurately state that is in [**hospital1 10**] however confused to time, events of noc, recent events--answering ""no"" to all questions.  moving arms, legs weakly.  speech clear.

cv/pulm:  vs per carevue--at beginning of shift bp low 80's on dopamine at 10mcg/kg/min.  d5ns at 250ml/hr given with bp gradually increased to 100's.  dopa decreased to 10mcg/kg/min with sbp maintaining 100 range.  np at 4l cont.  bs clear upper lobes, crackles developing lower lobes.  overnoc 4units ffp and 2units prbc's given--all without adverse reactions.

gi/gu:  pt npo.  ngt placed by dr. [**last name (stitle) 1752**].  baricat 900ml given however pt [**name prefix (prefixes) **] [**last name (prefixes) 2332**] 100ml around ngt.  to ct for ct of abd at 2400.  ct revealed ischemic colon-->pt rec'd ffp and prbc prior to transporting to or.  to or at 0430 by anesthesia for resection and ileostomy.  four of five sons with pt prior to leaving for or.  u/o borderline qs prior to fluids and blood/blood products not u/o qs q1h.

id:  tmax=100.7 po.  on gent, ampicillin and flagyl.  cultures pending.  ct positive for ischemic bowel as noted above.

integ:  buttocks excorriated.  stool grossly ob positive (dr. [**last name (stitle) 1752**] aware).  skin dry, no open areas noted.

psychosocial:  sons in to see pt upon adm to icu and again prior to leaving for or.  all pt's belongings (including clothes, purse, dentures and two rings--one yellow ring with green stone and one yellow ring with pink and white stones) sent home with son [**name (ni) 9494**].
emotional support given to pt and family.  trans to or at 0430 via bed with anesthesia.
"
3916,"resp: [**name (ni) **] pt on simv 16/400/5/+5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. inner cannula cleaned. pt remains on cvvhd with improved abg's. 7.39/44/108/28. [**last name (un) **]=113. during [**name (ni) **] pt bp decreased, 02 sats to 80's ^ wob. pt placed on 100% fio2 temporarily. plan to continue with support, no weaning expected today.
"
3917,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 16/10/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of thick whitish/yellowish secretions, as well as oral cavity.  mdi's administered q4 hrs combivent with no adverse reactions.  rsbi=60, sbt initiated.  no further changes noted.
"
3918,"respiratory care note:
     patient remains trached with a #8.0 portex.  cuff pressure measured and maintained at ~30.  bs are coarse throughout.  sx for small to often moderate amounts of thick pale yellow secretions via trach.  [** **]'s administered as ordered with no adverse reactions.  patient remained afebrile this shift.  rsbi this am is 57.6 on 0 peep and 5 psv.  spo2 remains 93-97%.  no abg's this shift.  will maintain current therapy.
"
3919,"resp: [**name (ni) **] pt on psv 10/5/50%. bs reveal clear apecies on ls, rs diminished. suctioned for moderate amounts of thick yellow secretions with some bloody tinged. mdi's administered q6 combivent with no adverse reactions. am abg's 7.33/46/115/25. fio2 decreased to 40%, ps to 5. rsbi=43. plan to continue with wean to sbt this am with possible extubation today.
"
3920,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 15/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds. mdi's administered q4 hrs combivent with no adverse reactions. suctioned for small to moderate amounts of tan thick secretions. fio2 decreased to 30%.am abg's 7.30/42/103/21. rsbi attempted and pt became very aggitated, ^ rr with low tv's. no further changes noted.
"
3921,"resp: [**name (ni) **] pt on [**last name (un) 205**] psv 18/10/40%  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned/lavarged for some thick tannish secretions & plugs. mdi's administered q4 hrs alb/atr / flov [**hospital1 **] with no adverse reactions. vent changes; ^ ps to 20 with no further changes noted. 02 sats remain @ 100%.
"
3922,"resp: [**name (ni) **] pt on a/c 14/600/+10/50%. pt has #8 portex trach with notable leak. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned moderate amounts of thick white/yellow secretions. [**name (ni) **]'s administered alb/atr/[**last name (un) **] as ordered with no adverse reactions. abg 7.38/61/119/37. no changes noc. will continue full vent support.
"
3923,"micu nsg admission note
25 y.o. woman admitted w/ drug od, s/p suicide attempt. intubated in ew to manage airway, sedated, narcan, mucomyst, ivf-> micu for management.

allergies: haldol (mother states she gets a rash and adverse reaction)
           thorazine (mother states she has adverse reactions)

phx: hx depression w/ multiple suicide attempts s/p sexual assault.
hx self mutilation, has multiple scars over arms and body. discharged from [**hospital 222**] hospital yesterday.

ros:

neuro: propofol off x 30 min to evaluate. +gag, mae, resedated until am.

resp: intubated w/ ventilatory support. 30%/ 600vt/ 14br/ 5cm peep.
clear resp, equal bs. scant blood tinged secretions, spec sent.

cardiac: 70-80nsr no vea, b/p 120/70

gi: ogt in place, no bs appreciated

renal: decreased u.o., monitoring s/p ivf replacement.

lines: #18 peripheralx2, function appropriately

skin: multiple scarring over body, no open wounds.

toxicology: + tylenol, uncertain about other substances.

assess: stable s/p drug od

plan: q4hr mucomyst, ivf, ekg, restrain prn, sedation and intubation throughout night, to reassess in am w/ probable extubation.
"
3924,"respiratory care note:
     received patient of ac as noted in carevue.  patient trached with a #8.0 portex perc. trach.  no changes have been made this shift.  bs are coarse throughout.  sx for small to often moderate amounts of tan thick secretions via trach.  [** **]'s administered as ordered with no adverse reactions noted.  patient remains afebrile this shift.  positional cuff leak noted.  cuff pressure measured and continues to be 30.  team aware of high cuff pressures for trach.  spo2 remains 98-100%.  will continue to monitor respiratory status.
"
3925,"7p-7a
neuro: pt sleepy at beginning of shift, following all commands, mae, perrla. pt presently a+ox3. denies pain.

cv: hr 80-90s sr w/ pacs, rare pvcs. at begiining of shift, pt on neo to keep sbp 90-110, sbp labile, on and off neo throughout shift, also on and off nitro during shift see carevue for details. ci>2. see carevue for details of filling pressures. pa nilssen aware of filling pressure readings and aware of cvp readings 0-6, pt received 1 unit of prbcs, no adverse reactions noted. epicardial wires intact, on v demand backup. +palpable pulses.

resp: ls clear but diminished. post abgs acidotic w/ pco2 50s, encouraged is and coughing and deep breathing, repeat abgs showed improvement, see carevue for details. sats >94%, at present on 6lnc sats 98%. much encouragement needed w/ use of is and coughing and deep breathing. ct at beginning of shift draining >100cc/hr, pa nilssen aware, coags sent, unit of prbcs infused as per order.ct dsg cdi, no crepitus no airleak.

gi/gu: abd softly distended, -bs. tolerating ice chips. foley draining clear yellow urine 100-300cc/hr.

endo: insulin gtt weaned to off. will continue to monitor glucose.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. wean nitro gtt as pt tolerates to keep sbp 90-110 maps <85. follow labs. deline in am, increase activity as pt tolerates. pain control.
"
3926,"resp:  resp pt on [**name (ni) **] a/c 26/500/+15/60% from tsicu.   alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal crackles with diminished bases.  suctioned for moderate amount of thick yellow secretions/bloody tinged from oral cavity.  mdi's administered of alb/atr/[**last name (un) **] with no adverse reactions.  02 sats 95-96%.  vent changes of ^rr to 28.  no further changes noted
"
3927,"resp: [**name (ni) **] pt on a/c 28/500/+10/70%. trach #8. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of rusty secretions at beginning of shift, yellow towards end. mdi's alb/atr administered as ordered with no adverse reactions. am abg pending.
"
3928,"resp: [**name (ni) **] pt on a/c 28/500/+10/70%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with diminished bases. suctioning copious bloody secretions. mdi's administerd as ordered with no adverse reactions. pt rr ^ 30's to 40's. morphine given with minimal affect. ct scan results negative. no changes or abg's noc. will continue full vent support.
"
3929,"resp: [**name (ni) **] pt on simv 14/500/15/+5/40%. ett #9 taped @ 24 lip. bs are clear with diminished bases bilaterally. suctioned for moderate amounts of thick yellow/bloody tinged secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. vent changes to psv 15/5/50% with am abg 7.47/40/80/30. rsbi=90. plan to continue to wean with possible extubation today.
"
3930,"npn 7a-7p

events:
pt. spiked to 101.6 this am and 102.3 this afternoon.  pt. pan cx'd x stool and sputum this am.  with this afternoon spike, pt. had resp. distress with hypoxia on abg (70's), tachypnea, htn to 220 and rigors. treated with apap, lopressor 10mg ivp with 25mg po, 12.5 demerol.  currently stablized.

review of systems:

[**name (ni) **]  pt. more lethargic and less interactive today.  conts to follow commands with right hand squeezing.  no spontaneous movements noted on left side.  perrla 3-4mm.  or cancelled in light of fever.  rescheduled for tom'row if not febrile.

resp-  received on fio2 of 35% currently requiring fio2 50-70% to maintain sat's >92%.  abg at 1540.  cxr done at the time of resp. distress, results pending.  sx'd q 4 hours for minimal to no secretions.  no sputum spec. obtained.  ls- clear anterior, diminished bibasilar posteriorly.

cv-  hr 70-100 nsr.  mg of 1.5 repleted with 2g.  received 1u prbc in prep for the or d/t hct <30%.  tolerated transfusion well, no adverse reactions noted.  pt. received tyelenol prior to transfusion.  suture sites appear clean and dry.  lue significantly more edemedous and hot compared to right ? dvt.  however, pt. has [**location (un) 890**] filter in place and could not be anticoagulated.  team considering ultra sound.  no signs of cellulitis noted at this time.  elevated on pillows at this time.

gi-  abd soft/ distended.  no bm this shift.  tf restarted at 1pm d/t cancellation of or.  to be stopped at mn for questionable v/p shunt placement tom'row.  ? start ivf at that time, no order presently.

gu-  u/o adequate 40-60cc/hr.  receiving lasix 20mg po qd.

id-  fever spikes x 2 today with tmax 102.3.  conts on iv levoquin.

[**name (ni) 4**] husband and son in this am and plan to visit again tom'row before surgery... appear to be updated on plan of care.
"
3931,"respiratory care
patient remains trached with no leak noted.  no vent changes made this shift.  mdi's administered as ordered.  no adverse reactions noted.  sx'd for a small to moderate amount of thick tan secretions.  will continue to monitor as needed.

"
3932,"resp: pt rec'd on simv 14/550/+5/5/50%. ett 8.0, taped @ 22 lip. bs are clear with diminished bases. suctioned for moderate amounts of thick brown plugs at start of shift but subsided toward morning. sample sent. mdi's administered alb/atr administered q6 as ordered with no adverse reactions. pt pa02 @ 77 then increased fio2 to 60%, rr ^ to 18 due to ^ co2. am abg 7.28/44/107/22. rsbi=>200. plan to maintain present settings.
"
3933,"resp:  [**name (ni) **] pt on 40% t/c and sitting in chair. pt put back to bed and placed back on [**last name (un) 205**] psv 14/5/40%.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned small to moderate amounts of tan/bloody tinged thick secretions.  mdi's administered q4 hrs/hhn with no adverse reactions. tv's remain in 300's with 02 sats @ 98%. no further changes noted.
"
3934,"resp: [**name (ni) **] pt on psv 14/5/40%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered combivent with no adverse reactions. vt's 400. ve's [**6-29**]. rsbi=57, decreased ps to 10 with 02 sat's @ 96%.
"
3935,"respiratory:  [**name (ni) **] pt on 50% cam.  pt placed back on [**last name (un) 205**] @ noc with settings simv 20/250/5/+5/40% as per dr. [**last name (stitle) **].  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small amount of thick yellow secretions.  mdi's administered q 4 atr with no adverse reactions. rsbi=40. no further changes noted.
"
3936,"resp: [**name (ni) **] pt on psv 18/5/40%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning for moderate amounts of thick white secretions. mdi's administered combivent with no adverse reactions. no abg's/no aline. code status changes, plans to be trached.
"
3937,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 8/5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilater aeration noted. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions.  am [**last name (un) **]'s 7.43/44/97/30. rsbi=88.  continue to wean with possible extubation today.
"
3938,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv12/500/15/+5/40%.  alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small amounts of thick yellowish secretions.  mdi's administered q4 atrovent with no adverse reactions.  pt gets  very anxious at times ^ rr. 02 sats remain in ^90's. ps decreased to 10 where it remains.  no further changes noted.
"
3939,"1900-0700 csru npn
neuro: alert, ox2 at beginning of shift. accusing nursing staff of trying to kill her. ""tell me the nurse's oath so i know you aren't trying to kill me!"" given 1 dose haldol 2 mg iv with good effect. no dilaudid given as pt has denied pain. spoke with niece ""pat"" - strong family hx of adverse reactions to narcotics (i.e. change in ms, hallucinations, aggitation). new order for ibuprofen prn, however pt refusing to take po's at this time. did get pt to take po lopressor. remains wrist restrained for safety as when unrestrained, pt reaches for swan line & chest tubes despite reorientation.

cv: sr, rare pvc's. ntg weaned to off. started on scheduled doses of hydralazine iv & lopressor po. sbp <150. pacer wires attached & functioning - no pacing required. serosang drainage from chest tubes. co/ci by thermodilution wnl. continues on amiodarone iv for ventricular ectopy. filling pressures slightly elevated, see carevue for detailed assessment/vitals/i&o.

resp: o2 weaned to 4 lnc, abg wnl's. no cough/congestion. l/s clear with dim bilat bases.

gi: no bs. took small sips of clears without difficulty. pt refusing ice chips/sips at this time ? d/t orientation.

gu: foley cath not draining. flushed with 40 ml sterile water, only got return of 20 ml. foley cath changed, now draining without difficulty. u/o marginal - hx of 1 kidney. urine clear, no sediment.

lytes: k+ & ca++ repleated as indicated.

endo: insulin gtt on for short time, but now off. last glucose 80.

social: spoke to niece/spokesperson ""pat"".

plan: ? d/c swan & transfer to [**hospital ward name **] 2. monitor glucose/lytes and treat as indicated. oob>chair today in anticipation of transfer. ? po amiodarone when pt more alert & coherent.
"
3940,"resp: [**name (ni) **] pt on a/c 18/450/+5/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody secretions to tannish. mdi's administered as ordered combivent with no adverse reactions. no abg's this shift. rsbi=169. will attempt to wean as tolerated.
"
3941,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 23/12/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x 3 small to moderate amounts of thick yellow secretions/bloody tinged/tannish plugs after lavarge.  02 sats @ 100%. mdi's given q4 alb/atr with no adverse reactions/ flovent [**hospital1 **].  vent changes: decrease ps to 18/peep to 10/fio2 to 40%.  am abg's 7.38/38/151/23.  no further change noted. family meeting expected today.


"
3942,"resp: [**name (ni) **] pt on psv 12/8/40%. ett#8.0 retaped and secured @ 23 lip. bs are clear in apecies with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's administerd q4 hrs alb/atr with no adverse reactions. abg's 7.33/52/83/29. rsbi=52. no further changes noted.
"
3943,"respiratory:  [**name (ni) **] pt on 40% t/c.  pt began to tired and was placed back on [**last name (un) 205**] psv 10/5/40%.  bs auscultated reveal bilateral diminished with scattered coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of thick yellowish secretions.  mdi's administered q4h with no adverse reactions. no further changes noted.
"
3944,"resp: pt rec'd via or on psv 22/12/40%. pt has #10 [**first name9 (namepattern2) 10396**] [**last name (un) 482**] trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4hrs with no adverse reactions. no abg's this shift. line not placed in or. plan is to place line today and dialysis before discharge to rehab.
"
3945,"resp: [**name (ni) **] pt on psv 16/10/35%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. no rsbi due to ^ peep. will continue to wean as tolerated.
"
3946,"resp: [**name (ni) **] pt on aprv 34/8/2.7/0.3/40%. ett #7.5, retaped and secured @ 21 lip. bs are clear bilaterally with diminished bases. suctioned for moderate amounts of white secretions. mdi's administered q 4 alb/atr with no adverse reactions. pt has strong cough. no [**name (ni) **] changes noc. am abg 7.41/40/181/26. will continue full [**name (ni) **] support. no schedule for trach as yet.
"
3947,"(continued)
 with gelfoam; no other obvious bleed.
gi: belly softly distended, active bs, no stool. nepro tf's at goal of 30cc/hr with no residuals.
endo: insulin gtt initiated for fsbs 180's; have achieved good control on current rate of 2u/hr (was as high as 5u/hr). cont's on hydrocortisone.
skin: bilateral ue's erythematous, edematous, weeping; elevated on pillows. no other skin breakdown.
social: several children and grandchildren visiting at start of shift; one dtr stayed the night in the room.

note: pt has doumented allergy to several drugs, including heparin and levoquin, both of which she is on. md's made aware, checked with family; apparently reactions not serious and pt wil remain on both, no adverse reactions noted.

a: remains critically ill with poor prognosis

p: continue all supportive measures; anticipate renal consult with possible initiation of cvvhd; support family; pt remains dnr but fill treat.
"
3948,"resp: [**name (ni) **] pt on a/c 22/450/+5/40%. pt has #8 portex trach. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift.02 sats @ 98%.  [**name (ni) **]=136. plan to wean to ps as tolerated.
"
3949,"resp:  [**name (ni) **] pt on [**last name (un) 205**] simv 18/550/10/+5/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral crackles with slight coarseness which improve with suctioning.  suctioned x3 moderate to copious amounts of thick yellow secretions, as well as oral cavity.  mdi's administered q4 hrs combivent with no adverse reactions.  vent changes as follows:  fi02 decreased to 40% with o2 sats in ^ 90's where they remain.  no rsbi performed as [**name8 (md) 20**] md. no further changes noted.

"
3950,"resp: pt rec'd on psv 22/12+/40%. pt has #10 air filled [**last name (un) **] trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administerd as ordered combivent with no adverse reactions. pt scheduled for or today for line placement. no abg's or rsbi due to ^ peep. no further changes noted.
"
3951,"resp: pt rec'd on psv 20/5/40%. pt has #8 portex trach. bs are coarse bilaterally. suctioned for small amounts of white thick secretions. mdi's administered combivent/alb as ordered with no adverse reactions.vt' 400-500, ve's 9, rr 25.  [** **]=171. will continue to wean as tolerated.
"
3952,"resp: pt rec'd on psv 24/10+/50%. ett # 7, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally and suctioning for moderate to copious amounts of thick yellow secretions. mdi's administered as ordered of combivent with no adverse reactions. vt's 300's ve's [**9-8**]. plan to trach today in or.  no further changes noted.
"
3953,"resp: [**name (ni) **] pt on psv 20/5/40%. pt has # 8 portex trach. ambu @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered with no adverse reactions. 02 sats @ 100%. vt's 500's. ve 12, rr 24. no changes noc. [**name (ni) **]=196. will continue on present settings.
"
3954,"resp:  [**name (ni) 92**] pt on [**name (ni) **] a/c 14 600/70%/+15. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x 3 for small to moderate amounts of thick bloody tinged secretions.  mdi's administered q 4 of alb/atr with no adverse reactions noted.  minimal air technique used to ^ maintain adequate cuff pressures.  02sats remain  in^ 90's 94-96% with no distress noted.  no rsbi performed dueto high peep pressures.  no further changes noted.
"
3955,"resp: [**name (ni) **] pt on psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. mdi's administered 2 p alb/2p atr with no adverse reactions. pt was extubated without incident and placed on 40% cam.
"
3956,"resp: [**name (ni) **] pt on a/c 20/400/+5/40% alarms on and functioning. ambu/syringe @ hob. pt has #10 portex ([**name (ni) 10396**]) cuff. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. no changes or abg's this shift. will continue full vent support.
"
3957,"resp: [**name (ni) **] pt on psv 20/5/40%. bs are coarse bilaterally. suctioned for small amounts of white thick secretions. mdi's administered as ordered comb/alb with no adverse reactions. no abg's this shift. 02 sats @ 100%. vt's 400's,rr 25-27. [**name (ni) **]=181. no changes this shift. plan to wean as tolerated.
"
3958,"resp: [**name (ni) **] pt on a/c 22/450/+5/50%. ett #7.0, 22 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with slight coarseness on rml. suctioned for small to moderate amounts of thick tannish secrections. mdi's administered q4 hrs alb/atr with no adverse reactions. vent changes of decrease in fio2 to 40% with abg pao2 @ 76, then increased to 50%. am abg pending. no rsbi due to ^ peep. plan is to wean as tolerated with acceptable abg's,
"
3959,"resp: [**name (ni) **] pt on a/c 15/500/+5/50%. placed pt on psv 12/5/50% and didn't tolerate, placed back on a/c settings. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bialteral crackles. suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr q4 with no adverse reactions. abg 7.45/39/70/28 and no changes noc. rsbi-120. will continue to wean appropriately.
"
3960,"resp: [**name (ni) **] pt on psv 10/5/50%. ett #8 @ 23 lip.alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. suctioned for moderate amounts of white frothy secretions. mdi's administered alb/atr with no adverse reactions. abg 7.31/68/99/36. rsbi=59.
"
3961,"resp: pt administered mdi's q4  hrs alb with no adverse reactions. some improvement noted following tx.
"
3962,"resp: [**name (ni) **] pt on a/c a/c 22/450/+1/50%. ett#7.0 taped @ 22 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral noted aeration with diminished bases. suctioned for moderate amounts of thick tannish secretions. mdi's alb/atr administered q4 hrs with no adverse reactions. abg's (see careview) am abg 7.29/37/95/19. will continue full vent support.
"
3963,"resp:  [**name (ni) **] pt on [**last name (un) 205**] a/c 10/500/+5/50%.  alarms on and functioning. ambu/syringed @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow/whitish secretions.  mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.36/38/97/22.  pt is full code, md to speak with family today for possible code status change.
"
3964,"resp:  [**name (ni) **] pt on t/c @ 40%.  pt placed back on [**last name (un) 205**] psv 5/5/40% to rest @ [**last name (un) **]. bs auscultated reveal bilateral clears sounds. improvement noted. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=61 this am.  plan to place back on t/c during the day and to get pt out of bed to chair.  will continue to wean appropriately.
"
3965,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow/white secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  rsbi=54. no a-line.  will continue to wean as tolerated.
"
3966,"admission
pt admitted from or at 1445 s/p maze, asd repair,cabgx4, left atrial appendage repair. to csru in sb 50s, a wires not working appropriately, despite polarities changed, a wires placed in v port to max ma [**name8 (md) 20**] np [**doctor last name **] working appropriately, v wires not capturing appropriatley. v wires secured. ekg not taken at this time d/t pt being paced and sbp decrease when not paced. to csru on neo and propofol. immediatley post-op, u/o 200-1000cc/hr, see carevue. 6 liters total given of crystalloid. 1 unit of prbcs no adverse reactions noted. ci > by fick, see carevue, np [**name6 (md) **] and np [**doctor last name 54**] aware of co/ci. mixed venous sent, result 54, np [**doctor last name 54**] aware, another liter of fluid given + 1 unit of prbcs.

neuro: pt sedated on propofol gtt. perrla. morphine for pain, noted change in vital signs.

cv: hr, noted as above, 84 apaced, no ectopy. goal sbp 110-120s. see carevue for details on neo gtts. see carevue for filling pressures and ci/co. np [**name6 (md) **] and np [**doctor last name 54**] aware, fluid and prbcs given. +dopplerable pedal pulses. right groin ecchymotic w/ small hematoma near right groin from old cath site, team aware.

resp: ls clear diminished. see carevue for details of abgs and vent changes. peep not needed to be increased to 10 [**name8 (md) 20**] np [**doctor last name 54**]. sats >96%.

gi/gu: abd soft, absent bs. ogt +placement, draining bilious/clear secretions, minimal drainage. ct oozy, see carevue for details, received protamine 50mg iv. foley draining clear yellow urine 200-1000cc/hr, np [**doctor last name **] aware, received total of 6 liters of crystalloid, np [**doctor last name 54**] aware.

endo: gtt not needed. fs 101.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. pain control. monitor ci.
"
3967,"resp: [**name (ni) **] pt on psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob. mdi's adminisered comvbivent/flovent as ordered without any adverse reactions. suctioned for small amounts of white secretions. rsbi=81. am abg 7.39/45/85/28. plan to continue with wean to extubate.
"
3968,"7a-7p
neuro: pt alert and oriented, disoriented to time only. mae weakly, stiff when tuning pt. see carevue for details of pupils. tylenol po via dophoff for pain, generalized and c/o bilat back of knees aches, np [**doctor last name 54**] aware no new orders.

cv: at approx. 1230, pt to afib rate 80-100s. np [**doctor last name 54**] aware, iv lopressor given total of 10mg ivp [**name8 (md) 20**] np [**doctor last name 54**]. converted at approx. 1500, sb 50s, np [**doctor last name 54**] aware. pt on po dose amiodarone 400mg daily. sbp >90, pt did not tolerate afib sbp 80s, neo as high as 2mcg/kg/min, able to wean neo when pt in sinus rhythm. cvp 9-16. received 1 unit of prbcs, no adverse reactions. aline femoral right intact. see carevue for details. + dopplerable pedal pulses. dusky toes.

resp: ls coarse clears after nt suctioning. nasal trumpet to right nare for frequent nt suctioning. suctioning thick tannish secretions small to copious amts via nasal trumpet. sats >98% on 4-6lnc. see carevue for abgs.

gi/gu: abd soft obese +bs, passing loose dark brown stool via fib. pt failed swallow eval, dophoff placed by np [**doctor last name 54**], ok to use [**name8 (md) 20**] np [**doctor last name 54**]. tf changed to impact w/ fiber goal 60cc/hr at present tolerating 50cc/hr, no residuals. straight cath for amber cloudy urine 15cc. cvvhdf goal -50cc/hr. filter changed secondary to filter clotted while pt in chair. goal 1liter neg for 24 hours. blood given not taken off output [**name8 (md) 20**] np [**doctor last name 54**], goal try to get neo gtt off, then may increase cvvhdf to -100cc/hr. see carevue for details of quinton cath.

endo: riss + lantus dose given sc in am as ordered.

skin: bullae to pt's back, derm into assess pt. broken blisters to bilat legs, groin and labia. groin w/ blisters. see carevue for details of skin assessment. when straight cath, yeast vaginal discharge noted, np [**doctor last name 54**] aware, miconazole ordered.

activity: ok to get pt oob [**name8 (md) 20**] np [**doctor last name 54**] even w/ fem a line by [**doctor last name **]. bed changed to air bed.

plan: monitor hemodynamics. monitor resp. status. nts prn. -50cc/hr via cvvhdf. pain control. wean neo to keep sbp>90.
"
3969,"resp: rec'd on a/c 20/600/+5/40%.ett #7.5 retaped and secured @ 21 teeht. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse which clear following suctioning. suctioned for small-moderate amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. am abg 7.40/52/110/33 with no changes noc. will continue full vent support.
"
3970,"resp: [**name (ni) **] pt on a/c 18/800/+5/70%. bs are diminished throught. suctioned for small amounts of thick tan secretions. mdi's administered q4 alb/atr with no adverse reactions. am abg's 7.45/43/83/31 with no vent changes noc. plan trip to mri today to r/o osteomyletitis.  will continue full vent support.
"
3971,"resp: [**name (ni) **] pt on psv 15/10/50%. bs are coarse bilaterally. suctioned for copious to moderate amounts of thick yellow secretions. mdi's adminstered q4 with no adverse reactions. no rsbi=^ peep or abg's this shift. plan to continue on present setting.
"
3972,"resp: [**name (ni) **] pt on psv 15/10+/50%. ett #7.0 taped @ 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged secretions. mdi's administered as ordered of alb with no adverse reactions. pt has episodes of ^ rr to 40's then settles down. am abg 7.50/36/79/29. no rsbi due to ^ peep. will continue to wean as tolerated.
"
3973,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 24/500/+15/65%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse. suctioned for moderate amounts of tan thick secretions. mdi's administered q 6 hrs with no adverse reactions. am abg's 7.40/50/108/32.  decreased fio2 to 50%.  questionable for ards protocol.

"
3974,"resp: [**name (ni) **] pt on psv 15/10/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged to tan secretions. q1-2 hrs. mdi's administered as ordered alb with no adverse reactions. no abg's this shift or changes. no rsbi due to ^ peep.
"
3975,"resp: pt rec'd on psv 15/10+/50%. alarms on and functioning.ambu/[**e-mail address 9422**] are coarse bilaterally. suctioned small to moderate thick yellow to greenish secretions. mdi's of alb administered as ordered with no adverse reactions. vt's 400-500, ve's 11, rr ^ 30's at times. no rsbi due to ^ peep. no abg's this shift. no changes. will continue with present settings. family meeting expected to determine [**e-mail address **] status.
"
3976,"resp: pt rec'd on ffv psv 8/5/50%. vt's 500's ve's [**12-5**], rr 20-22. placed on 70% f/t with cool humidification as tolerated. (see careview for series of abg's) following abg, pt placed back on psv 8/5/50%. hhn administered alb/atr with no adverse reactions. bs are coarse bilaterally. pt has r nasal trumpet. suctioned for moderated amounts of thick yellow and bloody tinged secretions. am abg 7.28/45/142/23. will continue alternating between ffv and f/t to hopefully avoid pt being trached.
"
3977,"resp:  [**name (ni) **] pt on a/c 20/600/+5/40%. ett #7.5,  retaped and secured 21 @ teeth. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally which improve following suctioning. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 combivent with no adverse reactions. no change noc, am abg pending.
"
3978,"resp:  [**name (ni) **] pt on [**last name (un) 205**] a/c 18/500/+10/60%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of white thick secretions.  mdi's administered q4 alb with no adverse reactions. am abg's 7.34/36/68/18. following family meeting pt is [**name (ni) **]/dni.
"
3979,"resp:pt remains intubated #8 ett, 22 lip and rec'd from or on a/c. bs are coarse with diminished rs.mdi's administered q 4 alb/atr with no adverse reactions. abg's 7.46/39/80/29. vent changes to psv 10/10/60% with additional abg's pending. will continue to wean appropriately.
"
3980,"admission
pt is a 77 year old male s/p cabgx3 and asd repair, see admission h+p for details of pmh and or events.

neuro: pt sedated on propofol. reversed per protocol as 1730, during pm rounds ? wean and extubate d/t earlier issues w/ low ci. pupils 2mm briskly reactive left slightly larger np [**doctor last name **] aware. demerol given x2 for shivers as ordered, resolved after 2nd dose.

cv: received av paced from or-> ekg done nsr pr 0.20- np [**doctor last name **] assessed. presently a paced 80s for sbp. sbp labile, on and off ntg and neo, presently on neo gtt w/ goal sbp 100-110 [**name8 (md) 20**] np [**doctor last name **]. ci<2 by thermodilution, fluid bolus x2 given bringing ci >2 by thermodilution briefly, see carevue for details, fick sent, ci>2 by fick. svo2 62-63%, see carevue, np [**doctor last name **] aware. 1 unit of prbc s given w/ no adverse reactions [**name8 (md) 20**] md [**doctor last name **] for low filling pressures. cvp 6-12. pa 25-30/15-20s. sternal dsg cdi, medistinal dsg cdi. + palpable pulses.

resp: ls clear. sats >98%. see carevue for abgs and vent settings. ct w/ minimal sang. drainage, see carevue.

gi/gu: abd soft absent bs. + placement of ogt. foley draining clear yellow urine 60-400cc/hr, see carevue.

endo: gtt per protocol.

social: son and daughter into visit and updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent, following ci.
"
3981,"resp: [**name (ni) **] pt on [**last name (un) 205**] a/c 20/400/50%/+10.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal coarse sounds. suctioned for small amounts of thick yellow secretions. mdi's administered q4 combivent/flov [**hospital1 **] with no adverse reactions. pt appreared rested and comfortable today. rsbi=37 with am abg's 7.37/47/101/28.  pt expected to go to or today for stent procedure.  no further changes noted
"
3982,"resp:  [**name (ni) 97**] pt on simv 26/700/10+/80%.  ett 8.0 24 @ lip.  alarms on and functioning. ambu/syringe @ hob.  bs are diminished bilaterally, with some aeration noted in upper lobes. suctioned for small amount of white secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. pt was bronched yesterday, then recruitment maneuver and became hypotensive.  fio2 ^ to 80%.  vent changes and abgs(see careview for settings and results) present settings simv 18/700/70%/12+.  am abg pending. possible bronch again today?
"
3983,"micu npn  0700-1500
see [** 3326**] for subjective/objective data.  neuro:  remains unresponsive; intermittently moves head and body.

cv/pulm:  r groin dialysis catheter removed at 0800 by renal fellow, per fellow pressure held x15min.  no bleeding following removal of catheter however 10min later site re-bleeding.  fellow in, site held by fellow for additional 15min by fellow.  no bleeding at that time however approx 20min later approx 200ml brb noted at site.  pressure held, intern notified.  two units ffp given, txm for 2units prbc.  no bleeding for 1and 1/2 hr then re-bled approx 50ml.  intern in, site packed by intern, sandbag applied.  ddvph hung at 1300 x1 dose.  receiving first of two units prbc's (hung at 1130; no adverse reactions noted thus far).  no further bleeding at site noted.  remains on levo at 0.7mcg/min.  remains vented per [** 3326**] (on ps).  bs coarse bil.

gi/gu:  tol tf at goal.  fib in place.  receives hemodialysis.  dialysis catheter removed as noted above due to purulent, fowl smelling drainage at site.  to go to ir for new dialysis cath [** **] in am, to have dialysis following [** **] of new catheter.

integ:  see [** 3326**]--healing herpatic lesions, decub on coccyx-->
duoderm applied.

id:  afebrile.  no change in meds.

psychosocial:  social work involved.  no visitors this shift thus far. emotional support given to pt.
"
3984,"micu addendum
no further bleeding from r groin site.  to ir at 1415 for [** **] of new dialysis catheter.  first of two units prbc's infused without adverse reactions; ffp completed without adverse reactions.  remainder assess per [** 3326**]/unchanged.
"
3985,"resp: pt rec'd on psv 15/5/50%. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. suctioned for small amounts of  bloody secretions. mdi's administerd as ordered with no adverse reactions. rsbi=28. will continue to wean as tolerated.
"
3986,"respiratory:  [**name (ni) 97**] pt on servo simv 16/650/12/+5/50%. alarms on and functioning. ambu/syrnge @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning.  pt [**name (ni) **] tonight for a moderate amount of thick bloody secretions.  mdi's administered of combivent q4/flovent [**hospital1 **] with adverse reactions. 02 sats 95-97% with no distress noted.  no further changes.
"
3987,"resp: [**name (ni) 97**] pt on a/c 22/650/10+/55%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, taped @ 22 lip. bs are coarse bilaterally. suctioned for moderate amounts of tan/yellow thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to wean as tolerated with present settings a.c 18/550/+8/55%. abg obtained with results 7.38/50/83/31. plan to trach today.
"
3988,"micu  npn
see [** 3326**] for subjective/objective data.  neuro:  opens eyes to verbal stimuli/tactile stimuli.  reaching r hand toward trach-->r hand restrained (see [** 3326**]).  no attempts to speak.

cv/pulm: bp low this pm-->72/40 with map 51.  intern notified, ns bolus 500ml over 2hrs hung with bp increased to 86-90/30-40, map high 50's to 60.  ns currently infusing, to be completed by [**2081**].  two lumen picc dsg changed.  rec'd 2units ffp prior to [**year (4 digits) **] of peg.  r ej dialysis cath dsg d+i.  remains vented on cpap+ps.  suctioned for sm amts thick yel-->clear sec via trach.  bs clear upper lobes, coarse lower lobes.  trach care done with 1/2 str h2o2.

gi/gu:  peg placed by dr. [**last name (stitle) **] at 1230 without incidence.  med with versed and [**name6 (md) **] by md; tolerated meds without adverse reactions.  peg may be used for meds this pm; to resume tf in am.  rec'd hemodialysis this am-->two liters off [**name6 (md) 9**] hemodialysis rn.  next dialysis due sat [**2153-11-17**].

integ:  healing zoster areas.  packing to r groin changed-->sm amts ser-sang drng on old dsg.  red area at base of coccyx; not open.  multi-podis boot [**month/day/year 3333**] r/l.  hand splints [**month/day/year 3333**] on/off.

psychosocial:  no family contact this shift.  emotional support given to pt.
"
3989,"resp: [**name (ni) 97**] pt on psv 5/5/50%. bs are diminished bilaterally. suctioned for small amounts of secretions. ambu/syringe @ hob.alarms on and functioning. mid's administered as ordered with no adverse reactions. no changes noc. plan is for pt to be trach possibly today.
"
3990,"resp: [**name (ni) 3373**] pt on a/c 28/500/+15/100%. alarms on and functioning. ambu/syringe @ hob. ett #7.5 rotated, retaped and secured @ 22 lip. bs are coarse with diminished bases. suctioned for scant to small amounts of bloody tinged secretions. mdi's administered alb with no adverse reactions. several attempts to place a-line without success. circuit changed to heated. vent changes to decrease fio2 to 80% and maintaing sats @ 96-97%. possible trach today? will continue full vent support.
"
3991,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 14/650/50%/+10.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases.  mdi's administered q4 alb/atr with no adverse reactions. suctioned small amount of thick pale yellow secretions. abg's=7.37/40/82, then increased fio2 to 60%, following abg's 7.37/40/103/24.  no further changes noted.
"
3992,"resp:  pt rec'd on [**last name (un) **] simv 14/550/5/+5/40%. ambu/sryinge @ hob.  auscultated bs reveal increased aeration bilaterally with a few scattered crackles which cleared with suctioning.  suctioned x3 small amount of thick yellowish secretions. mdi's administered q4hrs with no adverse reactions.  rsbi=24.  02 sats@ 100%. no further changes noted.
"
3993,"resp: [**name (ni) 97**] pt on simv/ps 26/700/18/+7/60%.  alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with diminished bases. suctioned for moderate amounts of thick white secretions. mdi's administed q6 hrs combivent/flovent [**hospital1 **] with no adverse reactions. am abg 7.40/32/82/21. no rsbi due to ^ fio2. plan to wean as [**name8 (md) 9**] md.

"
3994,"resp: [**name (ni) 97**] pt on a/c 15/500/+10/50%. trach 10 o.d/7 i.d. alarms on and functioning. ambu/syringe @ hob. bs are coase bilaterally. suctioned for moderate to copious thick yellow secretions. mdi's administered q4 hrs atr with no adverse reactions. no abg's or changes this shift. will continue full vent support.
"
3995,"admission note:

pt is a 83 yo healthy female admitted to [**hospital1 95**] with an embolic r stroke. pt was performing daily stretches this early am, felt weak and heavy on her left side, pt called her daughter then called ems, sent to er code stroke at 0945, ct scan showed embolic stroke to punctate areas of r parietal and frontal lobes (per er). tpa administered in er, focal sz activity noted in lle, mri obtained during sz activity, eeg leads placed after mri, 1 mg of ativan given---> resolution of focal sz activity, arrive in the tsicu at 1400.

neuro: alert and oriented to person place time and situation, slow to respond at times, l sided hemiparesis versus ataxia improving each hour, decreased l sided coordination and proprioception initially, decreasing l pronator drift, resolving l ptosis and facial droop, eom intact, no visual field deficits noted, impaierd sensation to light touch on l side but not deep pressure and pain, improving motor activity on l side in both ue and le, perrla 4mm, impaired cognition with simple addition and subtraction, clear speech.

cv: nsr, blp 120-160 systolic, goal bp between 110-180 systolic, easily palp pedal pulses on r, weak palp pedal pulses on l, afebrile, pneumoboot on, on anticoag for 24 hrs s/p tpa infusion, given 2 l ns bolus in er due to bradycardia during phenytoin administration, phuenytoin d/c'd.

resp: 98% o2 saturation on ra, blscta, on cough, + nasal congestion, nl rr and depth.

gi: last bm this am, active bs, soft abdomen.

gu: foley placed, adequate urine output > 100 cc per hour, on d5w with 150 meq of bicarb for 450 ml then ns at 100, labs sent for updated lytes.

endo: closely monitor bs q 2 hrs for elevated bs, 3 units og req insulin administrated for bs of 150.

skin: cdi with varicose veins.

id: afebrile, no wbc count.

assessment: s/p tpa admin for embolic stroke.

plan: monitor ns q 1 hour, maintain blood pressure 110-180 systolic, monitor bs frequently while on d5w, nursing treatments as indicated, watch for adverse reactions to tpa, cont to monitro and assess as ordered.



"
3996,"resp: [**name (ni) 97**] pt on psv 15/12/45%. ett retaped, secured and biteblock inplace. bs are coarse bilaterally. suctioned for moderate to copious amounts of yellow bloody tinged secretions. mdi's administered alb/atr q4 hr with no adverse reactions. am abg 7.44/47/124/33. vent changes to decrease ps to 12 peep to 10. will continue to wean appropriately.
"
3997,"resp: [**name (ni) 97**] pt on psv 10/5/40%. ett 7.5 23@ lip. alarms on and functioing. ambu/syringe @ hob. bs are diminished bilaterally. suctioned moderate amounts of thick tan to bloody secretions. mdi's administered comb q4/[**last name (un) **] [**hospital1 **] with no adverse reactions.  rsbi=68. plan to address code status with family meeting. no changes noc.
"
3998,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 10/500/+5/40%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration in apecies with diminished bases.  mdi's administered q 4 hrs of alb with no adverse reactions. rsbi=112.  will attempt to wean to ps this am as [**name8 (md) 9**] md. no further changes noted.
"
3999,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14 450/30/+5.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned small amount of thick tannish secretions.  mdi's administered q4 hrs combivent with no adverse reactions.  am abg's 7.44/36/130/25.  rsbi=133.  no further changes noted.
"
4000,"resp: [**name (ni) 97**] pt on psv 5/5/50%. ett 7.5, rotated, retaped and secured @ 20 lip. bs are coarse to clear and suctioned for moderate amounts of thick tan to yellow secretions. mdi's administered alb/atr with no adverse reactions. abg 7.36/40/147/24. see careview for rsbi. no changes noted. plan to keep on present settings.
"
4001,"resp: [**name (ni) 97**] pt on 50% t/c. bs are coarse bilaterally that clear following suctioning. suctioned for moderate amounts of thick yellow secretions. pt is able to expectorate some secretions with strong cough. mdi's administered via trach combivent with no adverse reactions. inner cannula replaced, drain sponge and new trach mask replaced. will continue to follow.
"
4002,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/600/+5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral wheezing. suctioned for small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs combivent with no adverse reactions. cuff pressure @ 21. rsbi=124.  vent changes: decreased fio2 to 40%.  02 sats remain @ 100%.  no further change noted.
"
4003,"resp: [**name (ni) 97**] pt on 40% t/c. ambu/syringe @ hob. bs are coarse bilaterally which clear following suctioning and cough. pt able to expectorate secretions.  mdi's administered q4 hr with no adverse reactions. will continue to follow.
"
4004,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds with some scattered wheezing. spoke to team and suggested mdi's. mdi's administered q4 hrs atr/[**last name (un) **] [**hospital1 **]. administered with no adverse reactions. suctioned for moderated amounts of thick yellow secretions. rr ^ to high30's and ^ ps to 20. am abg's 7.47/42/192/35.  vent changes: decreased fi02 to 40%, ps to 15. [**hospital1 239**]=116 with no further changes noted.
"
4005,"resp: pt arrived from osh trached w/#6 portex and placed on [**last name (un) **].  02 sats decreasing and bronch performed.  suctioned copious amounts of thick tan secretions with plugs.  02 sats improved.  abg's (see careview) am abg 723/74/103/33 which shows improvment over prior gas.  rr decreased to 14/450/+5/70%.  mdi's administered alb/atr q4 hrs with no adverse reactions.  pt exhibits some auto peeping. no further changes noted.
"
4006,"resp:  [**name (ni) **] pt on 50% t/c. bs auscultated reveal bilateral coarse sounds. suctioned for thick amounts of yellow secretions. mdi's administered q4 hrs of combivent with no adverse reactions. pt rr ^ to 40's then placed on psv 8/5/35% to rest over night. rsbi=57.  will place back on t/c @ 50% this am.  no further changes noted.
"
4007,"resp: [**name (ni) **] pt on psv 10/5/40%. ett 7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick bloody tinged secretions with some brown plugs. mdi's administered q4 hrs alb with no adverse reactions. rsbi=52. am abg 7.44/35/110/25. no changes noc.
"
4008,"resp: pt rec'd on psv 20/5/40%.ett &.5 retaped x2 and secured @ 23 lip.  bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. pt ^wob with desats to 80's placed on a/c 20/500/10+/40%. am abg 7.46/41/83/30. plan to continue on present settings.
"
4009,"resp: [**name (ni) **] pt on a/c 20/400/10+/30%. retaped and secured ett. bs are diminished bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. am abg 7.40/51/125/33.  plan to continue with present settings.
"
4010,"resp: pt rec'd on psv 15/5/40%. ett 7.5, retaped and secured @ 23 lip. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.49/46/99/36. rsbi=200. will continue with present settings.
"
4011,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/40%.  alarms on and functioning.  ambu/syringe @ hob.  cuff pressure @ 21.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 small amounts of tannish thick secretions.  mdi's administered q4hrs with no adverse reactions. no rsbi performed as [**name8 (md) 20**] md.  comfort measures only.  no further changes noted.
"
4012,"resp: pt presently on n/c @ 3 lpm. bs are coarse bilaterally with notable exp wheeze. nebs administered q3-6 hrs alb/atr with no adverse reactions.  pt says, ""she feels better following tx's"" although no significant change with tx.  xray shows no pleural effusions.  will continue to monitor and treat.
"
4013,"resp: pt remains on a/c 25/400/+10/60%. suctioning for moderate amounts of thick yellow secretions. mdi's administered q4 hr combivent with no adverse reactions. am abg 7.38/43/68/26. no rsbi due to^ peep.will continue full vent support.
"
4014,"resp: [**name (ni) **] pt on 40% t/c with humification. bs are coarse bilaerally. suctioned for moderate amounts of thick yellow secretions. mdi's adminstered q4 hrs alb/atr with no adverse reactions. pt has #7 [**last name (un) 482**] secured @ 12 flange. no distress noted 02 sats @ 98%. will continue to follow.
"
4015,"resp:  [**name (ni) **] pt on [**last name (un) 205**] psv 10/5/50%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds.  suctioned for small amount of white thick secretions.  mdi's administered q4 alb with no adverse reactions.  rsbi perfomred although no spontaneous breaths noted.  02 sats remain @ 100%. no further changes noted.
"
4016,"resp: pt rec'd on [**last name (un) 205**] psv 12/10/40%.  alarms on and functioning. ambu/syringe @ hob. cp @ 20, trach #7 portex. bs auscultated reveal bilateral aeration with diminished bases. mdi's administered @ 4 hrs alb with adverse reactions. suctioned for small amounts of bloody secretions. am abg's 7.48/32/146/25. no rsbi due to ^ peep. no further changes noted. will continue to wean appropriately.
"
4017,"resp: [**name (ni) **] pt on a/c 15/500/+5/30%. ett 7.5, retaped and secured @ 21 lip. ambu @ hob. bs are clear to diminished at bases bilaterally. suctioned for small to moderate amounts of white to pale yellow thick secretions. sputum sample sent. mdi's administered alb/atr as ordered with no adverse reactions. weaned to psv although pt did not tolerated and returned to a/c (see careview) rsbi attempted resulted in no resps, will attempt again in am. am abg 7.35/45/130/26. family meeting today to discuss cmo status.
"
4018,"resp: [**name (ni) **] pt on a/c 15/400/+12/30%. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered q4 hrs with no adverse reactions. pt had episodes of ^ wob, sedation issues.  xray reveal bilateral hyperinflation slightly worse than previous. abg's (see careview) vent changes to ^ rate to 20. am abg 7.32/52/147/28. plan: family meeting to discuss cmo status.
"
4019,"resp: [**name (ni) **] pt on psv 10/10/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. ps weaned to 8. am abg 7.44/44/107/31. rsbi=111. plan to wean as tolerated. awaiting cmo status.
"
4020,"resp:  admitted to micu via er for resp distress and placed on ffv bipap. transported to micu on 4 lpm n/c and desated into 70's. pt is on home 02 @ 2 lpm. placed on nrb, then 50vm to maintain 02 sats in 90's. hhn given q4 hrs alb/atr with no adverse reactions.  pt became increasingly dyspnic, and tachy then placed on ffv.  pt tolerated most of the night and taken off this am and placed back on 50% vm.  will continue to follow.
"
4021,"resp: [**name (ni) **] pt on psv 10/8/40%. ett #7.5, retaped and secured @ 23 lip. bs are coarse bilaterally and suctioned for copious amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes this shift. pt continues to breath in ^30-40's. rsbi=147. plan to continue with present settings.
"
4022,"resp: [**name (ni) **] pt on psv 10/5/40%. bs are slightly coarse with diminished bases. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=188 am abg 7.43/44/128/30. vt's 300's ve 11, rr 30-50's at times.  bp ^ 200 pt still appears to be uncomfortable. plan to continue with present settings.
"
4023,"resp: pt rec'd on a/c 25/400/+12/60%.ett#7.5/21 lip. bs reveal bilateral aeration with minimal suctioning. mdi's administered q6 combivent with no adverse reactions. am abg 7.36/45/118/26. vent changes to decrease fio2 to 50%, and pt desated to 90, then returned to 60% where she remains. will continue full vent support.
"
4024,"resp: pt rec'd on 6 lpm n/c with 70% f/t. bs are coarse bilaterally with npc. hhn [** 860**] ud atrovent with 0.63 xopenex as ordered with no adverse reactions. will continue to follow. no changes noc. 02 sats @ 100%.
"
4025,"resp: pt ordered for hhn ud atrovent/0.36 xopenex and administered q4 hrs with no adverse reactions. pt also odered for advair discus although pt unable to perform and md/rn aware. 02 @ 3 lpm n/c with 50% f/t. bs are coarse with no changes noc. will continue to follow.
"
4026,"nursing progress note:
pt is alert and oriented x 3. no neuro deficits noted. pt does continue to have c/o severe headaches on level [**8-11**] on a [**2-13**] pain analog scale. relief from dilauded 2mg iv. pt refused toradol, states it gave her severe nausea earlier. pt states that she is not allergic to dilauded and no adverse reactions noted. team is aware. pt's assessment is otherwise negative. cv is nsr, no ectopy with sbp 100-120's per rad art line and nibp cuff.  goal is to keep sbp < 150's. this has been accomplished with po lopressor(now decreased to 12.5 mg po q 12 hr) pt on room air. resp even and unlabored. taking reg diet without difficulty. foley drains qs. no bm yet.

ct and cta both negative. hopeful plan for transfer or home soon,
continue to monitor until then.
"
4027,"1900-0700

general: pt recieved prep for colonoscopy through the night, bm remain tarry ho aware. pt removed ngt accidentally while sleeping @ 2300 pt given zyprexia.pt medicated for anxiety @ 2330 with lorazepam and replace ngt without difficulty, cxr confirmed placement. hct@2200-30. prbc infusing this am.

neuro: pt sleeping, arousable, responds appropriately but seems groggy. oriented x3, following commands well, maes. cataract bilaterally. anxiety noted once last pm. no restlessness noted.

resp: pt using 2l nc after anxious episode @ 2300. o2sat stable 97-100%. lungs clear/diminished at the bases. no cough noted. no sob noted.

cv: c-monitor a fib through the night, without ectopy. no episodes of cp/ hemodynamics stable. lopressor held due to bp 94/40. pt remains on heparin drip @950units/hour. ptt sent in am. pt remains hypernatremic and d5w increased to 150cc/hr @2300 after chemistry panel reviewed.

gi: abd round soft + bs, prep completed and tarry stools continue. fecal incont. bag placed, incont of stools at this time. stool remains guiac positive. ngt to l nare intact clamped for bowel prep. pt receiving prbc transfusion, no adverse reactions noted.

gu: foley to bsd draining clear yellow urine approx. 50-75cc/hr. minimal edema to ext.

iv: r ij tlc intact.

plan: complete prbc, assess pt for possible colonoscopy today. monitor for excessive bleeding.

                           [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
4028,"resp: pt rec'd on a/c 14/450/10+/60%. ett#7.0, 22 lip. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see carview) vent changes to decrease peep to 7, then 5, increase rate to 16. am abg pending. will continue full vent support.
"
4029,"0700-1500 npn

ms. [**known lastname **] is an 83yo female admitted from osh via [**hospital1 10**] ed to [**hospital ward name **] 4/icu this am.  pmh significant for cad, s/p cabg, angina, ef 35%, chronic renal insufficiency, htn, gout, epigastric pain, non-hodgkins lymphoma, hemolytic anemia, mrsa ? source, depression, s/p laminectomy, s/p bil tkr.  at home takes lasix, coumadin, ""heart and gout medications"", presdisone.    overview of events:  vomited vs. spitting up brb this am (pt not sure) as well as melena stools.  two units prbc's given, third unit up at 1430; two units ffp given.  all blood products given without evidence of adverse reactions.  cordis placed after three attempts, anesthesia in to electively intubate pt for endoscopy.  started on levophed for bp 70's/30's in addition to multiple liters of ns and lr.  endoscopy in progress at this time.

neuro:  was a+ox3; currently sedated on propofol at 20mcg/kg/min.  perl, 2-3mm, brisk.  mae ad lib.

cv/pulm:  mp=afib (not new).  serial cardiac enzymes sent.  bp labile, pt remains on lr at 500-1000ml/hr, ns at 500ml/hr and prbc's third unit currently infusing.  access:  r cordis, r triple lumen femoral line and r 20guage periph iv.  intubated, placed on vent at 1245--
current settings ac10x100%x600x5peep.  bs clear on r, diminished on l with fine crackles left base.  sats difficult to obtain however when able to obtain sats are high 90's to 100%.

gi/gu:  abd round, soft, non-tender to palpation.  stooling melena-->
fib applied but ? stool too thick for bag.  endoscopy in progress at this time.  ngt removed by gi for endoscopy; prior to removal was lavaged x2, draining brb with clots-->500ml total this shift.  u/o clear yellow yellow urine, qs.

id/endo/integ:  afebrile.  sliding scale insulin coverage per [**month (only) **].  skin tear r shin (pt reported to previous shift rn that she hit her leg at home).  no other open areas noted.

psychosocial/plan:  md spoke with family re:  pts status.  endoscopy in progress at this time (lg ulcer found, surgery paged).  will continue fluid resuscitation, levo, labs.  cont vent support, sedation as needed.  emotional support given to pt while awake.  pt is full code, on contact precautions for history of mrsa.

"
4030,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 20/600/50%/+[**1-2**].  alarms on and functioning. ambu/syringe @ hob.  ett taped and secured.  bs auscultated reveal bilateral coarse sounds with an exp. wheeze noted.  mdi's administered q4hr alb with no adverse reactions.  suctioned x3 small to moderate tan thick secretions.  vent changes to decrease peep to 10 where it remains. no further changes noted.
"
4031,"resp: pt rec'd on psv 18/8+/50%. ambu/syringe @ hob. bs are reveal bilateral wheeze. suction moderate amounts of tan secretions and copious clear amounts from oral cavit.  administered mdi's atr as ordered with no adverse reactions. some improvement noted, although pt still has notable wheeze. ^ rr to 30's and placed on a/c 21/400/+8/50% as [**name8 (md) 9**] md to rest noc then to place back on psv in am. rsbi=164. pt is easily aggitated, and bites on tube. sedation issues to be addressed?? no plans to extubate today.
"
4032,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 24/600/+12/5/50% alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  mdi's administered q4 alb with no adverse reactions. eet repositioned and secured.  rsbi=190. no further changes noted.
"
4033,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 24/600/5/50%/+12.  ambu/syringe @ hob. alarms on & functioning.  bs auscultated reveal bilateral coarse sounds which clear with suctioning. suctioned x3 small amount of bloody tinged thick secretions.  mdi's administered q4hrs with no adverse reactions.  rsbi=170, no sbt initiated. pt remains comfortable with no further changes noted.
"
4034,"resp: pt rec'd on psv 15/+8/70%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are diminished bilaterally. vent changes to decrease fio2 to 60%. attempted 50% which resulted in pao2 of 72. mdi's administed of alb as ordered with no adverse reactions. vent changed out due to 02 sensor failure. pt placed on heated circuit. am abg on 60% 7.40/39/88/25. no further changes noted.
"
4035,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv10/550/5/5/40%.  ambu/syringe @ hob.  auscultated bs reveal bilateral slight coarse sounds which clear with suctioning.  suctioned x3 small to moderate amounts of thick yellowish secretions.  mdi's administered of alb/atro q4 with no adverse reactions.  rsbi=25. 02 sats @ 100% with no further changes noted.
"
4036,"resp: pt rec'd on psv 10/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of tannish secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg (see carview) vent changes to ^ fio2 to 60%. am abg 7.44/35/74/25. no rsbi due to ^ fio2.
"
4037,"resp:  [**name (ni) **] pt on [**name (ni) **] psv20/10 50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of tan thick secretions.  mdi's administered q4hr alb with no adverse reactions.  rsbi=230, no sbt initiated.  02 sats @97% with no further changes noted.
"
4038,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 10/550/+5/40%.  alarms on and functioning.  ambu/syringe @ hob. cuff pressure @ 22 cm h20.  bs auscultated reveal bilateral coarse sounds that clear with suctioning. suctioned x3 small to moderate thick lite yellow secretions.  increase in areation noted following suctioning., ^ temp noted.  mdi's administered q4 hrs with no adverse reactions.  02 sats remain @ 100%.
rsbi=35 with no further changes noted.
"
4039,"resp: [**name (ni) 97**] pt on psv 14/5/35% then placed back on a/c 16/350/+5/35%, due to periods of apnea. bs reveal bilateral aeration with diminished bases. mdi's administed alb/atr as ordered with no adverse reactions. small amount of yellow secretions suctioned. changed to heated wire circuit. am abg 7.49/51/141/40%. rsbi=no resps. plan to continue with wean to psv as tolerated.
"
4040,"resp:  [**name (ni) 97**] pt on [**last name (un) 444**] psv 10/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral slightly coarse sounds which improve after suctioning.  suctioned x3 small to moderate whitish/yellowish thick secretions.  mdi's administered combivent q4 hrs with no adverse reactions.  eet secured and retaped.  rsbi=80, sbt initiated.  no further changes noted.
"
4041,"msicu npn 0700-1400
 a&o x3. more alert this am. states bed (1st step) has made a big difference in comfort level. plan was to try to give her pain meds atc. in a.m. we started with 2 tabs of darvocet and 4 mg dilaudid po but she was very sleepy all morning. for next dose, in ? 6hrs, we plan to decrease dilaudid to 2mg and depending on pain level and alertness, decrease darvocet to 1 tab. ketamine has been weaned off with no increase in pain at this time.
 given 1st dose of xeloda. had sm amt of emesis 2hrs post dose but no other adverse reactions noted. treated with 0.5 mg iv ativan with relief.
 uo ~30cc/hr. she remains very volume overloaded for los. currently recieving d5.45ns at 50cc/hr. her po intake is very poor and she can't take most of her oral medication. nutrition to consult for ?[** 1466**]. she does not have a clean line for tpn.
 afebrile.
 family very supportive and in most of day. aware of transfer to medical floor.
"
4042,"resp:  pt received from or and placed on [**last name (un) 444**] psv 15/5/30%.  alarms and functioning.  ambu/syringe @ hob.  bs auscultated reveal sl coarse sounds which improve with suctioning.  suctioned x2 small to moderate amount of thick yellow secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=100.  02sats 97-99%. no other changes noted.
"
4043,"resp: rec;d pt on a/c 16/350/+5/35%. bs are clear with diminished bases. suctioned for small amounts of bloody tinged thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's. 02 sats @ 100%. rsbi =150. plan to wean to psv as tolerated.
"
4044,"resp: rec'd on psv 15/5/40%. bs are clear bilateally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. tv's 400. ve 11 with 02 sats @ 99%. rsbi=or procedure for trach/peg today. will continue with present settingss.
"
4045,"resp: [**name (ni) 97**] pt on a/c 14/450/+5/60%. ett #7.5, 19 @ lip. bs are clear with diminished bases. suctioned for small amounts of yellow secretions. mdi's administered alb/atr with no adverse reactions. vent changes (see careview) with abg's. wean to psv 10/5/35%. abg 7.47/45/88/34. rsbi=115. plan to continue to wean as tolerated.
"
4046,"resp: [**name (ni) 97**] pt on psv 5/5/50%. ett #7.5, retaped, rotated and secured @ 20 lip. bs are coarse to clear and suctioning moderate amounts of thick yellow frothy/thick secretions. mdi's administered alb/atr with no adverse reactions. no vent changes noc. am abg 7.38/38/164/23. rsbi=19. plan is to extubate when pt is more awake.
"
4047,"resp: pt rec'd on psv 5/5/40%. ett 7.5 rotated, retaped and secured @ 22 lip. bs are coarse bilaterally and suctioning for small amounts of bloody tinged secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.43/34/146/23. rsbi=29. plan to wean as tolerated.
"
4048,"resp: pt rec'd on psv 16/8/100%. trached #8 portex. bs are coarse bilaterally which improve with suctioning. suctioned moderate to copious bloody thick secretions. mdi's administered q4 hrs combivent with no adverse reactions. abg's (see careview)pt had episodes of desaturation which reflect vent changes. presently on psv 14/8/50%/. 02 sats @ 98%, vt's 700-800, ve 15l, rr 20's. no further changes noted.
"
4049,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. [**last name (un) **] small amount of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  vent changes psv decreased to 10.  rsbi=142, no sbt initiated.  no further changes noted.
"
4050,"resp:  [**name (ni) **] pt from [**name (ni) 104**] intubated and placed on [**last name (un) **] simv 10/850/50%/[**4-23**].  alarms on and functioning. ambu/syringe @ hob.  bs auscultated revealed bilateral coarse bs. suctioned for moderate amount of green/yellowish thick secretions.  mdi's given q2 hrs of alb with no adverse reactions.  bs presently are bilateral clear apecies with rs insp wheeze noted.  rsbi=25. no further changes noted.
"
4051,"resp:  [**name (ni) 97**] pt on a/c 18/400/+5/30%.  pt has #7 portex trach. bs are coarse to clear. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered with no adverse reactions. pt had i/d abdominal abscess procedure in or and remains on a/c.  rsbi attemped resulting in no resps. plan to wean to psv as tolerated.
"
4052,"resp:  [**name (ni) 97**] pt extubated and on 70% f/t with 4 lpm n/c in order to maintain sats in 90's.  bs auscultated reveal bilateral coarse sounds with some scattered wheezes noted. hhn given alb/atr q4 hrs with no adverse reactions. pt placed on ffvm @ [**name (ni) **] and remained on psv for a significant amount of time, then placed back on f/t 70%/4 lpm n/c.  questionable mental status? will continue to follow.
"
4053,"resp: [**name (ni) 97**] pt on t/c @ 60%. pt ^ wob then placed back on psv 10/5/50% to rest noc. suctioned for small amounts of thick yellow secreitons. mdi's administered of alb/atr as ordered without adverse reactions. rsbi=89, then ps decreased back to 5. will continue with trach trials today.
"
4054,"resp: [**name (ni) 97**] pt on psv 10/5/50%. portex #7 trach. bs reveal bilateral aeration noted with diminished bases. suction small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. trach care performed, some oozing around trach site. pt does have some episodes of ^ wob to 30's. no a-line/abg's this shift. rsbi=129. plan to wean as tolerated.
"
4055,"resp: [**name (ni) 97**] pt on psv 8/15+/60%. pt has #8 portex trach in place. alarms on and functioning. ambu/syringe @ hob. pt placed on a/c 18/550/15+/60% to rest noc. bs are coarse bilaterally which improve following suctioning. suctioned for moderate amounts of thick tan to bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. no further changes noted. 02 sats 93-96% with no abg's this shift. will continue to wean as tolerated.
"
4056,"resp: pt remains intubated on a/c 15/500/+10/50%. bs are coarse bilaterally. suctioned for thick amounts of tan secretions. mdi's comb q4 hrs with no adverse reactions. am abg 7.40/35/116/22. no vent changes noc. will continue full vent support.
"
4057,"resp: [**name (ni) **] pt on psv 12/5/50%. ett #7.5, taped @ 23 lip. bs are clear with diminished bases. suctioned for scant amount of white secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.43/45/140/31. rsbi=88. no changes noc. plan sbt in am then extubation.
"
4058,"resp: [**name (ni) **] pt on a/c 20/400/+5/40%. alarms on and functioning.  ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 of combivent with no adverse reactions. no changes or abg's this shift. will continue full vent support.
"
4059,"resp: rec;d pt on psv 15/10/30%. ett #8.0 retaped, rotated and advanced from 20 to 22 cm @ lip as per xray/md. 02 sats @ 100%. vt 600's, ve's 7. bs auscultated reveal bilateral clear apecies with slightly coarse bases. mdi's administered as ordered alb/atr with no adverse reactions. pt scheduled for or @ 1300 today. am abg 7.50/40/90/32. no rsbi due to ^ peep.
"
4060,"resp: [**name (ni) **] pt on psv 10/10/40%. ett #7.5, 23 @ lip. bs are coarse, diminished on rs. suctioned for large amounts of thick white/with occasional plugs. mdi's administered alb/atr with no adverse reactions. vt' 300-400, ve's 13-17, rr 36-47. pt had episodes of ^ wob [**name (ni) **], bolus given, bp issues, pt family meeting to change status to cmo. am abg 7.37/45/126/27. no rsbi due to ^ peep. will continue with present settings.
"
4061,"resp: pt rec'd on psv 7/7/50%. bs are coarse bilaterally. suctioned for small amounts of thick tan secretions. mdi's administered alb/atr/[**last name (un) **] as ordered with no adverse reactions. no abg's this shift with rsbi=99. will continue to wean as tolerated.
"
4062,"resp: pt rec'd on 35% humidified t/c. pt has #7 portex trach with cuff deflated. bs are coarse to clear and able to expectorate secretions. coughing up thick tan to bloody tinged secretions. mdi's administered via trach of combivent with no adverse reactions. or procedure today (stent).
"
4063,"resp: pt rec'd on 35% t/c with humidification. bs are coarse to clear and pt has strong cough. some bloody secretions expectorated, possibly due to aggressive suctioning during day. mdi's administered via trach of combivent with no adverse reactions. pt has #7 portex trach with cuff deflated. no resp distress noted. will continue to monitor.
"
4064,"resp: pt on 40% t/c with portex trach#8. bs are coarse bilaerally and suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. 02 sats continue @ 100% with plans for rehab. will continue to follow.
"
4065,"resp: [**name (ni) **] pt on a/c 16/470/+10/40%. ett 7.5, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally with occasional wheeze noted. suctioned for small to moderate amounts of yellow to white thick secretions. mdi's administered q4 combivent with no adverse reactions. no rsbi due to ^ peep. no abg's this shift or changes. plan is to wean as tolerated.
"
4066,"resp: pt remains on a/c 12/500/+10/50%. bs coarse to diminished with noted aeration. suctioned for small amounts of thick yellow secretions. mdi's administerd q4 combivent with no adverse reactions. no changes noc. am abg 7.42/45/124/30. will continue full vent support.
"
4067,"resp: [**name (ni) **] pt on a/c 12/500/+15/50%. bs are clear bilaterally/diminishe bases. suctioned for small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. rsbi= 7.46/39/175/29. will continue full vent support.
"
4068,"resp: [**name (ni) **] pt on a/c 16/500+5/60% ett #8.0 retaped and secured @ 24 lip. alarms on and functioning. ambu/syringe @ hob. bs are clear to coarse with minimal suctioning required. mdi's started and administered qid 4 p atr with no adverse reactions. no abg's or changes this shift. will continue full vent support.
"
4069,"1900-0700

general: received pt with labored resp and audible exp wheezing noted. abg 7.44/56/41/29/+3. resp treatment administered with minor relief. face tent increased to 70%, o2sat remained 88-100% through evening. intermit. periods of agitation noted. morphine 2mg given at 2230 with minimal benefit. cardizem 10mg ivp given at 2230. lasix 20mg given at 2330. potassium supplement ivpb completed. pt became more comfortable as the evening progressed. ptt 53, 3am bolus of heparin given + increased drip to 600u/hr.am labs drawn.

neuro: pt awake/alert/oriented, perla,follows commands well. moves all ext. uncooperative at times, attempting to remove o2.soft wrist restraints applied as needed. no neuro deficits noted.

resp:labored resp through evening, using accessory muscles. o2 sat 88-100%. lungs with exp wheezing and diminshed bs bilaterally. no cough noted. pt denies sob. multiple resp treatments received throughout the night. face tent remains at 70%.

cv: nsr-st through the evening with occaional pvcs noted. denies cp. weak but palpable pulses to ext. afebrile. bp 170-120, hr 115-88. nitroglycerin drip started and titrated to 2mcg/kg/min. no adverse reactions noted. skin warm/dry/intact.

gi: abd round slightly distended. +bs x 4 quad. receiving tpn for nutritional supplement. guiac neg stool x1.

gu: foley intact draining clear yellow urine.

iv: rij tlc intactdsg changed. heparin@600u/hr, nss@kvo, nitroglycerin@2mcg/kg/min, [**e-mail address 10421**]/hr. r piv d/c'd due to reddness and irritation.

plan: supportive care for unstable resp status. evaluation of fluid balance and treatment.
                          [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
4070,"resp: pt on 40% t/c with #8 portex trach.  [**e-mail address 10312**] reveal bilateral coarse sounds with occasional exp wheeze wi.th forced expiration. pt continues to have periods of anxiousness. mdi's administered via trach alb/atr with no adverse reactions. pt being screened for rehab. will continue to follow
"
4071,"resp: [**name (ni) **] pt on 50% t/c with 02 sats @ 100%. bs are coarse which clear with suctioning. suctioned for small amount of white secretions. mdi's adminisered alb/atr via trach with no adverse reactions. ambu/syringe @ [**name (ni) **]. fio2 decreased to 40% with 02 sats @ 100%. pt remains on t/c through night with no resp distress noted. will continue to follow.
"
4072,"resp: [**name (ni) **] pt on psv 5/5/30%. ett 7.5 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral coarseness which improve with suctioning. suctioning small to moderate amounts of tan-yellow-clear secretions. mdi's administered atr with no adverse reactions. am abg with results pending. rsbi=57. vt's 400-500. ve 11, rr 20-23. plan is to attempt extubation this am.
"
4073,"resp: pt rec'd on a/c 151/550/+5/40%. ett 7.0 rotated, and retaped @ @3 lip.  bs are coarse to clear with suctioning. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. pt remains on pressors. abg 7.42/27/89/18 with 02 sats @ 100%. rsbi=no resps with plan to continue working of guardian/cmo status. pt remains on full vent support.
"
4074,"resp: pt rec'd on simv 10/600/10+15/50%. pt has portex #8 trach. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administerd as order alb/atr with no adverse reactions. (see careview for vent changes and abg's). am abg 7.40/47/115/30. rsbi=68.  will continue to wean as tolerated
"
4075,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500+5/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 moderate amounts of tannish thick secretions, later in am greenish/yellow.  pt pushed out biteblock, reinserted, pt biting down on ett, decreasing sats to 88. hr ^ to 140's.  mdi's administered q4 combivent with no adverse reactions. rsbi=140, no further changes noted.
"
4076,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c14/500/10/50%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for thick yellow secretions. mdi's administered q4 with no adverse reactions.  no vent changes noc.  plan to trach today.
"
4077,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500/+5/60%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal ^ aeration on ls with notable decrease on rs. cxr taken revealing eet slipping into r mainsteam.  eet pulled back to 20 cm @ lip. equal bs noted.  mdi's administered q4hr combivent with no adverse reactions.  suctioned x 3 moderate amount of thick bloody tinged secretions.  pt is anxious when not sedated and tried to self extubate.  no further changes noted.
"
4078,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/500/50% /+5.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned moderate amount of thick tanish secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi initiated, no spontaneous breath taken.  02 sats @ 97%.  no further changes noted
"
4079,"resp: pt remains on pcv with changes in peep ^18/pinsp ^38 to maintain a dp of 20. multiple abg's (see carview). vt's 350, ve's [**9-4**] with 02 sats mid 90's. suctioned for small amounts of pale yellow secretions, some bloody tinged from oral cavity. mdi's administered as ordered with no adverse reactions. no further changes noted. will continue to wean as tolerated.
"
4080,"resp: [**name (ni) 97**] pt on pcv 42/+22/dp 20/r34/40%. ett #7, 23 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and diminished at bases. suctioned for moderate amounts of [**name (ni) **] yellow secretions. mdi's administered q 4 alb with no adverse reactions. had episodes of desaturation, then increased fio2 to 50% where it remains. no further changes noted. will continue full vent support.
"
4081,"resp: [**name (ni) 97**] pt on psv 12/7/40%. bs are coarse bilaterally.suctioned for moderate amounts of thick yellow secretions. mdi's administered combivent/[**last name (un) **] as ordered without adverse reactions. no abg's this shift. rsbi=85. plan to continue to wean psv as tolerated.
"
4082,"resp: [**name (ni) 97**] pt on a/c 20/500/+12/40%. bs reveal bilateral aeration with some coarseness, no wheeze noted. suctioned for small amounts of bloody tinged secretons. mdi's administered alb/atr with no adverse reactions. abg's pa02 decreased, then ^ fio2 to 50% with no improvement, then ^ to 60% and ^ peep to 15. am abg on changes pending. will continue to wean as tolerated.
"
4083,"resp: [**name (ni) 97**] pt on psv 10/10/40%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. sample sent. mdi's administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg 7.34/38/101/21. pt placed on simv 18/600/10/10/40% to rest noc. plan to continue to wean to psv as tolerated.
"
4084,"resp: [**name (ni) 97**] pt on a/c 18/600/+5/40%. ett 8.0 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally which improve following suctioning. suctioned for small amounts of thick yellow secretions as well as oral secretions.  mdi's administered q4 hrs [**last name (lf) 7186**], [**first name3 (lf) **] [**hospital1 **] with no adverse reactions. am abg 7.41/34/110/22. rbsi=98. plan to discuss with family code status. family does not want pt to be trached.
"
4085,"resp: [**name (ni) 97**] pt on a/c 30/550/18+/60%. ett#8, retaped,roated and secured @ 24 lip. esophogeal balloon in place. bs are clear bilaterally in apecies with diminished rs. 02 sats 93-95,then suction for copious amounts of thick brown plugs. vent changes to ^ peep to 20 and fio2 to 70%. (see careview for abg's) mdi's administered q4 combivent with no adverse reactions. am abg 7.44/48/88/31 then decreased peep to 18. will continue to wean fio2 as tolerated.
"
4086,"resp: [**name (ni) 97**] pt on psv 10/8+/40%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases. suctioned for small amounts of white thick to thin secretions. much improvement noted. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. no aline/abg's 02 sats @ 100%. rsbi=77. plan to continue t/c trials.
"
4087,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/400/+5/40%.  alarms on and functioning. ambu/syringe @  hob. bs auscultated reveal bilateral crackles with a few scattered wheezes.  suctioned x3 for moderate amounts of thick yellow secretions. mdi's given q4 hrs atr/alb with no adverse reactions.  rsbi=144 this am.  pt is alert and awake. 02 sats @ 100%. ett retaped and secure @ 20 cmh20/lip.  no further changes noted.
"
4088,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #8.0 taped @ 25 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for bloody thick secretions. mdi's administered alb as ordered with no adverse reactions. rsbi=43. am abg 7.44/36/111/25.  plan to extubate today.
"
4089,"resp: [**name (ni) 97**] pt on psv 10/8/50%. pt has #8 portex trach. ambu/syringe @ hob. alarms on and functioning. bs are coarse. suctioned for moderate amounts of tan to bloody tinged thick yellow secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. vt's 400's, ve's 11, rr 24. 02 sats @ 100%. no aline/or abg's this shift. rsbi=53. plan to continue with t/c trials today.
"
4090,"resp: [**name (ni) 97**] pt on psv 5/5/50%. pt has #8 portex. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow/tan secretions. mdi's administered of combvient/[**last name (un) **] as ordered without adverse reactions. pt had episode of ^ wob and rr, then ^ ps to 16, peep 8.  vt's 400-500, ve 12, rr 27. rsbi=92. no abg's (no a-line). will continue to wean with t/c trials as tolerated.
"
4091,"resp: [**name (ni) 97**] pt on 70% t/c and was on all day. bs remain coarse bilaterally. mdi's administered combivent/flovent with no adverse reactions. pt lasted to 3:00 am then became sob, ^ wob, suctioned for moderated to copious thick yellow secretions. pt was lavarged and ambued resulting in removal of plug. placed pt on vent psv 10/5/50% and has been comfortable with 02 sats @ 100%. plan to continue with t/c trials as tolerated.
"
4092,"resp: [**name (ni) 97**] pt on a/c 20/500/+15/60%. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral aeration with occasional wheeze, although improvement noted. suctioned for small amounts of tannish thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg  7.42/44/87/30. vent changes; decrease fio2 to 50%. 02 sats @ 95%. will continue to wean as tolerated.
"
4093,"resp: [**name (ni) 97**] pt on psv 5/5/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow to tan secretions. mdi;s administered q4 combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. pt had episode of desaturation and ps ^ to 15 peep ^ 8 02sats % 99-100%. weaned psv back to [**3-27**] with vt 400/ve 9/rr 22. rsbi =75. plan to attempt t/c trials as tolerated.
"
4094,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #7.5, 19@ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally. mdi's administered q 4hrs atrovent with no adverse reactions. am abg 7.45/34/121/24. rbsi=40 no changes this shift or gag reflex noted.
"
4095,"resp: [**name (ni) 97**] pt on a/c 18/450/+5/40%. ett#7.5, 19 @lip. alarms on and functioning. ambu/syringe @ hob. bs are clear with occasional coarse sounds which improve with suctioning. diminished bases bilaterally. suctioned for small amounts of thick white secretions. mdi's administered q4 hrs atrovent with no adverse reactions. trip to ct with results pending. am abg's7.50/26/363/21 with no changes. family meeting today to discuss cmo.
"
4096,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett 37.5, 19 @ lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear with diminished bases. suctioned for small amounts of yellow secretions. mdi's administered q4 hrs atrovent with no adverse reactions. [**name (ni) 239**]=44. am abg's 7.43/37/110/25. plan today is to wean to extubate.
"
4097,"resp: pt remains on vent a/c 12/500/+8/40% and is vent dependent. bs are slightly coarse which improve following suctioning. suctioned for small amounts of white thick secretions. mdi's administered as ordered with no adverse reactions. no changes or abg's this shift. 02 sats 2 97%. no rsbi due to vent dependency. will continue full vent support.
"
4098,"resp: [**name (ni) 97**] pt on a/c 24/450/+5/50%. alarms on and functioning. ambu/syringe @ hob. pt is [**name (ni) **] with # 8 [**last name (un) **] (foam filled) trach. bs reveal occasional wheeze with slight coarseness. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. vent changes to decrease fio2 to 40%, rate to 20, and tv 400 reflects abgs. am abg 7.40/58/88/37. no further changes noted.
"
4099,"resp: [**name (ni) 97**] pt on psv 8/5/50%. bs reveal noted aeration. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.46/35/91/26 on 40% fio2. rsbi=63, cuff check and adequate leak noted. continue to wean appropriately.
"
4100,"resp: [**name (ni) 97**] pt on a/c 18/450/+5/40%. alarms on and functioning. trach#8.0 shiley with no inner cannula. bs are coarse bilaterally. suctioned copious amounts of thick green secretions. mid's administered as ordered of atrovent with no adverse reactions. am abg 7.38/55/116/34. will proceed to wean as tolerated.
"
4101,"resp: [**name (ni) 97**] pt on a/c 24/500/+5/40%. pt has #8 portex trach. bs are coarse to clear bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. am abg 7.40/50/106/32. rsbi=62. plan: wean as tolerated.
"
4102,"resp: [**name (ni) 97**] pt on 50% t/c. pt became tired and complained of ^ wob then  placed back on vent to rest noc. psv 8/8/40%. suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. no abg's this shift. rsbi=33. plan: continue with t/c trials as tolerated.
"
4103,"resp: [**name (ni) 97**] pt on psv 8/8/40%. pt has #8 portex trach. bs are clear with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no abg's noc. rsbi=57. plan: continue with t/c trials as tolerated. pt being screened for rehab.
"
4104,"resp: [**name (ni) 97**] pt on a/c 32/600/10+/50%. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. pt biting on ett, block placed. ett retaped and secured. mdi's administered as ordered with no adverse reactions. abg's (see careview) vent changes to decrease rr to 28. am abg 7.30/36/146/18. rsbi= no resps.
"
4105,"7a-7p
neuro: pt alert, nodding appropriately, moving all extremeties. following all commands.perrla. morphine ivp given prn pain. denies pain at present time.

cv: hr initially 70-90s sr 1st degree avb. converted to raf 130s-140s, w/ stable sbp 110-120s at 1230, ntg weaned to off. lopressor 5mg given. total of 20mg ivp as ordered per pa [**doctor last name **]. mg 2gm given. amiodarone iv bolus 150mg x 2 given, gtt started at 1mg/hr as ordered. at present still hr 100-130 on gtt, pa [**doctor last name **] aware. during event, pt alert and nodding appropriately. swan placed at bedside, see carevue for filling pressures. ci >3 before af, after af ci>2, pa [**doctor last name **] aware. 1 unit of prbcs given for hct <28, no adverse reactions. repeat hct 33.2. epicardial wires in place atrial ma turned to off secondary to inappropriate atrial pacer spikes. v wires not capturing or sensing appropriately. palpable pulses.

resp: ls coarse. suctioned for scant thick tan. trial on cpap fio2 40%, 5peep, 8ps. abgs 7.30/47/133/24/97%, pa [**doctor last name **] called and aware, vent change to ac 8, improving abgs. see carevue for details.

gi/gu: abd soft hypoactive bs. ogt replaced secondary to tee done in am, +placement verified by two rns. lasix 200mg and diuril 500mg iv given as ordered, bringing u/o >100cc/hr.

endo: insulin gtt restarted, as high as 6units/hr.

social: husband visited and updated, sister called and updated w/poc.

plan: monitor hemodynamics. monitor resp. status. monitor blood glucose. monitor hr. monitor u/o. keep pt comfortable.
"
4106,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/400/+5/35%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with slighlly diminished bases. mdi's administered q4 of alb with no adverse reactions. suctioned small amounts of yellow/white secretions with an occasional plug. am abg's 7.40/62/97/40.  rsbi=26. no further change noted. extubation expected this am
"
4107,"resp: [**name (ni) 97**] pt on psv 15/8/50%. ett #8, 23 @ lip. bs are coarse bilaterally. suctioned for copious amounts of thick tan secretions. mdi's admistered as ordered alb/atr with no adverse reactions. am abg 7.40/45/99/25. rsbi=66. will continue to wean as tolerated.
"
4108,"resp: [**name (ni) 97**] pt on psv 10/10/40%. bs are coarse bilaterally. suctioned for thick amounts of tannish secretions. mdi's administerd as ordered alb/atr with no adverse reactions. pt desat in 80's with ^ wob and placed back on a/c. multiple abg's (see careview) with vent changes to decrease r to 20. rsbi= no resps. am abg pending. will wean to psv as tolerated.
"
4109,"resp:  rec'd a/c 20/600/+12/40%. bs are slightly coarse with diminished bases. suctioned for small amounts.suctioned moderate amounts from oral cavity. mdi's administered as ordered with no adverse reactions. am abg 7.30/43/90/22. no changes noc. no rsbi due to ^ peep
"
4110,"resp: [**name (ni) 97**] pt on psv 12/10/40%. ett 7.5 24 @ lip. bs are coarse bilaerally with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's adminisered as ordered with no adverse reactions. vt's 400-500, ve's 12'[**49**], rr 24 with ^ to 30's at times.  am abg 7.43/44/101/30. rsbi=^peep. no changes noc. continue to wean as tolerated.
"
4111,"resp: [**name (ni) 97**] pt intubated via er for airway protection. placed on a/c 16/500/+5/50%. bs are clear bilateraly with diminished bases. mdi's administered as ordered with no adverse reactions. rsbi=no resps x2.plan to wean as tolerated.
"
4112,"resp: rec;d pt on psv 15/10/50%. ett #8 retaped and secured @ 23 lip. bs are coarse bilaterally. suctioned for small to moderate amounts of thick yellow to tannish secretions. mdi administere as ordered alb/atr with no adverse reactions. pt had episode of tachycardia around midnight, lopressor administred pt back into sinus.  peep decreased to 8. am abg 7.40/45/99/29. rsbi=76. willl continue to wean as tolerated.
"
4113,"resp: pt remains intubated ett#8, 23 @ lip. psv 15/+/50%. bs are coarse bilaterally and suctioning copious amounts of thick white secreitons. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.34/42/160/24. rsbi=66. plan to trach and peg today.
"
4114,"resp: [**name (ni) 97**] pt on [**last name (un) **] simv 12/600/5/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs reveal i/e wheezes with rs diminished. suctioned moderate amounts of thick yellow secretions. mdi's administered q4 alb/atr and [**last name (un) **] [**hospital1 **] with no adverse reactions.  abg's 7.34/41/118/23. rsbi=44. no further changes noted.
"
4115,"resp: [**name (ni) 97**] pt on psv 12/10/40%. ett 7.5, 24 @ lip. bs are slightly coarse with diminished bases. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. vt's 500-600, ve's13, rr 28. no changes or abg's this shift. 02 sats @98%. family meeting today to discuss cmo with possible withdraw in afternoon. will continue with present settings.
"
4116,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 18/550/40%/+[**4-23**]. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds with slight coarse bases. suctioned x3 small amount of bloody secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=65, sbt initiated.  02 sats @ 99%.  no further changes noted.
"
4117,"resp:  [**name (ni) 97**] pt intubated from or.  ambu/syringe @ hob. placed on 7200 briefly then extubated and placed on sm @ 6lpm.  bs auscultated reveal bilateral diminished sounds, pt complains of not being able to breath.  02 sats remain 98-100%, rr 16-15. hhn ordered and administered x3 during noc alb/atr with improvement noted. no adverse reactions noted. pt on n/c @ 4lpm with no distress.  no further changes noted.
"
4118,"resp: pt rec'd on psv 10/5/40% ett 7.0 18@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small to moderate amounts of thick yellow to white secretions. mdi's administered alb with no adverse reactions. abg's (see careview)ativan administered and changes to place pt back on a/c. rsbi attempted. will try again in am when sedation lightened. plan to wean to psv as tolerated.
"
4119,"resp: pt rec'd on psv 5/5/40%. ett #8, taped @ 24 lip. ambu/syrine @ hob. bs are clear with diminished bases. suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. vt's 500-600, ve [**11-10**], rr 25. 02 sats @ 100%. am abg 7.38/40/114/25 with rsbi=74. plan to continue to wean as tolerated.
"
4120,"resp: [**name (ni) 97**] pt on psv 2/5/40%. alarms on and functioning. ambu/syringe @ hob. ett 7.5, taped & secured @ 23 lip, 23 cp. vt's 500, rr 16. bs auscultated reveal bilateral crackles. suctioned small amounts of thick white secretions. mdi administered q4 hrs with no adverse reactions. will continue full support.
"
4121,"resp: pt remains intubated on a/c 18/650/+10/50%. bs are clear bilaterally. suctioned for small amounts of secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.44/35/159/25. no vent changes noc. will continue full support.
"
4122,"resp: [**name (ni) 97**] pt on psv 10/5/40% (mmv back up rate) bs auscultated reveal bilateral crackles. suctioned for small to moderate amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. vt's 400-480, rr 18-22.am abg 7.40/59/97/30. no further changes noted. will continue to follow.
"
4123,"admission
pt is a 77 year old female admitted from cath lab, s/p stenting of left cx and rca. presented to er this am ~0600 from nh due to pt being lethargic,code stemi done after ekg done, intubated in er due ? responsiveness. on dopamine as high as 15mcg/kg/min in cath lab, at present time dopamine at 5mcg/kg/min.

neuro: pt tracks rn when being spoken to, does not follow commands, perrla. no indication of pain.

cv: hr 60-80s sr. arterial sheath [**name6 (md) **] by md [**last name (titles) 7625**], act 160. right groin cdi, no bleeding, no hematoma venous sheath kept in. dopamine at 5mcg/kg/min. sbp labile, 70-110s. fluid bolus 500cc given as ordered, improving sbp. hct for 23.9, transfused 1 unit of prbcs, no adverse reactions/ ekg done on arrival as ordered, elevated st, slightly improved per ccu team. +dopplerable right dp/pt, +dopplerable left dp, absent pt on left. ccu team aware, no new orders. next ck due 1900. bp on left arm only per ccu team, right has old fistula that does not work.

resp: ls clear. orally intubated, weaned vent to cpap [**5-10**] fio2 40%. ccu team aware of abgs (md [**doctor last name **]). see flowsheet for details. unable to get sats at times, ccu team and md [**doctor last name **] aware. sats when showing 100%. sputum culture sent.

gi/gu: abd soft hypoactive bs. ogt +placement. clamped at present [**doctor first name **], ok to hook up to lcs [**name8 (md) 9**] md [**last name (titles) 7626**]. foley draining 0-10cc/hr of amber color urine. left subclavian hd cath [**last name (titles) 240**]. ua and uc sent.

endo: per sliding scale.

plan: wean vent. assess neuro (pt with hx of dementia). ck due 1900. hct pending. blood cultures when aline placed. ?aline placement. wean dopamine. full code.
"
4124,"resp: [**name (ni) 97**] pt on psv 12/5/40%. alarms on and functioning. ambu/syringe @ hob. 7.5 ett taped and secured @ 23 lip. cp 23 cmh20. bs auscultated reveal bilateral crackles. suctioned for scant to small amounts of thick white secretions. mdi's administered q 4 hrs with no adverse reactions. vent changes to decrease ps to 10. am abg's 7.36/56/94/33. rsbi=63. no further changes noted.
"
4125,"resp: [**name (ni) 97**] pt on ac 12/600/+5/50%. ett #7.5 24@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for small amounts of thick tannish secretions. mdi's administered q4 alb/alb with no adverse reactions. am abg 7.40/32/140/21. rsbi=125. pt is scheduled for trach/peg in or today.
"
4126,"resp: [**name (ni) 97**] pt on a/c 18/650/+10/50%. ett#7.0, 24 @ lip. bs are slightly coarse. suctioned for small amounts of tannish secretions. mdi's administered q 4 hrs. alb/atr with no adverse reactions. am abg's 7.47/32/207/24. no vent changes noc. will continue full vent support.
"
4127,"resp: pt rec'd on 18/650/+12/50%.  bs are clear. mdi' administered alb/atr with no adverse reactions. vent changes to decrease peep +10. abg's 7.43/34/169/23. no further changes noted. will continue with full vent support.
"
4128,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 14/550/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral slight coarse sounds with crackles in bases. suctioned small amounts of white/yellowish secretions.  mdi's administered q4 atr/alb with no adverse reactions. placed pt on psv and didn't tolerate.  rsbi=155.  am abg's 7.33/44/101/24.  will continue to wean as tolerated.
"
4129,"resp: [**name (ni) 97**] pt on a/c 14/500/+5/40%. ett 7.0, 22 @ lip. bs are coarse to clear and suctioning small to moderate amounts of thick yellow secretions. mdi of atr administered as ordered with no adverse reactions. no abg's or changes noc. will continue present support.
"
4130,"0700-1900 npn
alert, oriented, coperative with care.  mae.  pain not well controlled this am, c/o sharp stabing pain with cramps, [**10-21**] pain.  neurotin dose started with minimal effect. pca increased and ativan iv given with limited effect.  aps into consult and epidural placed and started on bupivicane/dilaudid epidural with good effect.  able to titrate up without adverse reactions. given valium and ativan for breakthrough.  tmax 99.9, hr 60-60 nsr 4 beat run vtach x1, asymptomatic.  bp stable 130-140's.  pp palpable, sm amt generalized edema.  lungs clear, using is with encouragment.  abd tender, greatly improved with epidural, hypoactive bowel sounds.  ngt lcs.  urine adveraging 30cc/hr.  dsg intact, jp sites intact, no breakdown.  stoma pink, sm amt serosang output.  plan to increase activity as tolerated, monitor pain and medicate prn, monitor hemodynamics, provide emotional support to patient and family.
"
4131,"resp: pt on hi-flow mask @ 40%. nebs administered as ordered alb/atr with no adverse reactions. bs are coarse bilaterally with no change following tx. will continue to follow and monitor.
"
4132,"resp: pt rec'd on mmv (see carview for psv back up settings). bs are coarse bilaterally and suctioned for small amounts of thick yellow secretions. mdi's administered as ordered alb with no adverse reactions. am abg 7.37/36/143/22. rsbi=78. plan to wean psv to possible extubation today.
"
4133,"resp:  [**name (ni) 97**] pt on 7200 ps 20/+15/40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that clear with suctioning.  suctioned small to moderate thick yellowish/whitish secretions, and also out of oral cavity.  mdi's administered q 4hr alb/atr with no adverse reactions. eet retaped, moved and secured.  vent changes as follows; a/c 18/650/+15/40%.  02 sats remain in ^90's over noc with no additional changes noted.
"
4134,"resp: [**name (ni) 97**] pt on a/c 10/450/+5/45%. bs are coarse bilaterally. suctioned for small to moderate amounts of white secretions as well as oral secretions. mdi's administered alb as ordered with no adverse reactions. rsbi=127. pt more awake. plan to wean to ps as tolerated. no abg's no a=line
"
4135,"resp: [**name (ni) 97**] pt on a/c 20/500/+5/40%. bs reveal bilateral aeration. no wheeze noted. suctioned for small amounts of yellow secretions and bloody secretions x1, rn/md aware. mdi's administered q4 hrs combivent with no adverse reactions. rsbi attempted=no resps. no changes noc.  will continue full vent support.
"
4136,"resp: [**name (ni) 97**] pt on [**last name (un) **] simv 15/600/10/14+/50%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished bases with aeration noted in apecies. mdi's administered combivent 2 p with no adverse reactions.  suctioned for small amounts of white/yellow secretions. am abg's 7.38/44/98/27.  vent changes reflect abg's (see careview) no rsbi due to ^ peep. no further change ntoed.
"
4137,"resp:  [**name (ni) 97**] pt on 7200 a/c 18/650/50%/+20.  ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies,with some coarse bs in bases which clear with suctioning.  suctioned x2 small amounts of thick yellow secretions.  mdi's administered alb/atr q4h with no adverse reactions noted.  no rsbi performed due to ^peep.  no further changes noted.
"
4138,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 18/650/+20/50%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned small to moderate amounts of thick bloody tinged secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats remain in^ 90's 96-98% with no distress noted during the noc.  current vent settings remain and recent abg noted as 7.33,44,94,24,-2.  no further changes noted.
"
4139,"resp: [**name (ni) 52**] pt on a/c 22/600/+5/40%. ett # 8 @ 21 lip. bs reveal bilateral aeration with diminished bases, no wheezes noted. alarms on and functioning. ambu/syringe @ hob. suctioned for small amounts of tanish secretions. mdi's administered  q 4 alb/atr with no adverse reactions. abg (venous) 7.39/40/39/25. 02 sats @ 100%. attempted rsbi although pt not awake enough. will attempt again this am. plan is to wean as tolerated to ps with possible extubation.
"
4140,"resp: [**name (ni) 52**] pt on simv 7/450/5/+5/40%. pt has #7 [**last name (un) **] trach. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. [**last name (un) 1017**]=113. no abg's or changes this shift.
"
4141,"resp: [**name (ni) 52**] pt on simv 7/450/5/+5/40%. trach #7 [**last name (un) **] [**last name (un) 1999**]. bs are coarse bilaterally. suctioned for copious amounts of thick yellow secretions. mdi's administered q4 hrs of alb/atr with no adverse reactions. abg's 7.36/71/71/41. md aware and satisfied with results. will continue to maintain current vent settings.
"
4142,"resp: pt rec'd on a/c 14/500/+5/60%. bs auscultated reveal bilateral aeration in apecies with diminished bases. mdi's administered q 4 comb/[**last name (un) **] [**hospital1 **] with no adverse reactions. am abg's 7.44/38/93/27. suctioned for small amounts of thick bloody tinged secretions. proceeded to initiate wean decreasing fio2 to 50%. will continue to wean appropriately.
"
4143,"npn: s/p cabg

neuro: drowsy and lethargic at times. easily arouses. oriented to self,hospital,or family. occ sl confused to day/time. mae with equal strength. knees sl buckling with oob to chair. perrl. visited with husband and [**name2 (ni) 2585**]. [**name (ni) 2586**] hopes to be back to work in 4 weeks.
cv: 100-70's sr-st with occ to freq pac's-rare pvc's seen-triplet x2. on/off neo to .75 to keep map>60. ci>2.5. swan dc'd.  k repleted. lytes wnl. pacer set a s a demand at 60. pedal pulses by doppler. hct stable 32.6.
id: tmax 99. wbc 9. cont on postop vanco.
resp: lungs diminished in bases. cough prod of bloody to blood tinged secretions early. requiring 4l nc and 40% ftneb especially when dozing. ct/mt to sxn-no airleak-serosang dng decreasing. sats > 95%. gu: foley to gd with initially good uo-now trending low0500cc ns given. cr .5.
gi: abd obese,soft, nt, nd. periods of nausea especially with movement which pt states happens r/t her meniere's. reglan given x1. tol small amt clears.
endo: on insulin gtt per cts protocol-gl to 71-gtt now off.
comfort: dilaudid .5 mg iv q 2-3 hrs for pain with effect. pt cont to state multiple allergies to everything you try to give her. no adverse reactions seen. to have vicodin ordered for po pain med.
activity: oob to ch with 2 assists-tol well but very slow-c/o knees buckling and very tired.
incisions: sternum and ct with original dsd-old staining on sternum-d/i. l leg ace wrapped d/i.
a: stable -still requiring volume and +/- neo
p: wean neo as tol, 500cc ns bolus, monitor uo-? lasix later if needed. po pain med, replete lytes.
"
4144,"nsicu npn 0700-1500
see carevue for subjective/objective data.  neuro:  pupils 2mm, sluggish most of shift however at 1430 pupils 3mm, brisk.  does move all extremities on bed when propofol lightened, does withdraw to pain. purposeful movement-->consistently lifts left hand toward ett when un-
restrained.  icp drain in place, icp 12-22, drng blood tinged sec 11-24ml/hr.  spec obtained by md and sent to lab.  poor waveform--md aware.  icp flushed by md with minimal improvement in waveform.  +gag, +cough, +corneals.  dsg-->icp drain d+i.  one suture on icp drain out; again, md aware (not new).  to ct at 0800 for ct of head; results pending.

cv/pulm:  initially on neo--gradually weaned, turned to off at 1400 with bp 120's.  goal is to keep bp 120's-140's.  ekg done.  started on sq heparin.  hct=25; one unit prbc's hung at 1430 with no adverse reactions thus far.  mp=nsr, no vea noted.  maintenance iv kvo'd while prbc's infusing.  remains vented on ac10x600x50%x5peep.  peep was 10, decreased to 5, abg's pending.  suct for mod amts thick yel sec via ett and thick clear orally.  bs coarse bil.  no other vent changes made this shift.  ett rotated to l side mouth, [**name8 (md) 76**] md pulled back to 21cm lip line.  no rpt cxr done.

gi/gu:  ogt-->lcs drng 75ml coffee ground material.  tf started at 1430 fs promote with fiber at 10ml/hr.  goal=60ml/hr.  no bm, +flatus. hypoactive bs.  u/o qs q1h via foley.

integ:  no open areas noted.  changed to air mattress with 5assists tol well.  turned s/s but consistently left in supine position.

id:  tmax=100.1 po.  no change in abx.

psychosocial:  fam in to visit.  emotional support given to pt and fam.  per fam they will return this pm to visit again.
"
4145,"resp: pt rec'd intubated via or placed on [**last name (un) **] a/c 14/500/+5/60%.ett 7.5, taped @ 19 lip.  bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick bloody secretions with occasional plug. mdi initiated and administered q4 alb/[**last name (un) **] [**hospital1 **] with no adverse reactions. abg's (see careview) am abg's 7.38/42/86/26.  will continue full vent support.
"
4146,"ccu nursing progress note
s""i want to go home""
o: pt s/p right carotid stenting. pt alert, oriented x2. answers questions and speaking w/o aphasia. no difficulty swallowing liq.  follows commands. pt was not able to  sleep   frequently disoriented with escalating agitation. med w/ xanax w some effect.  daughters stayed w/ pt throughout the noc.
cv:mhr vp, no vea, sbp 120-130, +mur, dp palp bilat. r groin dsg d+i.
resp:lungs clear, sats 98% on ra.
gi:+bs, sm stool, guiac neg
gu: u/o 80-100cc/hr.
a/p: pt hemodynamically stable post stent. evidence of sundowning/acute delirium vs pt psychosis neurosis. this is the second night the pt has not slept according to family. family not wishing to try other sedatives or zyprexa due to adverse reactions to these meds in the past.
"
4147,"resp:  [**name (ni) 97**] pt on 40% cam (t/c).  bs auscultated revealed bilateral i/e wheeze. placed pt back on [**last name (un) **] mmv 12/500/+5/5/30% noc.  mdi's administered of comvbivent q4 hrs with no adverse reactions.  suctioned x3 small amounts of white thick secretions.  trach care performed, stitches removed, trach collar placed.  cuff pressure @ 20 cmh20.  02 sats ^ 90's 98%.  no rsbi performed since pt is being placed on t/c during the day.  no further changes noted.
"
4148,"resp: [**name (ni) 97**] pt on psv 10/10/50%. alarms on and functioning. ambu/syringe @ hob. ett #8.0 @ 21 lip. bs are coarse bilaterally. suctioned for small amounts of white secretions. sample obtained and sent. mid's administered as ordered alb/atr with no adverse reactions. am abg's 7.43/41/137/28. no rsbi due to ^ peep.
"
4149,"resp: [**name (ni) 97**] pt on 40% t/c. ambu @ hob. bs are coarse bilaterally with diminished ls in base. mdi's administered q6 hrs of alb with no adverse reactions. pt able to expectorate with spc. rusty thick secretions. 02 sats @ 100%. will continue to follow as per trach protocol.
"
4150,"resp:  [**name (ni) 97**] pt on 7200 psv 18/40% +5.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds that clear with suctioning. suctioned several times during the night for thick yellow/greenish secretions. pt tends to accumulate moderate amounts of whitish secretions also in oral cavity.  mdi's administered q4 hr, 6 p combivent with no adverse reactions.  pt was place on a/c 10/400/+5/40% at noc to rest.  rsbi=108 this morning so no sbt initiated.  returned pt to psv 18/5/40 this am and tolerating settings well.  no further changes noted.
"
4151,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 10/500/+12/50%. alarms on and functioning. ambu/syringe @ [**last name (un) **]. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of bloody tinged secretions with noted plugs.  mdi's administered q 4 hrs combivent with no adverse reactions.  no rsbi's performed due to ^ peep. am abg's 7.52/45/109/38. attempted to wean on psv, maintaining tv's/ve's appropriate although pt had periods of apnea. suggest possibly mmv to wean.  no further changes noted.
"
4152,"resp:  [**name (ni) 97**] pt on [**last name (un) **] a/c 20/400/40%/+8.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.   suctioned x3 moderate amount of thick bloody tinged secrections.  mdi's administered q4hr alb/atr with no adverse reactions.  o2 sats remain in ^90's.  no further changes noted.

"
4153,"resp: pt remains on psv 10/10/50%. bs are coarse bilaterally. suctioned for moderate amounts of tannish thick secretions with some bloody tinged. mdi's given q4 hrs combivent with no adverse reactions. abg's (see careview) am abg pending. no rsbi due to ^ peep. will continue to wean appropriately.
"
4154,"resp: [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small to moderate thick yellow secretions.  pt is able to self suction oral cavity.  mdi's administered alb/atr with no adverse reactions.  02 sats remain between 98-100%, maintaining adequate tv during the noc @ 350-400. pt does continue to have periods of apnea during noc, but in no distress.  no [**name6 (md) 239**] performed rn suggests let pt rest.  will advise day therpist to perform when pt is more awake.  no further changes noted.
"
4155,"resp: pt remains on psv 12.5.50%. vt's 600-700/ve 10/r 19, bs are slightly coarse suctioning small amounts of bloody tinged secretions. mdi's administered q4 combivent with no adverse reactions. am abg's 7.41/50/118/33. rsbi=166. no vent changes noc.
"
4156,"7a-7p
neuro: pt a+ox3,mae,perrla. dilaudid sc 2mg for pain.

cv: hr 80-100s sr no ectopy. sbp labile, on and off neo throughout day, see carevue for details. received one unit of prbcs, no adverse reactions. received lasix 20mg ivp after transfusion. +palpable pulses. generalized edema. at present to keep map >60, [**name8 (md) 9**] md [**last name (titles) 822**].

resp: ls wheezing throughout, audible at times especially w/ exertion. nebs q4 hours as scheduled. sats >97% on 4lnc.

gi/gu: abd soft,+bs,+flatus per pt. foley draining adequate amts of yellow urine-> light yellow after iv lasix.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. keep in unit overnoc, ? transfer to floor if remains off neo.
"
4157,"7p-7a
neuro: pt chinese speaking. pt alert granddaughter at bedside at beginning of shift translating, pt answering appropriately, follows commands,perrla, mae. granddaughter told pt in chinese not to touch ngt. medicated w/ dilaudid 2mg ivp q2 hours for incisional right ct pain, pt points to area and states ""pain"" or ""hurt"". at 0430, c/o left neck pain near jp and left shoulder, md [**doctor last name 896**] aware no new orders.

cv: hr at beginning of shift 110s, sbp 170 while intubated, md [**name6 (md) 1081**] and md [**doctor last name 896**] aware, additional lopressor iv given + hydralazine 10mg ivp. at 2100, hr again to 110s (after lopressor hr dips to 90 sr), md [**doctor last name 896**] aware additional lopressor iv 10mg given bringing hr down to 90s for approx 45min-1 hour. md [**doctor last name 896**] aware, labs ordered and sent. troponin 0.11 ck 488 md [**doctor last name 896**] aware, ekg done and reviewed by nd [**doctor last name 896**]. 1 unit of prbcs ordered and lopressor increased to 15mg iv q6hours. prbcs infused w/ no adverse reactions, md [**doctor last name 896**] aware of temp prior to transfusion, ok to give [**name6 (md) **] [**name8 (md) 9**] md [**last name (titles) 896**]. sbp 100-130s, see carevue. + palpable pulses.

resp: ls clear diminished. pt extubated at [**2109**], see carevue for post abg. sats >98% on 35% fio2 face tent, face tent kept on to keep pt's mouth and throat moist. sats on ra 94%-94%. see carevue for ct amts 2 right 1 left ct. jp to left neck draining serosang to bulb suction.

gi/gu: abd soft, tender to touch. multi abd dsgs from minimally invasive procedure, scant amt of serosang to dsgs. absent bs. j tube to gravity w/ scant amt of bile drainage. ngt to lwcs draining scant amt of thick [**name8 (md) **], md [**name6 (md) 896**] and md [**doctor last name 1081**] aware. continues at 3 [**11-26**] line as ordered, ngt not manipulated. foley draining clear yellow urine 30-80cc/hr. see carevue.

endo: per pt's scale. am glucose 69, 1 hour later 91.

plan: monitor hemodynamics. pain control. pulmonary toilet. increase activity. follow labs and treat as appropriate.



"
4158,"resp: pt rec'd on psv 5/5/30%. ett #7.5/22 lip. bs are coarse bilaterally. suctioned for copious to moderate amounts of thick bloody secretions iin beginning of shift then tapered off towards end. mdi
s alb/atr administered q4 with no adverse reactions. pt does have coughing episodes. rsbi=84. no changes this shift
"
4159,"pt came to micu6 from [**wardname 1699**] for merepenem desensitization because of multiple allergy.pt got here around [**2089**].completed desensitization without any complication.? c/o.

neuro: ox3.calm and cooperative.

id: frequent uti,now with e-coli. no signs of adverse reactions to merepanam.

cardio: nsr.vss.am lab pending.heparin drip per protocol.ptt qd.

resp: ls cta.

gi; abd soft. bowel sounds present.fsbs as noted.

gu: voids.minimal pain upon urination.clear yellow urine.

pain: severe left flank pain pain mgmt improved after multiple pain med adjustments as noted.

pain: ?c/o to floor today.

"
4160,"resp:  [**name (ni) 97**] pt on psv 15/5/40%. alarms on and functioning.  ambu and syringe @ hob.  bs auscultated reveal diminished bilateral bases, aeration noted in apecies. mdi's administered of alb q 4hrs with no adverse reactions.  suctioned x2 moderate amounts of thick yellow secretions. pt has episodes of ^rr and decrease in tv with suctioning.  pt was placed on a/c in order to stabilize and decrease the wob. bp decreased then pt again returned to psv at above settings where she remains. rsbi=135 with no further changes noted.
"
4161,"resp: [**name (ni) 52**] pt on a/c 14/450/5/50%. ett 8.0, 22 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are slightly coarse and suctioning moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. no vent changes noc. am abg 7.45/39/97/28. pt scheduled for cabg x4 today with mv. rsbi=72.
"
4162,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/500/+5/50% alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clears sounds with diminished bases. suctioned for scant amounts of white secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions. am abg's 7.39/45/179/28.  decreased fio2 to 40%. no further changes noted. will continue to wean appropriately.
"
4163,"ccu nursing note 0700-1900

s/p r groin av fistual repair under conscious sedation; return to ccu @ 1130

neuro: pt neurologically intact, ao x3, speech clear, maew with equal strength, follows commands, denies pain, lightheadedness, sob or cp.  bedrest till 5 pm today.

cv: hr 60-80s nsr with rare pvcs.  sbp 120-140 map > 60.  new peripheral iv 18g placed in l fa by or staff.  no ivf ordered. old r ac iv dc'd with cathereting intact; drsg [**name5 (ptitle) **].  hct 24.3 this am; 1 unit rbc ordered and transfused; no adverse reactions noted.  repeat hct 27.3.  peripheral pulses palpable. r groin ecchymotic, or drsg [**name5 (ptitle) 819**].  l groin drsg [**name5 (ptitle) 819**].

pulm:  received pt from or on facemask.  o2 weaned to off; spo2 94%; resps even and unlabored; no acute distress noted.  lungs clear bilaterally. no cough.

gi:  pt tolerating ice chips without difficulty. abdomen benign; bs present.

gu: voids clear yellow urine per bedpan.

skin:  skin grossly intact; no breakdown noted;

social:  numerous family members have telephone and spoken with the patient following the procedures.  all family members updated on pt status and plan of care.

plan: transfer to floor today (?[**hospital ward name **] 9) and d/c home tomorrow.
"
4164,"resp: [**name (ni) 97**] pt on [**last name (un) **] a/c 12/550/+5/60%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral aeration with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's given q2 hrs alb. with no adverse reactions. am abg's 7.37/52/92/31.  expect to wean to psv today and if tolerated, then possibly extubate
"
4165,"nsicu nsg adm note
ms. [**known lastname 6616**] is a 79yo female admitted to nsicu post op axillo [**hospital1 **]-fem bypass grafts to both legs.  pta she had abd, back and leg pain for 24hrs at home.  pain became severe and she presented to [**hospital1 95**] [**2191-2-8**]. pmh significant for mi, cabg [**2188**], htn, hypercholesterolemia, diabetic, ef 20% and depression.  she had been hospitalized 3days prior to this adm for r/o mi (neg for mi at that time).  she speaks [**year (4 digits) 413**], minimal english.  contacts are [**name2 (ni) 2905**]--phone [**telephone/fax (1) 11317**] and [**doctor first name **]--phone [**telephone/fax (1) 11318**].  [**doctor first name **] speaks english and [**doctor first name 413**]; [**doctor first name 2905**] is primarily [**doctor first name 413**] speaking.  in the or she rec'd a total of 1875ml prbc's and 6l cryst followed by lasix with a fair response.  in the icu she has rec'd additional 2units prbc's, 3units ffp, one 6pack platelets and numerous fluid boluses (goal is to keep pre-load high--cvp of 15 or greater).  she is currently on dobutamine at 5mcg, propofol at 30mcg, levo at 0.07mcg/kg/min and a bicarb gtt.

review of systems

neuro:  off propofol pt squeezes hands to command, opens eyes to command.  no attempts to speak around ett.  moving arms ad lib; no movements legs noted.  last assessment off propofol done at 0600.

cv/pulm:  dobutamine titrated up to maintain cvp>15 and ci>2.0.  blood products given as noted above; all transfused without adverse reactions.  levo remains at 0.07mcg/kg/min with map consistently>60.  dobutamine currently at 5mcg/kg/min.  fluid boluses per carevue in addition to blood products.  cvp trending down to 11-12--dr. [**last name (stitle) **] notified, additional ffp given.  remains vented with abg's improving--see carevue for vent settings and abg's.

gi/gu:  ogt placed, clamped.  no fluids given as ?bowel function.  hypoactive bowel sounds.  abd distended, soft.  mucous/bloody [**last name (un) 1366**] from rectum noted x3, foul smelling.  u/o qns--dr. [**last name (stitle) 11319**] notified, additional fluid and blood products given per carevue with little effect.  u/o now decreased to 5-8ml/hr.

integ:  l leg doppler pulses both dp and pt q1h.  l leg warm to touch with cap refill <3sec.  r leg pulses absent, leg increasingly mottled from toes to upper thigh, cold to touch.  r groin staples intact, dsg d+i.  l groin dsg d+i.  r side of buttocks white with ecchymosis, cold to touch.  r flank with ecchymotic area.  increasing edema throughout shift to hands and face.  no open areas noted.

id:  temp initially cool--bair hugger on, gradually warmed to current temp of 100.8 core temp.  bair hugger off when temp 99 range.  remains on kefzol.

psychosocial:  no fam contact [**name (ni) 23**].  [**name6 (md) 413**] speaking rn spoke to pt when lightened off propofol, briefly explained ett, restraints and that ""had an operation""; pt seemed to comprehend information.

"
4166,"resp:  [**name (ni) 97**] pt on 7200 a/c 20/500/+5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with improve some with suctioning. suctioned x3 small to moderate amounts of thick yellow secretions. mdi's administered q4hr of alb with no adverse reactions. rsbi=135, pt not initiating any breaths.  02 sats @ 100%. no further changes noted
"
4167,"resp: [**name (ni) 52**] pt on a/c 22/650/+7/100%. ett #9, taped @ 27 lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned for copious amounts of frothy bloody secretions. mdi's ordered and administered 2p atr q4-6h prn/alb 2p q6h prn with no adverse reactions. pt remains on 100% fio2, with sats @ 96%. peep ^ to 10, bp is stable on such. last abg 7.34/47/96/26 with am abg pending following changes in peep. will continue full vent support.
"
4168,"resp: [**name (ni) 52**] pt on a/c 22/650/70%/+13. ett#9, taped @ 28 lip. alarms on and functioning. ambu/syringe @  hob. bs are diminished bilaterally wish some coarseness noted. suctioning for small amounts of tan/bloody thick secretions. sputum sample obtain and sent. mdi's administered 6p alb/atr with no adverse reactions. last abg 7.40/39/77/25. 02 sats @ 97%, additional abg pending. plan to wean fio2 accordingly. continue full vent support.
"
4169,"resp: [**name (ni) 52**] pt on a/c 22/600/20+/60%. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases, improvement noted from previous days.  suctioned for small amounts of thick yellow/white secretions. mdi' administered as ordered combivent/flovent with no adverse reactions. several abg's (see careview) vent changes to decrease fio2 to 50%, and ^ peep to 22 following esophogeal ballon numbers.  no further changes noted. will continue to wean off fio2 as tolerated. no rsbi due to ^ peep.
"
4170,"resp: [**name (ni) 52**] pt trach/vented via sicu on psv 10/5/40%. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of thick tan secretions. mdi's administered q4 hr alb with no adverse reactions. abg 7.35/59/181/34. rsbi=48. t/c trials to continue today as tolerated.
"
4171,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral clear sounds. no wheeze noted. mdi's administered of alb/atr with frequency changed to q4 hrs. adverse reactions of ^ hr. suctioned for small amounts of thick white secretions. rsbi initiated and terminated due to ^ hr to 160's. vent changes to decrease ps to 10. abg's pending. will continue to wean appropriately.
"
4172,"resp: pt trached #7 portex on [**last name (un) **] psv 10/5+/35%. vt's 300's, ve 7l 02 sats@100%. bs auscultated reveal rs clear with ls coarse. lavaged and suctioned for moderate amounts of thick tan secretions. mdi's administered q4 alb with no adverse reactions. pt becomes anxious at times and continues to be tachy. am abg's 7.51/40/156/33, rsbi=73. decreased ps to 10. plan is to continue to wean and possible t/c trials today as tolerated.
"
4173,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/10+7/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with some rhonchi in apecies.  suctioned for thick amounts of yellow/tannish secretions. mdi's administered q4 hrs combivent with no adverse reactions.  am abg's 7.42/42/93/28. rsbi=147
"
4174,"resp: [**name (ni) 52**] pt on a/c 22/550/15+/60%. ett 7.5 taped @ 23 lip. bs are  diminished bilaterally with aeration noted. suctioned for large amounts of oral secretions with scant from ett. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. vent changes to decrease fio2 to 50%. am abg 7.34/38/92/21. no rsbi due to ^ peep. will continue to wean as tolerated.
"
4175,"resp:  [**name (ni) 52**] pt intubated from osh. eet #7 taped and secured 22@lip and placed on [**last name (un) **] a/c 10/500/+8/60%.  bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of charcoal tinged secretions.  mdi's administered q 4 combivent with no adverse reactions.  vent changes to decrease tv to 450/^ peep to 10. am abg's 7.35/37/83/21. no rsbi.  no further changes noted.
"
4176,"7a-11a
see carevue for details of assessment and vs. 1 unit of prbcs infusing no adverse reactions. lopressor and lasix given per pa [**doctor last name **]. pa [**doctor last name **] aware of hypotension when pt sleeping, continue w/ po meds as ordered per pa [**doctor last name **]. pa [**doctor last name **] aware of ct drained 100cc w/ getting oob. continue to monitor.
"
4177,"resp: [**name (ni) 52**] pt on a/c 22/550/25+/60%. ett 7.5 23 @ lip. bs are diminished bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered q6 combivent/[**last name (un) **] with no adverse reactions. vent changes to decrease fio2 to 50%, peep to 20, ^ tv to 600. am abg 7.31/34/172/18. plan to wean as tolerated. bicarb to be administered.
"
4178,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/500/+5/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small - moderated amounts of thick yellow secretions.  mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.45/44/149/32.  rsbi=73. no further changes noted.
"
4179,"resp: pt rec'd on psv 5/5/40%.  ett#8, [**e-mail address 9512**] are coarse bilaterally. sucitoned for copious amounts of brown thick secretions frequently. mdi's administered as ordered with no adverse reactions. no changes [**e-mail address **]. am abg 7.32/35/78/19 with [**e-mail address 239**]=84. plan to trach @ bedside this am.
"
4180,"resp: [**name (ni) 97**] pt on psv 5/5/40%. ett #8 portex. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4 hrs combivent/[**last name (un) **] [**hospital1 **] with no adverse reactions. [**hospital1 239**]=43. am abg pending. plan to wean to t/c trials today.
"
4181,"resp: [**name (ni) 97**] pt on psv 5/5/40%. pt has #8 portex.  bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered as ordered combivent/flovent with no adverse reactions. am abg 7.32/46/120/25. [**name (ni) 239**]=24. plan to continue with t/c trials as tolerated today.
"
4182,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 12/15/50%. alarms on and functioning.
ambu/syringe @ hob. bs auscultated reveal bilateral diminished sounds, slightly coarse in apecies.  suctioned for small amounts of thick white secretions.  mdi's administered q4hrs alb with no adverse reactions.  no rsbi due to ^ peep. am abg's 7.36/48/94/28.  plan to continue to wean as tolerated. no further changes noted.
"
4183,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/12/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned small amounts of thick white secretions. mdi's administered q4 hrs alb with no adverse reactions. periods of agitation when suctioning.  am abg's 7.35/39/99/22.  will continue to wean appropriately.
"
4184,"resp:  [**name (ni) 97**] pt on [**last name (un) **] psv 15/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral clear sounds.  mdi's administered q4hrs [**doctor last name **]/alb/atr with no adverse reactions.  02 sats remain in^ 90's @ 98%.  rsbi=40, although no sbt initiated.  pt is scheduled for trach/peg this friday.  no further changes noted.
"
4185,"nsg admission note
ms. [**known lastname 341**] is a 75 yo female admitted to [**hospital1 95**] from ed for ? gi bleeding, hct drop.  see fhp for complete history.  this am pt was walking, felt weak, bystanders called 911, transported to ed via ambulance.  in ed found to have hct 23.0.  treated with fluid, trans to micu a for serial hcts (q4h), prbc and close observation.

current status
neuro:  a+ox3.  speech clear.  mae ad lib.

cv/pulm:  mp=nsr, no ectopy.  vss.  hct at 1800 21.7; one unit prbc hung at 1850; no adverse reactions noted thus far.  breath sounds clear bil.  no sob or doe noted, pt on room air.

gi/gu:  abd soft, non-tender, bowel sounds present.  no flatus, no bm. no evidence of gi bleeding thus far.  u/o qs ad lib.

id/endo/integ:  afebrile.  endo--no issues.  skin intact.

psychosocial/plan:  emotional support given to pt.  no visitors this shift.  pt had many valuables with her (credit cards, money, id cards)--all sent to security--pink receipt in front of chart.  plan: q4h hct checks, transfuse prbc as ordered (started), cont to monitor i+o, cont with current nursing/medical regime.  to be scoped in am.
"
4186,"resp:  [**name (ni) 97**] pt on [**last name (un) **] simv 20/500/10/+12/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for moderate amounts of yellow thick secretions. mdi's administered q4 hrs alb with no adverse reactions. am abg's 7.38/49/92/30. no rsbi due to ^ peep. no further changes noted.
"
4187,"resp:  pt rec'd on [**last name (un) 993**] simv 18/650/ps 8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear after sux.  sux x's 3 for some small to mod amount of yellow/greenish thk secretions.  mdi's administered through in line alb/atr [**3-12**] p q4hrs with no adverse reactions.  pt 02 sats remain in ^90's 95-97% during the night/rr 20-23 with no distress noted.  pt appears comfortable with no further changes noted.
"
4188,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 18/650/60%/ps8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  mdi's administered q4 hrs alb/atr with no adverse reactions.  vent changes to rr as per abg's. decrease to rr @ 12:00 to 16, @ 2:00 to 14, and @ 5:00 to a rate of 12 with no further changes, pending additional abg.  pt is awake and alert, follows commands.  no further changes are noted.
"
4189,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/60%/ps8/+12.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds with clear with suctioning. sux x 3 for small to moderate yellowish thick secretions.  mdi;s administered alb/atro q4hrs with no adverse reactions.  no further changes noted.  pt resting comfortably.
"
4190,"resp: pt rec'd on psv 16/10/40%. ett #7.5, 22 @ lip.  ambu/syringe @ hob. bs are diminished bilaterally. suctioned for small amount of white thick secretions, rn suctioned for copious tan. mdi's administered as ordered of alb with no adverse reactions. am abg 7.44/31/131/22. no rsbi=^ peep. will continue present support.
"
4191,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 12/650/ps 8/+15/60%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sound which clear with suctioning.  suctioned small amounts of white thick secretions.  mdi's administered q4 alb/atr with no adverse reactions.  vent changes with a decrease in fio2 to 50%.  no further changes noted.
"
4192,"resp: pt rec'd on psv 12/10/40%. ett #8, retaped and secured @ 22 lip. bs reveal bilateral crackles with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered alb as ordered with no adverse reactions. no changes this shift. am abg 7.46/35/146/26. no rsbi due to ^ peep. will continue to wean as tolerated.
"
4193,"resp: [**name (ni) 52**] pt on psv 18/5/40%. ett 7.0 19@ lip. alarms on and functioning. ambu/syringe @ hob. bs are clear with diminished bases.mdi's administered as ordered with no adverse reactions. pt continues with low vt's and apnea @ times. vent changes to place on mmv with back up rates of vt 350/18/10+5/40% during night. am abg 7.51/35/115/29. rsbi=109+. placed pt on psv 5/5/40%.  will attempt sbt this am with possible extubation.
"
4194,"resp: [**name (ni) 52**] pt on psv 15/5.40% following trip to mri. alarms on and functioning. ambu/syringe @ hob. bs are clear bilaterally with diminished bases. suctioned for small amount of light tanish secretions. mdi""s administed alb/atr as ordered with no adverse reactions. changes to decrease ps to 5. rsbi=98.am abg 7.36/48/108/28. sbt initiated @ 5:45.
"
4195,"resp: [**name (ni) 52**] pt on psv 5/5/40%. ett 7.5, 18@ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. vt's 600. ve's [**6-22**]. rr 16. rsbi=34. no changes noc. am abg 7.34/35/121/20. plan to monitor metabolic status and treat accordingly.
"
4196,"resp: [**name (ni) 52**] pt on psv 10/8/40%.  ett 8.0 retaped and secured 23 lip, not rotated due to sore on r side of mouth. bs are coarse bilaterally. suctioned for moderate amountsof thick brown/plugs. mdi's administered as ordered of alb with no adverse reactions. am abg 7.44/39/100/27. rsbi=101. no changes this shift, will continue to wean as tolerated
"
4197,"resp: pt remains intubated ett 7.5, 22 @ lip on psv 10/8/40%. bs are coarse bilaterally. suctioned for small amounts of thick white secretions. mdi's administered alb as ordered with no adverse reactions. no abgs this shift. rsbi=54. pt remains on cvvhd. will continue to wean as tolerated.
"
4198,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 15/10/60%.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions, and from oral cavity.  mdi's administered q4h alb with no adverse reactions.  pt ^ rr to 40, place back on ac 12/ 450/ 10+/ 60% where the settings remain. 02 sats between 92-97% during noc.  no [**last name (un) 1017**] performed due to ^ peep/^ fio2.  no further changes noted.
"
4199,"resp: rec'd on a/c 20/500/12+/30%. ett #7.5, 25 lip.bs are coarse bilaterally. suctioned for moderate to copious amounts of thick bloody tinged secretions. mdi's administered q4 hrs. alb/atr with no adverse reactions and some improvement noted. am abg 7.43/42/126/29. open abdomen. no rsbi. will continue full vent support.
"
4200,"resp: [**name (ni) 52**] pt on mmv switched to psv 5/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished sounds. suctioned for small amounts of thick bloody tinged secretions. mdi's administerd q4 hrs combivent with no adverse reactions. am abg's 7.38/49/115/30. rsbi=30. plan to extubate today.

"
4201,"resp:  [**name (ni) 52**] pt on [**last name (un) **] cpap 5/+0/40%. ambu/syringe @ hob.  bs auscultated reveal sl coarse sounds which clear with suctioning. suctioned x3 small amount of thick whitish secretions. mdi's administered q4 hrs with no adverse reactions. rsbi=48.  no further changes noted.
"
4202,"resp: [**name (ni) 52**] pt on a/c 14/550/+5/40%. ett #8, taped and secured @ 23 lip. bs auscultated reveal bilateral diminished bases with slight coarse sounds in middle lobes. suctioned for small amounts of bloody thick secretions, copious amounts from oral cavity. mdi's administered q4 alb with no adverse reactions. no abg's today, pt scheduled today for trach in or @ 9:00. no vent changes noc.
"
4203,"resp: pt rec'd on psv 10/10/50%. pt has #8 [**last name (un) **] trach, secured @ 12.5 flange. bs are clear bilaerally and suctioned small amount of [**last name (un) 4953**] yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats @ 100%. no abg's or changes this shift. no rsbi due to ^ peep. plan: wean as tolerated.
"
4204,"resp: pt remains on psv 14/10 noc. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of thick yellow (greenish) secretions. sending sputum sample this am. mdi's administered q4 hrs combivent with no adverse reactions. pt more alert today following commands. am abg pending. will continue to wean appropriately.
"
4205,"resp: [**name (ni) 52**] pt on [**last name (un) **] a/c 24/550/+10/60%. alarms on and functioning. ambu/syinge @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick white secretions. [**last name (un) **]'s administered q4 alb/atr/[**last name (un) **] [**hospital1 **] with no adverse reactions. am abg's 7.45/43/95/31. no vent changes noc.
"
4206,"resp: [**name (ni) 52**] pt on a/c 15/550/5+/40%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are clear bilaterally. suctioned for moderate amounts of thick yellow secretons. mdi's administered alb/atr with no adverse reactions. no abg's this shift or changes. rsbi= no resps. will continue with present settings.
"
4207,"resp: pt rec'd on a/c 14/500/+8/40%. ett #8, retaped and secured @ 20 lip. bs are coarse bilaterally with occasional exp wheeze. suctioned for moderate amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. no abg's this shift (no aline). rsbi attempted with no spont resps. will continue full vent support.
"
4208,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 24/550/60%/10+. alarms on and functioniong. ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with some coarse sounds noted. suctioned for copious amounts of bloody thick secretions. circuit changed to heated. [**last name (un) **]'s administered q4 alb/atr and [**last name (un) **] [**hospital1 **] with no adverse reactions.  am abg's 7.45/43/120/31.  no vent changes as noted by md. plan to continue to wean as tolerated.
"
4209,"resp: [**name (ni) 52**] pt on a/c 15/550/+5/40%. ett #7.5 retaped and secured @ 21 lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. see careview for rsbi, plan to continue full vent support.
"
4210,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/5/40%. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned x3 small to moderate amounts of thick bloody secretions.  mdi's administered q4 alb/atr with no adverse reactions.  rsbi=155.  no further changes noted
"
4211,"resp:  [**name (ni) **] pt on [**name (ni) **] ps15/+5/50% alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning. suctioned x 3 small to moderate amount of  thick bloody/yellow tinged secretions.mdi's administered q4 hrs with no adverse reactions.  [**name (ni) 1017**]=85, sbt initiated.  not further changes noted.
"
4212,"resp: [**name (ni) 52**] pt on ac 550/15/5+/40%. ett retaped and rotated. bs are clear with diminished bases. suctioned for small amount of thick yellow to tan secretions. mdi's administed as ordered with no adverse reactions alb/atr. rsbi=136. plan to continue with present settings. family still to discuss cmo status.
"
4213,"resp: [**name (ni) 52**] pt on psv 10/10/50%. pt has air filled [**last name (un) **] trach secured @ 12.5 flange. 02 sats @ 100%. bs are clear with diminshed bases. suctioned for scant amount of white secretions mdi's administered alb/atr as ordered with no adverse reactions. vent changes to decrease fio2 to 40% and peep to 8. 02 sats remain @ 100%. plan: continue to wean as tolerated. no a-line.
"
4214,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 26/450/+10/50%.   alarms on and functioning. bs auscultated reveal bilateral diminished with some scattered rhonchi. suctioned for small amounts of  thick white secretions.  [**last name (un) **]'s administered q 4 hrs alb/atr with no adverse reactions. [**last name (un) **] given [**hospital1 **].  abg's drawn with notable vent changes (see careview) am abg's 7.41/45/104/30. present vent settings; a/c 20/45/10+/50%.  bedside abdominal ultrasound scheduled for today.
"
4215,"resp: pt rec'd on a/c 450/12/+8/40%. ett #7.5, 21 @ lip. alarms on and functioning. ambu/syringe @ hob. bs reveal bilateral coarseness in upper lobes with diminished bases. suctioned for small amounts of thick yellow. mdi's ordered and administered q6 hrs atr with no adverse reactions. rsbi=170. placed on psv 15/8/40% obtaining vt's 500's.  will continue to wean as tolerated.
"
4216,"resp: pt rec'd on psv 12/5/40%. pt has #8 portex trach. bs are clear and suction for small amounts of white secretions. mdi's administered alb/atr with out any adverse reactions. rsbi=60. pt has daily nif performed and t/c trials initiated and to continue today. pt has tendency to be anxious although with coaxing settles out. will continue to wean as tolerated.
"
4217,"1900-0700

   pt admitted from home for elective asa desenseitization to be followed by cardiac cath with stent placement. pt has significant hx: cad, mi [**67**], s/p rcs/pda, htn, hyperlipidemia, hypercholerolemia, menieres disease, ?copd, etoh, cocaine hx, + smoker.

neuro: pt awake,alert, oriented, follows all commands well. limited weight bearing and unsteady gait on r knee. dos not use assistive devices at home. pt non compliant with cardiac regiment at home ex-diet, lifestyle.

resp: nc 2l on, resp easy and regular with clear bs/diminished at bases. no cough noted. o2sat stable.

cv: nsr without ectopy, alarms on. hr 90-60, sbp 100-165, restarted on po meds. afebrile. asa desensitization completed without adverse reactions. nahco3^@75cc/hr. pt c/o of cp at 2315, ho at bedside 3 sl nitro q 5 minutes given with no relief, pain 7 out of 10, radiating to neck and back. denies sob/skin warm/dry. ekg completed showing st elevation in v1,v2,v3.  cardiac fellow to examine pt. nitroglycerine drip ^ titrating prn, heparin drip @ 750 units^ ptt 48.3. integrilin started at 0130. morphine givenx 3. pt finally became cp free. cpk:43.0. skin dry/intact, palpable pulses noted. pt awaiting cath this am. pt kept on bedrest.

gi/gu: abd round soft + bs, voids clear yellow urine via urinal.

iv: piv x2.

plan: cardiac cath, supportive cardiac care.
"
4218,"resp: pt remains on psv 15/5/60%. placed on 50% t/c for nearly 4 hrs and tolerated well. periods of desaturation with ^ fio2. on psv 15/5/60 noc. bs auscultated to reveal bilateral coarse sounds. suctioned for small amounts of tan thick secretions. pt is [** 554**] and awake. no abg's rsbi=>200. mdi's administered q4hr alb with no adverse reactions. will continue t/c trials as tolerated.
"
4219,"resp: [**name (ni) 52**] pt on a/c 14/500/10+/40%. suctioned for scant amount of thin white secretions. mdi's administered as ordered with no adverse reactions. no changes noc or rsbi due to ^ peep. plan to wean as tolerated. abg 7.42/34/77/23
"
4220,"resp: [**name (ni) 52**] pt on psv 12/8/40%. ett 7.5, 23 @ lip.  bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. this am secretions appear to be slightly green. mdi's ordered alb q6 hrsprn and administed with no adverse reactions. pt had anxiety episodes noc and antivan administered. rsbi=54. pt weaned to psv 8/5/40%. vt's 350/ve's [**6-20**],rr 22 with additional abg pending. will continue to wean with mechanic's in am.
"
4221,"resp: [**name (ni) 52**] pt on a/c/14/500/10+/70%. ett 7.5, 20 @ teeth. bs are clear with diminished bases. mdi's ordered 4p alb and administered with no adverse reactions. suctioned for scant clear thin secretions. vent changes/abg's (see careview) am abg 7.35/38/101/22 on  a/c 14/500/10/70%. no rsbi due to ^ peep. will continue with present vent settings.
"
4222,"resp: pt rec'd on a/c 14/450/+8/40%. ett #7, retaped and secured 20 @ lip. alarms on and functioning. ambu/syringe @ hob. bs are coarse bilaterally. suctioned small to moderate amounts of thick white secretions. mdi's administered q 4hrs alb/atr with no adverse reactions. no a line/abg's. rsbi=110.
"
4223,"resp: pt ordered for nebs of alb/atr. bs are diminished bilaterally. no adverse reactions following neb. will continue to follow.
"
4224,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv10/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  cuff pressure@ 21cmh20.  ett taped and secured.  bs auscultated reveal bilateral coarse sounds.  suctioned x3 for small to moderate thick yellow secretions.  improvement noted after suctioning.  mdi's administered q4 hrs of albuterol with no adverse reactions.  rsbi=21, although no sbt initiated.  pt is scheduled for trach today. 02 sats remain in ^ 90's. no further changes noted.
"
4225,"respiratory care
pt remains intubated (#7.5 ett 23@lip) and on vent support. vent changes were simv to psv due to spont breathing and increase in ps from 5 to 8 due to rr >35. lung sounds were course t/o. suctioned for scant amounts of thk yellow secretions. mdi's given with no adverse reactions. last abg was borderline normal. care plan is to continue to wean and ? of extubation tomorrow or friday. will continue to follow pt.
"
4226,"resp: [**name (ni) 52**] pt on a/c 12/450/+8/50%. ett #7.5 21 @ lip. bs are slightly coarse with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered atr as ordered with no adverse reactions. no abg's, attempted rsbi=no spont resps. pt becomes aggitated with decrease in sedation. will re attempt rsbi with plans of possible extubation this am.
"
4227,"resp: [**name (ni) 52**] pt on a/c 12/450/+8/60%. bs are slightly coarse suctioning for small amounts of thick light yellow secretions. mdi's administered atr with no adverse reactions. pt desaturates when sedation is light. abg 7.41/40/59/26. fio2 ^ 70%, peep 12 to maintain sats of 96%. rsbi >150.
"
4228,"resp: [**name (ni) 52**] pt on a/c 15/600/15+/50%. ett #8. bs are coarse bilaterally. suctioning moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt has frequent coughing episodes when awake. no rsbi due to ^ peep. am abg 7.44/42/76/29. plan to wean as tolerated.
"
4229,"resp: [**name (ni) 52**] pt on a/c 10/600/10+/40%. pt has #8 shiley trach. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions. no abg's this shift. 02 sats @ 97%. mdi's administered as ordered with no adverse reactions. rsbi=^peep. will continue with present vent settings.
"
4230,"resp: [**name (ni) 52**] pt on a/c 14/450/50%/10+. ett #7.5 taped @ 20 teeth. bs reveal bilateral crackles, and suctioning for small to moderate amounts of yellow (bile looking) secetions. bloody secretions from oral cavity. mdi's ordered and administered alb/atr with no adverse reactions. no abg's this shift (no a-line) or rsbi performed due to ^ peep. will continue with present settings.
"
4231,"resp: [**name (ni) 52**] pt on psv 15/10/50%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. changed out heated wire circuit, and inner cannula. suctioning copious amounts of bloody secretions. [**name (ni) **]'s administerd q4 hrs alb/atr no adverse reactions. vt's 400-500, rr 15-18. no vent changes noc.
"
4232,"resp:  [**name (ni) 52**] pt on psv 15/10/50%. alarms on and functioning. ambu/syringe @ hob. spare inner cannula in rm. 8.0 shiley trach. vt's 400-500, rr 17-24. trach care done, inner cannula changed. changed out heated wire vent circuit due to excessive blood (fluid) in tubing. bs auscultated reveal bilateral coarse sounds. suctioned for copious amounts of old (brown) blood. slight improvement from yesterday. [**name (ni) **]'s administered q 4 alb/atr with no adverse reactions. no vent changes noc, no abg's. will continue vent support.
"
4233,"resp: [**name (ni) 52**] pt on a/c 10/600/10+/40%. pt is trached with #8 shiley. bs are coarse bilaterally and suctioned for small amounts of thick yellow secretions. mdi's administered q4 hrs combivent with no adverse reactions. no rsbi=^peep. no changes or abg's this shift. plans for rehab.continue with present settings.
"
4234,"resp: [**name (ni) 52**] pt on psv 16/6/40%. ett #7.5, 21 lip. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned moderate amounts of thick yellow secretions. mdi's administered q4 hrs with no adverse reactions. no abg's this shift. rsbi=108. weaned to psv 12/5/40%. plan to continue to wean as tolerated.
"
4235,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 16/10+/50%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered q 4 hrs alb/atr with no adverse reactions.  attempted to wean ps to 14 and pt did not tolerate ^rr. difficult wean, becomes aggitated with lighten sedation. will continue to wean as appropriate. no further changes noted.
"
4236,"resp: [**name (ni) 52**] pt on pcv 27/dp22/+5/50%. ett 8, taped @ 25 and pulled out to 23 as [**name8 (md) 76**] md/xray. bs are slighly coarse/occasional exp. wheeze. suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=155. am abg 7.42/47/74/32. pt will be scheduled for trach when condition improves. plan: wean vent as tolerated.
"
4237,"resp: [**name (ni) 52**] pt on pcv. bs are coarse to clear and suctioning for small amounts of thick yellow secretions. mdi's administered as ordered alb/atr/[**last name (un) **] with no adverse reactions. rsbi=145. am abg 7.36/47/90/28. plan: wean to a/c as tolerated.
"
4238,"resp: pt rec'd on a/c 500/20/+12/30%. bs are coarse bilaterally. suctioned for moderate amounts of thick tan secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. ett #7.5, retaped and secured @ 25 lip. no changes this shift. am abg 7.45/37/141/27. will continue full vent support.

"
4239,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 12/10/40%. alarms on and functioning. ambu/syringe @ hob.  bs ausculatated reveal bilateral aeration with diminished bases.  mdi's administered q4 hrs alb/[**last name (lf) **], [**first name3 (lf) **] [**hospital1 **] with no adverse reactions. suctioned for moderate to copious amounts of thick yellow secretions. continue to wean as tolerated. am abg's 7.46/46/134/34.  no further changes noted.
"
4240,"[**2130-5-14**] ""b"" nsg progress note:

cvs:  tmax 102.7-tylenol given, down to 99.4 po. hr=92-114 sr with rare pvc's and pac's noted. iv mgso4 4gm given, kcl 20meq iv given. iv ns + 20meq kcl at 75cc/h. pulses present.

neuro:  a&ox3. mae. no deficits noted.

pain:  using pca mso4 appropriately with good pain relief noted. pain is in sternum when turning or coughing and deep breathing [**5-7**] reduced to [**2-6**] with pain med. no adverse reactions noted.

resp:  o2 4l nc. sats=95-98%, doing is 500-700. coughing and deep breathing well, small amts white sputum noted. lung sounds clear.

gu:  u/o=25-50cc/h given 2 boluses of 500cc iv lr per resident.

gi:  taking ice chips and sips of milk shakes.  water still causing some coughing.  +bs.

skin:  dsg on sternum intact with no drainage noted. 3 jp's draining serosanguinous. left heel red and sore,up on pillow.

plan:  antibx as ordered. increase diet today. continue weaning iv levophed.  encourage is, and deep breathing and coughing. tylenol for temp as needed.
"
4241,"7p-7a
neuro: alert, oriented x3. speech clear. mae with equal strength, follows commands.

cv: remains sr 60-70 with occasional pac's. sbp 110-130. a-wires capture and pace, set at a-demand 60; v-wires do not work, polarity changed. palpable distal pulses to extremities. svo2 >65; ci> 2.19. no gtts. started po metoprolol with good effect, no adverse reactions.

resp : ls clear, diminished at bases. 02sats>96% /2l nc. uses is to 750-800, coughs and deep breathes.

gi/gu: abd soft, not distended. +bowel sounds. tolerating po well. indwelling cath draining clear yellow urine to gravity, sufficient amts.

endo: riss continues as well as metformin.

plan: continue to monitor cv, continue pulmonary toilet. continue to advance diet and activity as tolerated. ?transfer to [**hospital ward name **] 2.
"
4242,"resp:  [**name (ni) **] pt on [**name (ni) **] simv 12/500/40%/+8/ps20. alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal coarse bs which improve with suctioning.  suctioned x3 small to moderate amounts of thick yellow secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. rotated/taped and secured ett tube @ 21 lip.  rsbi= 120, no sbt initiated. no vent changes noted
.
"
4243,"resp:  [**name (ni) 52**] pt on [**last name (un) **] on a/c 14/500/+5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal clear apecies, with slight coarse bs in bases.  suctioned x2 for small-moderate amounts of thick yellow secretions.  mdi's administered q4 hrs with no adverse reactions.  rsbi=52.  no further changes noted.
"
4244,"resp: [**name (ni) 52**] pt on [**last name (un) **] psv 10/8/50%. alarms on and functioning. ambu/syringe @ hob. transferred from ccu.  bs auscultated reveal bilateral ins/exp wheeze. mdi's administered q6 alb/atr with no adverse reactions. improvement noticed. rsbi=73. no abg's.
"
4245,"resp: [**name (ni) 52**] pt on [**last name (un) **] psb 10/10/50%.  ambu/syringe @ hob.  bs ausculatated reveal bilateral coarse bs which clear with suctioning. suctioned moderage to large amounts of thick whitish/yellowish secretions for oral and ett.  mdi's administered alb/atr/ser/[**hospital1 **] with no adverse reactions. pt tends to drop sats, 02 probe better positioned on pts forehead.  no distress is noted noc, with no changes.
"
4246,"resp: [**name (ni) 52**] pt on a/c 26/470/12/40%. ett #7 taped @ 24 lip. bs are clear bilaterally. suctioned for scant amount of white secretions. mdi's administered as ordred alb/atr with no adverse reactions. vent changes (see careview) rsbi=41. am abg 7.40/35/71/22. will continue to wean as tolerated.
"
4247,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/+5/40%.  alarms on and functioning.
ambu/syringe @ hob.  bs auscultated reveal bilateral clear apecies with diminished bases.  suctioned x2 scant to small amounts of whitish secretions.  mdi's administered q4 of albuterol with no adverse reactions.  rsbi=42 02 sats remain @ 100% with no further changes noted.
"
4248,"resp:  [**name (ni) 52**] pt on [**last name (un) **] a/c 14/600/50/+10.  ambu/syringe @ hob.  bs auscultated reveal bilaterl coarse sounds with clear with suctioning.  suctioned x3 small to moderate thick yellowish secretions.  mdi's administered q4hr combivent/servent/flovent [**hospital1 **] with no adverse reactions.  vent changes as follows:  rate ^ to 16, peep ^ 12, fio2 ^ 60% resulting in improved abg. no further changes noted.  rsbi performed this morning results equal 47, rr 20.
"
4249,"resp: [**name (ni) 52**] pt on a/c 26/470/+8/40%. ett #7.0 taped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered atr as ordered with no adverse reactions. rsbi=61 with am abg's pending (see carview for results) plan to continue on present settings.
"
4250,"resp0: [**name (ni) 52**] pt on [**last name (un) **] a/c 14/450/1.0/5+.  alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral diminished bases. suctioned for small amounts of thick yellow secretions. mdi's 2p [**last name (un) **] [**hospital1 **]/4p combivent q4 hrs with no adverse reactions. vent changes reflect abg's (see careview). present settings a/c 20/350/50%/5+. am abg's 7.41/37/211/24. no further changes noted.
"
4251,"resp: [**name (ni) 52**] pt on psv 5/5/40%. alarms on and functioning.  ett#8.0, taped @ 22 lip. ambu/syringe @ hob.  bs are coarse bilaterally. suctioned for small to moderate amounts of thick white secretions. mdi's administered alb/atr as ordered with no adverse reactions. vent changes to ^ ps to 10 due to ^ rr. am abg 7.41/53/104/35. rsbi=173.
"
4252,"resp: [**name (ni) 52**] pt po intubated ett 7.0 23 2 lip on a/c 18/500/5+/50%. bs are clear bilaterally. suctioned for small amount of brownish thin secretions. mdi's administered as ordered alb with no adverse reactions. intubation attempted fiberopticly but unsuccessful then intubated by direct larygoscopy and aspirated. abg 7.45/35/85/26. decreased fio2 to 40%. plan to extubate this am under direct supervision by anesthesia.
"
4253,"resp: [**name (ni) 52**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. am abg 7.23/42/229/25 with rsbi=28. pt continues on cvvhd. plan:continue to wean as tolerated.

"
4254,"pt update:

neuro: pt sedated. arouses to voice. mae on the bed. withdraws to painful stimuli. propofol weaned once precedex started @1300, and pt at comfortable level of sedation. pupils 3mm and reactive bilaterally. pt denies pain. ivig started @ 1400. no adverse reactions. rate advanced to 240cc/hr.

cv: hr 70-90s. nsr. no ectopy. sbp hypertensive in 190-200's in am. sbp max 210 @ 1200. treated with 10mg lasix and 15mg total hydralzine. htn continued until precedex given @ 0.7mcg/kg/hr. sbp came down to 120-140s where it remained through out rest of shift. ppp.

resp: attempt at ac early in shift. failed due to level of wob and increasing hr and bp. pt put back on cpap c/ ps. fio2 40, 5 and 5, 785 at 19. ls coarse with slight i/e wheeze. sxn'd for thick tan secretions.

gi: tf @ 20 via og tube. +bs. no bm.

gu: foley draining adequate amounts clear, yellow urine.

endo: iss.

plan: monitor for sbp htn. monitor infusion of ivig for fever, signs of adverse effect, etc.
"
4255,"resp: [**name (ni) 52**] pt on a/c 12/500/+5/40%. ett 7.5 rotated, retaped and secured @ 21 lip. bs are coarse to clear with suctioning. suctioned for small amounts of bloody/tinged secretions to tan by morning. mdi's administered as ordered alb/atr with no adverse reactions. no fever noc or changes. am abg 7.54/44/180/39. rsbi=86. plan: wean to psv as tolerated.
"
4256,"resp: pt rec'd on a/c 10/500/+5/50%. pt has #8 portex trach. bs are clear bilaterally with a few scattered crackles in bases. mdi's administered as ordered alb/atr/qvar with no adverse reactions. multiple abg's (see careview) with vent changes to ^ rr to 18, then 20 presently. cvvhd initiated noc and remains in am. am abg 7.34/42/104/24. no rsbi due to hemodyamic/no resps. plan: continue present mode of support.
"
4257,"resp: [**name (ni) 52**] pt on a/c 24/500/5+/50%. pt has #8 portex trach. bs are coarse to clear and suctioning small to moderate amounts of tan/bloody tinged secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. am abg 7.36/46/114/27. no changes noc. pt remains on cvvhd. no rsbi due to hemodynamic issues/no resps. plan: continue to wean as tolerated
"
4258,"resp: [**name (ni) 52**] pt on a/c 14/550/+5/40%. ett #8.0, rotated, retaped, and secured.  bs are coarse bilaterally and suctioned for small to moderate amounts of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. [**name (ni) 1017**]=82. no abg's or changes this shift. 02 sats @ 100%.  possible family meeting today to discuss cmo status?
"
4259,"resp:  [**name (ni) 52**] pt on a/c 16/600/10+/60%. bs are coarse bilaterally. suctioned for thick amounts of tan to yellow secretions. mdi's administered as ordered with no adverse reactions. weaned fio2 to 50%. am abg 7.42/25/125/17. no rsbi due to ^ peep. will continue to wean as tolerated.
"
4260,"addendum
back from or 1615. s/p exploration of mediastinum, drainage of pericardial effusion, and washout. received pt on propofol and vasopressin, levo added, and epi started [**name8 (md) 76**] md [**last name (titles) 10381**]. levo and vasopressin weaned to off [**name8 (md) 76**] md [**last name (titles) 10381**]. hct 21.9, 2 units of prbcs ordered and given, no adverse reactions noted. k 5.8, treated with 10units regular iv and 1 amp of d50 [**name8 (md) 76**] md [**last name (titles) 10381**], repeat 5.6, md [**doctor last name 10381**] aware, no new orders. pa 50s/30s. cvp 20. svo2 56-65. ci >2 via thermodilution. insulin gtt restarted for bs 214. see flowsheet for assessments and further details.

plan: hold heparin. hold vanco, level in am. wean epi as pt tolerates. monitor labs every 6 hours [**name8 (md) 76**] md [**name6 (md) 10381**] and md [**last name (titles) **].
"
4261,"resp: [**name (ni) 52**] pt on psv 12/14/50%. pt has #8 portex trach. bs are diminished with noted aeration. suctioned for small amounts of white secretions. mdi's administered of alb with no adverse reactions. pt had episode of desaturation then placed on a/c with fio2 @ 100% then titrated down. am abg 7.46/45/141/33 then weaned to psv 12/14/50%. plan to wean as tolerated. no rsbi=^ peep
"
4262,"resp: [**name (ni) 52**] pt on psv 22/10/70%. pt has #8 [**last name (un) **] air filled cuff, secured @ 12 flange. bs are coarse bilaterally and suctioned small amounts of greenish secretions. copious secretions of bile suctioned from nares/oral cavity. mdi's administered alb/atr with no adverse reactions. following rotation of pt in prone position, ett migrated to 8 with notable cuff leak. tube advanced to 12 with immediate improvement and no cuff leak. am abg 7.44/38/79/27 (following prone positioning). no changes noc. plan to continue present settings/wean when appropriate.
"
4263,"resp: [**name (ni) 52**] pt on psv 18.5/40%. pt has #8 trach with occasional positional leak. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered combivent with no adverse reactions. no abg's. o2 sats @ 98%. [**name (ni) 1017**]=141. plan to wean as tolerated.

"
4264,"resp: rec;d pt on a/c 22/500/10+/40%. ett #8, taped @ 24 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick yellow to white secretions. insp ^ to .9/i:e 1:2.0 am abg 7.40/45/74/29. mdi's administered alb/atr with no adverse reactions.  no rsbi due to ^ peep. no further changes noted. pt remains on rotating bed. plan: wean as tolerated.
"
4265,"7a-7p
neuro: propofol decreased, pt able to mae on commnds, lower extremeties weaker than upper. pt nodded head yes/no to questions. perrla. medicated prn w/ dilaudid iv for incisional pain.

cv: hr 80-90s sr w/ occasional pacs and rare pvcs. in and of afib, at 0815 pt in afib, md [**doctor last name **] aware, amio bolus 150mg iv, converted to sr w/ pacs. again at 1345 pt in afib, md [**doctor last name **] aware, amio 150mg iv bolus and gtt increased to 1mg/min. at present time pt in sr w/ rare pac. see flowsheet. pt transfused w/ 1 unit of prbcs no adverse reactions, repeat hct 27-26, md [**doctor last name **] aware, no new orders. sbp 90-100s/. milrinone weaned to off as [**name8 (md) 76**] md [**last name (titles) **]. svo2 >60s. ci>2 by fick. levophed weaned to 0.06mcg/kg/min. epi gtt continues at 0.02mcg/kg/min, vasopressin continues at 3units/hr. pa 30/20s. cvp 14-18. see flowheet for details. k taken at 1500 as [**name8 (md) 76**] md order, k 5.8, md [**doctor last name **] aware, kayexeleate given as per order. repeat k due at 1900 [**name8 (md) 76**] md [**last name (titles) **]. dopplerable bilat at/pt.

resp: ls clear/diminished. cpap [**5-22**] w/ acceptable abg ~3 hours. after 3 hours pt rr >35, pt placed back on cmv rate 12, 5 peep, fio2 40%, see flowsheet. sats 100%. ct no airleak, draining dark serosang small amts. see flowsheet for further details.

gi/gu: abd obese soft, hypoactive bs. ogt +placement draining bilious drainage. no tf today per team, ? to start tomorrow. foley draining clear yellow 15-30cc/hr. no crrt today per renal. most likely tomorrow per renal. lasix 40mg ivp tid given as ordered.

endo: insulin gtt per protocol.

skin: see flowsheet.

social: [**name (ni) 1976**] (wife) visited pt today ~ 2hous. updated w/ poc.

plan: monitor henodynamics. monitor resp. status. wean levophed as pttolerates. pain control. ? crrt tomorrow. monitor k.
"
4266,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are clear to coarse and suctioned for small amount of bloody tinged thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.34/44/156/25. rsbi=57. plan; possible trip to or today, although nothing confirmed.
"
4267,"resp: pt rec'd on a/c 15/500/+5/40%. ett 8 taped @ 22 lip. bs are coarse and suctioned for moderate amounts of thick tan to yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. am abg 7.50/39/120/31. rsbi=166. plan: wean as tolerated
"
4268,"resp: [**name (ni) 52**] pt on psv 5/5/40%. ett 7.5 taped @ 21 lip. bs are clear with scant amount of suctioning. mdis administered as ordered alb/atr with no adverse reactions. no abg's this shift. rsbi=52. plan is to extubate this am following [**name (ni) **].
"
4269,"resp: [**name (ni) 52**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no abg's this shift. pt had episode of desating to 88, then increased fio2 to 50%. 02 sats this am @ 98%, then decreased fio2 back to 40%. rsbi=26. plan to continue to wean as tolerated.cvvhd discontinued noc.
"
4270,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett 7.5, taped @ 23 lip. bs are coarse bilaterally and suctioning small to moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift 02 sats @ 100 %. rsbi=43. plan to trach/peg today.
"
4271,"resp: pt rec'd on mmv 10/500/10/5+/40%. ett 7.5. taped @ 21 lip. bs are coarse to clear with diminished bases. suctioned for small amounts of bloody tinged/tan thick secretions. mdi's administered alb/atr with no adverse reactions. pt remains to become aggitated when not sedated with ^ bpto 190. no vent changes noc. am abg 7.48/50/137/38. rsbi=52. plan to wean as tolerated.
"
4272,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.44/56/142/39. rsbi=107. no change noc. [**name (ni) **] trip pending. family in discussing transfer to [**hospital1 1771**] & women today.
"
4273,"resp: [**name (ni) 52**] pt on a/c 14/600/+5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for copious amounts of thick white secretions. mdi's administered q4 hrs alb/atr with no adverse reactions.  rsbi=127. no abg's 02 sats remain @ 100%. plan to continue to wean as tolerated on psv.
"
4274,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett #7.5, taped @ 23 lip. bs are coarse to clear and suctioned for moderate amounts of thick tan/yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. am abg 7.50/36/122/29. rsbi=71. plan is to trach/peg today.
"
4275,"resp: pt rec'd on a/c 15/600/+5/40%. pt has #8 portex trach is vent dependent. bs are coarse bilaterally and suctioned for moderate amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. attempted to wean to psv and pt did not tolerated became tachy with ^ wob immediately. rsbi=110. no aline or abgs. 02 sats @ 100%. plan to continue to wean to psv as tolerated.
"
4276,"resp: [**name (ni) 52**] pt on psv 10/5/50%. ett 7.5, taped  @ 23 lip. bs are coarse bilaterally and suctioning for moderate to copious thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes this shift. am abg 7.49/34/81/27 with a rsbi of 65. plan: family meeting today to discuss cmo status?
"
4277,"resp: [**name (ni) 52**] pt on 35% t/c t/c with humidification. bs are coarse to clear with spc. suctioned x1 for thick white secretions. mdi's administered alb/atr with no adverse reactions. inner cannula changed. 02 sats @ 100%. will continue to follow.
"
4278,"resp: rec'd on psv 10/5/40%. ett #8.0 taped @ 26 lip. bs are coarse to clear and suctioned for small amounts of thick bloody tinged secretions. mdi's administered as ordered alb/(atr d/c'd)with no adverse reactions. no changes noc or abg's. rsbi=38. family meeting to discuss trach? will continue to wean ps as tolerated.
"
4279,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 12/8/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral diminished bases with some coarse sounds noted throughout.  suctioned x3 for small amounts of white thick secretions.  mdi's administered q4 combivent with no adverse reactions.  rsbi=70, no sbt initiated with ^ rr to ^ 30's and decrease in mean to 2.  02 sats remain @ 98% noc with no further changes noted.
"
4280,"day shift update
neuro: pt not moving extremeties at beginning of shift, pt on fentanyl gtt at 100mcg/hr. pa [**last name (un) 9952**] aware. fentanyl gtt turned off, approximately 1 hour after turning off fentanyl pt mae, not following commands. pt grimacing w/ any touch abd. team aware, general surgery consulted. see gi part of note for details. left pupil slightly larger than right, though both react briskly to light.

cv: hr 90-110s afib rare pvcs. mg 2gm iv for ectopy. sbp labile, hypotensive, pa [**doctor last name **] aware, neo gtt started as per pa. pt received 3 units of prbcs, no adverse reactions. see flowsheet for details of extremeties and pulses.

resp: ls coarse. unable to get pleth at times. acceptable abgs on cmv rate 24, 5 peep. fio2 40%. suctioned for thick pale yellow. see flowsheet.

gi/gu: abd slightly round, soft, grimacing w/ any type of touching abd. +visible blood w/ loose bm, pa [**doctor last name **] aware. +hemmorroids, surgery team aware. at present time pt in or, for exploratory lap. urine output dropped w/ hypotension, pa [**doctor last name **] aware. see flowsheet for details.

skin: see flowsheet. draining serous fluid out of open areas.

endo: riss.

social: daughter updated w/ poc.

plan: ?mri once abd. issues resolved. pt in or at present time. monitor hemodynamics. monitor resp. status.
"
4281,"7p-7a
neuro: pt lightly sedated on propofol 10-15mcg/kg/[** **]. moves all extremeties weakly, followed commands (wiggled toes on command), perrla. morphine 2mg ivp prn for pain shown by grimace scale and by pt nodding head when asked if in pain.

cv: hr 80-90s 1st degree avb pr 0.25. rare pac noted. mg 2.5, k 4.6, no repletion needed. sbp labile 86-130s (130 while turning in bed), neo gtt as high as 2.0mcg/kg/[**name8 (md) **], md [**doctor last name 1118**] aware at [**2173**] of sbp 86/ while on 2.0mcg/kg/[**year (4 digits) **] of neo, 1 unit of prbcs ordered and given as ordered, followed by 20mg of ivp lasix. md [**doctor last name 1118**] aware of increased temp, ok to transfuse [**name8 (md) 76**] md. tylenol 650mg pr given, see carevue for details. no adverse reactions. [**md number(3) 7143**]/20s. cvp 13-16. ci>2.2 thermodilution see carevue for details. svo2 60-69, see carevue. sternal and medistinal dsgs cdi. right groin iabp site cdi, no hematoma. + dopplerable pedal pulses.

resp: ls diminished. improved oxygenation after pt placed on simv [**name8 (md) 76**] md [**last name (titles) 1118**] (to rest overnoc). presently, on simv rate 14 (breathing [**2-3**] over rate at rest) tv 600 fio2 60% ps 8 peep 12, see carevue for details of abgs and vent settings.

gi/gu: abd softly distended. hypoactive bs. foley draining 33-280cc/hr, increased u/o after lasix given at 2230, see carevue for details. creatinine 1.4 this am.

id: receiving post-op vanco doses. wbc 12.2. temp 101-100.3, bc and uc sent on day day shift. no secretions via ett yet to send a sputum cx. tylenol 650mg pr prn.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. closely monitor urine output. wean vent as pt tolerates.
"
4282,"resp: pt rec'd on 35% t/c. pt has ""#7 portex fen. trach. inner cannula changed. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow/bloody tinged secretions. pt has a strong cough and is able to expectorate secretions. mdi's administered alb/atr with no adverse reactions. no changes. 02 sats @ 100%. will continue to monitor
"
4283,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are coarse to clear and suctioning for small amounts of bloody tinged thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/65/131/41.pt following commands.  rsbi=54. family meeting to discuss possibility of trach? will continue to wean as tolerated.
"
4284,"resp: pt on 50% cam. bs auscultated reveal bilateral i/e wheeze which improve following tx administered of sd hhn of 2.5 mg albuterol/ns. no adverse reactions noted. pt is on droplet precautions pending results of pcp/tb tests.
"
4285,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  remains sedated with fentanyl at 15mcg/hr and versed at 1mg/hr.  spontaneous movement of arms noted, no movements of legs noted.  no attempts to speak or communicate; does not open eyes.

cv/pulm:  mp=afib, isolated pvc noted.  remained on vasopressin until 1530 when vasopressin off.  remained off until 1700 when bp dropping  to 68/41, remainins 68-72/42.  vasopressin restarted, dr. [**first name (stitle) **] notified.  prbc' infusing at this time; will re-try to dc vasopressin once prbc's have infused.  prbc's infusing without evidence of adverse reactions thus far.  l tlc, l a-line unchanged.  remains vented on ps was on [**4-5**] until traveled to ct scan then placed on a rate for ct.  upon return placed back on [**4-5**] but pt not tolerating [**4-5**], rr increased to 40's-->placed on [**11-5**] with rr improved to 20's.  bs coarse, diminished bil.  ct of chest and abdomen done; results pending.

gi/gu:  abd soft, non-tender, bowel sounds hypoactive.  tol tf at goal rate of 60ml/hr via ogt.  tol baricat pre-ct; now stooling liquid golden stool via mushroom catheter and occasionally oozing around mushroom.  u/o 20-40ml/hr.

id/endo/integ:  afebrile.  sliding scale coverage for fingersticks.  skin continues to weep requiring soft-sorb changes q2h-->arms, legs, back and buttocks.  multiple open areas noted, multiple skin tears noted--see carevue.

psychosocial/plan:  fam in to visit.  no decisions made by family re: re-intubation of pt if she is extubated.  encouraged fam to make these decisions at this time/prior to extubation planned for am.  emotional support given to pt and fam.  plan is [**month/day (1) **]'d vent support, npo after mn for ? extubation in am.  complete prbc's and re-check hct.  monitor vs, i+o, breath sounds.  [**month/day (1) **] with q2h skin care, current nursing/medical regime.  pt is dnr at this time.
"
4286,"resp: pt rec'd on psv 15/5/30%. alarms on and functioning. ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds. suctioned for small amounts of bloody tinged thick secretions. mdi's administered q 4 alb with no adverse reactions. pt had ^ in rr to 38 due to anxiety, ativan administered with good affect. rsbi=143, no abg's. attempted to wean psv but did not tolerate. will continue to wean appropriately.

"
4287,"2200-0700

received pt from [**hospital ward name 54**] 7 for meropenem desensitization. pt has bc x2 with gram negative rods and requiring meropenem for iv abx coverage.  pt awake, alert, orientedx3. follows commands well. moves upper ext well, lower ext bka bilaterally. speech clear and pt appropriate. no confusion noted. no neuro deficits.

resp: resp easy and regular without difficulty. no sob noted. o2 sat remain stable. lungs clear/diminished at the bases bilaterally.

cv:nsr without ectopy noted. hr 70-80s, sbp 130-150, low grade temps noted. denies pain at this time. meropenem desensitization started at 0245am. pt tolerating well. no adverse reactions. piv x1 to larm 20g intact.

gi/gu: pt on [**doctor first name 602**] diet. abd flat soft + bs, no bm noted. denies nausea. [**name (ni) **] pt. r arm av fistula not yet matured for use, +thrill/bruit. pt last received hd [**12-4**].

endo: riss.

plan: pt to finish meropenem desensitization and transfer back to [**wardname 1699**]-bed being held for pt.
"
4288,"resp: pt remains on psv 10/5/40%. bs are diminished bilaterally. suctioned for small amounts of thick tan secretions. mdi's administered q4 alb with no adverse reactions. am abg's 7.45/43/111/31. rsbi=148. no changes noc.
"
4289,"resp: [**name (ni) **] pt on [**name (ni) **] psv 5/5/40%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal noted aeration with slight i/wheeze on ls. suctioned for small amounts of thick yellow secretions mdi's administered q4 hrs alb/atr with no adverse reactions. abg's 7.41/55/136/36 rsbi=23.
"
4290,"resp: [**name (ni) 52**] pt on simv 10/600/5/+5/40%.  ambu/syringe @ hob.  pt has lg cuff leak, although tv's remain in 500's.  also noted secretions around trach site.  pt 02 sats decreased a few times during the noc.  bs auscultated reveal coarse bs bilateral with clear with suctioning.  suctioned x 4/5 times for bloody tinged thick secretions.  pt appears uncomfortable, rn aware.  mdi's administered q4 alb with no adverse reactions.  vent changes as follows:  rr ^ from 10, to 12, then 14, peep ^ 7, fio2^ 50%.  no further changes noted.
"
4291,"resp: [**name (ni) 52**] pt on a/c 12/400/10+/50%. pt has #8 portex trach. alarms on and functioning. ambu/syringe @ hob. bs are coarse to diminished.suctioning small amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes or abg's this shift. plan to continue full vent support.
"
4292,"respiratory care note:
     patient remains trached with a #8.0 portex and on full vent support.  no changes have been made this shift.  bs are coarse throughout.  sx for small amounts of tan thick secretions via trach.  no rsbi this am due to fio2 of 60%.  patient remained afebrile.  mdi's administered as ordered, including 300mg of tobramycin at ~0200.  no adverse reactions noted.  spo2 remains 95-98%.  plan is to continue with current course of therapy.
"
4293,"resp: pt rec'd on psv 12/12/40%. bs are coarse with occasional wheeze noted. mdi's administered q4 hrs alb/atr with no adverse reactions. suctioned for small amounts of thick secretions. no vent changes this shift. am abg 7.49/37/122/25. will contine to wean appropriately.
"
4294,"resp: [**name (ni) 52**] pt on a/c 16/500/10+/40%. bs are coarse bilaterally. suctioned for small amounts of thick yellow secretions. mdi's administered alb.atr with no adverse reactions. am abg 7.47/42/143/31. no rsbi due to ^ peep. noted occasional [**name (ni) 1999**] leak which is positional. will continue full vent support.
"
4295,"resp: [**name (ni) 52**] pt on a/c 12/400/10+/60%. alarms on and functioning. ambu/syringe @ hob. pt has #8portex trach. bs are relatively clear with some occasional wheeze noted. suctioned for small thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/59/115/41 then decreased fio2 to 59%. no rsbi due to ^ peep. will continue full vent support.
"
4296,"resp: pt administered 300 mg tobramycin @ 2:00 with no adverse reactions.
"
4297,"resp:  [**name (ni) 52**] pt on [**last name (un) **] psv 10/+5 40%.  ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small amounts of thick whitish secretions.  pt became tachy once during the noc, lavaged, ambu, suctioned for small thk whitish amount, but no further episodes during the noc.  mdi's administered q4 of alb with no adverse reactions.  rsbi=38.  no further changes noted.
"
4298,"resp: [**name (ni) 516**] pt on psv 10/5/40%. pt has #7 portex trach. inner cannula changed. bs reveal noted aeration with diminished bases.suctioned for small amounts of thick tan/yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/30/104/19. rsbi=96. plan: wean as tolerated, initiate dialysis?
"
4299,"resp: pt rec'd on psv 16/10/50%. ett 8.0 19 @ lip. bs are coarse bilaterally and suctioning for moderate to copious thick yellow secretions. mdi's administered q4 alb with no adverse reactions. no changes noc. am abg 7.41/41/123/27. no rsbi due to ^ peep and procedure today. pt is being trached in am.
"
4300,"admission
pt admitted from or at 1305 s/p avr tissue and mv repair. uneventful or per anesthesia. ozzy from ct upon arrival from or. np [**name6 (md) **] and md [**doctor last name 816**] aware, protamine 50mg iv given as ordered. peep increased as [**name8 (md) **] np see fowsheet for details. 1 unit of prbcs given as ordered, no adverse reactions. pt requiring multi fluid boluses for svos 48-50s.epi gtt started as ordered. going by fick for co/ci, see flowsheet, pt w/ hx of tricuspid regurgitation.

neuro: pt sedated, perrla. no indication of pain. body temp 34.9-35 on arrival, bair hugger applied.

cv: hr 80. apacing. underlying 40s sb. sbp labile. goal sbp 90-110. see flowsheet for details, on and off neo and ntg gtts. [**md number(3) 1227**]/15-20s. cvp 5-11. requiring multi fluid boluses for low pad and cvp. np [**doctor last name 307**] aware. +dopplerable pedal pulses.

resp: ls clear diminished bases. sats >96%. presently orally intubated on simv mode rate 12, not breathing over, 5 peep, 5ps. plan to wake and wean as tolerates.

gi/gu: abd obese soft, absent bs. ogt +placement, draining bilious drainage.foley draining clear yellow urine 45-100cc/hr.

endo: gtt started per protocol, see flowsheet.

plan:monitor hemodynamics. monitor resp. status. follow fick q2 hours. allegy to latex. monitor ct drainage.
"
4301,"resp: pt rec'd on psv 5/10+/40%. ett 7.5, rotated, taped and secured @ 23 lip. bs are clear bilaterally. suctioned for small amounts of yellow thick secretions. mdi's administered as ordered atrovent with no adverse reactions. no abg's this shift. rsbi=47. weaned peep to 5. plan to continue wean with possible extubation in am.
"
4302,"resp: [**name (ni) 516**] pt on psv 10/5/40%. pt has #7 portex trach. bs are clear with diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.32/36/120/19. rsbi=43. plan: continue wean as tolerated with possible t/c trials.


"
4303,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #7 portex trach. bs are slightly coarse which clear with suctioning/diminished bases. suctioned for small amounts of bloody secretions due to recent trach. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.39/31/123/19. rsbi=97. plan: continue to wean as tolerated.
"
4304,"resp: pt on 3 lpm n/c and ordered for nebs alb/atr q6 hrs prn. administered alb/atr with no adverse reactions. will continue to follow.
"
4305,"resp: [**name (ni) 516**] pt on a/c 25/400/12+/60%. bs are diminished with crackles in bases bilaterally. suctioning for small to moderate amounts of thick tan/yellow secretions. mdi's administered alb with no adverse reactions. no changes noc. am abg 7.21/47/75/20. no rsbi due to ^ peep. plan: wean as tolerated.
"
4306,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #7 portex trach. bs are slightly coarse to clear. suctioned for small amounts of bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt wob ^ with declining abg's and ^ bp then placed on a/c (see careview for settings)with improved am abg 7.38/32/111/20. rsbi=97 but d/c due to ^bp to 180. plan:wean back to psv as tolerated.
"
4307,"resp: [**name (ni) 52**] pt on psv 10/5/40%. ett#8 retaped and secured @ 26 lip. bs are coarse to clear and suctioned for small amoutns of blood thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt had noted ^ in wob then increased ps to 15. vt's 400-500/ve 11/rr 25. rsbi=83. pt remains on ps 15. plan to wean ps as tolerated.
"
4308,"resp:  [**name (ni) 52**] pt on a/c 12/500/+8/50%. ett 7.0 taped @ 22 lip. bs are clear with diminished bases. suctioned for small amounts of thick white secretions. mdi's administered of combivent with no adverse reactions.  abg 7.36/75/84/44.no rsbi due to or procedure today. no changes noc pt scheduled for trach/peg today?
"
4309,"resp: [**name (ni) 52**] pt on a/c 12/500/40%/+8. pt has #8 [**last name (un) **] air filled cuff which is secured @ 14 flange. bs are coarse to clear and suctioning for moderate amounts of thick bloody secretions which lighten in am. sputum sample obtained and sent. mdi's administered of combivent/ovar as ordered with no adverse reactions. rsbi=147. pt has coughing episodes causing desaturation at times. attempted psv but pt did not tolerate. plan maintain present settings.
"
4310,"resp: pt rec'd on a/c 14/450/+5/40%. pt has #8 portex trach. bs reveal ls clear with rs noted sub-q/crackles. suctioned for small amounts of white secretions. mdi's administered q4 alb/atr with no adverse reactions. abg 7.50/51/92/41. rsbi=200. plan to wean as tolerated.
"
4311,"addendum
back from or at 1345 s/p exploratory of right axillary artery and repair dissection bovine patch. right hand cool, +palpable right radial, +ulnar and brachial via doppler. see flowsheet. svo2 dropped to 48, np [**doctor last name 330**] aware, 1 unit of prbcs given as ordered, no adverse reactions. ok for sbp 120s [**name8 (md) 76**] np [**doctor last name 330**]. fluid bolus for low urine output and low svo2, improving svo2 to 55-60. also epi gtt increased to 0.03mcg/kg/[**name6 (md) **] [**name8 (md) 76**] np. [**name (ni) **] (hcp) spoke to rn and updated w/ poc. mg 2gm given for ventricular ectopy. epicardial wires attached, not checked due to ectopy and tachycardia.  ptt >150, np [**doctor last name 330**] aware, no new orders. np[**md number(3) 732**] of act 170, no new orders. continues on epi, insulin, propofol, on and off ntg. see flowsheet for details.
"
4312,"resp: [**name (ni) 52**] pt on psv 10/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for copious amounts of thick bloody secretions/plugs. mdi' administered alb/atr with no adverse reactions. rsbi=58. pt is to be discharged today, although possibility of bronch this am.
"
4313,"condition update
d: see carevue flowsheet for specifics
 patient afebrile. dose of 2 million pcn g given this am at 0900 without any adverse reactions. pt was then bronched at 1015. second dose of 4 million pcn given at 1400 also given without any adverse reaction. thoracic team aware and transfer orders written. awaiting bed on floor.
 patient is a/ox3 and restarted on po diet.
 medicated with dilaudid 4mg po x2 with good effect.
 2 ct and 1 [**last name (un) **] remain intact. without any leaks. left lung with diminished breathsounds. 2l nc with o2 sats 98-100%.
plan:
 transfer out to floor when bed avail.
 notify h.o. with any changes
"
4314,"resp: pt rec'd on psv 10/5/40%. pt has #8 portex trach, some ozzing form trach site. bs are coarse/diminished bases bilaterally. suctioned for copious amounts of thick yellow secretions until this am then became bloody. rn aware. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. rsbi=52. plan:wean as tolerated.
"
4315,"resp: pt rec'd on 35% t/c with humidification. pt has #7 portex. bs are coarse to clear and suctioned for small to moderate amounts of thick white to yellow secretions more towards morning. mdi's administered via trach alb/atr with no adverse reactions. pt has spc and is able to expectorate sputum.
"
4316,"resp: [**name (ni) 52**] pt on psv 15/5/40%. ett #8.0 retaped @ 26 lip. bs are clear in apecies with diminshed bases/crackles. suctioned for small amount of thin bloody secretions. mdi's administered as ordered alb/atr with no adverse reactions. no vent changes noc. vt's 500's/ve 10. rsbi=66. rec'g rbc unit. plan remain on present settings and to wean as tolerated.
"
4317,"resp: [**name (ni) 52**] pt on a/c 16/500/5+/40%. ett 8.0, rotated, retaped and secured @ 22 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick bloody tinged/yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. no-aline/no abg's this shift. no rsbi-or procedure this am.
"
4318,"resp: [**name (ni) 52**] pt on psv 12/5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered combivent with no adverse reactions. no abg's 02 sats @ 99%. [**name (ni) 1017**]=124. plan to d/c today to rehab.
"
4319,"resp: pt rec'd on a/c 16/500/+5/40%. ett 8/0 rotated, retaped and secured @ 22 lip. bs are clear to coarse and suctioned for small to moderate amounts of thick bloody tinged/yellow secretions. mdi's administered combivent/alb as ordered with no adverse reactions. vent changes to ^ rr to 18. rsbi attempted but no spont resps. am abg 7.42/54/112/36. plan to wean as tolerated.
"
4320,"resp: pt rec'd on psv 5/5/40%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are coarse bilaterally and suctioned for small to moderate amounts of thick bloody tinged secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt placed on a/c (see abg's in careview) a/c 18/500/+5/40%. am abg 7.37/33/138/20/-4. no further changes. rsbi=190. plan: wean as tolerated.
"
4321,"resp: [**name (ni) 52**] pt on psv 10/5/40%. bs are basically clear bilaterally. suctioned for scant to small amounts of bloody tinged thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes noc. am abg 7.35/38/131/22. rsbi=61. pt to or today for hip surgery.
"
4322,"resp: [**name (ni) 52**] pt on a/c 16/500/+5/40%. ett 7.5 taped @ 21 lip. bs are basically clear and suctioned for small amount of bloody tinged secretions. sample obtained and sent with results pending. mdi's administered alb/atr as ordered with no adverse reactions. am abg 7.44/37/154/26. rsbi=>200. weaned to psv 15/5/40% and pt tolerating. will continue to wean as tolerates.
"
4323,"resp: [**name (ni) 52**] pt on psv 10/12/60%. pt has #8 portex trach. inner cannula changed. bs are coarse bilaterally with diminished bases. suctioning for moderate to copious amounts of thick tan/yellow secretions, sample sent. mdi's administered as ordered alb/atr/qvar with no adverse reactions. abg's (see careview) no rsbi due to ^ peep.  am abg 7.42/58/68/39. plan: continue with t/c trials as tolerates.
"
4324,"resp: [**name (ni) 52**] pt on 40% cam, then ^ to 60% due to decreasing sat's. nebs ordered and administered q6 hrs alb/atr with no adverse reactions. will continue to treat.
"
4325,"resp: pt has #8 portex trach with pmv in place. pt is on 50% t/[**hospital1 **] are diminished bilaterally and suctioned for small amounts of white thick secretions. mdi's administered via trach/ambu with no adverse reactions. will continue to monitor.
"
4326,"readmit
pt readmitted at 0645 from [**hospital ward name 54**] 6, unresponsive, intubuted, left pleural ct placed on [**hospital ward name 54**] 6. bs 30s at 0600, treated on [**hospital ward name 54**] 6. to cvicu hypotensive on 3mcg of neo. levophed gtt added, also vasopressin added as ordered. see flowsheet for details. neo gtt weaned to off as per team. echo done at bedside at 0730. fem aline placed at 0715. pa catheter inserted at 0915. see flowsheet for details.

neuro: pt mae on arrival, though not following commands, sedated on propofol gtt. pupils 6mm, left sluggish, right nr. np [**doctor last name **] aware. propofol off at 1100 to assess abd [**name8 (md) 76**] np [**doctor last name **]. at 1130, pt restless, mae, not following commands, grimacing at baseline, hard to assess abd d/t baseline grimacing. np [**doctor last name **] at bedside, ok to restart propofol [**name8 (md) 76**] np.

cv: hr 50-70s sr rare pvc noted. hypotensive on arrival. sbp 80s on neo gtt at 3mcg/kg/min. levophed gtt added as ordered. also pitressin started as ordered. see flowsheet for details. pa catheter placed at bedside. wedge pressure 22. svo2 70s-80s. [**md number(3) 10822**]/15-20s. cvp 8-14. ci>2 via thermodilution. co 4.2-4.8. 2 units ffp given as ordered and 2 units of prbcs given as ordered. no adverse reactions noted. multi-lumen rij dc'd and tip sent for culture,dc'd without incident. sternum uneven, team aware. pt in or at present time for ? sternal washout/ ? explor. lap.

resp: ls coarse throughout. bronch done at bedside, scant amt of secretions. lactate [**10-30**]. csurg team aware. see flowsheet for abg results, ph 7.22 on arrival, 2 amps of bicarb iv given as ordered. repeat ph 7.35. np [**doctor last name **] updated throughout shift of abgs and lactate. fluid boluses given as [**name8 (md) 76**] np, total of 1.5lns.

gi/gu: abd soft, no bs. ogt draining bilious brown scant amts. bmx2 large liquid brown, c.diff sent. + ob stool. general surgery consulted. lfts elevated. coag elevated. foley inserted, amber clear urine sent. ua and uc sent as ordered.

endo: 1/2amp of d50 at 0800 for decreasing bs. followed bs q1 hr. see flowsheet.

id: bc from fem aline and [**location (un) **] left subclavian. hypothermic. temp 92.2-93.4, see flowsheet. np [**doctor last name **] aware. uc sent. bronch specimen sent. zosyn and flagyl given before or. vanco given to anesthesia, to be given in or.

social: family updated by md.

plan: pt in or (at present time) for sternal washout and ? exploratory laparotomy to assess abd. monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. full code.
"
4327,"resp: [**name (ni) 52**] pt on psv 10/5/50%. pt has #8 portex trach. bs are coarse to clear with diminished bases. suctioned for moderate amounts of thick yellow secretions. inner cannula clear. mdi's administered as ordered alb/atr/qvar with no adverse reactions. vt's 500/rr 27 with 02 sats in 90's. a-line removed this am. rsbi=51. plan: continue with t/c trails as tolerated.
"
4328,"resp: [**name (ni) 52**] pt on t/c with hi-flow @ 60%. 02 sats @ 95%. bs are coarse bilaterally and suctioning for copious amounts of thick yellow secretions frequently. mdi's administered alb/atr/ovar as ordered with no adverse reactions. pt remained on t/c until 02:00. no distress was noted, 02 sats in 90's rr 18-20, although pt was noticably more lethargic. abg revealed ^ co2 with ph7.2 then placed on vent psv 10/8/50%. improvement noted pt more awake. co2 @ 62. ph 7.39. rsbi=52. plan: continue with frequent suctioning and t/c trials.
"
4329,"resp: [**name (ni) 52**] pt on a/c 14/500/5+/40%. bs are coarse to clear with suctioning. secretions initially bloody tinged then more white towards morning. mdi's administered alb/atr as ordered with no adverse reactions. abg's (see careview) within normal range on a/c. weaned to psv 10/5/40% in am with abg's pending. rsbi=123. still remains tachy
"
4330,"resp: [**name (ni) 52**] pt on a/c 35/450/16+/60%. ett 7.5 taped @ 23 lip. bs are clear and suctioned for none/white secretions. mdi's administered alb/atr with no adverse reactions. abg 7.15/48/74/18. [**name (ni) **] changes to ^ peep to 18. bicarb initiated again. plan: meeting to discuss cmo status. continue full [**name (ni) **] support.
"
4331,"resp:  [**name (ni) 52**] pt on [**last name (un) **] simv 16/600/+5/10/40%. alarms on and functioning.  ambu/syringe @ hob. bs auscultated reveal bilateral coarse sounds which improve with suctioning. suctioned copious bloody secretions. mdi's administered q4 of combivent with no adverse reactions.  rsbi=90.  no futher changes noted.
"
4332,"11p-0700
pt admitted from or at 2145 [**2186-8-24**], ( s/p aicd/ddd permanent pacer placed [**2186-8-24**] am, hypotension while on floor, back to or). see admission history for details.

neuro: pt sedated first on propofol, propofol weaned off and fentanyl 50mcg/hr and versed 1mg/hr gtts started d/t hypotension 88-90s/. opens eyes on verbal command, moves extremeties with hands on care, hx of right arm w/ steel rod placement. perrla. no facial grimacing noted.

cv: ddd permanent pacer hr 80-120s (120s while dopamine infusing). v paced, varying w/ own intrinsic and a paced beats. dopamine changed, secondary to hr, to neo gtt for sbp 90-100s. labile bp. goal 90-100s sbp. see carevue for details. cvp 5-8. + palpable pedal pulses. received 1 unit of prbcs, no adverse reactions. post hct 27. hct from ct 17.2, pa [**doctor last name 739**] aware. trauma line to left groin bleeding when received from or, pa [**doctor last name 739**] at bedside, stitched, no further bleeding. k repleted, order to replete k <4.0.

resp:ls clear. orally intubated, suctioned for scant blood tinged. sats >96% on fio2 40% rte 14 simv, see carevue for details.  left ct intact, no air leak, no crepitus, draining sang. minimal amts, see carevue.

gi/gu: abd soft, +bs. ogt + placement to intermittent wall suction, scant amt of blood via ogt after suctioning pt, pa [**name (ni) 739**] aware, no new orders at present. once bp stabilized, lasix 40mg ivp given. foley draining clear yellow urine adequate amts. see carevue.

endo: insulin gtt started for fs 150s, see carevue.

social: no contact from family this shift.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent as pt tolerates. monitor ct drainage. keep pt comfortable.
"
4333,"resp: [**name (ni) 52**] pt on h/f @ 50%. bs auscultated reveal bilateral coarse sounds. nasal trumpet in place. hhn alb/atr administered q 4 hrs with no adverse reactions. pt on cpap 16 with 2 lpm 02 bleed in noc.
"
4334,"resp:  [**name (ni) 52**] pt on [**last name (un) 993**] a/c 10/500/40%/+10.  alarms on and functioning.  ambu/syringe @ hob.  bs auscultated reveal bilateral diminished breath sounds.  suctioned x3 small to moderate amounts of thick yellowish secretions.  mdi's administered q4 combivent with no adverse reactions.  no rsbi performed due to ^peep.  02 sats remain in ^ 90's @ 97-99%.  no further changes noted.
"
4335,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett 8.0 rotated, retaped @ 27 lip. bs are clear with diminished bases. scant amounts suctioned. mdi's administered as ordered alb/atr with no adverse reactions. [**name (ni) 520**] changes to decrease peep x1 increments and presently @ 14. am abg 7.47/43/79/28. no rsbi due to ^ peep. plan:continue to wean peep as tolerated/appropriate. presently on full [**name (ni) **] support.
"
4336,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett #8, rotated, retaped @ 27 lip. bite block in place. bs are coarse bilaterally and suctioning for copious amounts of thick yellow /brownish plugs. mdi's administered as ordered alb/atr with no adverse reactions. no rsbi due to^ peep. am. abg 7.34/43/103/24. plan: maintain full [**name (ni) **] support.
"
4337,"7a-7p
neuro: received pt sedated on fentanyl and versed gtts. weaned versed gtts to off. pt mae on command (spoken in french by translator), nodding appropriately to questions. fentanyl gtt wean to off to attempt cpap ps on ventilator. perrla. sleepy at present time.

cv: hr 80-90s sr rare pvc. sbp labile. aline overshooting/fling in aline waveform. nibp ~20-30points lower [**name6 (md) **] aline, md [**name6 (md) 859**] and md [**doctor last name 1357**] aware, go by nibp to titrate gtts [**name8 (md) **] md [**name6 (md) 859**] and md [**last name (titles) 1357**]. at present time on ntg to keep goal sbp 120-140. hct 25 this am, 1 unit of prbcs infused w/out adverse reactions, repeat hct 28, md [**doctor last name 859**] aware. ci [**2-20**] via thermodilution. [**md number(3) 5420**]/15-20. cvp 9-12. see flowsheet for details. 3+ generalized anasarca. +palpable pedal pulses.

resp: ls coarse, diminished bases. sats 100%. cxr done this am. attempted cpap/ps x2 unsuccessful d/t pt sleepy. will attempt when pt more awake. see flowsheet for abg/vent settings. ct to water seal, draining serosang. drainage, no airleak, no crepitus.

gi/gu: abd softly distended. hypoactive bs. ngt to suction draining bilious drainage. foley draining 80-400cc/hr of clear yellow urine. received 20mg of lasix ivp as ordered after blood transfusion. another dose of lasix 20mg x1 on hold for now [**name8 (md) **] md [**doctor last name 859**] since pt already 2.6 liters negative since midnoc. will need more lasix on pt's u/o starts to decrease [**name8 (md) **] md [**last name (titles) 859**].

endo: no coverage needed 90-100s.

social: friends into visit.

plan: monitor hemodynamics. monitor resp.status. monitor output. bp control by following cuff pressure. diurese. wean vent to cpap/ps.




"
4338,"resp: [**name (ni) 516**] pt on a/c 32/450/16+/50%. ett #8 rotated, retaped @ 27 lip. bs are clear/diminished bases. suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. new a-line inserted. am abg 7.36/45/78/26. plan was to decrease peep slowly, although with pao2 @ 78 peep remains @ 16. no rsbi=^ peep. plan: maintain full [**name (ni) **] support.
"
4339,"resp: [**name (ni) 516**] pt on a/c 34/380/12+/70%. ett 7.0 retaped, rotated and secured @ 20 lip. bs are coarse to clear and suctioned for small to moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. fio2 weaned to 60%. am abg pending.no rsbi due to ^ peep/fio2. plan: wean as tolerated.
"
4340,"resp: [**name (ni) 516**] pt intubated ett 7.0 taped @26 lip transfer from sicu via or. vent settings a/c 26/600/10/40%.  bs are clear bilaterally with diminished bases. sputum sample obtained and sent. suctioned for small amounts of thick yellow/tan secretions. cvvhd initiated.  mdi""s administered as ordered alb with no adverse reactions. am abg 7.33/37/119/20. pt had episode of desaturation following arrival from or, vent changes to ^peep/fio2 to 60%,then titrated back down to present settings. no rsbi due to ^ peep. no further changes noted. plan: wean as tolerated.
"
4341,"resp: pt rec'd on psv 8/5+/25%. pt has a #7 portex trach. bs are coarse bileratally and suctioned for small amounts of white secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt had episodes of aggitation, trying to get oob at times, with rr to 40's. placed on a/c 14/450/+5/25% in morning to control/reduce rr with immediate improvement.  will wean back to psv when pt calms. rsbi=72. no abg's this shift, 02 sats @ 99%.
"
4342,"resp: [**name (ni) 516**] pt on a/c 22/600/12+/40%. bs are clear with dminished bases and suctioned for small amount of white thick secretions. mdi's administered as ordered alb with no adverse reactions. no changes this shift. am abg 7.42/40/103/27. no rsbi due to ^ peep.  plan: maintain full vent support. or on monday.
"
4343,"resp: [**name (ni) 516**] pt on psv 8/5/35%. pt has #7 portex trach. bs are coarse to clear and suctioned for small amounts of thick tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. titrated fio2 down to 25% and ps to 6. 02 sats @ 99%. pt tolerated presents noc with no distress noted. rsbi=90. continue to wean with t/c trials as tolerated.
"
4344,"resp: [**name (ni) 516**] pt on a/c 20/700/17+100%. bs are coarse bilaterally and suctioning for moderate amounts of thick yellow secretions. mdi's administered with no adverse reactions. pt having episodes of desats with ^ bp, ^ hr. pt is dnr. pt expired @ 2:34 this am.
"
4345,"resp: [**name (ni) 516**] pt on psv 8/5/25%. pt has #8 portex. bs are coarse with decrease in aeration on ls. mucomyst/alb instilled as well as mdi's administered alb/atr with no adverse reactions. some green secretions oozing around trach site. bs reveal end exp. wheezing following administration of mucomyst. suctioned for small amounts of thick white/yellow secretions. episode of desaturation with ^ in ps & peep. weaned back to present settings in am. 02 sats @ 97% with adequate tv's. plan continue wean and attempt t/c trials if tolerates.
"
4346,"resp: pt rec'd on 40% f/t. alb/atr ud administered q6 hr with no adverse reactions. bs are coarse to clear. will continue to follow.
"
4347,"resp:  [**name (ni) **] pt on psv 12/5/40%. pt has #7 portex trach. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered atr as ordered with not adverse reactions.  rsbi=52. plan: pt is being screened for rehab. continue to wean as tolerated.
"
4348,"resp: [**name (ni) 516**] pt on psv 15/10/50%. ett #8, rotated, and retaped @ 26 lip. bs are clear/diminished bases bilaterally. sucioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.50/32/118/26. vent changes to decrease ps to 12, peep to 8. plan: wean as tolerated. rsbi to be done in am following pt tolerating decrease in peep
"
4349,"resp: pt rec'd on psv 5/5/40%. ett 8.0 taped @ 26 lip. bs are coarse to clear and suctioned for small to moderate white/yellow thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/43/148/30. rsbi=47. plan:trach/peg
"
4350,"resp: transferred from micu with incident, intubated with #7.5 ett, taped @ 21 lip. bs are clear on rs, diminished bases on ls. suctioned for small to moderate thick tan secretions. a-line in place. mdi's administered alb/atr with no adverse reactions. pt scheduled for radiation tx this am. plan to continue on present settings.
"
4351,"resp: pt rec'd on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear and suctioning for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.50/30/176/24. rsbi=55. possible t/c trials today?
"
4352,"resp: [**name (ni) 516**] pt on a/c 26/350/5+/50%. ett 7.5 taped @ 24 lip. bs are coarse and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. pt had episode of desaturation then peep ^ to 10. am abg  7.36/38/66/22. fio2 ^ to 60%. radiation treatment today. no further changes notes. no rsbi=peep
"
4353,"resp: [**name (ni) 516**] pt on psv 8/5/40%. ett 7.5, retaped and secured @ 21 lip. bs are coarse to clear and suctioning small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no abg's 02 sats @ 100%. vt 300's ve 7. rsbi=76. plan to continue diuresing with extubation on [**12-28**].
"
4354,"resp: mdi's administered of combivent as ordered without any adverse reactions.
"
4355,"resp: pt rec;d on psv 10/5/40%. ett 7.5, rotated, retaped and secured @ 25 lip. bs are clear with occasional coarse sounds. suctioned for small amount of tan secretions. mdi administered as ordered atr with no adverse reactions. am abg 7.37/46/135/28. rsbi=22. pt remains on cvvhd. plan to maintain present settings.
"
4356,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett #7.5, 21 @ lip. bs are coarse to clear and suctioned for small amounts of thick white secretions. mdi's administered alb/atr with no adverse reactions. pt had episode of ^ wob, then increased ps/peep temporarialy (see careview) and weaned to psv 5/5 this am. rsbi=90. plan is to extubate in am.
"
4357,"npn 0700-1900
events: weaned ntg to off, no c/o sob. weaned o2 to 2lnc. chemo regime started in [**hospital unit name 142**]. plt tx w/bump 16->39
neuro: afebrile, oob, amb in room, gait steady. med for back pain w/relief w/2-4mg dilaudid iv.
resp: ls:poor aeration t/o, exp wheezes t/o. denies sob. pre chemo hydration begun w/bicarb gtt @ 75cc/hr and mesna @42cc/hr, monitoring for sob, desaturation, may need lasix prn.
cv: b/p 160s/80s, cont w/2+edema. double lumen picc for access and 1perpheral 20guage iv added for chemo administration. plt transfusiom
gi: abd soft, distended, no bm today. refused lactulose as stated he moved bowels yesterday. pt w/fair appetite,eating most of food from trays.
gu: voiding clr yellow urine in urinal, now on chemo precautions.
plan: cytoxan administration tonight by oncology rn, monitor for s/s chf, adverse reactions.

"
4358,"11p-7a
neuro: pt alert and oriented, mae, follows commands, perrla. medicated w/ toradol, tylenol po, and dilaudid 0.25mg ivp prn for c/o incisional pain.

cv: apacing most of shift, d/t sbp 80s w/ intrinsic rate of 60s. hr at present 65 sr, no ectopy, sbp 96/44 w/neo gtt at 1.25mcg/kg/min. [**md number(3) 2282**]/10s, cvp 5-8, ci > 2 by thermodilution. epicardial wires attached and intact, see carevue. right radial aline dampened, going by femoral aline for bp readings. received 1 unit of prbcs for hct 25 as ordered,no adverse reactions, repeat hct 30. +palpable pulses.

resp: ls clear diminished. sats >94% on 2lnc. rr wnl. encouraged coughing and deep breathing.

gi/gu: abd soft, hypoactive bs. foley draining adequate amts of clear light yellow urine, see carevue.

endo: received pt w/ fs 48, 1/2amp of d50 given iv. gtt restarted for fs>200, see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean neo as pt tolerates. follow intake and output, treat as appropriate.
"
4359,"code status;dnr/dni

allergies;nkda

access;two piv one on each hand

cvs;a-fib on coumadin hr 80-110 frequent pvc's nbp 110-130/50-70 extremities are edematous pedal pulses are palpable.iv fluid d/cd at am.transfused one unit of prbc today without any adverse reactions.lytes and crit repeated,please see careview for results.metoprolol was d/cd after am dose.

resp;breathing efforts are normal rr 16-28 ls are clear spo2 100% on room air.

neuro;alert and oriented x 3 follows all commands moves all extrimities.medicated with versed 0.5 mg/iv and fentanyl 25 mg/iv for procedure at 1600 and pt is sleeping now.

gi;upper endoscopy done verbally reported as no active bleeding.still has active [**last name (un) **] emptied 150 ml from bag since am.ng tube to be pulled out and feed can be started as [**name8 (md) 21**] md.abdomen soft distended with positive bs.on pantoprozole iv.

gu; diuresed with 20 mg lasix prior and 20 mg/iv after blood transfusion.

skin;redness at back and haematoma on lt side of his thighs positioned q4h.

id;afebrile not on any antibiotics

endo;fs 270,s fixed dose d/cd and updated the sliding scale

social;daughter called and updated

plan;?to restart metoprolol
monitor vital signs
repeat crit /transfusions if remains low
n/g to pull out and restart feed when pt is awake
? call out
"
4360,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett 7.5, taped @ 24 lip. bs are coarse to clear and suctioning moderate to copious thick yellow/greenish secretions. mdi's administered as ordered combivent with no adverse reactions. am abg 7.48/40/99/31. rsbi=46. no changes noc. plan to wean as tolerated.
"
4361,"resp: [**name (ni) 516**] pt on psv 10/8/50%. ett #8, taped @ 20 lip. bs are coarse to clear and suctioned for small to moderate yellow/tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.45/49/93/35. vent changes to decrease peep to 5. rsbi=92. plan to continue wean as tolerated.
"
4362,"resp: [**name (ni) 516**] pt on a/c 26/550/+8/40%. ett 8.0 rotated and retaped @ 23 lip. bs are coarse to clear and suctioning moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt remains with ^ temp. attempted rsbi=132. no aline. 02 sats @ 94%. plan: wean as tolerated.
"
4363,"11p-7a
neuro: received pt on propofol, weaned to off, mae, follows commands, perrla. see carevue for details. nodded yes when asked if in pain, medicated w/ morphine 2mg ivp prn.

cv: hr 80-90s sr rare pacs, mg 2gm repleted. epicardial wires turned off d/t inappropriate spiking. following cuff pressures, aline waveform inaccurate, see carevue. sbp 100s-130s, after propofol weaned to off, sbp by cuff increasing 140-150s ntg restarted, see carevue. [**md number(3) 1227**]/17-20s, cvp 8-15, ci>2, see carevue for filling pressures. + dopplerable bilat pt, absent right dp unchanged from previous shift.

resp: ls clear. orally intubated, weaned from cpap 10/5-> [**6-16**] at 0600 w/ acceptable abgs, though still sleepy. see carevue for abgs and vent changes. sats 99-100%. rr 20s. tv 300s.

gi/gu: abd soft, absent bs. +placement of ogt, draining bilious drainage scant amts. low u/o 5-15cc/hr, pa [**doctor last name **] aware, albumin 500ccx2, additional 1l fluid bolus w/ no improvement. 1 unit of prbcs given, no adverse reactions, lasix 20mg ivp after blood increasing u/o >100cc/hr, see carevue.

endo: gtt per protocol.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. plan to extubate this morning. ?deline.

"
4364,"respiratory care:

pt remain orally intubated & sedated on spontaneous ventilation. we weaned ips this morning after early am abg. rsbi done ~89. bs are dim bil. mdi's adm as ordered with no adverse reactions. we are sxtn for small amt of thick whitish secretions, some orally, cough present. plan: wan as tolerate, ?sbt and continue present icu monitoring. will follow.

"
4365,"resp: [**name (ni) 516**] pt on psv 10/8/50%. ett #8 retaped, rotated and secured @ 22 lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no abg's noc. 02 sats @ 96%. rsbi=175. plan to continue to wean as tolerated.
"
4366,"resp: [**name (ni) 516**] pt on a/c 22/550/+10/40%. bs are clear with diminished rs base. suctioned for small amount of thick secretions. mdi's administered alb/atr with no adverse reactions. no changes noc. pt remains on fentanyl/midaz. am abg 7.47/36/119/27. rsbi=no resps. plan: pending ip assessment, possible or for sent placement?
"
4367,"resp: [**name (ni) 516**] pt on psv 12/10/60%. bs are coarse to clear and suctioning for copious thick bloody/rusty plugs/secretions. sample sent. several vent changes due to pt aggitation and desaturation/^ wob (see careview for changes) mdi's administered (see carview for dosage/drug) with no adverse reactions. present settings;psv 20/12/50% with am abg 7.45/52/82/37.  no rsbi due to ^ peep/or procedure. plan: or for trach today.
"
4368,"resp: [**name (ni) 516**] pt on psv 12/10/50%. ett 8.0 taped @ 20 lip. bs are coarse to clear. suctioned for small to moderate tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt desating to 80's then increased peep to 14, weaned to 12. am abg 7.43/38/78/26. no rsbi due to ^ peep.  will continue to wean as tolerated.
"
4369,"resp: pt rec'd on a/c 12/450/5+/75%. bs are clear bilaterally. suctioned for small amounts of tan secretions and moderate amount x1 bloody clots from oral cavity. mdi's administered alb/atr with no adverse reactions. colistin neb tx given. pt continues to have ^ hr, ^ wob with rr to 40's. peep ^ to 15 with ^ sedation for noted improvement.no rsbi=^fio2/peep. fio2 weaned to 60%. plan to continue wean as tolerated.
"
4370,"resp: [**name (ni) 516**] pt on psv 12/14+/50%. ett 8.0 taped @ 20 lip.  bs are coarse bilaterally. suctioned for small to moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.42/38/73/25. rsbi=^peep. will continue to wean as tolerated.
"
4371,"resp: [**name (ni) 516**] pt on a/c 28/500/+8/40%. ett # 8.0 retaped @ 23 lip. bs are clear/diminished bilaterally with poor chest rise. suctioned for small amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.29/47/121/24. rsbi=178. plan: maintain present support.
"
4372,"resp: [**name (ni) 516**] pt on 50% t/c and tolerated well this shift. bs are coarse to clear with suctioning. suctioned for small amounts of thick yellow secretions. mdi's administered via t/c with spacer alb/atr with no adverse reactions. pt remains anxious at times. will continue with t/c trials as toelrated.
"
4373,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, retaped and secured @ 20 lip. bs are clear with diminished bases. suctioned for small to moderate amounts of thick white secretions. mdi's administered as ordered of atrovent with no adverse reactions. vent changes to decrease ps to [**10-17**]/and presently on 5 which reflect abg's (see careview) presently on ps [**2124-5-14**] %. am abg 7.44/37/113/26. will attempt [**month/day/year **] in am. plan is to wean to extubate today.
"
4374,"resp: [**name (ni) 516**] pt on a/c 22/550/14+/50%. pt has #8 portex trach with some bloody oozing from trach site. suctioned for minimal secrections. bs are clear with diminished bases. mdi's administered alb/atr with no adverse reactions.  am abg 7.49/39/91/31, no rsbi due to ^ peep. plan: wean as tolerated.
"
4375,"resp: [**name (ni) 516**] pt on psv 14/12+/50%. bs are coarse to clear and suctioned for small amount of secretions. pt has #8 portex trach. mdi's administered alb/atr/qvar with no adverse reactions. periods of desaturation to 80's and fio2 ^ to 60%. abg's (see careview). am abg on 50% 7.46/43/69/32. fio2 ^ back to 60%. no rsbi due to ^ peep. plan to continue to wean as tolerated.
"
4376,"resp: [**name (ni) 516**] pt on psv 10/5/50%. pt has #8 portex trach. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered combivent/alb prn as ordered with no adverse reactions. pt has episodes of anxiousness with ^ wob to 30's. rsbi=91. plan to wean as tolerate and initiate t/c trials.
"
4377,"resp: [**name (ni) 516**] pt on mmv 500/6/10/5/40%. ett 7.5, taped @ 25 lip. bs are coarse to clear. suctioned for moderate amounts of secretions. mdi's administered alb/atr with no adverse reactions. vt's 500-600 with ve's [**5-31**]. c02^ then placed on a/c 18/500/+5/40%. am abg 7.45/52/67/37. fio2 ^ to 50%. additional abg pending. plan to wean to psv as tolerated.
"
4378,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett #7.5, 25 lip. bs are coarse to clear and suctioned for small to moderate amounts of thin/frothy white secretions. mdi's administered as ordered alb/atr with no adverse reactions. vt's 400-500, ve's 6. 02 sats @ 100. abg 7.36/60/125/35. rsbi=31. plan to continue to wean as tolerated.
"
4379,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5 taped @ 23 lip. bs are clear bilaterally and suctioned for scant amount of secretions. mdi's administered as ordered alb/atr/qvar with no adverse reactions. no changes noc. pt is awake and alert and only remains intubated noc due to difficult airway/stent procedure po. rsbi=25. plan"": extubate this am with anesthesia present.
"
4380,"resp: pt has #8 portex trach and is on 50% t/c. bs are coarse to clear and suctioning moderate amounts of thick yellow to white secretions. mdi's administered via trach of combivent with no adverse reactions. no abg's this shift. 02 sats @ 98%.
"
4381,"7a-7p
neuro: received pt on propofol and fentanyl gtts. daily wake- up done per csurg team. with propofol off x 1/2 hour, pt awoke moving upper extremeties, agitated, not following commands, resedated. csurg and vascular teams aware. perrla. medicated w/ fentanyl gtt for pain, propofol weaned off, midaz gtt started as ordered.

cv: hr 80-90s sr w/ bbb, w/ occasional-> freq. ventricular bigeminy, np [**doctor last name 307**] aware. lytes checked q 4-6hours. i ca++ repleted as ordered. sbp 100s-120s. left radial aline sharp and intact. right ac arterial sheath transduced and w/ sharp waveform. sheath to stay in today per vascular. cvp 8-14. plavix and asa given as ordered for recent stent placements. see flowsheet for assessment of pulses. + dopplerable right pt/dt. right leg warm to touch. left amp dsg changed, staples intact, oozing small amts of serosang, to keep dry sterile dsg over, not to constrict left amp per vascualar. staples from right leg fasciotomy sites removed by vascular, large amts of sang. drainage, np [**doctor last name **] aware, hct sent. hct resulted to be 20. np [**doctor last name **] aware, 2 units of prbcs given as ordered, no adverse reactions. repeat hct 24.8, np [**doctor last name 307**] aware, no new orders at present time.  see flowsheet for details.

resp: ls coarse diminished at bases. sats >94%. tolerating cpap 10 peep, 12ps. rr 12-18. acceptable abgs. see flowsheet for details of vent changes and abgs.

gi/gu: abd soft absent to hypoactive bs. ogt +placement, draining greesnish clear. foley draining amber to clear yellow dark urine. on bicarb gtt for protection of kidneys and ck >30,000. np [**doctor last name 307**] aware of all labs throughout day. bicarb gtt off at 1745 [**name8 (md) **] np. continue maintenance fluid ns 250cc/hr as [**name8 (md) **] np. pt received lasix 20mg ivp btw blood, increasing u/o >100cc/hr.

endo: insulin gtt per protocol.

skin: see flowsheet.

plan: monitor hemodynamics. monitor resp. status. goal cvp ~12. next labs due [**2096**] [**name8 (md) **] np [**doctor last name 307**]. follow ck. monitor u/o.


"
4382,"resp: [**name (ni) 516**] pt on a/c 12/500/+8/50%. bs are coarse bilaterally and suctioning for moderate amounts of thick bloody tinged yellow secretions. hr remains tachy with increased close to 140 and rr in ^ 30's. combivent administered as ordered with no adverse reactions. no changes noc.am abg 7.37/35/89/21. plan: continue full vent support
"
4383,"resp: [**name (ni) 516**] pt on psv 5/5/40%. bs are coarse bilaterally. suctioned for moderate amounts of thick white secretions as well as oral secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift 02 sats @ 100%. rsbi=82. plan to wean as tolerated, trach discussion?
"
4384,"resp: pt on 2 lpm nc. nebs alb/atr given with no adverse reactions. will continue to follow.
"
4385,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett #7.5 retaped and secured @ 22 lip. bs are clear with diminished bases. suctioned for small amounts white thick secretions. mdi's administered q4 hrs alb/atr with no adverse reactions. am abg 7.52/30/146/25. rsbi=75. no changes noc. will continue with present settings.
"
4386,"resp:  [**name (ni) 516**] pt on a/c 22/600/10+/60%. pt has #8 portex trach. bs are clear with diminished bases. suctioned for small amounts of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. weaned vent settings to present psv 10/5/50% (see careview for changes) rsbi=55. am abg 7.48/44/98/34 on psv. plan: continue to wean with possible t/c trials today.
"
4387,"resp: [**name (ni) 516**] pt on a/c 12/500/+5/40%. ett 7.5, 21 @ lip. bs are clear bilaterally. suctioned for no/scant clear secretions. mdi's atrovent administered with no adverse reactions. am abg 7.45/34/189/24. rsbi=34 plan: wean as tolerated.
"
4388,"resp: pt rec'd on psv 15/5/50%.  pt has #8 portex trach. bs are coarse bilaterally with decreased bs in l base. suctioned for large amounts of white frothy thick secretions. mdi's administered alb/atr with no adverse reactions. pt had large bm with immediate episodes of desaturation to low 80's and ^ wob with rr to 40's and hr >120. placed on a/c (md aware) with positive results then weaned back to psv. rn repositoned pt around 5:30 and pt once again had episodes of desats to 80's along with ^ wob to 40's and remains tachy.requiring to be placed back on a/c to rest. no rsbi due to above issues. pt is extremely sensitive to any movement/repositioning. plan is to wean back to psv when pt recovers.
"
4389,"resp: [**name (ni) 516**] pt on psv 10/5/40%/ ett #7.5, taped @ 23 lip. bs are coarse bilaterally and suctioning moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.44/45/80/32. rsbi=82. plan to extubate this am following cuff leak.
"
4390,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, 23 @ lip. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered of alb with no adverse reactions. vent changes to decrease ps to 10. vt'd 400's, ve's 10. no abg's this shift with rsbi=116. bal negative. will continue to wean as tolerated.
"
4391,"resp:  rec'dpt on a/c14/600/+5/40%. ett 8.0, rotated, retaped and secured @ 26 lip. bs are coarse bilaterally and suctioning for copious amounts of thick yellow secretions qhr. mdi's administered alb/atr as ordered with no adverse reactions.  abg's 7.48/40/104/31. rsbi=hemodynamic unstability. hr continues to be tachy with ^ bp. pt has no gag. no changes this shift. plan is to wean to psv, although questionable with 6 hr & bp.
"
4392,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett #7, rotated and retaped @ 20 lip. bs are coarse to clear and suctioning for moderate amounts of thick yellow secretions. mdi's administed as ordered alb/atr wtih no adverse reactions. pt had ^ wob with declining abgs then placed on a/c 18/400/+5/50% with immediate improvement noted. rsbi attempted for 184 although pt reacted with ^ bp to 180. am abg 7.38/48/95/29. plan: attempt to wean back to psv as tolerated.
"
4393,"resp:  pt has #8 portex trach and is on 40% t/c with humidification. bs are coarse bilaerally and pt able to expectorate secretions.  ud of tobramycin administered in line trach (door is to be closed while treatment is being administered and masks worn up to 1 hr following tx) with no adverse reactions. water bottle filled and drain placed in line. will continue to follow.
"
4394,"resp care
pt given neb tx. bs course with diffuse exp. wheezes that clear after neb tx and with producitive coughs. no adverse reactions.
"
4395,"resp: [**name (ni) 516**] pt on a/c 16/500/+5/40%. bs are clear bilaterally. suctioned for scant amounts of white secretions. mdi's administered atr as ordered with no adverse reactions. am abg 7.44/30/185/21. decreased rate to 12. rsbi=75. no further changes noted. continue on present settings.
"
4396,"resp: [**name (ni) 516**] pt [**name (ni) **] #8 ett @ 24 lip. xray confirmed placement. bs are clear with diminished bs. suctioned for small amounts of thick yellow/white secretion (large amounts of oral secretions) mdi's administered as ordered alb/atr with no adverse reactions. multiple abg's see careview. pt had vats left attempted;left open thoracotomy with decortication with a bronch. settings a/c 22/600/12/100% post op and weaned fio2 to 60%, peep to 10. no rsbi due to ^ peep.  am abg 7.50/43/105/35. plan to continue to wean.
"
4397,"resp: [**name (ni) 516**] pt on a/c 18/400/+5/50%. ett 7.0. taped @ 20 lip. bs reveal bilateral exp wheeze with improvement following mdi's. suctioned for small to moderate amounts of thick yellow secretions. mdi's administered alb/atr/qvar as ordered with no adverse reactions. no changes noc. am abg 7.37/49/92/29. rsbi=177. plan: continue full vent support. trach expected next week.
"
4398,"nursing progress note 1900-0700
*full code

*access: 22g r wrist piv

*nkda

** please see admit note/fhp for admit info and hx.

neuro: pt had difficulty sleeping, given 2.5mg ambien x2 w/ little effect.  no c/o pain or discomfort overnight.  moves self in bed, turning on own.  may require assist to ambulate to commode when she eventually has to go.

cardiac:  sb w/o ectopy, hr 42-57, sbp 92-134, remains off dopamine.  cardiac consult w/ interpreter assist, stated they don't feel this is a cardiac issue.  hr of 50's is her baseline per patient.  cardiac feels she may have dropped pressure d/t vagal stimulation caused by pain from diverticulitis.  lactate last evening was 2.2 from 2.6.  awaiting am labs for hct and lytes.

resp:  o2sat 93-97 on ra, rr 12-21, ls clear, no c/o difficulty breathing or sob.

gi/gu:  tolerating reg heart healthy diet, +bs, no stool this shift, started on bowel regimen (has commode @ bedside, c.diff cx if pt stools), abd soft/non-tender.  urine out foley yellow/clear, 20-100cc/hr.

id:  afebrile. flagyl and cipro for diverticulitis w/ no signs of adverse reactions.  iv site wnl, skin intact.

psychosocial:  had friend visit in evening, received a few phone calls as well.  is looking forward to getting out of icu and getting disconnected from monitor.  request that foley be taken out, but this nurse explained that we need to closely monitor her urine output in the event that her bp drops.

dispo:  cont to monitor bp (restart dopamine gtt if required), awaiting am labs, assist pt to commode when bowel regimen begins to work, cont med regimen and abx, cont icu care @ this time.  possibly a call out to floor today.
"
4399,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 24 lip. bs are coarse bilaerally and suctioning for moderate amounts of thick yellow/greenish looking secretions. mdi's administered as ordered alb/atr with no adverse reactions. abg 7.48/49/141/38. rsbi=46. no changes noc. plan: or/trach/peg vs cmo. family still undecisive.
"
4400,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 23 lip. bs are coarse bilaterally and suctioning for moderate amounts of thick tan/yellow and occasional plug.  mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. 02 sats @ 98%. rsbi=64. plan: family still unable to make decision on code status/or/trach/peg. family meeting again scheduled for today to discuss.
"
4401,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.0 taped @ 19 lip. bs are coarse and suctioning thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. am abg 7.50/32/186/26. rsbi=75. maintain support.
"
4402,"resp: [**name (ni) 516**] pt on psv 5/5/40%.  ett 7.0 taped @ 24 lip. bs are coarse to clear and suctioned for moderate amounts of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt has periods of anxiousness and lifting head off pillow. sedation administered. rsbi=162.  no changes noc. plan: family meeting to discuss trach/or?
"
4403,"resp: [**name (ni) 516**] pt on a/c 20/500/+5/50%. bs are coarse to clear and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.34/38/187/21. rsbi=30. weaned to psv 10/5/50% tolerating well with adequate tv's/ve's. cvvhd discontinued. plan: continue to wean as tolerated.
"
4404,"resp: [**name (ni) 516**] pt on a/c 14/400/+5/40%. pt has #7 portex trach. bs are clear bilaterally and suctioned for some bloody tinged due to new trach. scant white secretions in am. mdi's administered alb/atr with no adverse reactions. abg's (see careview) rsbi=52. weaned to psv 8/5/30% with additional abg's pending. plan: continue with wean to possbile t/c trials if tolerates
"
4405,"resp: [**name (ni) 516**] pt on a/c 22/500/10+/40%. ett 8.0 taped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for thick tan/yellow secretions. large amounts of oral secretions. mdi's administered as ordered with no adverse reactions. no abg's this shift or vent changes. no rsbi due to ^ peep and or procedure today. pt expected to transfer to sicu following or.
"
4406,"resp: [**name (ni) 516**] pt on psv 18/5/45%. pt has #8 portext trach. bs are clear with occasional crackle and suctioned for small amounts of white thick secretions. mdi's administered alb/atr with no adverse reactions. no changes noc or abg's. rsbi=100. plan is possible d/c to rehab this am.
"
4407,"respiratory care note
pt received on psv 18/5 as noted. bs clear bilaterally and diminished in the bases. pt suctioned for small amts thick, tan secretions. ps weaned throughout the morning from 18 to 14. pt tolerated well with vt ranges 405-431 and rr 28-31. mdi's given a/o without any adverse reactions. plan to transfer pt to [**hospital **] rehab at [**hospital1 1589**] this afternoon.
"
4408,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett 7.5, taped @ 21 lip. bs are coarse bilaterally and suctioning for small amounts of white/yellow thick secretions. mdi's admimistered as ordered with no adverse reactions. no changes noc or rsbi performed due to or procedure today (trach). am abg pending, see carevue.
"
4409,"resp: pt rec'd on a/c 22/500/+5/50%. ett 7.5 taped @ 22 lip. bs are clear with diminished bases. suctioned for basically none. mdi's administered of alb/atr with no adverse reactions. pt remains on cvvhd=no rsbi. am abg 7.38/31/173/19. vent changes to decrease rr to 20. plan: wean as tolerated.
"
4410,"resp: pt rec'd on psv 11/5/50%. pt has #8 portex trach. bs are coarse bilaterally and suctioning for moderate to copious amounts of bloody thick secretions. mdi's administered alb/atr with no adverse reactions. pt has episodes of ^ wob with rr to 40. ps ^ to 15 and sedation administered with noted improvement. abg 7.41/35/112/23. rsbi=64. pt weaned back to psv 11. plan: continue to wean as tolerated.
"
4411,"resp: [**name (ni) 516**] pt on a/c 22/500/+5/40%.  ett 8.0 taped @ 24 lip. bs are diminished bilaerally. suctioned for moderate amounts of thick white secretions. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=51. weaned to psv 5/5/40%. vt's 400-500, rr 26, 02 sats @ 99%. plan: additional abg/sbt with extubation expected today.
"
4412,"resp: [**name (ni) 516**] pt on psv 8/5/40%. ett 8.0 taped @ 24 lip. bs are clear to diminished. suctioned for small/mod tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. weaned ps to 5/peep 5. rsbi=73. plan: wean to extubated this am. niv possible if pt begins to fail.
"
4413,"resp: [**name (ni) 516**] pt on a/c 24/400/+10/60%. ett 7.5, taped @ 20 lip. bs reveal bilateral clear apecies with diminished bases.suctioned for small amounts of yellow to tan thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. no changes noc.  noted improvement in am abg's 7.45/66/73/47. no rsbi due to ^ peep/^fio2. plan: maintain present support.
"
4414,"resp: [**name (ni) 516**] pt on psv 5/10+/40%.  ett 7.0 taped @ 24 lip. bs are diminished bilaterally and suctioned for small to moderate [**name (ni) 1444**] tinged/plugs/secretions. mdi's administered alb/atr as orderd with no adverse reactions. no abg's this shift 02 sats @ 98%. no rsbu due to ^ peep. plan: family meeting to discuss cmo/trach/peg/or?
"
4415,"resp:  [**name (ni) 516**] pt on a/c 14/550/+5/40%. pt has #8 portex trach. suctioned for small to moderate amounts of tan to white thick secretions. mdi's administered as ordered of atr with no adverse reactions. no abg's or changes this shift. rsbi=no resps but will attempt again in am. plan to wean as tolerated.
"
4416,"resp: pt rec'd on a/c 10/550/+5/40%. pt has #8 portex trach. bs are coarse bilaterally and suctioned for small amounts of thick bloody secretions. mdi's administered as ordered atrovent with no adverse reactions. multiple vent changes (see careview) am abg 7.42/33/181/22. rr decreased to 14. no rsbi due to or procedure today. pt to be peg.
"
4417,"resp: pt rec'd on a/c 14/550/+5/40%. pt has #8 portex trach. inner cannula changed.  bs are coarse to clear. suctioned for scant to small amounts of thick tan secretions. mdi's administered as ordered of atrovent with no adverse reactions. no vent changes noc or abg's. rsbi=121. continue plans for placement in rehab. plan to wean to psv as tolerated.
"
4418,"resp: [**name (ni) 516**] pt on psv 12/10/60%. pt has #8 portex trach. bs are coarse to clear. suctioning for copious bloody secretions, pt developed epitaxis noc and subsided this am. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.46/35/112/26. vent changes to decrease ps to 10/peep to 8/fio2 to 50%. rsbi=61. plan to continue to wean as tolerated.
"
4419,"resp: [**name (ni) 516**] pt on 50% t/c. pt has #8 portex trach. pt began to desat then ambu/suctioned [**name (ni) 2160**] amounts of thick brown plugs. 02 sats 90-91%. nebs of albuterol administered x1, then mdi's combivent with no adverse reactions. pt is begin d/c to rehab this am.
"
4420,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has # 8 portex trach. bs are coarse and suctioned for moderate amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. pt placed on t/c trial around 3:00 @ 50% with humidification. cuff inflated. 02 sats @ 96%, rr 28 and tolerating well. will continue to monitor/assess.
"
4421,"resp: [**name (ni) 516**] pt on a/c 22/500/+14/40%.  ett #8, taped a@ 25 lip. bs are coarese bilaerally and suctioned moderate amounts of thick yellow/tan secretions. mdi's administered alb/atr as ordered with no adverse reactions. am abg pending. plan: pt scheduled for or for trach/peg this am. no rsbi=^peep.
"
4422,"resp: [**name (ni) 516**] pt on psv 12/10/50%. bs are basically clear with some scattered crackles with diminished bases. suctioned for scant amount of clear secretions. mdi's administered alb as ordered with no adverse reactions. am abg 7.41/42/102/28. no rsbi due to amount of peep. check leak is noted today. pt remains positive,and may continue with lasix today. no further changes noted. maintain present settings.
"
4423,"cvs;hr 80-100 a-fib no ectopy abp 100-120/40-70 on vasopressin 1.2 u/hr anasarca pedal pulses are doppled,extrimities are warm,left toes are dusky.hct 27.5 @ 2100 one unit prbc transfused without any any adverse reactions.for access a-line and pa line remains intact.recieving regular dose of albumin q6h.

neuro;sedated with fentanyl 50 mcg/hr,pt is comfortable,nodding head and appropriate with answering.not moving extrimities.

resp;recieved on cmv 40/400/20/5 no vent changes over night,saturation probe is not sensing well frequent abg was done to confirm o2 sats,po2 >130.ls are coarse throughout,required occasional suction for thin whitish secretions.

gi;abdominal dressing was done by surgen yesterday with jp in place,connected to wall suction draining serous drain please carevue for details,getting tpn for nutrition.no bowel movement at this shift.

gu;draining adequate amounts of amber color urine via foley catheter.

skin;anasarca,multiple skin breakdown and oozing from extrimities.sacral dressing intact,positioned and back care given as needed.lower extrimities are warm positive pedal pulses.

id;core temperature 38.2,on antibiotics vanco/flagyl/levaquin

social;no contact from family at this shift.

plan;abdominal wound closure--add on, consent taken over phone by surgen and filed.
type and screen send yesterday
pain management,monitor lytes,replete lytes as needed
continue albumin
update with pt and family.
"
4424,"resp: pt rec'd on 40% cam. nebs administered of mucomyst 3 cc's and albuterol with no adverse reactions. also ns nebulizer x1. bs are coarse bilaterally. will continue to follow.
"
4425,"resp: [**name (ni) 516**] pt on psv 10/5/40% @ start of shift then pt ^ wob and ^ rr and bp. increased ps back to 15 and pt tolerated well. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow secretions. mdi's administered alb with no adverse reactions. am abg 7.50/37/124/30. rsbi=87. plan: wean ps as tolerated.
"
4426,"resp: [**name (ni) 516**] pt on a/c 24/450/5+/50%. bs are basically clear with some occasional coarseness. suctioned for small amounts of thick yellow/tan secretions. mdi's administered as ordered alb/[**name (ni) **] with no adverse reactions. no changes noc or abg's. pt had some episodes of ^ wob when [**name (ni) **] light. rsbi=173. plan: continue present mode of support.

"
4427,"resp: [**name (ni) 516**] pt on psv 15/5/40%. ett 8.0 retaped @ 24 lip. bs are clear bilaterally with diminished bases. suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. rsbi=62. no abg's this shift. plan: pt scheduled for trach today.
"
4428,"resp: [**name (ni) 516**] pt on a/c 24/450/+8/50%. ett #7.5, rotated, retaped and secured @ 23 lip. bs are coarse to clear with exp wheeze noted at start of shift and suctioning for moderate to copious amounts of thick yellow secretions. mdi's administered as ordered alb/[**name (ni) **] with no adverse reactions. no abg's this shift/no a-line. 02 sats @ 99%. rsbi=134. plan: wean as tolerated.
"
4429,"resp: [**name (ni) 516**] pt on 24/450/+8/50%. ett 7.5 taped @ 23 lip. bs are coarse to clear bilaterally. suctioned for moderate amounts of thick yellow secretions which seems to be an improvement over yesterday, although continues to have fever.mdi's administered alb/[**name (ni) **] with no adverse reactions. no changes noc. am abg 7.44/40/97/28. rsbi=152. plan;wean as tolerated.
"
4430,"pt came to micu from [**wardname 665**] for merepenem desensitization  because of multiple allergy around [**2090**].completed desensitization without any complication. c/o ?

neuro:ox3. calm &cooperative

id: frequent uti now with e-coli. no signs of adverse reactions to merepenem.

cardio: nsr,vss.am lab pending. heparin drip per protocol. ptt qd.

resp: ls cta.

gi: abd soft. bowel sounds present. fsbs as noted.

gu:voids,minimal pain upon urination.clear yellow urine.

pain: severe left flank pain. pain mgt improved after multiple pain med adustments as noted.

plan ? c/o to floor today.
"
4431,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has #7 portex trach. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats maintained @ 98% with adequate tv's. rsbi=20. plan: continue wean/sbt with possible t/c trials.
"
4432,"resp: [**name (ni) 516**] pt on psv 15/5/40%. pt has #8 portex trach. bs are slightly coarse/diminished ls. suctioned for small/moderate amounts of white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's noc. rsbi=68. plan: wean as tolerated with possible t/c trials.
"
4433,"resp: pt rec'd on psv 15/5/40%. ett 7.5 taped @ 21 lip. bs are clear in apecies with diminished bases. suctioned for small amounts of white/pale yellow secretions. mdi's administered of alb with no adverse reactions no changes noc. am abg 7.48/35/104/27. rsbi=102. plan: wean as tolerated.
"
4434,"resp: [**name (ni) 516**] pt on psv 15/10+/60%. pt has #8 portex trach. bs are coarse to clear and suctioning small to moderate amounts of thick brown/plugs secretions.mdi's administered as ordered combivent/alb prn with no adverse reactions. no rsbi due to ^ peep. am abg 7.50/37/182/30. vent changes to decrease ps to 10, fio2 to 50%. plan to continue to wean as tolerated.
"
4435,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are clear to coarse bilaterally. suctioned for small amount of tan thick secretions. mdi's administered combivent q4 hrs with no adverse reactions. rr ^ to 30's then ^ psv to 10. tv's 500-600. no abg's this shift. rsbi=44. plan to wean as tolerated.
"
4436,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear. suctioned small amounts of thick yellow secretions. mdi's administered q4 hrs combiven with no adverse reactions. pt became ^ wob with rr to 30's then increased psv to 10. am abg 7.46/41/153/30
rsbi=49. plan to wean ps as tolerated.
"
4437,"resp: [**name (ni) 516**] pt on psv 12/5/40%. ett 7.5, taped @ 20 lip. bs are clear with diminished bases. suctioned for small amount of white thick secretions. mdi's administered alb/atr as ordered with no adverse reactions. rsbi=51. am abg pending. plan: continue to wean ps as tolerated.
"
4438,"resp: pt rec'd on psv 5/5/70%. pt has #8 portex trach. bs are clear with slight coarse bases which clear with suctioning. suctioned for small amounts of thick bloody tinged, then tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. pt fio2 wean to 50%. am abg 7.48/29/78 with 02 sats of 99%. rsbi=38. continue to wean as tolerated/possible t/c trials?
"
4439,"resp: [**name (ni) 516**] pt on psv 5/5/40%. pt has #8 portex trach. bs are coarse to clear and suctioned for clear to yellow thick secretions. mdi's administered as order alb/atr with tobramycin nebs. no adverse reactions noted. pt has episodes of desaturations to 80's then increased fio2 back to 50% resulting in saturations >94%.  am abt 7.44/31/83/22. rsbi=19. plan to continue to wean as tolerated and attempt t/c trials again today.
"
4440,"resp: [**name (ni) 516**] pt on psv 8/10+/60%.  ett 8.0 retaped @ 24 lip. bs are coarse bilaterally. suctioned for moderate amounts of thick yellow secretions as well as large amounts of oral secretions. mdi's administered alb/atr as ordered with no adverse reactions. trip to ct scheduled for this am. no rsbi due to ^ peep. 02 sats @ 97%. plan to trach/peg this tuesday. plan: maintain present settings.
"
4441,"resp: pt rec'd on simv 14/500/14/+5/40%.  pt has #8 [**last name (un) **] air filled cuff trach, secured @ 14cm flange. bs are coarse bilaterally and [**last name (un) 7273**] thick white to yellow secretions. some improvement following suctioning. mdi's of combivent administered as ordered with no adverse reactions. no changes noc. rsbi=86. plan to continue with t/c trials as tolerated.
"
4442,"resp: pt rec'd on a/c 16/500/+5/40%. bs are coarse bilaterally and suctioned for small amount of tan thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's or aline. 02 sats @ 100%. rsbi=no resps. plan to continue to wean to psv as tolerated.
"
4443,"resp: [**name (ni) 516**] pt on a/c 24/300/10+/40%. bs are coarse and suctioned for small to moderate amounts of bloody tinged thick secretions to tan. no changes noc. mdi's administered alb with no adverse reactions. 02 sats @ 98% tonight. am abg 7.45/43/83/31. no rsbi due to ^ peep. will continue full vent support.
"
4444,"resp: [**name (ni) 516**] pt on a/c 16/500/10+/60%. bs are coarse to clear. suctioned for moderate amounts of thick bloody to tannish secretions. mdi's administered of alb with no adverse reactions. 02 sats continue to fluctuate with turning and light sedation. weaned to psv 16/10/60%. placed on 100% temporarily when pt turned. am abg 7.45/42/84/30. plan to wean as tolerated. discussion of trach?
"
4445,"resp: [**name (ni) 516**] pt on a/c 24/650/+14/60%. ett 7.5 taped @ 22 lip. bs are diminished bilaterally with minimal suctioning. mdi's administered as ordered comb/[**last name (un) **] with no adverse reactions. abg 7.36/42/80/25. no rsbi due to ^ peep. plan to wean as tolerates.
"
4446,"resp: [**name (ni) 516**] pt on psv 8/12/60%. pt has #8 portex trach. bs are coarse to clear and suctioning moderate amounts of thick bloody tinged to tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. cuff pressures @ 22 cmh20. vent changes to decrease ps to 10, then 8, fio2 to 50%, then 40%. rsbi=38. am abg 7.39/43/169/27. icp's continue to fluctuate noc. no further changes noted. plan:continue to wean as tolerates.
"
4447,"resp: pt rec'd on a/c 16/500/40%/5+. bs are coarse bilaterally.suctioned for small to moderate amounts of thick tan secreitons, sample sent.  mdi's administered alb/atr with no adverse reactions. no abg's 02 sats remain at 100%. vent circut changed to heated. rsbi=150. plan to wean to psv as tolerated.
"
4448,"resp: [**name (ni) 516**] pt on a/c 20/600/+15/70%. ett 7.0, taped @ 23 lip. bs reveal bilateral clear apecies with diminished ls base. suctioned moderate amounts of thick bloody tinged secretions. mdi's administered as ordered alb/ovar with no adverse reactions. pt continues to demonstrate abdominal desynchronous breathing. improved abg's oxygenation then weaned fio2 to 50%. am abg 7.34/35/91/20. no rsbi due to ^ peep. plan: continue wean as tolerated.
"
4449,"resp: [**name (ni) 516**] pt on psv 10/10/60%. ett 7.5 rotated, retaped and secured @ 22 lip. **note** ett was cut back.  bs are coarse bilaterally and suctioned for moderate-copious amounts of thick yellow/white secretions. mdi's administered as ordered combivent/[**last name (un) **] with no adverse reactions. no changes noc. am abg 7.24/47/76/26. no rsbi due to ^ peep. plan: continue to wean as tolerated
"
4450,"resp: [**name (ni) 516**] pt on simv 18/550/5/+5/40%. ett # 7.5 taped @ 21 lip. bs are clear with diminished bases. suctioned for scant amount of clear thin secretions. mdi's administered combivent/alb with no adverse reactions. abg 7.42/37/97/25. no changes noc. rsbi=no resps. plan: wean as tolerated.
"
4451,"resp: [**name (ni) 516**] pt on simv 14/550/5/5/50%. ett 7.5, retaped, rotated and secured @ 21 lip. bs are clear with diminished bases. suctioned minimal to no secretions. mdi's administered combivent/alb as ordered with no adverse reactions. am abg 7.30/50/137/26. vent changes to ^ r to 18, decrease fio2 to 40%. no rsbi due to hemndynamic instability. plan is to wean as tolerated.
"
4452,"7a-7p
neuro: pt sedated and paralyzed on fentanyl,midaz,and fentanyl gtts. pupils 3mm sluggish, equal.

cv: hr 60s sr w/ rare pvcs. as day progressed, hr 56-58 junctional pa [**doctor last name 87**] aware, no new orders. pt has epicardial wires v wires only, pacer not checked d/t ventricular ectopy. 1 episode of 25 beat run of vt self limiting, mg 2gm given. sbp 90s-100s. levophed gtt weaned to off. epi gtt continues at 0.02mcg/kg/min. vasopressin continues at 2.4units/hr. [**md number(3) 7566**]/30s. cvp 15-20. ci>2 by fick, team aware. at beginning of shift svo2 58-59, md [**doctor last name 859**] aware, 1 unit of prbcs infused as ordered, no adverse reactions. svo2 >60 after 1 unit of prbc. chest remains open w/ wound vac in place, draining serosang small amts. 4+ pitting edema. +dopplerable pedal pulses.

resp: ls clear diminished. sats 100%. continues on cmv mode rate 16, not breathing over vent, fio2 40% peep5. see carevue for abgs and vent settings. pa [**doctor last name 87**] aware of abg at~ 1700, no new orders.

gi/gu: abd softly distended. tf on hold at present time d/t high residuals, [**name8 (md) **] md [**last name (titles) 859**]. hypoactive faint bs. ogt to lcs/g tube to gravity draining bilious drainage, pa [**doctor last name 87**] aware. foley draining 5-10cc/hr of clear yellow urine. cvvhdf clotted x1, renal fellow aware and increased replacement fluid to 2000cc/hr. pt negative 1100cc since midnoc thus far. goal -100cc/hr as pt tolerates.see flowsheet for details.

endo: riss.

plan: monitor hemodynamics. monitor resp. status. cvvhdf goal -100cc/hr as pt tolerates. monitor hr.


"
4453,"7a-7p
neuro: pt able to respond to stimuli throughout shift with responses to voice at times. goal to keep pt sedated.  pt thrashing arms and legs at times. pt currently on midaz and fentanyl with periods of midaz boluses in between [**name8 (md) **] np [**doctor last name 307**].  perrla sluggish in am and more brisk in afternoon.  pt able to mae's when more awake. no temp at this time and pt continuing on iv vanco.

cv: hr- sr/st with frequent pac's/pvc's 90's-120's at beginning of shift. at 1200, hr 80's with pac's. amiodarone drip contiuing at 1mg/min as ordered. placed on asynch 96 via epicardial wires in order keep pt out of a-fib [**name8 (md) **] np [**doctor last name 307**]. right radial a-line dampened and bleeding at site at 0900. np at bedside with several attempts to place a-line at another site. at 1030, left fem placed with positive fling. weaning drips (neo, levophed, vasopressin) according to fem map >60 [**name8 (md) **] np. electrolytes monitored and wnl throughout shift. see flow sheet for pulses. svo2 50's-60's with co [**4-8**]. ci above 2 per thermodilution. see flow sheet. np [**doctor last name 307**] aware. pt given multi-fluid boluses and hespan given as ordered. pa's 30's/20's and cvp 16-20. pt with hct of 21 at 1400. np [**doctor last name 307**] aware and pt transfused 2 units of prbc's with no adverse reactions. repeat hct pending.

resp: ls-coarse in am. cta/dim at bases in afternoon. pt given mdi's per respiratory. pt suctioned as needed with small amounts of thick white sputum. pt on cmv mode, rate 16, 5 peep, 650 tidal volume, and 60 fio2. abg's drawn in am with respiratory acidosis. resolved with settings on vent increased to 20 and peep increased to 8. abg rechecked and vent rate increased to rate of 24. resolving respiratoy acidosis. lactic acid 2.4 but resolving and 1.6 when rechecked after fluid given.  see flow sheet for abg's and flow sheet changes. np[**md number(3) 94**] throughout the shift. sats 93-96%. chest tube draining minimal amounts of serosang with no air leak.

gi/gu: abd soft with absent/hypoactive bs. pt with ng tube draining bilious/clear.  foley intact draining minimal amounts of urine 10-40cc/hr. np [**doctor last name **] aware. after fluid and blood given, pt given 20mg iv lasix with still minimal amount of urine output.

endo: pt continuing on insulin drip per protocol.

skin: see flow sheet. skin intact.

plan: keep pt hemodynamically stable with goal bp map >60 and titrate drips. pain control. monitor blood sugars and insulin protocol. monitor abg's. monitor urine output.
"
4454,"resp: [**name (ni) 516**] pt on psv 10/5/40%. ett 38.0 retaped, rotated and secured @ 24 lip. bs are diminished in bases with noted aeration in apecies. suctioned for small amount of white/tannish secretions.circuit changed to heated wire circuit. mdi's administered alb/atr with no adverse reactions. noted ^ in wob, then placed back on a/c 18/550/5+/40%. am abg 7.41/41/145/27. plan to continue to wean to psv as tolerated.
"
4455,"resp: [**name (ni) 516**] pt on psv 15/5/35%. ett #8, retaped, rotated and secured @ 24 lip.  bs are coarse bilaterally and suctioned for moderate amounts of thick yellow to tannish secretions. pt placed on a/c 12/400/5+/35% to rest noc. mdi's administered q4 hrs alb/atr with no adverse reactions. rsbi=116. plan to continue to wean to psv.  no plans for pt to have trach, although may consider?
"
4456,"resp: [**name (ni) 516**] pt on psv 8/15+/50%. bs are diminished and suctioning for small to moderate amounts of thick bloody tinged to yellow secretions. mdi's administered alb/atr as ordered with no adverse reactions. pt continues to be desychronous with vent and had ^ wob episode then placed on a/c to rest noc. noticeable improvement noted and weand back to psv this am. pending abg to follow. plan: continue to wean as tolerated, possible dialysis? following renal consult.
"
4457,"resp: [**name (ni) 516**] pt on psv 12/8/50%. ett 7.4 taped @ 24 lip. bs are coarse to clear bilaerally and suctioned for small to moderate amounts of thick yellow secretions. mdi's administered as ordered comb/alb with no adverse reactions. abg 7.45/47/86/34. rsbi=62. weaned psv to [**11-11**]+ plan to continue wean as tolerated, extubate?
"
4458,"resp: [**name (ni) 516**] pt on psv 5/5/40%. bs are coarse bilaterally and suctioned for moderate amounts of thick yellow/greenish secretions. changed to heated wire circuit. mdi's administered as ordered alb/atr with no adverse reactions. no changes noc. rsbi=53. am abg 7.45/42/85/30. family meeting today to cmo?
"
4459,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5 found @ 27 then retaped and pulled back to 24 as per xray. bs are coarse to clear and suctioning moderate amounts to small thick yellow secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.45/40/144/29. rsbi=82. family mmeeting today for cmo status.
"
4460,"resp: [**name (ni) 516**] pt on psv 5/5/40%. ett 7.5, rotated, retaped and secured @ 24 lip. bs reveal ls clear with rs noted exp wheezes. suctioned for moderate amounts of thick greenish secretions. mdi's initiated and administered alb/atr as ordered with no adverse reactions.  bs in am noted exp wheezes on rs and diminished ls. am abg 7.45/40/104/29. rsbi 50. no changes noc. pt has cooling blanket/temp 101. plan: continue wean as tolerates
"
4461,"resp: [**name (ni) 516**] pt on psv 10/5/50%.  ett 6.5, taped @ 20 lip. bs are coarse bilaterally. suctioned for moderate to copious yellow to green plugs this am. mdi's administered alb/atr with no adverse reactions. 02 sats @ 98%. vt's 400. rsbi=70. pt spiking temp of 102. sbt scheduled for this am, question extubation with onset of temp and ^ hr to 120's. am abg pending.
"
4462,"resp: [**name (ni) 516**] pt on a/c 20/450/+8/40%. ett 7.5 taped @ 24 lip. bs are diminished bilaterally and suctioned for small amount of white thick secretions. mdi's administered as ordered alb/atr with no adverse reactions. no abg's this shift. plan: pt is to be trach/peg today.
"
4463,"7p-7a
neuro: pt attempts to open eyes w/ stimuli, perrla, random movements of hands and toes, not to command. medicated prn w/ morphine for pain noted by pt's grimacing.

cv: hr 100-110s. st. sbp >90 while on levo gtt. weaning levo gtt as pt tolerates, goal map>65 per vascular team, see carevue. cvp 12-14. lopressor held d/t levophed and hypotension, md bridges aware. k 5.4-5.3, md bridges aware, k gtt stopped from cvvhd.  received 2 units of prbcs, no adverse reactions. fingers and toes dusky. + palpable pulses.

resp: ls coarse. orally intubated, ps decreased to 18, w/ acceptable abgs, see carevue. rr 20s. tv 500-600 on cpap [**6-22**], fio2 50%. see carevue for further details. sats 94-100%, poor waveform at times. ct w/ no-> scant serosang drainage, flushed as ordered.

gi/gu: abd firmly distended, hypoactive bs. tf nutren renal at goal of 10cc/hr, w/ minimal residuals. flexiseal intact, draining loose brown stool. foley draining 8-15cc/hr of clear yellow urine. cvvhdf running pt even as pt's bp tolerates. see carevue for details.

endo: per pt's scale.

social: wife and son into visit at beginning of shift. vascular md [**doctor last name 2261**] spoke to son [**name (ni) 351**] re: pt and ct results.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean levophed to off, then start to remove fluid via cvvhdf slowly. skin care. keep pt comfortable.
"
4464,"resp: [**name (ni) 516**] pt on psv 10/5/40%. bs are coarse to clear. suctioned for moderate amount of thick yellow/tan secretions in am. pt is nasally intubated in r nare. noted audible cuff leak. pt has episodes of decreased ve and placed on mmv then returned to psv in am. mdi's administered alb with no adverse reactions. no further changes noted. rsbi=48. plan to monitor and extubate when appropriate.
"
4465,"resp:  [**name (ni) 516**] pt on psv 10/5/40%. ett 7.5, rotated, retaped and secured @ 23 lip. bs are coarse bilaterally. changed circuit out to heated wire which improved secretions, although still suctioning a moderate amount of thick yellow secretions. mdi's administered as ordered alb/atr with no adverse reactions. am abg 7.46/39/115/29.  rsbi=99. plan to continue on present settings.
"
4466,"resp> pt rec'd on psv 10/5/40%. pt has #8 portex trach. bs are coarse and suctioned for small amounts of thick yellow secretions. mdi's administered alb/atr with no adverse reactions. no changes or abg's this shift. 02 [** **] @ 100%. rsbi=43. plan to continue to wean as tolerated.
"
4467,"7a-7p
neuro: received pt on nimbex/fentanyl/midaz gtts. nimbex gtt dc'd as per csurg team this am. continuing fentanyl/midaz gtts for sedation while intubated. pt opens eyes to name, perrla, mae, follows commands.

cv: hr 70-90s sr no ectopy. sbp labile. weaned levo gtt to off, see flowsheet. received 1 unit of prbcs as ordered, no adverse reactions. repeat hct 29.9. cvp 9-12. new tlc placed to left subclavian. old right subclavian tip sent for culture. +[** **] left pt/ absent left dp, md [**doctor last name 420**] aware, not new. +[**doctor last name **] right pedal pulses.

resp: ls clear / coarse at bases. sats 94-98%. pt orally intubated on cmv rate 27, breathing 0-5 over set rate, peep weaned from 12 to 10. fio2 increased to 50% w/ pao2 70s, after right ct placement, repeat abgs showing pao2 120s, fio2 weaned back to 40%, md [**doctor last name **] aware. see flowsheet for abgs/vent changes. nasal tampon to right nare intact. suctioning small amts of blood tinged secretions from back of throat. new right pneumo, ct placed by md [**doctor last name **], scant amt of serosang drainage, no air leak, no crepitus. bronch done this am, large mucus plugs seen to left bronchus, suctioned and specimens sent [**name8 (md) **] md [**last name (titles) **].

gi/gu: abd soft, hypoactive bs. no bm. +placement of ogt, draining brownish/bilious. tpn as ordered. foley draining 30-100cc/hr of clear yellow.

endo: no gtt started d/t bs 90s-120s.

skin: see flowsheet.

id: fungal cultures sent. tmax 99.3 po. antibiotics as ordered.

plan: monitor hemodynamics. monitor resp. status. wean vent as pt tolerates. comfort/pain control.
"
4468,"nicu npn addendum:
prbc transfusion started but after 15 min site leaking, enough to redden band-aid. was removed and iv restarted in left foot. is infusing well, no complications at site or adverse reactions observed during transfusion so far.
"
4469,"npn


34 [**4-24**] week infant admitted to nicu warmer. infant pale but
active and responsive. vs stable. bp mean 40; sat 97%
d-stick 73. cbc and bx sent. crit 17.5->received 15cc's/kg
of prbc's over 4 hours without adverse reactions. will
recheck crit in 6 hours. infant very active, resting
comfortably between cares, sucks well on binki, vital signs
unchanged. blood culture pending. no antibiotics given.
erythromicin and vitamin k given as ordered. parents in and
spoke with nnp at bedside. infant currently resting
comfortably in room air with sat of 100%. nnp placed dluvc
infusing d10w at 60cc's/kg. piv heplocked.

see flowseet for further details.


"
4470,"npn:


2. infant remains on nco2 200cc flow, 30% fio2. rrs-40s-60s.
ls clear and equal, ic/sc rtxns noted upon exam. infant
remains on [** **] as ordered, no spells thus far. cont
towean fio2 as tolerated.

3. wgt-2070g, up 20g. tf remain @ 150cc/kg/d of bm30 with
promod. infant tolerating ng feeds well over 1hr. no attempt
to po feed made. abd benign, no spits, min aspirates. vdg
and stooling adaquate amts, stool heme neg. cont to monitor
wgt gain and feeding tolerance.

4. [**known lastname **] remains swaddled in an oac, temps remain stable.
alert and active with cares. bringing hands to face,
fontanels remain soft and flat. hep b vaccine administered
to infant this pm, no adverse reactions noted. consent
prsent in chart. cont to [**doctor last name 730**] dev needs.

5. mom and [**name (ni) 3809**] in tonight, updated @ bedside on infants
condition. mom independently participating in cares, held
infant x 1hr. asking appropriate questions. cont to update
and educate as needed.


"
4471,"nursing note days

7 hyperbilirubinemia
11 infant with potential sepsis

#1 resp: hfov, map 14, dp 19. no vent changes today, 2 abgs
done, see flowsheet. fio2 60-75%. baby gram done at 1530,
see [** 96**] note, keeping baby positioned w/ right side up. ls
course, large airleak. suctioned for mod cloudy secretions
in ett, and large tan and blood tinged from mouth and nose.
con't to monitor, check next abg at 2100.

#2 fen: tf 100cc/k/d, no basing fluids on current weight of
812g. recieving tpn d30, il, and dopamine in d12.5 by picc.
1/2 ns w/ hep running in radial art line. piv in right arm
hep locked. ds 60&56. uo: 1.7cc/k/hr for 12hrs. no stool.
abd full, soft, no bs (?hypoactive). ng repogle to low
intermittent suction, draining ~2cc of dark green bilious
aspirate per 12hrs. con't to monitor closely.

#4 g&d/pain&stress: alert and active, agitated easily w/
noise and bright lights. recieved fentanyl ~q3hrs, responded
well. maintaining stable temps nested in sheepsking w/ tight
boundries on servo controlled warmer. under tent for noise
controll. con't to support dev needs. due for 30day hus
thurs.

#5 family: mom in to visit today for ~1hr. asking
appropriate questions, talked to and touched baby. very
[**name2 (ni) **]. con't to support and update as needed. planning to
come in for family meeting at 3pm tomorrow and to kangaroo
sibling.

#8 cv: no murmor heard this shift. infant pale, pink, hr
140-190s. cbc checked at 0900. plt count 98, hct 33.6.
transfused 1st alequot of 20cc/k [**name2 (ni) 4103**]; 8cc over 4hrs,
completed at 1900. no adverse reactions, vitals checked per
protocol. due for next 8cc tonight. infant on dopamine drip
(60mg/50cc d12.5); required 6-7mcg/k/m this shift to keep
maps 32-36. con't to monitor and support.

#11 sepsis: cbc and cx sent at 0900. culture pending. see
flowsheet for cbc results. infant started on vanco and gent
iv, first doses given this am. con't to monitor for signs of
infection and administer meds per orders, check levels w/
3rd doses.

revisions to pathway:

  7 hyperbilirubinemia; d/c'd
  11 infant with potential sepsis; added
    start date: [**2149-3-4**]

"
4472,"7am-7pm


2. received infant in nasal cannula 200cc flow in room air.
resp rate stable as per flow sheet. breath sounds clear and
equal. o2 sats 92-100%. infant currently receiving
transfusion of prbc's for symptomatic anemia. tol procedure
well. no adverse reactions noted at this time.
14.intermittent murmur audible. color pale, mottled at
times. mild to mod intercostal/subcostal retractions noted.
stable at this time receiving prbc's.
cont to monitor per protocol.
3. no contact with [**name2 (ni) 26**] this shift. md spoke with [**name2 (ni) 26**]
re: transfusion procedure.
4. tf 140cc/kg/day. pe26 with promod. tol well. small spits,
min aspirates. abd full, active bowel sounds. voiding qs see
flow sheet. no stool x2 days. abd girth stable.
tol full feeds.
cont per plan.
6. in open crib cobedding with sibling. maintaining temp.
swaddled with boundries. sucks on pacifier
intermittently.wakes for feeds.
tol handling and minor stress with current stress
precautions.
cont plan.




"
4473,"pca progress note 3-11p


fen: feeding plan changed by order of feeding team consult.
tf: min 80cc/kg/d of neosure22 q3 hours. pt [**name (ni) 2563**] full
bottles+ at both feeds this shift. pt remains on reflux
percautions. pt mottles throughout with cares. abd is
benign; soft w/ +bs. v/s qs. infant is active to eat feeding
time, appears to stress and tire toward end of feeds,
becoming tachypnic and arching frequently, often until
bottle is removed. please refer to pt's chart for additional
fen data. continue to monitor and support feeding plan,
while encouraging all po feeds as tolerated.

dev:
  pt's temp remains stable while swaddled in [**name (ni) 133**]. axillary
temps have been inacurate due to pt sitting in swing with
arms uncovered. rectal temps are stable. pt woke for 1st
feed, and needed to be woken for 2nd. she is [**name (ni) **] and very
active with cares. activly sucks on pacifier for comfort
when waking. loves to be cuddled and held. continue to
encourage and support developmental milestones.

par: no  contact with [**name2 (ni) **] by this pca so far this shift.

sepsis:
  day 30 of 42 of oxicillin. no temp noted.  broviac line is
patent. no issues. plan to continue meds as ordered and
monitor for s&sx of toxicity or adverse reactions.


"
4474,"nursing status/progress note 7a-7p


#2 infant now under double photo tx w/yeye and genital
protection in place. to check a bili later this afternoon
along with cbc and lytes (last k 3.1). rec'd 2nd of 3 doses
immunoglobulin this am w/o adverse reactions, 3rd dose to be
given again in am. infant is jaundiced with pink mucosa.
further plan as per bili/lab results this afternoon. con't
to monitor.

#3 piv hl'd this am, and is bottling enf 20 well on a
""demand"" schedule. is voiding, and has been stooling
frequently. monitor intake on oral feeds.

#4 no parental contact so far this shift, but reportedly
parents are very involved. family meeting planned for 4pm
this afternoon. will con't to update and support.

#5 infant remains under photo tx on ""off"" warmer and is
maintaining temp well. is on all enteral feeds, bili level
has been decreasing and are con't to monitor. is very active
and alert with cares, is waking for feeds and settling well
afterward. will con't present interventions at this time.




"
4475,"npn 7a-7p


#1 tf at 140cc/k/d, bottling ~[**1-30**] volume but sometimes takes
all. has some head-bobbing and retractions when bottling and
when getting tired during feed. ngt in place. increased cals
to 34 of bm/neosure. voiding and [**month/day (2) **], circ site w/o
bleeding/oozing. on nitrofurantoin for hydronephrosis. no
adverse reactions noted so far. con't to monitor wt, check
lytes in am.

#2 [**month/day (2) **] took care plan (for play-time/positioning) home
with some discharge info. has been sleeping comfortably b/t
activities, wakes for feeds, bottles eagerly but gets a bit
tired. likes to suck on pacifier and sit in swing. will
receive eip when discharged.

#3 [**month/day (2) **] disappointed that [**month/day (2) **] would not be discharged,
but today they completed most of discharge teaching and
[**month/day (2) **] will have renal u/s and vcug at tch tomorrow prior to
discharge so out-patient app'ts have been cancelled. will
try to arrange for urology (dr. [**last name (stitle) 5004**] to see [**last name (stitle) **] on
friday when [**last name (stitle) 26**] bring [**last name (stitle) **] in to tch for cardiology
app't with dr. [**last name (stitle) 4998**]. vna will visit home tomorrow at 3pm,
as [**last name (stitle) **] will be discharge as early as possible in am.
([**location (un) **] home infusion will drop off equipment at house
today). mom states she is comfortable with passing ngt (and
she demonstrated on friday). discharge medication dosing and
administration was reviewed and return demonstrated
(needless syringes given).
-circ done, passed hearing screen, passed car seat test, and
synagis given. con't to support/review teaching.

#4 [**location (un) 345**] has murmur, hr 140-160's, is pale-pink (mottled at
times). hct 44/retic 2.7. observing for s&s of chf. is on
lasix, kcl, and digoxin. will be followed by dr. [**last name (stitle) 4998**] at
tch (app't fri [**2-25**] 10:30 am). con't to monitor.



"
4476,"npn 1900-0700

16 heme

fen:  cw 2245g (down 60g).  infant npo for pneumotosis by
kub & bloody stools.  tf 140cc/kg/day via [**known lastname **]: pnd10 +
il.  prn piv hl l hand.  abd remains distended, firm, occ
soft loops, active bs.  ag= 29-30cm.  kubs done 2200 & 0300;
[**name8 (md) 90**] [**name8 (md) 1**] somewhat unchanged, bowel somewhat less distended at
0300 film.  repogle to cont lws.  scant amt cloudy/bilious
secretions in [**last name (un) **] trap (~1cc).  voiding qs, lg stools with
each diaper change.  stools rusty in color, mucousy, with
some blood streaks present; heme positive.  [**last name (un) 1**] aware.  ds=
96, 84.  lytes sent: 138/3.2/99/31.

dev:  temps stable while nested on open warmer.
active/lethargic with cares.  occ wakes crying btwn.
settles with pacifier. [**last name (un) 383**].  mae.

par:  mom in to visit at [**2148**].  updated at bedside by this
rn.  asking approp questions, approp concerned.  discussed
possibility of transfer to tch for study.  consents to be
obtained if needed, with interpreter.  [**year (4 digits) 143**] called at 2400
for update.  continue to support and update [**year (4 digits) **] as
needed.

bili:  recent bili 11.8/7.9.  infant with hx of elevated
direct bili.  actigal d/c'd yesterday due to npo status.  pt
may be transfered to tch for omega study, [**name8 (md) 90**] [**name8 (md) 1**].  continue
to monitor.

a/b's:  rec'd infant in ra.  infant placed in nc at 2400 for
freq drifts/spells; nc 100%, 60cc.  infant able to wean to
20cc at end of shift.  rr 30-50s, ls c/=, mild ic/sc
retractions.  2 spells thus far this shift.  required stim
and bbo2 for resolvement.  total of 4 spells in 24hrs.
continue to monitor.

id:  infant on zosyn tid for nec.  med admin as ordered.
cbc repeated at 0400; results pending.  temps stable.
infant active/lethargic with cares.  continue to monitor for
s/s sepsis.

heme:  infant transfused total 2 alloquots prbcs overnoc
(10cc/kg x2) for hct 25.7.  consent signed in chart.  no
adverse reactions noted.  soft murmur auscultated.  hr
150-160s, infant pink, mod gen edema.  bp stable 78/40 (53).


revisions to pathway:

  16 heme; added
    start date: [**2156-3-30**]

"
4477,"npn 1900-0700


resp:  infant in nasal [**doctor last name **] cpap 5, fio2 37-49%.  ls
clear/=, mild sc retractions.  rr 20-40s.  sxn'd mouth x1
for moderate amt clear secretions.  occ drifts, no spells
thus far this shift.  pt on iv [**doctor last name 775**] [**hospital1 **].  continue to
monitor.

fen:  cw 2185g (up 85g).  pt remains npo.  tf 130cc/k/day.
picc l ac patent and infusing pn d10 + il.  piv r hand
hep-locked.  repogle to cont lws.  4.2cc clear secretions
aspirated at 2100; discarded.  tube irrigated with 2cc
sterile h20 (asp entire volume back).  suction canister
changed at 2100 due to not maintaining proper suction.
repogle now appears to be draining secretions adequately.
abd soft, [**hospital1 **], round.  no loops, active bs.  ag stable,
27cm.  8hr uo= 3.0cc/k/hr, no stool thus far this shift, pt
is passing gas.  surgery fellow from tch in to consult.  no
plans for repeat kub as yet.  2 aloquots prbcs transfused
overnoc (20cc/k) for hct of 28.4.  consent present in chart.
 tolerated transfusion well, no adverse reactions.

par:  dad called x1 thus far this shift.  updated by this
rn.  asking [**hospital1 **] questions.  provided much support by this
rn.  continue to update and support as needed.

dev:  temps remain boarderline low; 97.8ax swaddled with
t-shirt, 2top blankets, hat.  [**hospital1 1**] aware.  a/a, irritable
with cares.  settles well with sucrose pacifier.  slept well
tonight in btwn cares.  moves hands to face.  [**last name (lf) 383**], [**first name3 (lf) 57**].

sepsis:  pt now day 3 of 14 with abx clinda and zosyn.  meds
admin as ordered.  temps boarderline low, will monitor
closely.  bc negative.  stool cultures: fecal culture
negative, campylobacter culture negative, prelim results of
viral culture negative.  will monitor for s/s sepsis
closely.


"
4478,"nursing progress note


#1. o: infant remains on hifi ventalation on unchanged
settings of map 7, delta p 14. fio2 overnight has been
29-32%. brief o2 sat drifts noted overnight. no bradycardia
noted thus far. ett suctioned for sm/mod white. breath
sounds are coarse and equal. ic/sc retractions noted. cbg
7.25-50-44-23--5. no changes made. last dose of indocin
given tonight.  a: stable on current settings. p: continue
to monitor resp status.

#2. o: infant transfused 2nd aloquot of 20cc/k transfusion
of prbc's tonight. no adverse reactions noted. last dose of
indocin given. no murmur heard tonight. infant [** 211**] and well
perfused. bp stable. a: s/p transfusion and indocin
treatment. p: continue to monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d of d6.5pn and
il's infusing well via dluvc line. infant npo. abd soft and
flat with active bowel sounds. no loops. no meconium thus
far. infant voiding 3.8cc/k/hr today. d/s 219-226. wgt is up
41gms tonight to 450gms. a: npo. p: continue to monitor fen
status. check elec's on sunday morning.

#5. o: infant remains in heated isolette with stable temp.
he is alert and active with cares. maew. sucking on fingers
intermittently. a: aga. p: continue to assess and support
developmental needs.

#6. o: mom called x1 for brief update. apologized for not
showing up at 1600. she stated she will be in today. a:
involved mother. p: continue to inform and support.

#8. o: infant remains under single phototherapy. eye shieds
in place. a: hyperbili. p: continue to inform and support.


"
4479,"nursing progress note


#1. o: infant remains on ampicillin and gentamicin for
sepsis. today is day [**10-30**]. cultures remain negative. a:
sepsis. p: continue with treatment.

#2. o: infant remains on prong cpap 5. fio2 has been 27-26%.
(27-30% while prone position). rr 40's-50's. breath sounds
are clear and equal. mild/mod ic/sc retractions noted. no
spells. remains on caffiene. a: stable. p: continue to
monitor resp status.

#3. o: infant completed 2nd aloquot of prbc's this evening.
lasix given. infant received total of 20cc/k of prbc's. no
adverse reactions noted during transfusion. infant pink and
well perfused. soft murmur heard. a: low hct. p: continue to
monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d. currently d9pn
and il's infusing well via picc at 120cc/k/d. feeds of bm
are at 30cc/k/d. no spits or aspirates. ag stable. abd
remains full and soft. no loops. active bowel sounds. d/ss
125. no stools. voiding 5.9cc/k/hr. wgt is up 10gms tonight
to 1025gms. a: advancing on feeds. p: continue to advance
feeds 10cc/k/[**hospital1 **] as tolerated. a.m. elec's pending.

#6. o: infant remains in servo control isolette with stable
temp. he is alert and active with cares. maew. otherwise
sleeping well. hc remains unchanged at 24cm's. a: aga. p:
continue to assess and support developmental needs. ?hus
today.

#7. no contact from [**name2 (ni) 4**] this shift.

#9. o: rebound bili sent this a.m. awaiting results.


"
4480,"nursing notes:


#2resp;
  o:[**known lastname 932**] remains in nc 30-40%fio2, 200ccflow to maintain
02sat's>92%. rr40-60's. lungs cta. sc/ic retx. 4bradys
w/apnea noted thus far this shift. 2requiring bb02!
dr.[**last name (stitle) 962**] aware. remains on caffiene, diuril,kcl. cbc
w/diff and blood cx. done this am r/t bradys. no shift in
cbc noted. blood cx.results pending. hct-23.6! [**known lastname 932**]
currently w/blood transfusion in progress. (see flow sheet).
no adverse reactions noted thus far. vss. 35cc to infuse of
prbc over 4hrs. [**known lastname **] aware per dr.[**last name (stitle) 962**]. a;inc. resp
effort, inc. apnea/bradys r/t anemia? no sepsis noted today.
p:monitor. observe transfusion.
#2fen;
  o:tf=140cc/k/d. bm26w/pm. 54ccq4hrs. po feeding qshift, bf
when mom at bedside. [**known lastname 932**] [**last name (namepattern1) 62**]. 45 cc w/nuk nipple this
pm. occasional periods of discoordination noted. active and
interested when po feeding. all other feeds gavaged over
40min. no spits, no evidence of reflux noted thus far this
shift. remains on reglan/zantac and reflux precautions
maintained. abd.soft,[**last name (namepattern1) 211**],no loops. voiding, no stool this
shift. last stool, noted last nite.a;stable, working on po
feeding.p;continue current feeding plan.
#3g/d;
  o:[**last name (namepattern1) 3**],active,and appropriate w/cares. occasionally
waking for feeds. stable temps in open crib.dressed,
swaddled,and positioned with [**last name (un) 58**] bumper. maew w/mild
hypertonia noted. ot involved. [**last name (un) **].sucks on pacificer at
times.a;agap;continue to assess and support g/d milestones.
#4parents:
  o:dr.[**last name (stitle) 328**] called mom this am w/update. no furthur
contact noted this shift.p;continue to educate and support.



"
4481,"npn 0700-1900
heme: infant born with known rh-isoimmunization. ivig given at 1230 today. infusion given over 4hrs and completed at 1630. no adverse reactions. vitals signs done as ordered, see flowsheet. no plan for further ivig infusion at this time. plan to check q4hr biliirubin levels. see attending note for further details.

bili: infant continues on triple phototherapy since 0800 today with eye shields in place. bili levels checked q4hrs this shift. bili presently 5.5/0.3, down from 6.5/0.3.
p: continue to monitor closely for hyperbilirubinemia.


**please refer to attending's notes above for details.
"
4482,"npn 0700-1900
heme: infant born with known rh-isoimmunization. ivig given at 1230 today. infusion given over 4hrs and completed at 1630. no adverse reactions. vitals signs done as ordered, see flowsheet. no plan for further ivig infusion at this time. plan to check q4hr biliirubin levels. see attending note for further details.

bili: infant continues on triple phototherapy since 0800 today with eye shields in place. bili levels checked q4hrs this shift. bili presently 5.5/0.3, down from 6.5/0.3.
p: continue to monitor closely for hyperbilirubinemia.


**please refer to attending's notes above for details.
"
4483,"progress note 7p-7a


fen: tf [** 145**] 120cc/k enfamil ar all po. waking to eat q/ 4
hrs. intake over last 24 hrs=175cc/k. abdomen soft and
benign. voiding/no stools so far this shift. no spit noted.
will continue to monitor feeding tolerance and progression.

dev: temps stable swaddled in [** 13**]. active and [** 29**] w/
cares. comforted by pacifer. will continue to support
developemental needs.

a's and b's: day [**1-3**]. no spells noted so far this shift.
will continue to monitor closely.

tachy: hr and bp wnl. continues on propanilol q. 8hrs.
tolerating well with no adverse reactions noted so far. will
continue to monitor closely.


"
4484,"nursing note 1900-0700


resp: recieved in simv 26/6 x29bpm. abg at 0200 was
7.45/44/54/32/5. breath rate weened to 27. fio2 55-70%,
increased slightly w/ [** **] ween. ls course/crackly but has
good aeration. sats v. [**known lastname **]. rr 27-50, rides [**known lastname **] often.
lasix given x1. stable on current settings, con't to
monitor. check [**known lastname 1380**] gas this am.

fen: weight 936, up 1gram. tf 100cc/k/d of pn d18 w/hep and
il. npo. ds109. abd soft and full, no loops. girth up 3cm to
20.5. bs active. uo: 4.7cc/k/hr x12hrs. no stools. con't w/
current plan.

cv: soft murmor heard w/ all cares. pulses normal, brisk cap
refil, hyperactive precordium. hr 150-180s. recieved
dopamine drip at 5mcg throughout night, turned off at 6am.
keeping maps 32-38. given 10cc/k prbc transfusion w/ lasix
x1 at 8pm for hct of 34 yesterday. also given 15cc/k
platelet transfusion at 6am after plt count dropped from 88
to 66 o/n. no adverse reactions noted, vitals assessed per
protocol. [**known lastname **] out currently 0.8cc. stable at this time, bp
means 30-36. con't to monitor closely and check bps q 15min.


parenting: no contact w/ [**name2 (ni) **] so far this shift. [**name2 (ni) 18**]
spoke w/ [**name2 (ni) **] yesterday evening to give update on
[**name2 (ni) 168**]'s condition. con't to support and update as needed.

bili: [**name2 (ni) **] pink. last bili level checked on [**2152-4-25**].
recieving phenobarbitol for increased direct bili. con't to
monitor for jaundice and check bili levels per orders.

r/o sepsis: [**date range **] remains w/out signs of infection at this
time.  temps stable, alert and active. continues on gent and
oxacillin iv. con't to monitor closely.


"
4485,"npn 1900-0700


resp/heme:  infant on nasal prong cpap 7, fio2 29-35%, incr
with cares.  ls c/=, ic/sc retractions.  rr 20-50s.  sxn po
x1 thus far this shift, no secretions noted.  2 spells noted
thus far this shift.  total of 11 spells in 24hrs.  infant
transfused 1 alloquot directed donor prbcs; 12.5ml over
4hrs.  no adverse reactions noted.  consent signed in chart.
 lasix given x1 after transfusion complete.  pt on caffeine
and vit a.  continue to monitor.

fen:  cw 830g (down 5g).  tf 140cc/kg/day.  ef currently at
60cc/kg/day bm/sc20.  non-cent picc patent and infusing
pnd10 + il at 80cc/kg/day.  prn piv rl; hl.  appears to be
tolerating pg feeds well.  no spits, max asp 1.2cc; benign,
refed.  abd full, soft, soft loops noted x1, hyperactive to
active bs.  ag= 20-21cm.  8hr uo= 5cc/kg/hr, trace mec
stools noted qdiaper change.

dev:  temps stable while nested in servo isolette.  a/a with
cares, sleeps well btwn.  likes pacifier, moves hands to
face.  [**last name (lf) 457**], [**first name3 (lf) 83**].  pt planned for repeat hus today; hx of
nml hus.

par:  mom called x1 thus far this shift.  updated by this
rn.  asking approp questions.  plans to be in to visit
today.  continue to update and support parents as needed.


"
4486,"npn 1900-0700

8 potential for sepsis

resp:  [**name (ni) **] pt on conv vent settings 21/6, r 19.  0200 abg
was 7.24/40/42/18/-9, therefore decreased pip by 1 to
current settings 20/6, r 19.  0600 cbg 7.25/43/36/20/-9.
fio2 21-38%, mostly in 30s since last setting change.  rr
30-50s, sc/ic retractions.  ls wheezy/sl diminished.  air
leak noted thru ett.  sxn x1 sm amt cloudy via ett/oral.  1
spell tonight.  hr to 68, o2 sat 81% after cares.  mild stim
and incr o2 required to resolve.  cont to monitor resp
status.

fen:  cw 965g (up 3g).  pt remains npo.  tf 120cc/kg/d.
dluvc infusing pn d12.5.  repogle to gravity; 0.1cc clear
asp.  abd soft, hypoactive bs, no loops.  ag 21-22cm.  12hr
uo= 4.5cc/k/hr, no stool this shift.  lytes drawn:
143/4.0/117/15.  triglycerides: 165.  glucose=140.

dev:  maintaining temps nested in servo isolette.  pt is
a/a.  irritable with cares; settles with hand containment
and decr stim.  moves hands to face, sucks on thumb.  r & l
feet edematous/bruised (r>l).  excoriated area on abdomen
improved; bacitracin applied.  repeat hus today.

social: mom in most of noc tonight (2200-0100; 0400-0630).
updated at bedside by this rn and nnp.  asking appropriate
questions.  appeared loving/affectionate to nb.  plans to be
in later today to participate in cares.

bili:  single phototx restarted at 0600 for rebound bili
5.3/0.2 (up from 3.4/0.2).  eye mask in place.  pt ruddy, no
stool this shift.  cont to monitor.

cv:  infant transfused tonight.  9cc prbcs transfused over
4hrs.  pt tol well; no adverse reactions.  bp means 30-50s.
hr 130-150s.  no murmur auscultated; s/p 1 course indocin.
palmar pulses absent.  pt ruddy.  total blood out since
transfusion tonight: 1.2cc.





revisions to pathway:

  8 potential for sepsis; resolved

"
4487,"npn 1900-0700


resp:  infant remains on conv [** **] settings 18/5, r 18.  abg
2200: 7.23/46/105/20/-8; no changes made.  fio2 27-35%, incr
with cares.  ls coarse, sxn'd q3-4h thick cloudy secretions
via ett, small po and nares.  no bradys thus far this shift.
 caffeine held tonight for tachycardia.  pt continues on vit
a.  continue to monitor.

fen:  cw 852g (up 92g).  feeds restarted at 0100 at
100cc/k/day pe24.  picc infusing d10 ns + 0.5u hep/cc at
1.5cc/hr.  no spits, min asp.  abd full, soft.  ag noted to
be incr at 2200 (20.5cm with soft loops).  [** 41**] aware.  ag
now back to baseline at 18cm without loops.  uo improving.
8hr uo= 9.2cc/k/hr.  no stool thus far this shift.  lytes
sent 2200: 123/5.1/96/18.  na improving (up from 118 on
days).  lytes to be resent at 0500.  ds= 89.

par:  mom called x2 thus far this shift and in to visit with
dad at 2300.  updated at bedside by this rn, [** 41**] [**doctor last name **], and
md [**last name (titles) **].   mom expressed her concerns to this rn.  very
emotional and worried about her daughter.  much support
provided.  anxious to hear hus results this am.  continue to
support and update as needed.

dev:  temps stable while nested in servo isolette.  a/a with
cares, irritable at times btwn.  settles with hand
containment and pacifier.  moves hands to face.  anterior
font appears slightly full.  [**last name (titles) 41**] aware.  hus to be done in
am.  continue to monitor.

cv:  loud murmur auscultated.  pt tachycardic this shift,
170-190s (occ to 200s).  team aware.  caffeine therefore
held at 2100.  bp means stable (37-56).  most recent cuff
74/44 (56).  pt transfused 2nd aloquot (8cc) prbcs at 2330
over 4hrs.  consent signed in chart.  no adverse reactions
noted.  post-hct to be sent later today.  continue to
monitor cv status.


"
4488,"npn 1900-0700


sepsis:  infant now day 4 of minimum 7 day course iv abx amp
and gent.  meds to be admin as ordered.  infant continues to
have foul odor.  repeat cbc dol 1 with left shift; bc
negative.  cbc to be repeated later today.  lp planned.
continue to monitor for s/s sepsis.

resp:  intubated on hifi settings map 6, delta p 14.  delta
p weaned x2 overnoc according to abgs.  most recent abg
0300: 7.34/44/56/25/-2 (decr from amp 16 to 14 at this
time).  fio2 23-33%.  ls coarse bilat.  sxn'd mod-lg white
via ett & po.  ic/sc retractions.  no bradys thus far this
shift, occ drifts.  pt is on vit a.  continue to monitor.

fen:  bw 605g  cw 555g (up 5g).  pt npo.  tf 170cc/kg/day:
uac: sterile h20 + 7.7meq naace + 0.5uhep/cc; dluvc: pnd10
(70cc/kg/day) + d10w + 0.5uhep/cc.  ds stable, 63, 92.  abd
soft, flat, bs unappreciated.  ag= 14.5cm.  ngt pulled by
pt, not replaced at this time due to npo status.  12hr uo=
5.9cc/kg/hr, no stool this shift.  q6h lytes, most recent
0400: 145/3.2/112/22/14.  bun: 35, creat: 0.8, mg: 3.2.

dev:  infant nested on servo warmer with water pillow,
sheepskin, tent.  ear muffs provided for comfort with noise.
 fentanyl given prn x1 thus far this shift for unsettled
aggitation, with good effect.  infant can become aggitated
at times, usually settles well with hand containment or decr
stim.  aquaphor applied [**hospital1 56**] as ordered, skin intact.  eyes
fused bilat, rt eye appears to be opening slightly.

par:  parents in to visit for early part of shift
(~[**2171**]-2400).  updated at bedside by this rn.  asking approp
questions.  dad participated in temp taking and diaper
change.  continue to update and support parents as needed.

cv:  loud murmur ausculated.  pda by echo.  1st course
indocin started yesterday.  2nd dose given at 2330.  [**location (un) **]
pulses absent, good cap refill.  ruddy, wp.  hr 140-170s,
uac means 28-41.  cuff 72/44 (50).  infant transfused
overnoc prbcs (20cc/kg total).  consent signed in chart.  no
adverse reactions noted with 1st alloquot.


"
4489,"nsg note 0700-[**2041**]


resp:infant received in nasal prong cpap-6, 21% fio2. cpap
decreased to 5 at 0930, infant tolerated well. placed in
room air at 1430. bilateral lung sounds clear and equal with
good aeration. respiratory rate 20-50's. saturations
99-100%. mild subcostal retractions. no spells. p:continue
to assess and support respiratory status.

c/v:infant's heart rate 120-140's, nsr. no murmur
auscultated. pink and well perfused. received second aliquot
of prbc's, 14 ml, over four hours. tolerated tranfusion
well, no adverse reactions. bp's stable 60/29 (40).
p:continue to assess and support cardiovascular status.
repeat hct lab.

f/n:infant on total fluids of 80cc/kg/day. npo. tpn @
80cc/kg/day via double lumen uvl, primary port @4.8cc/hr.
d/s stable-76. abdomen benign, +bowel sounds. girth stable
at 22.5cm. voiding, small mec smear. p:continue to assess
and support nutritional status.

dev:infant maintaining temperatures, nested on servo warmer.
appropriate for gestational age. alert and active for care
times, sleeping well between. comforts with boundaries.
sucking on pacifier well. p:continue to assess and support
growth and development.

par:mom called this morning. dad in for a visit. asking
appropriate questions. discussed respiratory status and plan
for second aliquot of prbc's. very loving with [**known lastname **].
p:continue to support and update parents.

id:infant continues on ampicillin and gentamycin for a 48
hour rule out. blood cultures pending. no signs/symptoms of
sepsis. temperature's stable, active and alert, stable
respiratory status. p:continue to monitor for signs of
infection.


"
4490,"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**]

"
4491,"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**]



"
4492,"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**]"
4493,"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**]



"
4494,"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**]"
4495,"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**]"
4496,"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**]"
4497,"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**]"
4498,"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**]
"
4499,"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.



"
4500,"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**]



"
4501,"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**]

"
4502,"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**]"
4503,"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**]



"
4504,"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**]"
4505,"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**]"
4506,"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**]"
4507,"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**]
"
4508,"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



"
4509,"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**]"
4510,"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**]"
4511,"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.



"
4512,"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**]
"
4513,"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**]"
4514,"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**]
"
4515,"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**]
"
4516,"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**]
"
4517,"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



"
4518,"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**]

"
4519,"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**]"
4520,"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**]

"
4521,"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**]"
4522,"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**]"
4523,"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**]"
4524,"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**]"
4525,"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**]"
4526,"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.



"
4527,"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**]"
4528,"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.



"
4529,"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 **]
"
4530,"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).



"
4531,"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**]
"
4532,"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



"
4533,"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**].



"
4534,"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**]"
4535,"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**]

"
4536,"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**]
"
4537,"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**]



"
4538,"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 **].



"
4539,"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**].



"
4540,"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



"
4541,"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 **]
"
4542,"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**]"
4543,"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**]
"
4544,"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**]"
4545,"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**]"
4546,"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**]"
4547,"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**]
"
4548,"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) **].



"
4549,"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



"
4550,"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



"
4551,"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**]
"
4552,"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**]

"
4553,"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**]"
4554,"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**]
"
4555,"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**]"
4556,"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.
"
4557,"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
"
4558,"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 ------
"
4559,"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
"
4560,"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 ------
"
4561,"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.
"
4562,"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:
"
4563,"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
"
4564,"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.
"
4565,"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.
"
4566,"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:
"
4567,"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
"
4568,"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 ------
"
4569,"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:
"
4570,"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.
"
4571,"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.
"
4572,"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
"
4573,"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
"
4574,"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
"
4575,"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
"
4576,"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
"
4577,"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
"
4578,"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
"
4579,"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
"
4580,"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
"
4581,"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
"
4582,"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
"
4583,"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
"
4584,"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 ------
"
4585,"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 ------
"
4586,"[**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.




"
4587,"[**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.

"
4588,"[**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.



"
4589,"[**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.

"
4590,"[**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.



"
4591,"[**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)

"
4592,"[**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.




"
4593,"[**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)

"
4594,"[**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)

"
4595,"[**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)

"
4596,"[**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.


"
4597,"[**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.

"
4598,"[**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.



"
4599,"[**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.



"
4600,"[**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.


"
4601,"[**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)

"
4602,"[**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.

"
4603,"[**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)

"
4604,"[**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.

"
4605,"[**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.


"
4606,"[**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.






"
4607,"[**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.

"
4608,"[**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.

"
4609,"[**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.


"
4610,"[**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.


"
4611,"[**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)

"
4612,"[**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.









"
4613,"[**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.

"
4614,"[**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.

"
4615,"[**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)

"
4616,"[**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.


"
4617,"[**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.

"
4618,"[**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)


"
4619,"[**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.


"
4620,"[**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.


"
4621,"[**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.



"
4622,"[**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.


"
4623,"[**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.


"
4624,"[**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)

"
4625,"[**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**].


"
4626,"[**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.



"
4627,"[**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)

"
4628,"[**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**].


"
4629,"[**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**].


"
4630,"[**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.



"
4631,"[**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)

"
4632,"[**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.



"
4633,"[**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.


"
4634,"[**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.

"
4635,"[**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.


"
4636,"[**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  21 year old man with
 reason for this examination:
  r/o inj
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: eez sat [**2185-1-29**] 12:58 am
  aorta ok. tiny, non-linear focus of decreased attenuation in posterior spleen,
  less than 1cm deep, too small to characterize by ct, but cannot exclude a
  small laceration. no perisplenic hematoma is present. no free fluid in abdomen
  or pelvis. no free air.
 ______________________________________________________________________________
                                 final report *abnormal!
 indication:    motor vehicle accident.

 technique: helically acquired axial images were obtained of the abdomen and
 pelvis from the lung bases to the pubic symphysis with 150 cc of optiray
 contrast.  there were no adverse reactions to contrast administration.
 multiplanar reformations were made.

 ct chest with contrast: the aorta is well opacified demonstrating no
 extravasation or contour abnormality. there is no aortic dissection or para
 aortic hematoma. age appropriate thymus tissue and a small pretracheal lymph
 node are present. evaluation of the lung parenchyma is limited due to
 respiratory motion but there are no gross consolidations or pulmonary
 contusions.  there is no pneumothorax. no rib fractures are seen.  there are
 no pleural or pericardial effusions.

 ct abdomen with contrast:  no hepatic lacerations or parahepatic hematoma is
 present.  there is no hematoma adjacent to the spleen but there is a tiny
 focal area of decreased attenuation along the posterior splenic border. no rib
 fractures are seen in this region.  there is no perisplenic hematoma. the area
 of decreased attenuation is too small to accurately characterize by ct, but
 overall depth is less than 1 cm.  the kidneys enhance symmetrically without
 evidence of obstruction or injury.  the adrenal glands, duodenum, pancreas and
 gallbladder are unremarkable.  intra abdominal loops are normal. there is no
 free air or free fluid within the abdomen or pelvis.

 ct pelvis with contrast: distal ureters are unremarkable. the bladder contains
 a foley catheter but is otherwise unremarkable. there is no free fluid in the
 pelvis or pelvic or inguinal lymphadenopathy.

 no fractures are seen.

 multiplanar reconstructions: coronal and sagittal reformats show no evidence
 of traumatic aortic injury.

                                                             (over)

 [**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report *abnormal!
 (cont)
 impression:
 1) no evidence of aortic injury.
 2) tiny focus of decreased attenuation in the posterior spleen, too small to
 characterize on ct.  there is no adjacent hematoma. overall depth of the area
 of decreased attenuation is less than 1 cm. a tiny laceration cannot be
 excluded.


"
4637,"[**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  59 year old man with
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications: trauma.

 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.  there were no adverse reactions to contrast administration.
 additional delay sequences of the superior mediastium and liver/spleen were
 acquired.

 ct of the chest with iv contrast: on the initial sequence, there is fluid
 density anterior to the distal ascending aorta.  on the delayed scan with a
 breath hold, this is not seen.  there is a small retrosternal hematoma, but
 the fat adjacent to the aorta is unremarkable. there is no evidence of
 extravasation of iv contrast from the aorta. on the reconstructed images, the
 aortic contours are smooth. there is no evidence of disssection.  there are
 areas of calcification in the aortic arch, and in the left subclavian artery.
 no pneumothorax is seen.  no focal pulmonary consolidations or contusions are
 seen.  there are no pleural or pericardial effusions.  no pathologically
 enlarged axillary, hilar, or mediastinal lymph nodes are seen.  no rib
 fractures are seen.  visualized portions of the clavicles and scapula appear
 intact.

 ct of the abdomen with iv contrast:  the liver and spleen are intact without
 focal laceration or adjacent hematoma.  the adrenal glands, pancreas, and
 kidneys show no evidence of acute traumatic injury.  there is no free
 intraabdominal air.  there is no free fluid within the abdomen or in the
 mesentery.  bowel loops are all normal in course and caliber.  the abdominal
 aorta is unremarkable.

 ct of the pelvis with iv contrast: the bladder contains a foley catheter with
 internal air.  there is no free fluid in the pelvis.  distal bowel is normal.

 bone windows: there is a comminuted fracture of the proximal right femur.
 within the proximal femoral diaphysis, there are three major fragments, one of
 which is anterior, the other lateral, and the final one is medial.  the
 lateral fragment is contiguous with the greater trochanter, femoral neck, and
 head. the anterior fragment is small and extends superiorly to the level of
 the femoral neck, where there is a small anterior cortical defect within the
 femoral neck, but no full thickness femoral neck fracture.  the smallest
 fragment is the medial fragment, which is highly comminuted, and it consists
 mostly of an avulsed lesser trochanter.  the left proximal femur is intact.
                                                             (over)

 [**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 osseous structures of the pelvis appear intact.  no spinal fractures are seen.
 note is made of a likely healed left 11th rib fracture laterally. there is
 extensive costal cartilage calcinosis.

 ct reconstructions:  coronal and sagittal reformations show a normal aortic
 contour.

 impression:
 1.  no aortic extravasation, periaortic hematoma, or dissection.
 2.  no evidence of acute traumatic intraabdominal injury.
 3.  comminuted fracture of the proximal right femur as described above.


"
4638,"[**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
     66 year old man with persistent fevers, increasing abdominal pain, s/p
  ex-lap. also decreasing hematocrit.
 reason for this examination:
  evaluate for abscess/intra-abdominal infection, as well as source of bleeding.
  with po and iv contrast.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  fevers, increasing abdominal pain after exploratory laparotomy,
 decreasing hematocrit.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 findings:  comparison is made to the prior torso ct from [**12-28**] and the
 gallbladder ultrasound from [**2119-1-6**].

 ct of the abdomen with iv contrast:  there are moderate-sized bilateral
 pleural effusions with associated bibasilar atelectasis.  again identified is
 a likely cyst within the right posterior hepatic lobe inferiorly (segment vi).
 there is stable intrahepatic biliary ductal dilatation.  the gallbladder
 contains calcified stones and asymmetrical areas of wall thickening consistent
 with the previously seen adenomyomatosis.  the common bile duct remains
 prominent extending into the duodenum.  there is no stranding around the
 gallbladder.  the pancreas is unremarkable.  the adrenal glands and kidneys
 are unchanged.  within the posterior aspect of the spleen is a wedge-shaped
 focal area of decreased attenuation, which likely reprents an infarct.  the
 spleen has progressively enlarged over the past two ct scans, now measuring
 over 13 cm. the appearance of the stomach is unchanged. there is no evidence
 of bowel obstruction.

 ct of the pelvis with iv contrast:  again, there is a small amount of fluid in
 the pelvis, but no loculated pockets with enhancing rims or internal air to
 indicate an abscess.  multiple cecal diverticula are seen.  the appendix is
 visualized, and is filled with oral contrast, and normal.  again, there is a
 suggestion of cecal, and transverse colonic wall thickening.  again, these
 segments are not fully distended, limiting evaluation.  there is some ascites
 in the right inguinal fat-containing hernia.

 osseous structures:  no suspicious lytic or sclerotic lesions are present.

 impression:
                                                             (over)

 [**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 1) no definite intraabdominal abscess.  moderate bilateral pleural effusions
 with associated bibasilar atelectasis.
 2) progressive splenic enlargment compared to [**2118-12-28**] and [**2118-12-16**]. the spleen
 now measures over 13cm. findings are suspicous for possible lymphoma in the
 absence of other etiologies for splenic enlargement.

 results were discussed with dr. [**last name (stitle) 4478**] at 9:55 pm on [**2119-1-8**].

"
4639,"[**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old woman with s/p intramural hemmorage in sigmoid
 reason for this examination:
  s/p intramural hemmorage in sigmoid-?resolved
 ______________________________________________________________________________
                                 final report
 indications:  status post intramural hemorrhage in sigmoid colon.  evaluate
 for resolution.

 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.  non-ionic contrast was used secondary to the patient's
 asthma history.  there were no adverse reactions to contrast administration.

 findings:  comparison is made with the study from [**2158-12-7**].

 ct of the abdomen with iv contrast:  no focal lung lesions are identified.
 there are no pleural or pericardial effusions.  no focal liver lesions are
 identified.  the spleen contains several punctate calcifications, likely
 calcified granulomas.  the adrenal glands, pancreas, stomach, and
 intraabdominal loops of small bowel are unremarkable.  there is a single focus
 of decreased attenuation in the lower pole of the left kidney which likely
 represents a simple cyst, and is unchanged in appearance since the prior
 study.  the kidneys otherwise enhance symmetrically without evidence of focal
 mass or obstruction.  there is no ascites or pathological mesenteric or
 retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast:  there has been marked reduction in the
 previously seen sigmoidal wall thickening.  extensive diverticular disease and
 likely muscular hypertrophy in the sigmoid colon, but there is no evidence of
 surrounding stranding to indicate acute diverticulitis.  the previously seen
 small amount of free fluid in the pelvis has also resolved. distal ureters and
 bladder are unremarkable.  there is no pathological pelvic lymphadenopathy.

 a small sclerotic focus is seen in the superior pubic ramus, which is likely a
 bone island.  additional sclerotic foci are seen in lower-thoracic vertebral
 bodies, which are also likely bone islands.  no suspicious lytic lesions are
 identified.

 impression:
 1) marked improvement in the previously seen sigmoidal wall thickening, and
 resolution of free fluid in the pelvis.  extensive diverticular disease is
 present, but there is no evidence of acute diverticulitis.

 2) tiny left renal cyst.

 3) multiple splenic granulomas.
                                                             (over)

 [**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)



"
4640,"[**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  66 year old man with h/o gallstone/necrotizing pancreatitis and multiple
  drainage procedures
 reason for this examination:
  pancreatic protocol - renewed pancreatitis?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  history of necrotizing/gallstone pancreatitis.  evaluate for
 acute pancreatitis.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 comparison:  [**2107-2-10**] abdominal ct scan.

 findings:

 ct of the abdomen with iv contrast:  there are small bilateral pleural
 effusions, left greater than right, with associated compressive atelectasis of
 both lower lobes.  no focal liver lesions are identified.  the spleen, adrenal
 glands, kidneys, and stomach are unremarkable.  again seen are two drainage
 catheters in the region of the pancreas and a jejunostomy tube.  located
 immediately below the catheters are fluid pockets with internal air.  these
 appear slightly smaller than on the previous study.  only the head of the
 pancreas enhances. the degree of inflammatory change surrounding the pancreas
 has not changed appreciably. the fluid pocket adjacent to the tip of the
 pancreas extending inferiorly is unchanged.  the degree of abdominal
 stranding/fluid is unchanged.

 ct of the pelvis with iv contrast:  the distal ureters and bladder are
 unremarkable.  the bladder contains a foley catheter and internal air.  no
 sigmoid bowel wall thickening.  no pathologically enlarged inguinal or pelvic
 lymph nodes are seen.

 osseous structures are unchanged, again showing diffuse degenerative changes.

 impression:
 peripancreatic fluid collections with internal air slightly smaller adjacent
 to the two drainage catheters.  the degree of inflammatory stranding around
 the pancreas and in the abdomen has not changed significantly. only the
 pancreatic head enhances.

                                                             (over)

 [**2107-3-6**] 2:50 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 95461**]
 ct 150cc nonionic contrast
 reason: pancreatic protocol - renewed pancreatitis?
 admitting diagnosis: pancreatitis
 field of view: 38 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)


"
4641,"[**2146-12-28**] 7:12 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8484**]
 ct 100cc non ionic contrast
 reason: trauma
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with mva
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  trauma.

 technique:  axial images of the abdomen and pelvis were acquired helically
 from the lung bases through the pubic symphysis with 150 cc optiray contrast.
 there were no adverse reactions to contrast administration.

 findings:

 ct of the abdomen w/iv contrast:  there is a small focal area of consolidation
 in the right lower lobe, medial basal segment.  no pleural or pericardial
 effusions are seen.  there is periportal edema, consistent with vigorous fluid
 resuscitation.  the liver is intact without evidence of laceration.  the
 spleen appears intact.  the adrenal glands, kidneys, pancreas, and duodenum
 are all unremarkable.  the gallbladder is normal.  there is a general lack of
 intra-abdominal fat, limiting sensitivity for mesenteric injury.  there is no
 free fluid in the abdomen.  no free air is seen.

 ct of the pelvis w/iv contrast:  the bladder contains a foley catheter and
 air.  sigmoid colon and rectum are unremarkable.  there is no free fluid in
 the pelvis.

 no pelvic fractures are seen.  note is made of a densely sclerotic area in the
 left femoral neck, which likely represents a bone island.  there is a
 diminutive first right lumbar rib.  no rib fractures are seen.

 impression:

 1. no evidence of acute traumatic intra-abdominal injury.
 2. likely diminutive right first lumbar rib. no acute fracture.


"
4642,"[**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  62 year old woman with hx of bladder cancer with resection of tumor and
  retroperitoneal disection as well as chemotherapy.
 reason for this examination:
  pt with hx of bladder cancer with resection of right kidney and ureter as well
  as retroperitoneal dissection and has received chemotherapy now needs  ct of
  torso for staging.
 ______________________________________________________________________________
                                 final report
 indication:  renal cancer, status post resection of right kidney, ureter, and
 retroperitoneal dissection.

 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.

 comparison:  comparison is only able to be made to the study from [**2171-10-28**].  the more recent torso ct from [**2171-12-9**] is not available
 secondary to pacs malfunction.

 ct of the chest with iv contrast:  there are no pathologically enlarged
 axillary, hilar, or mediastinal lymph nodes.  there are no pleural or
 pericardial effusions.  again identified are multiple bilateral pulmonary
 nodules.  one previously seen nodule in the right lung base laterally is not
 visualized on the current study, but the largest nodule, in the left lung
 base, has increased in size.  the bronchi remain patent to the subsegmental
 levels.  the heart and great vessels is unremarkable.

 ct of the abdomen with iv contrast:  there has been marked progression of the
 patient's multiple hepatic masses.  there is some local biliary ductal
 dilatation adjacent to one of the masses in the right lobe.  surgical clips
 are seen in the right renal fossa from prior nephrectomy.  no soft tissue
 density suggestive of disease recurrence is present in this area.  there is a
 slight prominence of the first and second portion of the duodenum, but the
 bowel is not fully opacified, limiting evaluation.  the pancreas and adrenal
 glands, along with the spleen, and stomach are unremarkable.  the left kidney
 enhances uniformly.  there is no filling defect in the left renal pelvis or
 ureter.  no pathologically enlarged mesenteric or retroperitoneal lymph nodes
 are seen.  the descending aorta is calcified.  there is no ascites.

 ct of the pelvis with iv contrast:  the appearance of the cystic structure in
 the right adnexa is unchanged.  again seen is stranding in the presacral fat,
 likely post operative in nature, which is unchanged since [**2171-10-28**].
 the distal left ureter is unremarkable, with a normal appearing left ureteral
 jet.  the bladder is within normal limits.  there is no free fluid in the
 pelvis or pathological inguinal or pelvic lymphadenopathy, although multiple
                                                             (over)

 [**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 small pelvic nodes are seen which do not meet size criteria for pathological
 enlargement by ct scan.  the sigmoid colon and rectum are unremarkable.

 no new suspicious lytic or sclerotic osseous lesions are identified.

 impression:  progression of multiple intrahepatic masses, some of which are
 associated with localized biliary ductal dilatation.  no ascites.  enlargement
 of pulmonary nodule in left lung base.  findings all consistent with
 progression of disease.

"
4643,"[**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   42 year old man with pod#10 s/p ex-lap, small bowel resection x4, found to
  have celiac sprue, t-cell lymphoma on path, now w/ temps post-op, and new pus
  draining from ex-lap wound.
 reason for this examination:
  evaluate for perforations, fluid collections, wound infection.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: celiac  sprue, multiple small bowel resections, now with post
 operative fevers, pus draining from exploratory laparotomy wound.  evaluate
 for intraabdominal abscess or perforation.

 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 contrast.  there were no adverse reactions to contrast
 administration.

 findings:  comparison is made to the study from [**2150-3-2**].

 ct abdomen with iv contrast: again seen is a rounded 4 mm nodule in the right
 lower lobe which is unchanged in appearance.  there is bibasilar atelectasis.
 no focal consolidations suggestive of pneumonia are present.  no focal hepatic
 lesions or splenic lesions are seen.  the pancreas and gallbladder are normal
 in appearance.  both adrenal glands and kidneys are unremarkable.  multiple
 surgical suture lines are seen throughout the small bowel.  there are multiple
 dilated small bowel loops, and enlarged mesenteric lymph nodes.  the
 appearance is unchanged since [**2150-3-2**]. there is no free intraperitoneal
 air. again seen is a heterogeneous area of attenuation in the anterior
 abdominal wall in between the rectus muscles, which measures 13 x 22 mm on
 today's study.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable.  again seen is a small amount of fluid adjacent to the
 sigmoid mesocolon which is slightly smaller than on the previous study.  no
 new intrapelvic abscess is present.  there is no pathologic inguinal or pelvic
 lymphadenopathy.

 impression: no new focal intraabdominal abscess.  stable appearance of
 multiple small bowel resections, with dilated small bowel loops and mesenteric
 lymphadenopathy.

                                                             (over)

 [**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

"
4644,"[**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  32 year old woman with ard and pancreatitis s/p multiple medication overdose
 reason for this examination:
  please check pancreas for necorsis by pancreatitis protocol and evaluate lungs
  for ards
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  multiple medication overdose, with pancreatitis and acute
 respiratory distress.

 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 patient's debility.  there were no adverse reactions to
 contrast administration.

 findings:  reference is made to the portable ap chest x-ray from [**2167-2-16**].

 ct of the chest with iv contrast:  again seen are sternal wires.  the
 orogastric and post-pyloric feeding tubes in appropriate positions.  the
 endotracheal tube is present in satisfactory position.  there are extensive
 bilateral areas of ground-glass opacity and consolidation consistent with
 ards.  there are small bilateral pleural effusions.  no pericardial effusion
 is seen.  oral contrast is seen within the thoracic esophagus, suggestive of
 possible aspiration. there are multiple prominent mediastinal lymph nodes,
 which are likely reactive.

 ct of the abdomen with iv contrast:  no focal hepatic lesions are identified.
 the spleen, adrenal glands, kidneys, stomach, and intra-abdominal loops of
 small and large bowel are unremarkable.  the gallbladder is mildly distended,
 but there is no adjacent stranding to suggest acute cholecystitis.  the
 pancreas enhances symmetrically without adjacent fluid collection.  there is
 minimal stranding adjacent to the pancreatic tail, consistent with the
 patient's known pancreatitis.  there is no ascites or pathological mesenteric
 or retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast: the appendix, distal ureters, sigmoid
 colon, and rectum are within normal limits.  there is a small amount of free
 fluid within the pouch of [**location (un) **].  the bladder contains a foley catheter.
 there is no pathological inguinal or pelvic lymphadenopathy.

 no suspicious lytic or sclerotic osseous lesions are identified.

 impression:
                                                             (over)

 [**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 1)  stranding adjacent to the tail of the pancreas consistent with patient's
 known pancreatitis.  no peripancreatic fluid collection or hematoma or
 abnormal pancreatic perfusion.

 2)  ards.


"
4645,"[**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  44 year old man with all s/p allo-bmt with likely cmv colitis here with new,
  diffuse abdominal tenderness.
 reason for this examination:
  eval for evidence of perforation, other pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 history:  all s/p bone marrow transplant. diffuse abdominal tenderness, likely
 cmv colitis.

 comparison:  no prior ct studies.

 technique:  helically acquired contiguous axial images of the abdomen and
 pelvis were obtained with intravenous optiray per cte  protocol.  however,
 oral contrast was not administered secondary to the patient's inability to
 tolerate po intake or an ng tube, due to esophageal ulcers.  coronal
 reconstructions were performed.

 contrast: 122 cc  of intravenous optray were administered through a right
 antecubital iv catheter. during the initial injection, a few cc's of optiray
 squirted out between the external portion of the iv catheter and the power
 injector tubing. there was no subcutaneous infiltration of optiray. the
 intravenous line remained patent, allowing for normal drawing back of blood
 and flushing with saline.  the power injector was reconnected to the iv
 catheter, and injection of optiray was continued without further
 complications. the intravenous line was removed immediately after the study to
 reduce the risk of infection.  there was no adverse reaction to optiray during
 or immediately following the study.

 abdomen ct with intravenous contrast:  several subcentimeter nodular opacities
 are present at the visualized lung bases.  the largest opacity in the right
 lower lobe measures 8 mm, and the largest opacity in the left lower lobe
 measures  5 mm.  there are no pleural effusions.

 there is diffuse wall thickening in the proximal small bowel, with associated
 stranding and small lymph nodes in the proximal mesentery.  both the proximal
 and distal small bowel is distended with fluid.  however, there is no wall
 thickening in the distal small bowel, including the terminal ileum.  this
 appearance is consistent with enteritis, which may be due to graft-vs-host
 disease or infection.

 there is a 2 mm appendicolith within the appendix.  the appendix does not
 contain any air.  it measures 8 mm in cross-section diameter at the level of
 the appendicolith, but appears smaller distal to the stone. the cecal tip
 appears mildly thickened. there is some periappendiceal stranding, which is
                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)
 less advanced than the stranding in the proximal small bowel mesentery. there
 is no periappendiceal free air or fluid collection. these findings are
 equivocal regarding the presence of appendicitis. there may be mild typhlitis
 at the cecal tip , consistent with graft-vs-host disease. serial clinical
 exams are suggested. if clinically indicated, repeat imaging of the appendix
 may be helpful.

 the remainder of the ascending colon and the transverse colon are distended
 with fluid, without wall thickening.  the descending and sigmoid colon are
 collapsed. there is no free air or free fluid. in addition to the previously
 described proximal mesenteric stranding and small mesenteric lymph nodes,
 there is stranding and small lymph nodes in the para-aortic retroperitoneum.
 the liver, gallbladder, spleen, pancreas, kidneys, adrenal glands and ureters
 are unremarkable.

 pelvis ct with intravenous contrast:  calcifications are seen within the
 prostate gland.  the bladder, seminal vesicles and rectum are unremarkable.
 there is no pelvic or inguinal lymphadenopathy. there is no free fluid.

 bone windows:  there are no suspicious lytic or sclerotic lesions within the
 visualized osseous structures.

 ct reconstructions:  coronal reconstructions confirm the presence of wall
 thickening in the proximal small  bowel, with adjacent mesenteric stranding.

 the findings were discussed with dr. [**last name (stitle) 104418**] at 11:40 pm on [**2140-4-5**].

 impression:

 1)  proximal enteritis, which may represent graft-vs-host disease or
 infection.

 2)  appendicolith.  the appearance of the appendix is equivocal for
 appendicitis.  there may be mild typhlitis. serial abdominal exams are
 suggested. if clinically indicated, repeated imaging of the appendix may be
 helpful.

 3) subcentimeter peripheral nodular opacities at both lung bases, which are
 nonspecific. follow-up is suggested.





                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)




"
4646,"[**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  60 year old man with
 reason for this examination:
  fu aortic dissection and last week 4 d sx sob, chest pain radiating to back
 ______________________________________________________________________________
                                 final report
 indications: followup of aortic dissection. chest pain radiating to back.

 technique: contiguous axial images of the chest and abdomen were acquired
 helically from the lung apices through the proximal common iliac vessels,
 before and after administration of 150 cc of optiray contrast, secondary to
 the rapid bolus injection rate required for ct angiography of the aorta. there
 were no adverse reactions to contrast administration. coronal reformations
 were made.

 findings: comparison is made to the chest cta from [**2178-11-3**].

 ct chest with iv contrast:  again seen are changes from repair of a prior
 aortic dissection, with graft material extending from the aortic root to the
 proximal aortic arch. no extravasation is seen.  previously seen small amount
 of contrast in the false lumen and aortic arch is no longer present. the
 origins of the brachiocephalic, left common carotid, and subclavian arteries
 are all patent. no contrast is seen in the false lumen, until the dome of the
 right hemidiaphragm. there is a tiny circular area of contrast present which
 is not continuous with either the true lumen or the more inferiorly mixing
 contrast within the false lumen. there is symmetrical opacification of the
 true and false lumens by the level of the aortic hiatus in the diaphragm. the
 true lumen perfuses the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left renal artery is fed by both
 the true and false lumens.  the dissection flap extends into both common iliac
 vessels for a longer extent into the left than into the right. there is no
 peri-aortic hematoma or evidence of active extravasation. there are no pleural
 or pericardial effusions. emphysematous changes are seen in the lungs. again
 identified is a small, ill defined right middle lobe nodule which is unchanged
 in appearance. bibasilar atelectasis is seen.  no pathologically enlarged,
 axillary, hilar, or mediastinal lymph nodes are seen.

 ct abdomen with iv contrast: limited evaluation with only one phase of
 contrast shows no focal hepatic or splenic lesions. multiple bilateral renal
 cysts are present which are unchanged in appearance. visualized portions of
 intra-abdominal bowel loops are unremarkable.  the adrenal glands are normal.
 ct reconstructions: coronal reformats show a stable appearance of the aortic
 disection, without definite evidence of leak.

 impression:

 1. status post surgical repair of prior type a dissection. overall, appearance
                                                             (over)

 [**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 is unchanged compared to [**2178-11-3**].  the previously seen small amount of
 contrast in the false lumen in the aortic arch is no longer present.  the true
 lumen supplies the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left kidney is supplied from
 both the false and true lumen. there is a small rounded contrast pocket within
 the false lumen located slightly above the site of mixing, but this is not
 definitely connectable to either the true lumen, or to the mixing contrast.



"
4647,"[**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  55 year old woman with
 reason for this examination:
  55 yo female.  change in bowel habits.  unable to do colonoscopy secondary to
  adverse reactions to sedations.  request ct colonography to screen for colon
  ca.
 ______________________________________________________________________________
                                 final report
 indication:  recent change in bowel habits, unable to tolerate conventional
 colonoscopy secondary to adverse reaction to conscious sedation.  assess for
 colon cancer.

 technique:  contiguous axial images were obtained from the lung bases to the
 pubic symphysis after insufflation of intrarectal air in the prone and supine
 positions.  iv contrast was not administered.

 comparison:  ct abdomen/pelvis of [**2180-9-28**].

 ct colonography:  no suspicious lesions are seen.  there is no evidence of
 polyps, masses, strictures, or inflammatory disease.  there is a small amount
 of fluid within the cecum, descending colon and sigmoid which displaces with
 repositioning.  there is minimal retained fecal matter.

 ct of abdomen w/o iv contrast:  the imaged portions of the lung bases again
 show a 1-2 mm noncalcified nodule of the peripheral right lower lobe.  the
 liver, spleen, pancreas, adrenal glands, kidneys, and unopacified loops of
 small bowel are unremarkable.  there is no free air, free fluid, or
 lymphadenopathy.  the patient has had a previous cholecystectomy.

 ct of pelvis w/o iv contrast:  the rectum, urinary bladder and adnexal regions
 are unremarkable.  there is no free air, free fluid, or lymphadenopathy.

 bone windows:  there are no suspicious osseous lesions.

 multiplanar reformatted images and full endoluminal navigation performed in
 the antegrade and retrograde direction confirm and aid in the above findings.

 conclusion:
 1)  no significant polyp or mass identified (greater than 1 cm).  please note
 that the sensitivity of ct colonography for polyps greater than 1 cm is
 85-90%.  the sensitivity for polyps 6-9 mm is about 60-70%.  flat lesions may
 be missed with ct colonography.

 2)  stable 1-2 mm noncalcified nodule within the right lower lobe, likely
 representing a benign granuloma.  in the absence of any known primary
 malignancies, no further follow up is needed.

                                                             (over)

 [**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
                                 final report
 (cont)

"
4648,"[**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  36 year old man with cerebral palsy, epilepsy and history of recurrent
  aspiration pneumonias now with fever, rll cavitation
 reason for this examination:
  please assess for lung abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  cerebral palsy, epilepsy, and history of recurrent aspiration
 pneumonia.  now with fever, and right lower lobe cavitation on chest x-ray.
 please assess for lung abscess.

 comparison:  no prior chest ct.  chest radiograph of [**2191-11-7**] is
 available for comparison.

 technique:  axial multidetector ct images were obtained from the thoracic
 inlet through the adrenal glands without intravenous contrast.

 chest ct without contrast:  there is extensive consolidation in the right
 middle and lower lobes.  evaluation of these areas is somewhat limited by the
 patient's body habitus, lack of intravenous contrast enhancement, and streak
 artifact from surgical hardware in the spine.  there is a large rounded cavity
 with irregular margins and a fluid level in the right lower lobe, which
 appears most consistent with an abscess.  there are necrotizing areas in the
 adjacent lung in the right lower and middle lobes.  no definite pleural
 disease is seen in this area or in the remainder of the thorax.  there are
 patchy peribronchiolar ground-glass opacities in the dependent portions of the
 left lung, suggestive of aspiration.  paraseptal emphysema is noted in the
 medial left lower lobe.

 the airways appear patent to the level of segmental bronchi.  there is no
 mediastinal or axillary lymphadenopathy.  the heart and great vessels appear
 unremarkable.

 there is high-density material layering within the gallbladder, suggestive of
 previously administered intravenous contrast.  the patient did not have any
 radiology studies with intravenous contrast at our institution. alternatively,
 this finding may represent unusually dense sludge or stones. clinical
 correlation is suggested. there is a hiatal hernia.  there are gas-distended
 bowel loops in the upper abdomen.  clinical correlation is suggested.
 evaluation of the visualized portions of the liver, spleen, pancreas, adrenal
 glands, and kidneys is limited by streak artifact from the [**location (un) 1354**] rod in
 the spine. no abnormalities are detected.  marked scoliosis is noted.

 the findings were discussed with dr. [**last name (stitle) 25949**] at 10:50 a.m. on [**2191-11-8**].

 impression:
                                                             (over)

 [**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
                                 final report
 (cont)

 1.  necrotizing right middle and lower lobe pneumonia with a large abscess in
 the right lower lobe.

 2.  patchy ground-glass opacities in the left lung, with appearance suggestive
 of aspiration.

 3.  dense material in the gallbladder, which may represent intravenous
 contrast or unusually dense sludge or stones.  contrast in the gallbladder
 could represent an adverse reaction to intravenous contrast, or it may be seen
 in renal failure.

 4.  gas-distented bowel loops, incompletely assessed. consider dedicated
 abdominal radiograph series.

 5.  hiatal hernia.


"
4649,"[**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  72 year old woman pod4 from r. colectomy for cecal mass, now with fevers,
  tachycardia, incr abd distention, tenderness
 reason for this examination:
  assess for leak, collections
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  72-year-old female with abdominal distention.

 comparisons:  comparison is made to ct of the abdomen from [**2126-11-19**] and ct
 of the abdomen from [**2126-11-14**].

 technique:  ct of the abdomen and pelvis with oral and iv contrast.  150 cc of
 optiray 350 were administered without adverse reaction.

 coronal reconstructions were performed.

 ct of the abdomen with oral and iv contrast:  there are mild atelectatic
 changes in the right base.  there are no pleural effusions.  there is a small
 hiatal hernia.  there is no pericardial effusion.  the liver is slightly
 fatty.  however, there are no focal lesions.  there are two gallstones within
 the gallbladder.  there is no evidence of cholecystitis.  the spleen, adrenal
 glands are unremarkable.  there is a small hypodense area in the mid pole of
 the right kidney that was not completely evaluated in this study.  although
 statistically, it most likely represents a simple cyst, ultrasound could be
 performed to further evaluate this.

 there is a large transverse incision in the right aspect of the abdomen. there
 is fluid and air in the subcutaneous tissues, which could be postoperative.
 however, infection cannot be excluded on the basis of the ct scan.

 the proximal small bowel loops contain contrast and are dilated.  the distal
 small bowel loops are slightly decompressed.  however, there is contrast in
 the distal small bowel loops and the appearance most likely represents an
 ileus.  there are staples in the splenic flexure of the colon from prior right
 colectomy.  there are several slightly thickened small bowel loops, however,
 this appearance could be postoperative.  there is no evidence of free air or
 fluid collections within the abdomen.

 ct of the pelvis with oral and iv contrast:  there are multiple diverticula
 within the colon without evidence of diverticulitis.  as described above, the
 same postoperative changes are present in the pelvis.  there are also multiple
 mesenteric lymph nodes that are small and do not meet ct criteria for
 pathology.  there is no significant free fluid in the pelvis.  there is a
 foley catheter within the urinary bladder, which contains air.  the rectum is
                                                             (over)

 [**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
                                 final report
 (cont)
 unremarkable.

 bone windows:  there are no suspicious lytic or blastic lesions.

 impression:

 1.  postoperative changes as described above.  fluid and air in subcutaneous
 tissues could be postoperative, but infection cannot be excluded by ct scan.

 2.  mildly dilated loops of small bowel likely representing ileus.

 3.  multiple small mesenteric lymph nodes as described above.  they do not
 meet ct criteria for pathology and attention at followup is recommended.

 4.  multiple gallstones.

 5.  fatty liver without focal lesions in the liver.

 6.  diverticular disease without evidence of diverticulitis.

 7.  small hypodense area in the mid pole of the right kidney was not
 completely evaluated in this study.  although statistically, it most likely
 represents a simple cyst, ultrasound could be performed to further evaluate
 this.

"
4650,"[**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old man with group g strep sepsis and unknown source
 reason for this examination:
  abscess?  gi pathology which might cause bacteremia?
 contraindications for iv contrast:
  esrd, gets hd on mondays, needs to have hd after scan;esrd, hd on mondays
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2186-7-31**] 11:56 pm
  1. no acute intra-abdominal process.
  2. ragged appearance of l4-l5 intervertebral disc endplates - this can be seen
  in discitis - correlate with patient's clinical condition.
 pfi version #1 jekh mon [**2186-7-31**] 12:59 pm
  no acute intra-abdominal process; specifically no evidence of a bacteremic
  source.
 ______________________________________________________________________________
                                 final report
 history:  45-year-old male with group g strep sepsis, an unknown source.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was given without complication or adverse reaction.
 coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  visualized portion of the lung bases appears unremarkable.

 the liver shows no focal lesion or biliary duct dilation.  the gallbladder is
 decompressed.  the spleen is normal in size and appearance.  pancreas shows no
 surrounding fluid collection.  the adrenal glands are normal appearing
 bilaterally.

 the kidneys enhance with and excrete contrast symmetrically without evidence
 of hydronephrosis or perinephric fluid collection.  in the inferior pole of
 the right kidney is a hypodensity that is too small to characterize but likely
 represents a simple cyst.

 the small and large intestine show no evidence of obstruction or wall edema.
 the appendix is visualized and is normal.  there is no free air, free fluid,
 or lymphadenopathy.

 pelvis:  the bladder, prostate, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.

 bones:  there are no aggressive appearing lytic or sclerotic lesions.
 moderate degenerative changes are seen throughout the lumbar spine.  anterior
                                                             (over)

 [**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 osteophytes are also noted throughout the lumbar spine.  at the l4-l5 level,
 there is enplate sclerosis, likely degenerative, however there is ragged or an
 erosive/destructive appearance to the adjacent endplates with mild soft tissue
 prominence anteriorly.

 impression:
 1. no acute intra-abdominal or intra-pelvic process.
 2. abnormal appearance of l4-l5 level, as described above, concerning for
 discitis/ostemyelitis - correlate with patient's clinical condition.

 findings discussed with [**first name8 (namepattern2) **] [**last name (un) 29352**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone at 8:49 am
 on [**2186-8-1**].

"
4651,"[**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old man with fall from roof, unequal bps
 reason for this examination:
  pls evaluate aortic arch
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2189-8-17**] 4:50 pm
  chest:
  1. 50% r anterior ptx w/ mediastinal shift and compressive effects on both
  lungs; r chest tube enters low and is oriented in posterior pleural space
  (away from ptx).
  2. no l ptx.
  3. no aortic or injury.
  4. extensive r chest wall emphysema.
  5. r posterolateral rib fx [**3-24**]; l posterolateral rib fx [**8-24**]; r clavicle fx.

  abdomen/pelvis:
  1. worsening hepatic and splenic lacerations w/ growing perihepatic and
  perisplenic hematomas - active extrav around spleen; small amt blood tracking
  along b paracolic gutters.
  2. prominent r adrenal gland - ? hematoma.
  3. no free intraabdominal air.
  4. extensive r abd/flank wall emphysema extending into r groin; early r flank
  hematoma.
  5. no spine or pelvic fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  75-year-old male with fall off roof of rv.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was given without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  torso ct from [**2189-8-17**], from an outside hospital at
 1304.

 findings:

 chest:  the patient is intubated with the tube terminating in the mid trachea.
 there is a pneumothorax involving 50% of the right hemithorax and is situated
 mostly anteriorly.  a chest tube placed on the right exists in the posterior
 pleural space, but does not come in contact with this pneumothorax.  there is
 severe mass effect on the right lung, mediastinum and left lung, consistent
 with tension pneumothorax.  additionally, extensive pneumomediastinum and
 pneumopericardium is noted.  both lungs demonstrate extensive atelectasis
 primarily in their lower lobes.  the heart shows no pericardial effusion.
 there is no mediastinal hematoma.  the aorta demonstrates no evidence of
                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 dissection.  there is no contrast extravasation.  extensive chest wall
 emphysema is demonstrated.

 abdomen:  multiple liver lacerations are demonstrated in segments v, vi, vii
 and viii with surrounding dense fluid around the liver and tracking along the
 right paracolic gutter.  a single focus of peripheral contrast blush is
 demonstrated in segment viii (2; 41), concerning for active extravasation.
 this appearance appears worse and has progressed from prior ct.

 multiple splenic lacerations are demonstrated with a growing surrounding
 splenic hematoma.  additionally, multiple areas of contrast blush are noted,
 concerning for active extravasation.  this fluid tracks along the left
 paracolic gutter.  this too represents an increase from prior study.

 thickening of the head of the right adrenal gland is compatible with hematoma.

 the kidneys enhance with and excrete contrast symmetrically.  there are no
 perinephric fluid collections.  pancreas appears unremarkable.  the small and
 large intestine show no evidence of obstruction or wall thickening.  there is
 no free air.  the abdominal aorta is intact.

 continued subcutaneous emphysema and a developing right flank hematoma are
 demonstrated along the right abdominal wall.

 pelvis:  the bladder contains locules of gas and a foley balloon.  the
 prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.  gas tracking along the right abdominal wall tracks down into
 the right groin.

 bones:  multiple segmental fractures are demonstrated in the right
 posterolateral ribs from the third rib through the twelfth rib; there is
 additionally a fracture of the right clavicle.  multiple posterolateral rib
 fracture is also noted in the left ribs 9 through 12 although they appear to
 be older in age.  no acute left rib fracture is seen.  no spinal fracture is
 demonstrated.  the sternum is intact.  the pelvis is intact.  a total hip
 arthroplasty on the left is in place without evidence of periprosthetic
 fracture or loosening.

 impression:
 1.  right tension pneumothorax; right chest tube and posterior pleural space,
 not evacuating this pneumothorax; mediastinal deviation and compression of the
 right and left lungs are concerning for tension pneumothorax.
 pneumomediastinum and pneumopericardium is also present along with extensive
 right chest and abdominal wall subcutaneous emphysema extending into the
 groin.

                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  extensive hepatic and splenic lacerations with growing perihepatic and
 perisplenic hematomas with areas concerning for active extravasation.

 points 1 and 2 were called to or 15 at the time of dictation to make the
 operating team aware.

 3.  multiple segmental rib fractures on the right; the potential for flail
 chest exists.  right clavicular fracture.

 4.  right adrenal hematoma.

"
4652,"[**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  36 year old woman with hemorrhagic pancreatitis s/p ercp for choledochal cyst
  s/p ex-laps/washouts, perc drain drain removed on [**2129-10-10**].
 reason for this examination:
  please do a ct scan of the abdomen and pelvis w/ oral and iv contrast to assess
  for recurrent collection. patientis having ongoing pain. please page dr. [**first name8 (namepattern2) **]
  [**last name (namepattern1) 1350**] w/ a wet read, thanks.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  36-year-old female with choledochal cyst status post ercp,
 complicated by hemorrhage pancreatitis and persistent fluid collection, now
 with percutaneous drain removed with recurrent abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; optiray 350 intravenous
 contrast was administered without complication or adverse reaction.  coronal
 and sagittal reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis with contrast from [**2129-8-26**].

 findings:

 abdomen:  the visualized portion of the lungs appears unremarkable.

 the liver demonstrates no defined hypodensity measuring 15 x 9 mm in the axial
 plane (4; 15), which is incompletely characterized but similar appearance to
 prior study.  again is seen fusiform aneurysmal dilatation of the cbd
 measuring 39 x 20 mm in the axial plane, compatible with a type 1 choledochal
 cyst.  the gallbladder is decompressed.  the spleen, pancreas and adrenal
 glands appear unremarkable.

 multiple fluid collections are seen in the abdomen.  two fluid collections
 just beneath the hepatic flexure of the colon are seen measuring 22 x 15 and
 44 x 11 mm in the axial plane (4; 33).  these are slightly decreased in size
 when compared to prior study.  further down in the right mid to lower abdomen
 is a larger fluid collection measuring 44 x 25 mm in the axial plane; two
 smaller fluid collections are seen lateral to it measuring 16 x 14 mm (4; 43)
 and 18 x 13 mm (4; 45).  these fluid collections are thick rimmed and
 peripherally enhancing.  there is extensive inflammatory fat stranding around
 them.  there is extensive right colonic wall thickening and pericolonic
 stranding, compatible with reactive change.  additionally, reactive fluid
 stranding around the right kidney represents reactive change.  there is no
 free air.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  no free fluid
 or lymphadenopathy is seen.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 multiple abdominal fluid collections as described above, concerning for
 abscesses, the largest of which measures 4.4 x 2.5 cm in the axial plane and
 is amenable to percutaneous drainage from an anterior approach.  these
 findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 1350**] at 16:40 on [**2129-10-18**] by [**first name8 (namepattern2) 405**]
 [**last name (namepattern1) 406**] over the phone.

"
4653,"[**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  51f s/p polytrauma, mult bilateral rib fx, bilateral ptx, now with bilateral
  chest tubes
 reason for this examination:
  pls assess residual ptx
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh tue [**2116-10-27**] 3:46 pm
  pfi:
  1.  worsening bilateral pneumothoraces; chest tubes within the major fissures
  bilaterally, but the right one has a side hole outside of the chest cavity.
  significant collapse of portions of the right upper and right lower lobes.
  extensive chest wall emphysema.
  2.  unchanged bilateral rib and lumbar transverse process fractures; complex
  pelvic fracture better evaluated on pelvic ct performed on same day.
  minimally displaced sternal fracture.
  3.  retroperitoneal and right paracolic fluid; thickening of the cecal wall
  likely represents an injury to the bowel, such as bowel wall hematoma.
  4.  no evidence of left renal injury.
 pfi version #1 jekh tue [**2116-10-27**] 2:51 pm
  pfi:
  1.  worsening bilateral pneumothoraces; current chest tubes still within the
  major fissures bilaterally.  significant collapse of portions of the right
  upper and right lower lobes.
  2.  unchanged bilateral rib and lumbar transverse process fractures; complex
  pelvic fracture better evaluated on pelvic ct performed on same day.
  minimally displaced sternal fracture.
  3.  retroperitoneal and right pericolic fluid extending from the pancreatic
  head, likely representing an injury in that location; thickening of the cecal
  and internal ileal walls either represents reactive changes from the
  aforementioned fluid versus an injury to the bowel:
  4.  no evidence of left renal injury.
 ______________________________________________________________________________
                                 final report
 history:  a 51-year-old female with multiple traumatic injuries including
 bilateral pneumothoraces with chest tubes.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  trauma torso ct from [**2116-10-25**].

 findings:

 chest:  the patient is still intubated with the endotracheal tube in
 appropriate position.  an endogastric tube courses inferiorly to the distal
                                                             (over)

 [**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 esophagus (2; 48).

 bilateral chest tubes are seen, both entering the major fissures; the right
 one has a side hole outside of the chest cavity (2;23).  bilateral
 pneumothoraces have increased significantly from prior study, now encompassing
 40% of the right hemithorax and about 20% of the left hemithorax. neither
 chest tube sits within the pneumothoraces which are both positioned
 anteriorly, extensive subcutaneous gas has progressed tracking along the
 anterolateral chest wall.  there is no mediastinal shift or diaphragmatic
 flattening.  there is significant atelectasis of the right upper and right
 lower lung lobes.

 there is no pleural or pericardial effusion.  the aorta appears intact.
 minimal mediastinal hematoma persists in the region of a minimally displaced
 sternal fracture (2; 31).

 abdomen:  there is no perihepatic or perisplenic fluid.  the gallbladder
 demonstrates vicarious contrast excretion, indicating a degree of renal
 failure.  the adrenal glands are normal bilaterally.  the previously described
 suspected left lower pole renal contusion has resolved.

 the pancreas appears intact.  there continues to be retroperitoneal fluid
 extending from the head down to the right flank/paracolic gutter.  this fluid
 is not increased from prior study.  there is thickening of the cecal wall,
 possibly represent an injury to the bowel in that locale.  there is no free
 air.

 the previously described subcutaneous emphysema in the chest extends down into
 the left flank.

 pelvis:  streak artifact from external pelvic fixation hardware limits
 assessment of fine detail of the pelvis.  within that limitation, the bladder
 is somewhat decompressed around a foley balloon.  there continues to be a
 fibroid uterus and the rectum is unremarkable.  there is still a small amount
 of free fluid in the pelvis.  additionally, there is subcutaneous gas in the
 right inguinal region as well as anterior to the pubic symphysis, likely the
 sequelae of hardware placement.

 bones:  again multiple rib fractures are seen affecting the anterolateral
 portions of the right first through seventh ribs and the left first through
 eighth ribs.  the previously described fracture of the right clavicle is not
 well visualized on the current study.  again seen are left transverse process
 fractures of the left lumbar vertebrae, first through fifth.  again seen is a
 severe pelvic fracture with significant displacement about the pubic symphysis
 and right sacroiliac joint and comminuted fracture fragments at the right
                                                             (over)

 [**2116-10-27**] 9:47 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44061**]
 reason: pls assess residual ptx
 admitting diagnosis: pelvic fracture
  contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 iliac crest.  this structure is better evaluated on the pelvic ct performed on
 the same day in which specific bone algorithms were used.

 impression:
 1.  worsening bilateral pneumothoraces.  this finding was discussed with
 [**first name8 (namepattern2) 2763**] [**last name (namepattern1) 2764**] at 11:42 am on [**2116-10-27**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
 2.  chest tubes within the major fissures bilaterally, but the right one has a
 side hole outside of the chest cavity.  significant collapse of portions of
 the right upper and right lower lobes.  extensive chest wall emphysema.
 3.  unchanged bilateral rib and lumbar transverse process fractures; complex
 pelvic fracture better evaluated on pelvic ct performed on same day. minimally
 displaced sternal fracture.
 4.  retroperitoneal and right paracolic fluid and thickening of the cecal
 wall is compatible with contusion. there is no free air to suggest perforation
 5. no evidence of left renal or pancreatic injury.

 findings 2, 4, and 5 were discussed with [**first name4 (namepattern1) 1789**] [**last name (namepattern1) 4749**] at 15:53 on [**2116-10-27**] by
 [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


"
4654,"[**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old woman with ho diverticulitis with abd pain ttp llq
 reason for this examination:
  pls eval ro acute proc
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**hospital 5197**] fri [**2163-8-19**] 12:03 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 wet read version #1
 wet read version #2 [**first name9 (namepattern2) 5197**] [**doctor first name 73**] [**2163-8-18**] 8:16 pm
  s/p partial colectomy; no diverticulitis or abscess.

 ______________________________________________________________________________
 provisional findings impression (pfi): [**year (4 digits) 5197**] fri [**2163-8-19**] 12:02 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 ______________________________________________________________________________
                                 final report
 history:  75-year-old female with a history of diverticulitis, now with left
 lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with iv contrast; 130 cc of optiray
 intravenous contrast was given.  there was no adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases demonstrate a 6 mm pulmonary nodule.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder is distended but shows no stones or wall edema.  the spleen is
 normal in size.  the pancreas shows no masses.  bilateral adrenal nodules,
 each about 1 cm, are incompletely characterized.  the kidneys enhance with and
 excrete contrast symmetrically.  at the superior pole of the left kidney is a
 well-circumscribed hypodensity measuring 3 cm in diameter, most compatible
                                                             (over)

 [**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 with a simple cyst.

 the small and large intestines show no evidence of obstruction.  the appendix
 is normal.  anastomosis is seen in the distal colon, most compatible with
 prior sigmoid resection.  there is no free air or free fluid.  scattered tiny
 fat-containing midline hernias are noted.

 pelvis:  the bladder and rectum appear unremarkable.  the patient is status
 post hysterectomy.  there is no free fluid or lymphadenopathy.  bilateral
 fat-containing inguinal hernias are noted.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  status post sigmoid colectomy without evidence of complication.  no
 evidence of diverticulitis.
 2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
 factors (non-smoker and no cancer history), follow-up ct in one year is
 recommended to document stability.
 3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
 for further evaluation.

 findings discussed with [**first name5 (namepattern1) 5296**] [**last name (namepattern1) 5297**] 12:05 am on [**2163-8-19**] by [**first name8 (namepattern2) 873**]
 [**last name (namepattern1) 5298**] over the phone.

"
4655,"[**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 46m with abd pain, n/v
 reason for this examination:
  r/o appy, other acute intraabdominal process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2200-3-29**] 7:08 pm
  inflammed duodenum w/ surrounding fluid and focal area of wall discontinuity,
  concerning for contained duodenal perforation; no free air; normal appendix

 wet read version #1
 wet read version #2 jekh sat [**2200-3-29**] 6:23 pm
  duodenitis; no free air; normal appendix

 ______________________________________________________________________________
                                 final report
 history:  46-year-old male with abdominal pain, nausea and vomiting.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the lung bases are clear.

 the liver contour is nodular with caudate and left lateral lobe hypertrophy
 and atrophy of the right posterior lobe of the liver, compatible with
 cirrhosis.  there is no intrahepatic biliary dilatation or definite focal
 hepatic lesion. portal vein is patent. calcified stones within the gallbladder
 fundus and neck are present.  there is no wall edema or pericholecystic
 stranding.  the spleen is normal in size and appearance.  the adrenal glands
 show no nodules.  the kidneys enhance with and excrete contrast symmetrically;
 subcentimeter hypodensities in both kidneys are too small to characterize,
 likely representing cysts; focal cortical scarring in the left kidney is
 compatible with prior infection or infarction.

 there is marked wall thickening and extensive surrounding fat stranding and
 mural edema involving the distal stomach and proximal duodenum, centered about
 the duodenal bulb.  a focal outpouching of the duodenal bulb is present,
 concerning for an ulcer, less likely a diverticulum.  no free air is seen,
 though a fluid collection is noted posterior to the distal stomach in the
 lesser sac measuring 19 x 19 mm.  the pancreatic head is adjacent to this
 inflammatory process and appears indistinct, although the pancreatic body and
 tail are also mildly atrophic.

 the remainder of the small and large bowel show no evidence of wall edema or
 obstruction.  the appendix is normal.  there is no lymphadenopathy or free
                                                             (over)

 [**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 air.

 pelvis:  gas is seen in the bladder and correlation with recent
 catheterization is recommended.  the prostate and rectum appear unremarkable.
 there is no free fluid or lymphadenopathy. small bilateral fat containing
 inguinal hernias are present.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. findings concerning for a contained perforation of a duodenal bulb ulcer
 with adjacent surrounding inflammation and associated duodenitis.  small focal
 fluid collection is present in the lesser sac. findings discussed with [**first name8 (namepattern2) **]
 [**known firstname **] at 19:00 [**2200-3-29**] by [**first name8 (namepattern2) 510**] [**last name (namepattern1) 5773**] over the phone.

 2. cirrhosis.

 3. cholelithiasis.

 4. gas within the bladder lumen. correlate with any history of recent
 instrumentation; otherwise, findings are concerning for an infectious process.

"
4656,"[**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  50 year old woman with pedestrain struck by tow truck. no obvious injury other
  than head lac
 reason for this examination:
  trauma?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2133-3-19**] 7:55 pm
  1. no intrathoracic injury.
  2. distended stomach but no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old female pedestrian struck by a tow truck.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of thyroid demonstrates a 5-mm hypodensity in
 the left lobe of the thyroid (2; 6).  there is no axillary, hilar, or
 mediastinal lymphadenopathy.  the aorta is of normal caliber along its course
 without evidence of dissection or injury.  no mediastinal hematoma is present.
 the pulmonary arterial tree shows no central filling defect.  there is no
 pleural or pericardial effusion.  the lungs show a subtle ground-glass opacity
 in the right lower lobe which may represent an area of contusion or
 aspiration.  there is no pneumothorax.

 abdomen:  an area of enhancement in the left lobe of the liver likely
 represents a hemangioma or perfusion anomaly (2;50).  the gallbladder, spleen,
 pancreas, and adrenal glands appear unremarkable.  there is no perihepatic,
 perisplenic, or pericolic fluid.  there is no free fluid or free air.  the
 kidneys enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; bilateral subcentimeter hypodensities are too small to
 characterize but likely represent cysts.  the aorta is of a normal caliber
 along its course without evidence of injury.  small and large bowels show no
 evidence of wall edema or obstruction; the stomach, however, is notably
 distended with gas.

 pelvis:  the bladder is decompressed.  the uterus and rectum appear
 unremarkable.

 bones:  there is no acute fracture; old left rib fractures are present.  there
                                                             (over)

 [**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  small nonspecific area of ground glass in the right lung.  otherwise
 essentially unremarkable exam without acute intra-abdominal or intrathoracic
 injury; no acute fracture.
 2.  distended stomach may benefit from ng tube.

"
4657,"[**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 65f with clinical question:
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2142-3-17**] 11:09 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; surrounding hematoma but no pelvic free fluid; hematoma along l medial
  thigh as well; hairline fx through l iliac w/ probable involvement of l si
  joint, but no sacral fx.
 wet read version #1
 wet read version #2 jekh sat [**2142-3-17**] 10:25 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; hairline fx through l iliac w/ probable involvement of l si joint, but
  no sacral fx.
 ______________________________________________________________________________
                                 final report
 history:  65-year-old female pedestrian status post struck by suv.

 study:  ct of the torso with contrast; coronal and sagittal reformatted images
 were also generated.  130 cc of omnipaque 350 intravenous contrast was
 administered without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  the aorta is of normal caliber along its course without evidence of
 injury; incidental note is made of a common origin of the brachiocephalic and
 left common carotid arteries, a normal variant (2a; 14).  the pulmonary artery
 shows no central filling defects.  there is no pleural or pericardial
 effusion.  the lungs are clear without evidence of contusion.  there is no
 pneumothorax.

 abdomen:  a subcentimeter hypodensity in the dome of the liver is too small to
 characterize but likely represents a cyst rather than a contusion/laceration
 as there is no perihepatic fluid.  a subcentimeter hypodensity in the
 periphery of the spleen also likely represents a cyst or hemangioma rather
 than a contusion or laceration as there is no perisplenic fluid.  the pancreas
 and adrenal glands appear unremarkable.  the kidneys enhance with and excrete
 contrast symmetrically; a well-circumscribed 1-cm hypodensity in the mid pole
                                                             (over)

 [**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 of right kidney is most compatible with a simple cyst.  there is no
 retroperitoneal fluid collection.  the small and large bowel show no evidence
 of obstruction or injury.  there is no free air or free fluid.  the abdominal
 aorta is of normal caliber along its course without evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.  the left obturator musculature is thickened,
 likely representing intramuscular or contained hematoma.  additional
 incompletely image hematoma of the medial left thigh is present.

 bones:  there is a burst fracture of the l1 vertebral body with 8-mm
 retropulsed fragments into the central canal.  additionally, a minimally
 displaced fracture is present along the right aspect of the lamina of l1.  a
 small amount of adjacent hematoma is seen around the anterolateral aspects of
 the vertebral body.  loss of height is approximately 50%.

 additionally, minimally displaced fractures of the left superior and inferior
 pubic rami are present; the lateral aspect of the superior pubic rami is
 fractured while the medial aspect of the inferior pubic rami is fractured.
 additionally, a hairline fracture is present along the left iliac bone just
 adjacent to the si joint and extending into the si joint on the left.  the
 sacrum itself appears intact.

 impression:
 1.  no acute intra-abdominal or intrathoracic injury.
 2.  l1 burst fracture with retropulsed fragments and minimally displaced
 fracture of the right l1 lamina; these findings suggest an unstable fracture
 and if clinical concern for cord injury exists, mr would be recommended.
 3.  fracture of the left pelvis as described above.

 these findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 7304**] in person at 10:00 a.m. and
 again at 11:05 a.m. by phone on [**2142-3-17**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
4658,"[**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  52m, h/o longstanding crohn's, started on [**first name9 (namepattern2) 22562**] [**2187-2-3**], has had better but
  incomplete control (all to remicaid).  has had a couple flares in the interum.
  returns today with s/s c/w flare.  c/o increased abd pain, esp in lrlq to deep
  palpation.  denies f/c/v, does c/o n/d which is normal for pt.  does report
  lrlq pain immidiately after eating or drinking nearly every time.  pt states
  otherwise, he feels well.  with dirty uaiv/po contrast pleaseplease eval
  kidneys and bowel,
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2188-3-22**] 6:43 pm
  1. s/p cholecystectomy, splenectomy, and total colectomy.
  2. l-sided loop of bowel w/ thickened wall and surrounding inflammation, c/w
  crohn's flare; no abscess.
  3. mild perinephric stranding but no e/o pyelonephritis or perinephric fluid
  collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with a history of crohn's disease, now with
 abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  oral contrast was also administered.

 coronal and sagittal reformatted images were also generated.

 comparison:  [**2186-11-29**].

 findings:

 abdomen:  the visualized portion of the lung bases are clear.  the liver shows
 no focal lesion or intrahepatic biliary dilatation.  clips in the gallbladder
 fossa compatible with prior cholecystectomy.  the spleen is surgically absent.
 pancreas shows no masses.  the adrenal glands show no nodules.  the kidneys
 enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; minimal perinephric stranding is present without an organized
 fluid collection or striated nephrogram.  patient is status post total
 colectomy without evidence of obstruction.  loops of bowel in the left abdomen
 demonstrate thickened wall with subtle surrounding fat stranding.  possible
 early phlegmon may be present in the left lower abdomen (2:54,601:38) without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude.  nearby scattered mesenteric lymph nodes are seen.  equivocal
 tethering of bowel loops in this area is also noted.  trace amount of reactive
 fluid is also seen in the mesentery.  there is no free air.  incidental note
                                                             (over)

 [**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is made of ventral abdominal wall mesh.

 pelvis:  the bladder and prostate appear unremarkable.  there is a transition
 in the diameter of the lumen from the small bowel to the rectosigmoid colon
 region through which contrast is passing (2; 62).  there is no free fluid or
 lymphadenopathy in the pelvis.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 intervertebral discs
 primarily in the form of vacuum phenomenon and endplate sclerosis.

 impression:
 1. status post cholecystectomy, splenectomy, and total colectomy.
 2. left-sided bowel with wall thickening and surrounding inflammation; given
 patient history compatible with an inflammatory process such as the patient's
 known crohn's disease.  infection might have a similar appearance .
 possible early phlegmon may be present in the left lower abdomen without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude. mre is more sensitive and may be helpful for further evaluation.

"
4659,"[**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  [**age over 90 **] year old woman with mcv, positive fast
 reason for this examination:
  bleeding?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2102-1-26**] 4:38 pm
  1. r [**5-21**] lateral rib fx and l [**3-22**] lateral rib fx (segmental fx in l 9 and
  10).
  2. splenic lac and contusion; possible small liver lac; hemoperitoneum.
  3. dense fluid near r colon may represent contusion; no active extrav seen to
  suggest vascular injury.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  [**age over 90 **]-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  outside hospital ct of the torso without contrast from [**1-26**], [**2101**] at 13:43.

 findings:

 chest:  the visualized portion of the thyroid gland shows bilateral
 hypodensities in each lobe for which ultrasound may be considered if
 clinically indicated.  there is no axillary, mediastinal, or hilar
 lymphadenopathy.  the aorta is of normal caliber along its course without
 evidence of dissection or mediastinal hematoma.  the pulmonary arterial trunk
 shows no central filling defect.  the heart size is within normal limits
 without pericardial effusion.  there is no significant pleural effusion.  the
 lungs demonstrate bibasilar atelectasis but no consolidation or contusion.  a
 small hiatal hernia is present.

 abdomen:  a hypodense streak along the dome of the liver is equivocal for
 laceration versus a lobulation (2; 32-39).  extensive dense fluid is seen
 around the liver and spleen.  the uppermost portion of the spleen demonstrates
 a vertically oriented hypodensity that may represent a laceration (601b; 32).
 more inferiorly in the spleen is a hypodensity oriented in the ap dimension
 that may represent either laceration or lobulation (2; 45 and 601b; 38).  at
 the very least, there is a splenic contusion (602b; 54).  a calcified splenic
 artery aneurysm is noted measuring 9 mm in diameter (2; 46 and 601b; 28).

 a duodenal diverticulum is present.  the pancreatic duct appears contiguous
 and there is no peripancreatic fluid; the pancreas is atrophic.  the right
 adrenal gland appears normal; the left adrenal gland demonstrates a rounded
                                                             (over)

 [**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 soft tissue density measuring 13 mm in diameter that is incompletely
 characterized (2; 48) - ct or mr may be considered as clinically indicated.
 the kidneys enhance with contrast symmetrically without evidence of
 perinephric fluid.  incidental note is made of a calcified aneurysm of the
 left renal artery (2; 52) which measures 7 mm in diameter.

 the small bowel shows no areas of wall edema.  no free air is seen.  the large
 bowel demonstrates diverticulosis, but no evidence of bowel wall edema.
 complex fluid is seen sitting adjacent to the right colon (2; 61) within the
 mesentery (2; 62 and 601b; 26) and along a loop of jejunum.  a
 small-to-moderate amount of dense fluid is seen coursing throughout the
 mesentery and along the paracolic gutters.

 the aorta is of a normal caliber along its course without evidence of injury
 or active extravasation.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  dense free
 fluid seen in the pelvis, contiguous with that seen in the abdomen.  a
 left-sided [**doctor last name 13736**] hernia is present (2; 91).

 bones:  multiple minimally displaced fractures are present in the lateral
 aspects of the right ribs 6, 7, 8, 9, and 10 and in the left ribs 4 through
 11; of note, the fractures in left ribs 9 and 10 are segmental in nature.
 there does not appear to be an acute injury to the spine, although multilevel
 degenerative changes are present.  the clavicles are intact bilaterally.  the
 sternum is intact.  the pelvis and proximal femurs are intact.

 impression:  multiple rib fractures as described above with possible splenic
 (and less likely hepatic) lacerations with hemoperitoneum tracking along the
 right colon and jejunum concerning for bowel injury.  findings were discussed
 with [**first name4 (namepattern1) 9505**] [**last name (namepattern1) 612**] at 4 p.m. on [**2102-1-26**] in person by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
4660,"[**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 43f with mvc, supobtimal fast,abrasion to abdomen, unrestrained
  driverclinical question: ? intrabdominal injury
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2150-3-5**] 5:33 pm
  1. bilateral dependent pulmonary edema.
  2. no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  42-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of normal caliber along its course without evidence of injury or
 mediastinal hematoma.  the pulmonary arterial tree shows no central filling
 defect.  the heart size is within normal limits and there may be trace
 pericardial fluid.  the lungs are clear of consolidation.  bibasilar
 ground-glass opacities, likely representing dependent edema. less likely
 contusions.  there is no pleural effusion or pneumothorax.

 abdomen:  the liver, spleen, adrenal glands, and pancreas appear normal.
 gallstones are present.  there is no perihepatic, perisplenic or pericolic
 gutter fluid.  there is no fluid in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically.  there is no free air or lymphadenopathy.
 the aorta is of normal caliber along its course of the abdomen without
 evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  foley catherter
 in place.  there is no free fluid or lymphadenopathy.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.  a wedge
 deformity in the t11 vertebral body is of indeterminate age but shows no
 retropulsed fragments or adjacent hematoma.

 impression:
 1.  dependent regions of ground glass in the lungs may represent edema, less
 likely contusion.  otherwise no evidence of intrathoracic or intra-abdominal
 injury.
                                                             (over)

 [**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  t11 wedge deformity of indeterminate age - correlate clinically.
 3.  cholelithiasis.

"
4661,"[**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  24 year old man with s/p mvc and was ejected from vehicle +etoh
 reason for this examination:
  ?intrathoracic or intraabdominal injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2186-1-28**] 6:33 am
  1. no intrathoracic injury.
  2. small subcapsular hematoma of liver (2:43 and 301b:25); no free fluid in
  abdomen or pelvis.
  3. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 wet read version #1
 wet read version #2 jekh sat [**2186-1-28**] 6:27 am
  1. no intrathoracic or intraabdominal injury.
  2. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 ______________________________________________________________________________
                                 final report
 history:  24-year-old male status post mvc and ejected from vehicle.
 left-sided upper extremity weakness.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.

 comparison:  none.

 findings:

 the visualized portion of the thyroid appears normal.  there is no axillary,
 hilar, or mediastinal lymphadenopathy.  the aorta is of a normal caliber along
 its course without evidence of mediastinal hematoma.  the pulmonary arterial
 trunk is of a normal caliber with no central filling defect.  the heart shows
 no pericardial effusion.  there is no pleural effusion or pneumothorax.  the
 lungs are clear.

 abdomen:  there is no free fluid around the liver or spleen or tracking along
 the paracolic gutters.  the spleen, pancreas, adrenal glands, and kidneys
 appear normal.  the bowel wall is not edematous.  there is no free air.

 pelvis:  a foley is in the bladder with excreted contrast within the bladder.
 the prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.

 bones:  horizontally oriented fractures are seen through the posterior
 elements of the t9 vertebra.  the vertebral body does not definitively show
                                                             (over)

 [**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture, but a small right anterior hematoma is present in the soft tissue
 surrounding the vertebral body at that level.

 impression:
 1.  no intrathoracic injury.
 2.  horizontally oriented fracture of the posterior elements of t9 with right
 anterior surrounding soft tissue hematoma; mr is recommended to [**clip number (radiology) 4247**] for
 ligamentous, disc, and cord injury.

"
4662,"[**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 50m with h/o cirrhosis, fever and ams of unclear [**name2 (ni) 97919**]
  question: intraabd infection?
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2186-1-11**] 8:28 pm
  1. cirrhotic liver w/ small amt of perihepatic ascites, splenomegaly, and
  recannulized umbilical vein (a portion of which sits in a small umbilical
  hernia).
  2. small pericardial effusion.
  3. no organized intraabdominal fluid collection; normal appendix; no bowel
  wall edema; no hydronephrosis; no peripancreatic stranding/fluid collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old male with cirrhosis, now with fever and altered mental
 status.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases are clear.  small pericardial effusion is
 present.

 the liver is shrunken and nodular compatible with cirrhosis.  small amount of
 perihepatic ascites is present.  the gallbladder is distended with a mildly
 thickened wall (likely secondary to hepatic disease).  small amount of
 pericholecystic fluid is also seen.  the spleen is enlarged measuring 14.8 cm
 in length.  the portal vein appears patent. there is a dilated recanalized
 umbilical vein, a portion of which has herniated through a small umbilical
 hernia (2; 60). the pancreas appears normal. the adrenal glands appear normal.
 the kidneys enhance and excrete contrast symmetrically without hydronephrosis.


 the small and large bowel show no evidence of ileus or obstruction.  there is
 no free air or lymphadenopathy.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  there is no pelvic free fluid or lymphadenopathy.  a
 small left buttock hematoma is present.

                                                             (over)

 [**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive appearing lytic or sclerotic lesions.

 impression:
 1.  cirrhotic liver with a small amount of ascites.
 2.  small pericardial effusion.
 3.  umbilical hernia containing a loop of the dilated, recannalized umbilical
 vein.

"
4663,"[**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old woman with paralysis of lower extremities
 reason for this examination:
  please eval for acute process - s/p fall, unable to move her lower extremities
  and no sensation
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2101-10-21**] 10:31 pm
  1. splaying of l1 and l2 spinous process w/ subtle malalignment of l2 and l3,
  concerning for ligametous injury, and in the setting of paralysis, consequent
  central canal injury - mr is recommended.
  2. herniation of stomach into thorax.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old female with lower extremity paralysis after fall.

 study:  ct of the torso with contrast; 130 cc of optiray intravenous contrast
 was given without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of a normal caliber along its course with a few scattered areas of
 calcified atherosclerotic disease in the aortic arch and descending aorta;
 there is no evidence of intramural hematoma or dissection.  there is no
 central pulmonary arterial filling defect.  there is no pericardial or pleural
 effusion.  a small amount of fluid is seen in the pericardial recess adjacent
 to the ascending aorta.  the lungs are clear with bibasilar atelectasis.  the
 stomach has herniated into the thorax.

 abdomen:  there is no perihepatic fluid.  a non-specific hypodensity is seen
 in hepatic segment iv, too small to characterize but most likely a cyst.  the
 gallbladder is decompressed.  there is no perisplenic fluid.  the pancreas and
 adrenal glands are normal.  the kidneys enhance with and excrete contrast
 symmetrically.  small and large bowel show no obstruction or wall edema.
 there is no free fluid or free air.

 pelvis:  the bladder is decompressed around a foley.  the uterus and rectum
 appear unremarkable.  there is no free fluid or lymphadenopathy.

 bones:  there is splaying of the posterior elements at the level of l1-l2 with
 more subtle malalignment of l2 and l3 (602b; 36).  [**year (4 digits) **] material is seen
 within the spinal canal at this level and above.  otherwise, the pelvis and
 proximal femurs are intact.  no rib fractures are noted.

                                                             (over)

 [**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 impression:
 1.  splaying of the l1-l2 spinous processes is concerning for ligamentous
 injury and given the patient's history of paraplegia, mr should be performed.
 relatively [**name2 (ni) 3409**] material within the spinal canal is concerning for epidural
 hematoma.  findings were discussed with dr. [**last name (stitle) 3382**] in person at 22:00 on
 [**2101-10-21**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] and [**first name8 (namepattern2) **] [**doctor last name 853**].
 2.  no intrathoracic or intra-abdominal injury.

"
4664,"[**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  31 year old woman with sudden onset abdominal pain, h/o cirrhosis
 reason for this examination:
  eval surgical pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2180-9-8**] 3:18 am
  1. cirrhotic liver w/ tips; patent portal vessels.
  2. decompressed gb w/ wall edema, unchanged from [**2180-7-21**] ct; likely reflective
  of hepatic dysfunction.
  3. small amt of ascites, increased since [**2180-7-21**] ct; if clincial concern for
  pancreatitis, correlate w/ lipase.
  4. normal appendix.
  5. no obstruction or free air.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  31-year-old female with sudden onset of abdominal pain and history
 of cirrhosis.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was used without adverse reaction and complication.
 coronal and sagittal reformatted images were also generated.

 comparison:  [**2180-7-21**].

 findings:

 abdomen:  the visualized lung bases are clear.  the liver demonstrates a
 portosystemic shunt.  the portal vein appears patent; assessment of the shunt
 is limited by the phase of the contrast although it also appears patent.  the
 liver demonstrates a nodular contour compatible with cirrhosis.  the
 gallbladder is decompressed although it shows small amount of wall edema.  the
 spleen is enlarged measuring 15.7 cm in its long axis (601b; 36).  coil
 material is seen in the region of the duodenum, likely to occlude varices.
 the splenic vein and sma are patent.

 the adrenal glands and pancreas show no masses.  subtle fluid-stranding is
 seen near the pancreatic tail and in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis.  the
 small and large bowel show no evidence of obstruction or wall edema.  there is
 no free air.  small amount of ascites is seen.  incidental note is made of a
 small fat-containing umbilical hernia.  the appendix is normal.

 pelvis:  the bladder, uterus and rectum appear unremarkable.  a small amount
 of fluid contiguous with the aforementioned ascites is seen.  there is no
 lymphadenopathy.

                                                             (over)

 [**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. cirrhotic liver with portosystemic shunt in place.  splenomegaly and small
 amount of ascites.  gallbladder wall edema most likely reflects sequela of
 hepatic dysfunction.
 2. if there is clinical concern for pancreatitis, correlate with lipase.

"
4665,"[**2191-9-29**] 3:17 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 1246**]
 reason: please eval for colitis, diverticulitis, intrabdominal infec
  contrast: visapaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  88 year old woman with altered mental status, increased diarrhea x10 bm
  yesterday, and llq abdominal pain.
 reason for this examination:
  please eval for colitis, diverticulitis, intrabdominal infection
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh fri [**2191-9-30**] 1:06 am
  1.  biatrial enlargement and edematous liver, compatible with right heart
  failure.
  2.  cholelithiasis without evidence of cholecystitis.
  3.  ascites and bilateral pleural effusions with associated left lower lobe
  atelectasis.
  4.  t11 compression deformity, new from [**2191-6-20**].
 pfi version #1 jekh fri [**2191-9-30**] 1:05 am
  1.  biatrial enlargement and edematous liver, compatible with right heart
  failure.
  2.  cholelithiasis without evidence of cholecystitis.
  3.  ascites and bilateral pleural effusions with associated left lower lobe
  atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  88-year-old female with altered mental status and increase in
 diarrhea; left lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 100 cc of visipaque was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  abdomen/pelvis cts from [**2191-6-20**] and [**2187-6-26**].

 findings:

 lumg bases:  there has been interval development of bilateral pleural
 effusions, simple and layering and small no right and moderate on left.
 bilateral lower lobe compressive atelectasis is more notable on the left.
 calcified atherosclerotic disease is seen in the coronary arteries.  marked
 biatrial cardiac chamber enlargement is noted.

 abdomen:  heterogeneous mottled enhancement of the hepatic parenchyma likely
 reflects passive congestion secondary to right heart failure. there is a
 stable  hypodensity in segment [**doctor first name **] that is too small to characterize, but
 likely represents a simple cyst.  there is no intrahepatic biliary dilatation.
 mild periportal edema is noted.  the gallbladder contains gallstones.  both
 the liver and spleen contain a few punctate calcifications, compatible with
 prior granulomatous disease.

 the pancreas is atrophic.  the adrenal glands appear normal.  the kidneys
                                                             (over)

 [**2191-9-29**] 3:17 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 1246**]
 reason: please eval for colitis, diverticulitis, intrabdominal infec
  contrast: visapaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 enhance symmetrically, although excretion appears delayed on the left with
 slight fullness of the left upper renal collecting system. there is no sign of
 distal obstruction and overall configuration is stable.   well-circumscribed
 hypodensities in both kidneys are most compatible with simple cysts, the
 largest of which is seen in the mid pole of the left kidney and measures 16 mm
 in diameter.

 the small and large intestine show no sign of obstruction.  a significant
 fecal and gas burden is demonstrated throughout the colon.

 there is an unchanged appearance to a calcified retroperitoneal mass anterior
 to the aorto-iliac bifurcation measuring 28 x 20 mm in axial plane (2; 47) and
 has been stable since [**2187**].

 a small amount of ascites is seen, simple in nature.  there is no free air.

 pelvis:  the bladder is distended.  the clips posterior to the bladder are
 compatible with prior hysterectomy. clips along the pelvic sidewall likely
 reflect prior lymph node dissection.  stool is seen in the rectum.  at the
 rectosigmoid junction, there is underdistension though no frank bowel wall
 thickening.  scattered diverticula are seen in the sigmoid colon, although
 there is no evidence of an inflamed diverticulum.

 bones:  again, compression deformities are seen at l4, l2, and l1 as well as
 t11.  the t11 compression deformity is new from [**2191-6-20**].  sclerotic
 changes are seen about the si joints. body wall edema noted.

 impression:
 1.  biatrial enlargement with bilateral pleural effusions, body wall edema,
 ascites and congested liver, likely secondary to right heart failure.
 2.  cholelithiasis without evidence of cholecystitis.
 3.  t11 compression deformity, new from [**2191-6-20**].
 4.  stable size and appearance of calcified mass in the lower abdomen anterior
 to the aorto-iliac bifurcation. given stability since [**2187**], a benign etiology
 is suggested.

"
4666,"[**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with new onset rlq abdominal pain, nausea, and vomiting
  starting last night. hx of percutaneous gallbladder tube that was removed
  earlier this year. pt is on coumadin
 reason for this examination:
  please eval for intrabdominal infection, sbo, nephrolithiasis, intraperiotneal
  or retroperiotneal bleed.
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2167-9-3**] 3:31 pm
  no acute intraabdominal process - specifically, normal appendix, no
  obstruction, no stones, no retroperitoneal collection, no abscess.

 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  a 57-year-old male with new-onset right lower quadrant pain, nausea,
 and vomiting.  on coumadin, and history of percutaneous gallbladder tube
 removed earlier this year.

 study:  ct of the abdomen and pelvis with and without contrast; mdct images
 were generated through the abdomen without iv contrast; coronal and sagittal
 reformatted images were generated.  subsequent mdct images were generated
 through the abdomen and pelvis after the administration of 130 ml of optiray
 intravenous contrast without adverse reaction or complication.  coronal and
 sagittal reformatted images were again generated.

 comparison:  [**2167-7-6**].

 findings:

 abdomen:  the visualized portions of the lung bases are clear.  calcified
 atherosclerotic disease is seen in both coronary arteries.

 diffuse fatty infiltration of the liver is noted. the liver otherwise shows no
 focal lesion or intrahepatic biliary dilatation.  the gallbladder is normal
 without stones, wall edema, or pericholecystic fluid.  the spleen is normal in
 size.  the pancreas and adrenal glands show no masses.  the kidneys enhance
 and excrete contrast symmetrically.  there is no hydronephrosis,
 hydroureteral, renal or ureteral calculi, or perinephric inflammation.  the
 small and large bowel shows no evidence of obstruction or wall edema.  there
 is no free air, free fluid, or lymphadenopathy.  no retroperitoneal fluid
 collections are seen. small fat-containing umbilical hernia is present.

 pelvis:  the bladder, prostate, and rectum are unremarkable.  the appendix is
 normal.  there is no free fluid or lymphadenopathy in the pelvis.
 calcification of the vas deferens suggests diabetes.

                                                             (over)

 [**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:  no acute intraabdominal process. fatty liver.
                                                                       dfddp

"
4667,"[**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  84 yf presents from nursing home w/ dyspnea, tachypnea, tachycardia, otherwsie
  also complaining of abdominal pain, recently discharge from hospital with
  sepsis/bacteremia
 reason for this examination:
  ?pe, ?abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2180-9-20**] 5:39 am
  1. no pe or acute aortic syndrome.
  2. moderate r and small l pleural effusions w/ compressive atlectasis.
  3. reflux of contrast from r heart into hepatic veins, indicative of heart
  failure.
  4. continued rectal inflammation - proctitis.
  5. no abscess.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  84-year-old female with dyspnea, tachycardia, tachypnea and
 abdominal pain.

 study:  chest cta and ct of the abdomen and pelvis with contrast.  mdct images
 were generated through the chest without iv contrast.  subsequent mdct images
 were generated through the chest after the administration of 130 ml of optiray
 intravenous contrast in the pulmonary arterial phase without adverse reaction
 or complication.  coronal, sagittal, and right and left oblique reformatted
 images were also generated.

 subsequent mdct images were generated through the abdomen and pelvis in the
 venous phase of the same contrast administration.  coronal and sagittal
 reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis without contrast from [**2180-9-12**] and ct of the abdomen and pelvis without contrast from [**2180-9-5**].

 findings:

 chest cta:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course without evidence of intramural hematoma or
 dissection.  the pulmonary arterial trunk is of normal caliber, and there are
 no filling defects down to the subsegmental level.  there is no pericardial
 effusion.  bilateral simple pleural effusions are seen, moderate on the right
 and small on the left, with associated atelectasis; fluid is also tracking
 into the left major fissure.  fine assessment of the lung parenchyma is
 somewhat limited due to motion artifact.

 abdomen:  the liver shows minimal biliary prominence, an expected finding in a
                                                             (over)

 [**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 post-cholecystectomy patient of this age.  the spleen is normal in size, and a
 hypodensity in its anterior [**doctor last name 39**] is too small to characterize but is unchanged
 from prior studies.  the pancreas demonstrates no masses or fluid collections.
 the adrenal glands are normal appearing bilaterally.  the kidneys enhance with
 and excrete contrast symmetrically; hypodensity in the right lower pole is too
 small to characterize, likely represents a cyst.  the small and large
 intestine show no evidence of obstruction or wall thickening.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta.  there is no
 lymphadenopathy, free air, or free fluid.

 pelvis:  the bladder is decompressed around a foley and a single locule of gas
 within the bladder is likely from that catheterization.  the uterus appears
 unremarkable.  the rectum demonstrates hyperenhancing mucosa with thickening
 of the wall and a small amount of stranding in the perirectal fat, all
 compatible with proctitis and similar in appearance to the prior two ct scans.

 bones:  severe degenerative changes are seen throughout the thoracolumbar
 spine; compression deformity of the t10 vertebral body is similar in
 appearance compared to the ct of the torso from [**2177-11-7**].

 impression:
 1.  no pe or acute aortic syndrome.
 2.  moderate right and small left pleural effusions with compressive
 atelectasis.
 3.  rectal wall inflammation compatible with proctitis.
 4.  no evidence of abscess.

"
4668,"condition update:
d/a:  t max 99.9 most of day, spike to 102.6 in ct.

neuro:  pt lethargic, [**name (ni) 759**] to voice, perl, at times will attempt to answer questions, at times no verbal response.  will locate painful stimuli, and mae's minimally on bed, not to command.  denies pain.  oriented x1 only.  pt with rigors at times, tremulous however no s+s of seizure activity.

cv:  hr 70's when afebrile to 120's when febrile.  neo titrated for [**name (ni) **] map > 60, [**name (ni) **] >90.  cvp 3-17.  fluid balance mn-1630 + 1111 cc's.  scant generalized edema, + ascitic abdomen.

resp:  ls clear, diminished.  when stimulated, pt rr increases and becomes wheezy at times.  ? if administration of meropenum contributes to overall worsening picture so benadryl now given before meropenum administration and it is given over 1 hour.  no s+s of adverse reaction noted today with x2 doses of meropenum.  pt on [**name (ni) 3674**] cool mist with am abg:  7.42, 46, 134, 31, 5.

gi:  abdomen distended, ascitic.  + bs.  no bm. tube feeds @ [**name (ni) **] via post-pyloric tube stopped this morning in preparation for procedure.  ivf started.  pt to angio and then to ct scan for ct guided placement of catheter.  pt remains in ct at this time intubated, with anesthesia, radiologist, and nursing in room.

gu:  foley-bsd with clear amber urine/icteric.

sx:  [**name (ni) **] [**name (ni) 731**] was [**name (ni) **] for consents.

r:  septic, dependent on pressors, currently in ct scan for drain placement.

p:  continue to titrate neo for [**name (ni) **] > 90, map > 60.  tobramycin levels due with next dose.  continue current close monitoring and management.




"
4669,"npn 2300-0700:

pt tansfered from oncology floor, 7 [**hospital ward name 320**] at 2300 for gi bleed. +melanous stool, hct 21 down from 29.4. tx 2u at 7 [**hospital ward name 320**], 1 pack of platelets. after 1u prbc, hct remained at 21. neuro stable. a&ox3. oob supervised, gait slow, steady. equal strength, no weakness. perrla. no pain. ra, satting 95-100%. no distress. lungs clear. nsr-st, no ectopy. hypotensive, sbp 80's-90's, baseline as [**name6 (md) 20**] oncology rn. asymthomatic. pt w/ fuo, on prn tylenol 650mg given atc. pt spiked to 101.5. pt w/ chills at 0200. tylenol 650mg, benadryl 25mg po w/ good relief. ho aware, pan cx'd on floor. pt urinate in toilet, unable to get sample. npo, tolerated h2o with pills. no n/v/t. stool brown, small amt of blood clots evident, not bright red.  ordered for prbc x 4u, platelets 1 pack. tx'd 3u of prbc, 1pack of platelets via r subclavian hickman (triple port) w/ no adverse reaction. cortisol level test done and sent at 0700 w/ am labs.
"
4670,"[**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 52m with new r pleural effusion
 reason for this examination:
  charac of fluiid?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with new right pleural effusion and abdominal pain.

 study:  ct of the torso with contrast; 150 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest radiograph from [**2164-8-17**] at 9:59 a.m.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  scattered
 axillary and mediastinal lymph nodes are present, although none meet
 pathologic size criteria.  multiple prominent bilateral hilar lymph nodes are
 present measuring 14 mm in their short axis on the right and 12 and 6 mm in
 their short axis on the left (601:45).  the aorta is of a normal caliber along
 its course with incidental note made of a common origin of the brachiocephalic
 and left common carotid arteries, a normal variant.  the pulmonary arterial
 trunk caliber is at the upper limits of normal, and there are no central
 filling defects.

 again is noted a large loculated effusion with minimally complex to simple
 fluid, unlikely to be hemorrhagic.  there is associated consolidation of
 nearly all the right lower and right middle lobes as well as compressive
 atelectatic effect on the right upper lobe.  portions of these collapsed lobes
 show variable enhancement, and multiple rounded hypodensities may in fact
 represent saccular bronchiectasis versus multiple foci of necrotizing
 pneumonia.  the left lung shows a clear upper lobe and saccular bronchiectasis
 of the lower lobe with diffuse bronchial wall thickenking in addition to some
 dependent atelectasis.  there is no pleural effusion on the left, and there is
 no pericardial effusion.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 subtle dense material in the neck of the gallbladder may represent small
 stones or sludge, but there is no pericholecystic fluid, wall edema or
 gallbladder distention.  the pancreas shows no masses or peripancreatic fluid
 collections.  the spleen is normal in size and appearance with a small 1-cm
 splenule noted anteroinferiorly.  the adrenal glands show no nodules.  the
 kidneys enhance with and excrete contrast symmetrically.  multiple
 well-circumscribed hypodensities are present in both kidneys, too small to
 characterize but likely representing simple cysts.  the small and large bowel
                                                             (over)

 [**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 show no evidence of obstruction or wall edema.  the aorta, ivc and portal vein
 appear normal.  there is no free fluid, free air or lymphadenopathy.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  there is no
 pelvic lymphadenopathy or free fluid.

 bones:  a schmorl's node is present at the inferior endplate of l4 and t12.
 otherwise, there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  large loculated right pleural effusion; saccular bronchiectasis of the
 bilateral lower lobes and consolidation of the right middle and right lower
 lobes with heterogeneous hypoenhancement and rounded hypodensities that may
 represent either the underlying saccular bronchiectasis versus multifocal
 necrotizing pneumonia.
 2.  cholelithiasis without cholecystitis.
 3.  hilar lymphadenopathy may be reactive; follow up imaging after treatment
 is recommended to ensure resolution.

"
4671,"[**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 81m with sudden onset rlq pain at mcburney's point since yesterday.
  +rebound at pcp office
 reason for this examination:
  eval for appy, intra-abd process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh tue [**2194-9-23**] 11:02 pm
  1. no appendix seen, but no secondary signs of appendicitis.
  2. sigmoid diverticulosis w/o diverticulitis.
  3. l iliac vein [**year (4 digits) **]; early contrast phase limits evaluation of patency.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  81-year-old male with sudden-onset right lower quadrant pain
 yesterday.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2191-3-23**] ct of the torso with contrast.

 findings:

 abdomen:  visualized portion of the lung bases show minimal dependent
 atelectasis.  a moderate hiatal hernia is also present.  pacer leads are also
 present in the right ventricle.  the liver shows no focal lesion or
 intrahepatic biliary dilatation.  clips in gallbladder fossa are compatible
 with prior cholecystectomy.  the spleen is normal in size and appearance.  the
 adrenal glands show no nodules.  the pancreas shows no masses or fluid
 collections.  multiple hypodensities are present in both kidneys, too small to
 characterize, likely represents simple cysts.  the kidneys enhance with and
 excrete contrast symmetrically without evidence of hydronephrosis.  small and
 large bowel show no evidence of wall edema or obstruction.  diverticulosis is
 noted in the descending and sigmoid colon without diverticulitis.  there is no
 free air, free fluid or lymphadenopathy.  the appendix is not visualized.

 pelvis:  the bladder is unremarkable.  a left external iliac vein [**year (4 digits) **] is
 present, but due to early phase of contrast administration, its patency is not
 well evaluated on the current study.

 bones:  no aggressive-appearing lytic or sclerotic lesion is present.
 degenerative changes are present in the lower lumber spine, primarily in the
 form of facet joint hypertrophy and osteophytes.

 impression:
 1.  appendix not visualized, but no secondary signs of appendicitis.
                                                             (over)

 [**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  descending and sigmoid diverticulosis without diverticulitis.
 3.  status post cholecystectomy.
 4.  left external iliac vein [**clip number (radiology) **], incompletely evaluated for patency.

"
4672,"[**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 80f with nausea/vomiting, diffuse abd pain
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2188-10-10**] 5:17 am
  1. no acute intraabdominal process.
  2. cirrhosis, ascites, splenomegaly, and smv thrombosis w/ downstream
  reconstitution (similar to [**2188-6-8**] ct).
  3. stable panc tail ipmn.
  4. cholelithiasis w/o cholecystitis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  80-year-old female with nausea, vomiting and diffuse abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; omnipaque iv contrast was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2188-6-8**].

 findings:

 abdomen:  the lower portion of the chest demonstrates calcified
 atherosclerotic disease of the coronary arteries as well as mitral and aortic
 valve calcifications.  the central line tip sits in the upper part of the
 right atrium.

 again the liver demonstrates a shrunken nodular contour compatible with
 cirrhosis.  the portal vein is patent and thrombosis of the smv persists with
 downstream reconstitution, similar to prior exam.  the gallbladder is
 decompressed with dense layering material within it.  the spleen is large
 measuring 15.6 cm in its long axis (2:26).  the adrenal glands are normal
 appearing bilaterally.  again the pancreas demonstrates a 13 mm hypodensity in
 the tail that is circumscribed and stable from prior exam, likely an ipmn.
 kidneys enhance with contrast symmetrically but are noted to be atrophic in
 this patient with known end-stage renal disease.  incidental note is made of a
 circumaortic left renal vein.  the small and large bowel show no evidence of
 obstruction.  a thickened appearance of the wall is likely secondary to the
 large amount of ascites that is present.  there is no free air.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta and into its
 major branches.

 pelvis:  streak artifact from bilateral hip hardware limits assessment of fine
 detail.  within that limitation, the bladder and rectum appear unremarkable.
 calcified uterine fibroids are present.
                                                             (over)

 [**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 level in the form of vacuum
 phenomenon as well as at the l3-l4 level in the form of narrowing, endplate
 sclerosis, and anterior osteophytes.  a hip arthroplasty is present on the
 right and repair of a proximal femoral fracture is evident on the left in the
 form of screw and plate fixation hardware.  old healed pubic rami and
 bilateral rib fractures are unchanged from prior exam.

 impression:
 1.  no acute intra-abdominal process.
 2.  cirrhosis, ascites, splenomegaly, and stable smv thrombosis with
 downstream reconstitution.
 3.  stable pancreatic tail ipmn.
 4.  cholelithiasis without cholecystitis.

"
4673,"[**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 79f with fever, leukocytosis, elevated lactate, abd ttp.pt is on
  dialysis; renal aware of contrast and plan for dialysis.
 reason for this examination:
  acute abd process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2136-10-3**] 3:31 am
  1. no pe or aortic dissection.
  2. small b pleural effusions w/ mild pulmonary edema.
  3. cardiomegaly.
  4. nonspecific periportal edema in the liver.
  5. decompressed gb w/ mild wall edema - nonspecific but can be seen in chf,
  hypoproteinemia, or liver dysfunction.
  6. atrophic kidneys w/ multiple indeterminate lesions, some of which are
  cysts.
  7. sigmoid diverticulosis w/o diverticulitis.
  8. small amt of free fluid of unclear etiology, possibly reactive.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  79-year-old female with fever, leukocytosis, elevated lactate, and
 tenderness to palpation.

 study:  ct of the torso with contrast.  although the patient's creatinine was
 6.2, the patient is on dialysis and renal team is aware and plans for dialysis
 after the scan.  100 ml of omnipaque intravenous contrast was administered
 without adverse reaction or complication.  images were acquired in the
 arterial phase.

 images were then acquired in the chest, abdomen, and pelvis.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of the thyroid demonstrates a heterogeneous 1.8
 x 1.3 cm nodule in the left lobe of thyroid (2:7).  no axillary, hilar, or
 mediastinal lymphadenopathy is noted.  the aorta is of a normal caliber along
 its course without evidence of dissection or intramural hematoma; incidental
 note is made of a common origin of the brachiocephalic and left common carotid
 arteries, a normal variant.  the pulmonary arterial trunk is of a normal
 caliber and there are no filling defects to the subsegmental level.  the heart
 size is large, but there is no pericardial effusion.  small bilateral pleural
 effusions are present, but they are nonhemorrhagic in nature and minimal
 associated atelectasis is present.  scattered areas of ground-glass opacity
 are most compatible with pulmonary edema.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 abdomen:  within the limits of early phase scan, the liver shows no focal
 lesion and mild-to-moderate periportal edema.  contrast is seen refluxing into
 the hepatic veins, raising the possibility of hepatic congestion.  the
 gallbladder is decompressed, but shows moderate wall edema/pericholecystic
 fluid.  no calcified stones are noted.  the spleen is normal in size.  the
 pancreas and adrenal glands show no masses or nodules.

 the kidneys enhance symmetrically but are atrophic.  both kidneys demonstrate
 multiple hypodense exophytic indeterminate lesions, some of which are cysts,
 but some of which have more mass-like or have more soft tissue-like densities.
 neither kidney demonstrates hydronephrosis.

 the small and large bowel shows no evidence of obstruction or wall edema.
 there is no pneumatosis or portal venous gas.  scattered diverticula are
 present along the descending and sigmoid colon.  there is no free air or
 lymphadenopathy.

 the abdominal aorta is of normal caliber along its course.  the celiac and sma
 are widely patent.  the renal arteries and [**female first name (un) 85**] are not narrowed.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  small amount of
 free fluid is present in the pelvis.  sigmoid diverticulosis is present
 without evidence of diverticulitis.  no lymphadenopathy is seen.

 bones:  a lucent lesion with a sclerotic rim is present in the right iliac
 bone measuring 15 x 13 mm in the coronal plane (601b:49), and is
 benign-appearing.  mild-to-moderate multilevel degenerative changes are
 present throughout the thoracolumbar spine.

 impression:
 1.  no pe or aortic dissection.
 2.  cardiomegaly and pulmonary edema.
 3.  heterogeneous nodule of the left lobe of the thyroid as described above.
 ultrasound may be considered as clinically indicated.
 4.  atrophic kidneys with multiple indeterminate lesions, some of which are
 cysts, but many of which are incompletely characterized, so rcc cannot be
 excluded; mr may be considered for further characterization.
 5.  descending and sigmoid colonic diverticulosis without diverticulitis.
 6.  periportal edema and decompressed gallbladder with wall edema, which is a
 nonspecific finding and may reflect chf, hyperproteinemia, or hepatic
 dysfunction.
 7.  small amount of free fluid in the pelvis, possibly reactive.
 8.  benign-appearing but indeterminate lytic lesion in the right iliac bone
 without evidence of cortical disruption.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

"
4674,"[**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 83m with vomiting, fever, lethargy
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2191-7-28**] 3:33 am
  1. hiatal hernia.
  2. cholelithiasis w/o cholecystitis.
  3. nonspecific perinephric stranding.
  4. enlarged prostate.
  5. l fat-containing inguinal hernia, also containing a small portion of
  bladder, similar to prior ct in [**2188**].
  6. mild-to-moderate colonic fecal burden.
  7. no acute findings.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with vomiting, fever, and lethargy.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  abdomen ct from [**2189-10-7**], and abdomen and pelvis ct from
 [**2188-10-2**].

 findings:

 abdomen:  bibasilar atelectasis is present as well as a small hiatal hernia.
 calcified atherosclerotic disease is present in the coronary arteries, and
 mitral valve calcifications are also present.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder shows a single calcified layering stone, but no wall edema or
 pericholecystic fluid.  spleen is normal in size.  the pancreas is markedly
 atrophic with a punctate calcification, possibly representing a degree of
 chronic pancreatitis.  the adrenal glands are normal appearing bilaterally.

 the kidneys enhance with and excrete contrast symmetrically.  small
 subcentimeter hypodensities in each kidney are too small to characterize, but
 likely represents cysts.  mild urothelial thickening is present in the left
 renal pelvis.  non-specific perinephric stranding is present bilaterally.

 the small and large bowel show no evidence of wall edema or obstruction.  the
 colon demonstrates a moderate fecal burden.  the aorta is of a normal caliber
 along its course with areas of calcified and non-calcified atherosclerotic
 disease present.  scattered subcentimeter retroperitoneal lymph nodes are seen
                                                             (over)

 [**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in the periaortic stations, but none meet pathologic size criteria.  there is
 no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley balloon with herniation of
 the left aspect of the bladder into the primarily fat-containing left inguinal
 hernia.  the prostate continues to be enlarged.  there is no pelvic
 lymphadenopathy or free fluid, and the rectum appears unremarkable.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 mild-to-moderate degenerative changes are seen throughout the thoracolumbar
 spine.

 impression:
 1.  no acute intra-abdominal process; moderate colonic fecal burden.
 2.  hiatal hernia.
 3.  enlarged prostate and left fat- and bladder-containing inguinal hernia.
 4.  mildly thickened left renal pelvis urothelium of unclear significance; no
 evidence of hydronephrosis or pyelonephritis.

"
4675,"[**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  85 year old woman s/p colectomy for bowel ischemia, now with rigid abdomen,
  fever
 reason for this examination:
  s/p colectomy, now with rigid abdomen, fever. please do ct abd/pelvis with po
  contrast
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2194-9-1**] 7:13 pm
  1. sbo w/ transition pt at ileostomy exit site; cause appears to be mass
  effect from herniated mesenteric fat adjacent to the ileostomy.
  2. s/p r colectomy w/ tiny locules of gas adjacent to colonic staple line -
  may be post-operative although leak cannot be excluded.
  3. small amt of complex free fluid in abdomen/pelvis - ddx includes blood or
  bowel leak contents - correlate w/ exam and hct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  85-year-old female status post right partial colectomy, now with
 rigid abdomen, and fevers.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2194-8-18**].

 findings:

 abdomen:  the visualized lung bases demonstrate a moderate right and small
 left pleural effusion with associated atelectasis.

 the previously described hemangioma in the left lobe of the liver is not well
 visualized on the current exam given difference in the phase of the contrast
 administration.  the gallbladder is distended, but shows no hyperdense stones
 or wall edema.  the spleen is normal in size.  no peripancreatic fluid
 collections are present.  the cbd again is still prominent with minimal
 central intrahepatic biliary dilatation as well as a prominent pancreatic
 duct.  the adrenal glands are normal appearing bilaterally.  multiple
 hypodensities within both kidneys are too small to characterize but compatible
 with simple cysts.  the kidneys enhance and excrete contrast symmetrically.
 the aorta is of a normal caliber along its course with scattered areas of
 calcified atherosclerotic disease.  there is no lymphadenopathy.

 the stomach and small bowel are distended with multiple air-fluid levels all
 the way to the ileostomy exiting from the right lower quadrant of ventral
 abdominal wall.  a locule of mesenteric fat has herniated through the ventral
 abdominal wall narrowing the lumen of the ileostomy, resulting in relative
                                                             (over)

 [**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 transition point.

 the patient is status post right colectomy; a small amount of right paracolic
 gutter fluid is present with adjacent peritoneal enhancement, potentially
 reflecting post-surgical changes in the resection bed (2:38).  a blind-ending
 left/transverse colon is present with gaseous distention of the transverse
 portion and apparent wall discontinuity/hypoenhancement at its posterior wall
 (2:38) and potentially involving the aterior wall as well.  near the staple
 line and at the anterior wall of the transverse colon are few small locules of
 intraperitoneal gas (2:39).  additionally, there is a small amount of gas
 within a ventral wall subcutaneous fat.  small amount of intra-abdominal free
 fluid is present and is of borderline complexity.

 pelvis:  the bladder is decompressed around a foley balloon.  uterus
 demonstrates multiple calcified fibroids.  the distal colon shows sigmoid
 diverticulosis with no evidence for diverticulitis.  minimally complex free
 fluid is present in the pelvis.  multiple inguinal lymph nodes are present,
 prominent in size but not meeting pathologic size criteria and are likely
 reactive in nature.  the right sided intramuscular hematoma is unchanged.

 bones:  no aggressive-appearing lytic or sclerotic lesions are present.
 degenerative disc disease is present at the l4-l5 level with endplate
 sclerosis and small anterior osteophytes.

 impression:
 1.  post operative changes of recent right hemicolectomy.  distended remaining
 transverse colonic pouch with apparent area of wall
 discontinuity/hypoenhancement; given the small locules of adjacent gas and
 minimal complex free fluid, colonic perforation potentially from ischemia is a
 possibility.
 2.  status post right colectomy with end ileostomy.  small bowel distnsion
 with relative transition point and mesenteric fat herniation through the
 ventral abdominal wall resulting in possible small-bowel obstruction vs ileus.
 3.  new bilateral effusions and adjacent atelectasis.

 findings raising possibility of ischemia/postoperative leak of the transverse
 colon were were discussed with [**first name8 (namepattern2) 4486**] [**last name (namepattern1) 30172**] at 19:52 by [**first name4 (namepattern1) 30173**] [**last name (namepattern1) 30174**] by
 phone.

"
4676,"[**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 60m with hcc, abd pain and fever recently d/ced
 reason for this examination:
  1: eval for pe 2. ct abd for eval for fluid collection in ruq, possible
  hepatobilary etiology for ruq pain and fever
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2119-8-7**] 11:38 pm
  1. large porta hepatis mass invading the r portal vein w/ 2 crossing biliary
  stents, and multiple hepatic mets.
  2. 2 new (from [**2119-8-2**] ct) large dilated intrahepatic ducts (2: 16 and 22)
  that are more rounded and rim enhancing, appearing more abscess-like.
  3. stable collection near the pancreatic tail compared to [**2119-8-2**] ct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with hepatocellular carcinoma, now with abdominal
 pain and fever after recent discharge.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2119-8-2**] abdominal ct.

 findings:

 abdomen:  the visualized portions of the lung bases demonstrate streaky
 atelectasis. right gynecomastia is incompletely imaged. no pleural effusion.
 prominent 9-mm right diaphragmatic lymph node is unchanged.

 the spleen is normal in size and appearance.  the adrenal glands show no
 nodules.  the kidneys enhance with and excrete contrast symmetrically without
 focal lesion or hydronephrosis. the small and large bowel show no evidence of
 obstruction or wall edema.  a lobulated low-attenuation peripancreatic
 collection adjacent to the tail, is redemonstrated and currently measures 4.6
 x 3.0 cm in greatest conglomerate axial dimensions, which is similar to the
 prior study where it measured approximately 4.3 x 2.8 cm at similar level. the
 pancreas is otherwise unremarkable.

 a dominant ill-defined enhancing hypodense mass involving segments [**last name (lf) 70637**], [**first name3 (lf) 751**],
 and ivb measuring 6.1 x 5.4 cm in the axial plane (2:20) is similar in size
 and appearance from the prior study and results in biliary obstruction in both
 hepatic lobes.  it has invaded the bifurcation of the main portal vein as well
 as the left and right portal veins, and has occluded the anterior right portal
 venous branch, unchanged. multiple stable-appearing ill-defined, peripherally
 enhancing satellite lesions are present primarily involving the right hepatic
 lobe, concerning for metastases.  incidental note is made of a fiducial seed
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in segment [**clip number (radiology) 70637**] of the liver (2:22).  enlarged porta hepatis and
 paraesophageal lymph nodes are present, similar to the prior exam.

 since the prior study, there has been marked interval increase in size of
 lobulated tubular hypodensities with rim enhancement within segments vii and
 [**clip number (radiology) 70637**] compatible with marked worsening of biliary obstruction and cholangitis
 (2:16, 2:22). new rounded rim-enhancing hypodensities are noted adjacent to
 these dilated bile ducts compatible with abscesses (2:14), the largest
 discrete abscess measuring 12-mm which is located at the junctions of segments
 vii and [**clip number (radiology) 70637**] (2:14). additionally, the more inferiorly located blown-out
 intrahepatic bile duct in segment [**clip number (radiology) 70637**] demonstrates extension into the
 subcapsular space with a focal subcapsular abscess noted measuring 2.1 x 0.9
 cm (2:20).

 moderate intrahepatic biliary dilatation elsewhere in the right lobe as well
 as in the left lobe of the liver is not significantly changed. two metal
 biliary stents are seen coursing from the main left and right hepatic ducts
 through the common bile duct and terminate within the duodenum. as before, the
 left stent traverses the mass; the right stent terminates within the mass
 (2:23). a small amount of pneumobilia is present within the gallbladder and
 cystic duct, an expected finding in a patient with stents.

 there is no free air or free fluid.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  the appendix
 is normal.  there is no pelvic lymphadenopathy or free fluid.

 bones:  there is degenerative disc disease at l5-s1 intervertebral disc.
 additionally, there is subtle grade i anterolisthesis of l4 on l5.  otherwise,
 there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  worsening biliary obstruction in segments vii and [**clip number (radiology) 70637**] with peribiliary
 enhancement and multiple new adjacent rim enhancing round hypodensities
 compatible with cholangitis and abscess formation. the blown-out intrahepatic
 bile duct within the inferior aspect of segment [**clip number (radiology) 70637**] extends into the
 subcapsular space with a focal subcapsular abscess identified.

 2.  relatively unchanged appearance of dominant mass compatible with
 hepatocellular carcinoma within segments [**doctor first name 751**], ivb and [**doctor first name 70637**] with invasion into
 the portal venous system and biliary obstruction. numerous ill-defined lesions
 primarily within the right lobe of the liver which appear similar compared to
 the prior exam likely reflect metastases, although developing abscess
 formation cannot be completely excluded.

 3.  moderate left intrahepatic biliary dilatation is similar.
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)

 4.  no significant change in peripancreatic tail lobulated fluid collection.

"
4677,"[**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  43 year old man with new diagnosis of [**hospital 21613**] transferred from outside hospital
  with possible septic arthritis and pneumonia, still spiking fevers despite
  treatment with vanc/meropenem/azithro, and with worsening abdominal pain and
  distension
 reason for this examination:
  ? acute intra-abdominal infection, ? degree of pneumonia, ? other acute process
  to explain abdominal pain and fevers
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  43-year-old male with new diagnosis of aml, now with fevers despite
 treatment with broad-spectrum antibiotics as well as worsening abdominal pain
 and distention.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest cta from [**2123-5-8**] from an outside hospital.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  a
 prominent lymph node in the right axilla measures 9 mm in its short axis (2;
 12).  scattered small mediastinal lymph nodes are present, the largest of
 which is in the precarinal station measuring 11 mm in its short axis (2; 25).
 additionally, a right hilar lymph node measures 10 mm in its short axis (2;
 34).  the aorta is of a normal caliber along its course.  an incidental note
 is made of the left vertebral artery filling directly off the aortic arch, a
 normal variant (2; 20).  the pulmonary arterial trunk shows no central filling
 defect.  the heart demonstrates a simple pericardial effusion measuring a
 maximum thickness of 11 mm in the axial plane (2; 38).  additionally, small
 amount of bilateral pleural effusions are present, simple in nature, with
 associated atelectasis.  additionally, scattered areas of airspace opacity in
 the right upper and superior segment of the right lower lobes are compatible
 with pneumonia.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 the gallbladder shows no stones or wall edema.  the spleen measures 14.8 cm in
 its long axis.  the adrenal glands show no nodules.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis or
 masses.  the aorta is of a normal caliber along its course; the celiac axis is
 mildly narrowed as it ducks beneath the diaphragmatic crus.  the small and
 large bowel show no evidence of obstruction or wall edema.  scattered
 retroperitoneal and mesenteric lymph nodes are noted although do not meet
 pathologic size criteria.  portions of the lower retroperitoneum have a
                                                             (over)

 [**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 ""[**doctor first name 2778**]"" appearance, of unknown clinical significance.  the appendix is
 visualized and is fluid filled but not dilated, nor is there adjacent
 inflammation (2; 106 and 301b; 33).  there is no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  bilateral inguinal lymph nodes are present measuring 9
 mm in their short axes (2; 124).  there is no free fluid.

 bones:  there is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  airspace opacity at the right upper lobe and superior segment of the right
 lower lobe compatible with pneumonia; small-to-moderate bilateral pleural
 effusions and small-to-moderate pericardial effusion, all of which fluid is
 simple in nature.
 2.  scattered areas of prominent lymph nodes and splenomegaly compatible with
 patient's known diagnosis of leukemia.

"
4678,"ccu npn
please see admit note for pmh, allergies and events leading to ccu admit.

pt arrived to ccu ~1500, awake, alert, oriented.
hr 75 sr no vea, 139/60.
lungs cta
sats 98% on ra
appitite fine
vdg qs
pt given benadryl 25mg po at 1830, prior to 1st dose of asa. benadryl iv, epinepherine at bedside, methyl prednisone will be tubed from pharmacy if needed.
a: pt admitted to ccu for asa desensitization, premedicated
p: administer metered asa per protocol, monitor for adverse reaction.
"
4679,"npn shift 1900-0700:

[**2107**]: pt extubated at [**2107**] by rt w/ anesthesia at bedside. pt lifting head, following commands prior to extubation. tol extubation. post abg wnl. weaned o2 to 2l nc. sat 100%. no s/s of resp distress. b/l bs clear, prod cough, clear sputum.

2200: prbc ordered for hct of 21.0. complete at 0100. at 1245 pt noted to have macular, red, generalized rash to hair line, bue, and ble. no s/s of resp distress. temp up from 97.7 to 99.4. vss. ho called and at bedside. tylenol 1000mg, benadryl 50mg iv given as per ho. blood done, not suspected to be cause of rash. prbc#2 tx 0200-0400. tol tx well, disaplaying no s/s of an adverse reaction. no recurrence of rash.

0600: pt a&ox3 at start of shift, approp. towards morning, pt w/ poor st memory, a&ox2, inapprop. abg sent, wnl. 7.35/29/181/17. pt in compensated metabolic alkolosis. hco3=16. am hct stable at 34.7. plt=66 wbc=1.4. pt in neutrapenic precautions. repleted last night of ca+,k+,mg+,kphos. am k+=4.4, mg+=2.6, phos 2.2, ionized ca+=1.19. no repletion ordered as of yet. tol clears. +bmx2, brown, loose, guiac neg.
"
4680,"npn 7a-7p
see carevue for specifics:

neuro status unchanged, quadraplegia, speaks both spanish & english attempts to mouth words, diff to understand, appears to nod approp to questions. denies pain. tmax 99.4, hr low 100s-120s, sbp 90s-140s, hct continued to drop 22.9, inr 1.7, 2 units ffp & 2 units prbc given without adverse reaction. to ir for ivc filter placement via r groin, tol procedure well. (+)fem & pps, site c/d/i. no vent changes, trached on ac 600x15, fio2 50%, peep 5, continues with mod amts of oral secretions needing freq mouth suctioning and oral care. ls coarse & diminished at bases spo2 99-100%. abd soft, nt/nd (+)bsx4, no bm this shift, tfs held for procedure, gt flushed without diff. foley with adequate u/o, bs qid with sc coverage. a/p stable,  continue with serial hcts if continue to trend down gi to repeat scope in am, monitor r groin/pulses may remove dsg in 24hrs per ir, pulmonary toileting with freq mouth care, ? restart tfs this evening vs am in case of need for repeat scope. provide emotional support.
"
4681,"ccu nursing progress note
s-""i feel ok""
o-neuro- alert and oriented x3, very pleasant and cooperative. understands and speaks english fairly well. alitttle sleepy after benadryl po.
cv-one episode of hypotension with sbp 84/40 after benadryl before asa densitization. ho aware and received ns 250cc bolus over 15 minutes.
vss hr 64-70 nsr, 104-135/50-61. received 10 ingremental doses of asa without signs of stridor, sob, rash, hypotension.
resp-ls coarse with occ esp wheeze, freq congested productive cough. sputum sent for c/s. sputum thick dark tan moderate amount.
id afebrile, mrsa precautions.
gu-voiding well in bed without difficulty.
gi-npo for possible heart cath.
skin- ruddy complexion but no rash noted.
activity-bedrest maintained during test.
access-rij tlc dressing changed and piv removed day 4.
dispo-transfer back to [**hospital ward name 3**] 3, health care proxy completed.
a/p-no adverse reaction s/p asa desensitization.
continue to assess and monitor for delayed adverse reaction

"
4682,"7p to 7a micu progress note

neuro - pt initially sedated with boluses of fentanyl and ativan immediately following intubation. placed on fentanyl drip which is currently infusing at 30mcgs/hr and propofol at 40mcgs/kg/min with greater sedative effect. pt opens eyes spont. localizes pain. mae.

resp - pt remains intubated with vent settings adjusted throughout the noc. see careview for details. currently on ac 600 x 10 with 50% fio2 and 5 peep with abg 7.36/39/140/-[**3-7**]. fio2 decreased to 40% - will draw repeat abg. lungs with inspir and expir wheezing, diminished lll. receiving albuterol nebs by resp therapist. sx initially for thick brownish plug ( specimen sent for c+s and gm stain). secretions eventually became more clear. ultrasound of left thoracic cavity showed small left pleural effusion which was too small to be tapped safely.

c-v - hr 88-111 st, no ectopy noted. bp 88-130/59-78 with map > 60 via aline. + peripheral pulses. pt with repeated needle sticks to right lateral neck and right groin for line placement. in lieu of elevated inr, pressure dssg applied to neck and iv sandbag placed on groin - no hematoma noted at either site.

gi - abd distended but soft, hypoactive bs. ngt placed, placment confirmed by x-ray. coffee-ground emesis noted on lavage, cleared with 200 ccs ns. ngt to lis currently draining bilious fluid. lactulose therapy initiated for ? hepatic encephelopathy. no stool at this time.
abd ct on [**1-8**] showed marked fatty infiltrates of the liver and sm amt of ascites as well as calcifications in the pancreas and colon wall thickening.

f/e - iv ns infusing at 250ccs/hr. pt with minimal u/o. voiding only 6-22ccs/hr via foley cath. given 3 1000 cc fluid boluses with no effect on u/o. md aware. urine lytes sent. initial k 3.0. given 40 meq kcl iv with repeat k of 3.2 at 0100. [**month/year (2) **] with an additional 40 meq kcl iv. ca 6.9. alb 2.1 phos 2.5 bun 4 creat .9. [**month/year (2) **] with 2 gms ca gluc iv.

heme - hct stable at 23.1 initially oozing from lip s/p intub. bleeding resolved.

id - temp sl hypothermic at 97 rectally. pna rx's with vanco q 12 hrs and flagyll q 8 hrs. ceftriaxone dcd. pt given 2 gms ceftaz iv x 1. awaiting id approval for subsequent doses. md aware of hx of allergy to kefzol, dose given without any overt adverse reaction.
pt on contact precautions for hx mrsa sputum.

skin - pt increasingly edematous around neck d/t lg amt of ivf administered throughout the day. already + 4 liters as of 0500 today.
skin intact except for dime-sized area on right buttocks - barrier cream applied.

endo - hx of adrenal insuff and diabetes. receiving hydrocortisone iv q8hrs. [**month/year (2) 770**].

access - r upper arm pic, multi-lumen r fem line, r radial aline.


social - numerous family and friends visited last eve. son slept overnight in the visitors lounge. updated on pt's condition by rn and md.



"
4683,"[**2126-8-27**] admission note:

pt arrived from [**location **] at 645am. she reports a few days of having a cold and fever.  came to ed with increasing sob,wheezing,t=102.  in ed she received 4l iv fluid.  sbp=70's iv dopamine drip started at 2.5mcg/kg/min.  received tylenol after which temp =98.6po.  blood and urine cultures sent. cxr done.  received:  flagyl,levofloxacin,vanco-
mycin,benadryl,decadron, and neb treatments.

she arrived on 100%nrb with no sob or wheezing noted.  lung sounds coarse, sats=97%.  hr=84sr no ectopy.  sbp=128.  skin warm dry and intact.  +bowel sounds, abdomen soft nontender.  pulses palpable. alert and oriented but sleepy, follows commands and answers all questions appropriately.  pmh=asthma, copd, ms.[**first name (titles) **] [**last name (titles) **],g-tube placement.  allergies:  azmacort,clindamycin,clarithromycin,ceftri-
axone,optiray.   she also reports difficulty with versed,fentanyl and morphine but has received these at times with no adverse reaction also.  she lives at home with her husband, [**name (ni) 1717**] and expects to return home upon discharge.
"
4684,"micu nursing progress note 11am-11pm:
neuro: pt having what is felt to be adverse reaction to the haldol which was given in previous 12hrs. periods of muscle stiffness and ridgidity noted felt to be dystonic reaction. each episode treated successfully with benadryl. twice given 50mg with good effect. third time was treated with 25mg iv benadry then 1mg po cogentin. seems  to be working fairly well. he is confused at times, thinks he can get up oob by himself and go to the bathroom. twice assisted back to bed and requires frequent reminders to stay in bed for safety. he was assisted bed to chair twice and tolerated this well. his family have been present on/off throughout the day. he is angry and rude to them at times. very short tempered. he seems to be easily agitated and bears watching for the same episodes of sundowning that has been occurring on previous shifts. ciwa scale has been followed but no ativan has been ordered as we usually treat for scale greater than 10. his intern is reviewing the order and may need to order ativan or valium prn.

cardiac: bp stable. hr elevated into 110 with agitation.

resp: o2 4l n/c most of the shift. rr high in the 35-40 range most of the time. good sat 94%-99%.

gi: eating small amts po's. has not moved his bowels since admission. given colace and ordered for dulcolax which i will give him soon.

gu: foley draining well. urine is slightly bloody tonight from him trying to get oob himself this afternoon and pulling which occurred. i can d/c foley tonight and pt will be dtv in am.

social: family was spoken to today by case management who mentioned that pt may be a candidate for drug rehab. they were not receptive to this and state that they are overwhelmed, just almost lost their son and do not want to talk about this at this time. this does need to be addressed but can wait till tomorrow when team are able to address these issues with him and his family.
"
4685,"cardiovascular: pt. remains in a controlled sinus rythym in the 60-70's with no noted ectopy. r&l lower ext's require use of a doppler to note pulses, no noted edema at this time. hct:29.3 one unit of prbc's ordered and infused at 2100. tylenol & benadryl given p.o. to aid in adverse reaction prevention. epitaxis remains to saturate gauze every hour.  m.d's are aware and orders to continue integrillin gtt on pt's chart. plans to monitor and educate the pt. regarding adverse  signs. pt. states ""i understand what you are talking about."" pt. is able to repeat these instructions back to the nurse. [**first name (titles) **] [**last name (titles) **]. of hematuria noted in folet collection bag. m.d.'s are aware of this. with no orderes obtained at this time. daughter called last hs to check in on pt. she is a nurse, and is very nice. nasal packing performed once with [**last name (titles) **] [**last name (titles) **]. of petroleum ointment applied to aid in comfort level. no further bleeding is noted at this time. pt. rema1ns in good spirts.
"
4686,"addendum: pt has now completed the desensitization protocol without any further adverse reaction. solumedrol, epi, and benadryl at the bedside at all times.
"
4687,"npn 1900-0700:

events: pt has required low-dose levo for bp management. crrt/uf resumed without complication.

ros:
neuro: pt remains on fentanyl 150mcg/hr and versed 1mg/hr with good effect. she is generally comfortable at rest and requires [** **] for turning. moving l arm only, weakly and without purpose. perrl, sluggish. did not appear to respond to her son.
resp: [**name2 (ni) **] vent changes made; most recent abg 7.33/43/121 on cmv .4/550/14/5. minimal thick tan, [**name2 (ni) **] blood-tinged secretions. although she has minimal secretions, her pp's increase significantly when she needs to be suctioned at all. ls: e wheezes, diminished lower. sats consistently 99-100%.
c-v: hypotensive at start of shift, requiring initiation of low-dose levo, which she has remained on. hr mostly 70's-90's, afib, with [**name2 (ni) **] pvc's. during the evening she had period of time during which she had intermittent slowing of hr with different-appearing qrs complex, representing a different conduction pathway. beats were well-perfused, with no significant drop in bp. she has been in her usual rhythm for the past several hours. ck's 218. 280, mb flat. troponin slightly elevated at .09, but pt has renal failure. cvp 20-21; lytes wnl.
gi: tf's continue at goal; belly obese but benign, no significant stool past several days.
gu: ampho bladder irrigation changed to continuous infusion; uo difficult to measure exactly, but seems to be running 10-30cc/hr. crrt/uf resumed at 0030, with current goal of -100cc/hr, which we are meeting without difficulty. please note that fluid balance on flow sheet is off by ~42cc/hr d/t ampho irrigant not accounted for in intake. ca gtt per sliding scale. bun/creat stable at 71/1.6.
id: afebrile, no need for bair hugger. wbc up to 18.8 (15.4). single dose of vanco given over 4 hours after pre-medication with benadryl. dose was well-tolerated with no evidence of adverse reaction.
heme: ptt therapeutic at 49.1; plt's wnl, hct stable at 30.3. no evidence of further bleeding.
endo: insulin gtt titrated prn.
skin: skin folds under breasts and in groin remain cracked/bleeding slightly. areas cleaned gently, double [**last name (un) **] and gauze applied. coccyx/perianal areas unchanged. upper l thigh blistering and draining now. l breast erythematous; both lower legs more red and blistering. ? if she has cellulitis in legs and breast.
access: r ij hd cath, r radial a-line, l sc mlc.
social: son [**name (ni) **] in to visit; he was updated on events of the day.

a: more stable night; tolerating crrt/uf once again.

p: current plan is to continue to remove fluid with goal of 3-4l/day off. would favor supporting bp as needed to facilitate this goal, as it appears to be about the only thing we can offer that might make a difference. per renal notes, plan to reassess when we have removed ~25kg (pt is ~55l positive for los, though this is improved from 59l a couple of days ago). otherwise, continue current management, ensuring pt comfort as a primary goal.
"
4688,"update
o: resp status: attempts to wean sedation to extubate unsuccessful d/t pt agitation/biting ett. propofol changed to precedex by 1700 & pt although tremulous & anxious calmer than while on propofol. suctioned q3-4h for sm amts tan secretions.lavaged w no appreciable change in amt of secretions.

cv status: hemodynamics stable subseq to iab dc.plan pa line dc subseq to vent wean.distal pulses dp's palp bilat and pt's+ w doppler.

skin: hives noted over trunk and thigh area after vancomycin nearly finished, ho notified-> benadryl given w rash receding w/in 20-30 mins. antibx changed to kefzol and pharm notified of pt drug allergy.
temp ^ w adverse reaction to vanco& ho notified. tylenol 1300mg pr given.

neuro status: as noted above pt poorly tol propofol wean,req versed and reinstituting propofol gtt until precedex cleared by pharmacy. pt opens eyes intermittently to voice, shaking arms intermittently. reinforced to pt the need for soft restraint until ett out,pt nodding but continues to have freq hand movement and tremors.pt denies pain upon questioning


endocrine: remains on low dose insulin gtt for glucose control.
a/p: attempt wean to extubate-> cpap w ps as tol while on precedex.cont to monitor glucoses and titrate per protocol.
"
4689,"npn
pt recieved from the er s/p 2 week history of headache, nausea, vomiting found [**5-29**] at home by friend lethargic. pt's daughter called by pt's friend and decided to call 911. pt taken to [**hospital 4223**] [**hospital 506**] hospital where a cxr and cat scan showed lung mass (l upper chest opacity) and ct head with l frontal mass with 5mml to r shift and hemnmorhagic l cerebellar mass causing tonsillar herniation. pt medflighted to [**hospital1 3**] for further eval/rx.
neuro deficit/pt disoriented to year will often respond ""[**2161**]"".
otherwise perrla 3mm each, mae with equal strength, no hand drift noted. tongue midline, smile symmetrical, no seizure activity. neuro sx = headache initially [**7-1**]. mri with and w/o contrast done. loading dose of dilantin 1000mg ordered in ew was given in icu. pt states allergy to steroids is increased hr, decadron given in ew without any adverse reaction and repeated x 1 in icu per dr [**last name (stitle) **]. pharmacy aware.
pain/as above [**7-1**] generalized h/a treated with dilaudid 0.5 mg ivp which decreased h/a pain to 3 then down to 1.
fluid deficit/pt c/o being thirsty, urine concentrated yellow, oral mucosa dry. pt recieved ns with kcl 40 meq at 250 cc/hr in the ew (1 liter). then iv changed to d5ns with 20meq kcl at 80ml/hr. pt is npo with exception of taking meds.
hypokalemic/k repleted in the ew as added to main iv for k 3.1. serum k level pending.
o2 sat 93%. at 12mn pt's o2 sat was 93% added 02 at 3lnp and sats improved to 97-98%.
icu prophylactics/h2blocker started, compression boots applied, sc heparin started.
psychosocial/pt,s sister [**name (ni) 2168**] in to see pt and with pt signed on as [**hospital **] healthcare proxy, form in chart. [**name (ni) 29**] brother has his phd and works with oncology research. pt has 2 young adult children who were in to visit. pt's family very concerned with recent developments in pt's health and decided to stay in hotel in [**location (un) 496**]. pt has hx of bipolar disease, anxiety disorder and depression. see [**month (only) **] for psych meds. pt is pleasant, calm and cooperative. she did ask for her xanax but neurosurg resident dr [**last name (stitle) **] did not want pt to take xanax. pain med as documented above has made pt comfortable and no further c/o anxiety after pain med given.
plan:nvs q1hr, notify neurosurg with changes.
emotional support for pt and her family.
monitor serum k's and replete as needed.
needs social work consult.


"
4690,"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**]

"
4691,"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**]"
4692,"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**]
"
4693,"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**]"
4694,"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**]
"
4695,"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**]"
4696,"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.



"
4697,"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).



"
4698,"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 **].



"
4699,"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**]



"
4700,"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**]"
4701,"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) **].



"
4702,"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**]

"
4703,"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**]"
4704,"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**]
"
4705,"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**]"
4706,"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**]
"
4707,"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**]"
4708,"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.



"
4709,"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).



"
4710,"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**]"
4711,"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) **].



"
4712,"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**]"
4713,"admission
pt admitted from or at 1305 s/p avr tissue and mv repair. uneventful or per anesthesia. ozzy from ct upon arrival from or. np [**name6 (md) **] and md [**doctor last name 816**] aware, protamine 50mg iv given as ordered. peep increased as [**name8 (md) **] np see fowsheet for details. 1 unit of prbcs given as ordered, no adverse reactions. pt requiring multi fluid boluses for svos 48-50s.epi gtt started as ordered. going by fick for co/ci, see flowsheet, pt w/ hx of tricuspid regurgitation.

neuro: pt sedated, perrla. no indication of pain. body temp 34.9-35 on arrival, bair hugger applied.

cv: hr 80. apacing. underlying 40s sb. sbp labile. goal sbp 90-110. see flowsheet for details, on and off neo and ntg gtts. [**md number(3) 1227**]/15-20s. cvp 5-11. requiring multi fluid boluses for low pad and cvp. np [**doctor last name 307**] aware. +dopplerable pedal pulses.

resp: ls clear diminished bases. sats >96%. presently orally intubated on simv mode rate 12, not breathing over, 5 peep, 5ps. plan to wake and wean as tolerates.

gi/gu: abd obese soft, absent bs. ogt +placement, draining bilious drainage.foley draining clear yellow urine 45-100cc/hr.

endo: gtt started per protocol, see flowsheet.

plan:monitor hemodynamics. monitor resp. status. follow fick q2 hours. allegy to latex. monitor ct drainage.
"
4714,"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.
"
4715,"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.
"
4716,"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:
"
4717,"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**]
"
4718,"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**]

"
4719,"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**]"
4720,"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.



"
4721,"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**]"
4722,"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**]
"
4723,"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.



"
4724,"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



"
4725,"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**]

"
4726,"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**]
"
4727,"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**]



"
4728,"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**]

"
4729,"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**]

"
4730,"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**]"
4731,"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.


"
4732,"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**]



"
4733,"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**]"
4734,"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**]"
4735,"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**]

"
4736,"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**]
"
4737,"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**]
"
4738,"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**]

"
4739,"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**]

"
4740,"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**]"
4741,"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.



"
4742,"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



"
4743,"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**]"
4744,"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**]"
4745,"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**]"
4746,"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**]
"
4747,"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**]
"
4748,"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**]
"
4749,"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**]"
4750,"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**]"
4751,"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**]"
4752,"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



"
4753,"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 **]
"
4754,"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**]

"
4755,"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**]
"
4756,"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**]

"
4757,"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**]"
4758,"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**]"
4759,"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**]"
4760,"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**]"
4761,"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**]"
4762,"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**]"
4763,"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.



"
4764,"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**]

"
4765,"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.



"
4766,"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**]"
4767,"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.



"
4768,"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**]"
4769,"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.



"
4770,"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 **]
"
4771,"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.



"
4772,"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).



"
4773,"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**]
"
4774,"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**]
"
4775,"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



"
4776,"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**].



"
4777,"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**]"
4778,"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**]"
4779,"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



"
4780,"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**]
"
4781,"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**]"
4782,"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**]

"
4783,"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 **].



"
4784,"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**]"
4785,"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**].



"
4786,"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**]"
4787,"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**]



"
4788,"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**]"
4789,"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**]

"
4790,"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**]"
4791,"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**]"
4792,"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



"
4793,"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**]"
4794,"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**]"
4795,"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**]



"
4796,"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**]
"
4797,"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) **]"
4798,"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



"
4799,"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**]
"
4800,"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**]"
4801,"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**]"
4802,"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**]
"
4803,"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**]
"
4804,"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:
.


"
4805,"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.


"
4806,"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



"
4807,"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



"
4808,"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) **].



"
4809,"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.


"
4810,"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**]"
4811,"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



"
4812,"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



"
4813,"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**]
"
4814,"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**]
"
4815,"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 **]
"
4816,"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**]
"
4817,"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



"
4818,"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.
"
4819,"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.
"
4820,"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.
"
4821,"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.
"
4822,"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.
"
4823,"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:
"
4824,"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
"
4825,"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:
"
4826,"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.
"
4827,"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.
"
4828,"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.
"
4829,"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
"
4830,"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.
"
4831,"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.
"
4832,"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.
"
4833,"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.
"
4834,"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:
"
4835,"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
"
4836,"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
"
4837,"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 ------
"
4838,"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
"
4839,"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
"
4840,"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
"
4841,"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 ------
"
4842,"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:
"
4843,"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 ------
"
4844,"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:
"
4845,"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:
"
4846,"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:
"
4847,"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:
"
4848,"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 ------
"
4849,"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:
"
4850,"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 ------
"
4851,"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:
"
4852,"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.
"
4853,"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:
"
4854,"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:
"
4855,"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.
"
4856,"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 ------
"
4857,"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:
"
4858,"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
"
4859,"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:
"
4860,"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
"
4861,"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 ------
"
4862,"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:
"
4863,"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.
"
4864,"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:
"
4865,"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:
"
4866,"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 ------
"
4867,"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.
"
4868,"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 ------
"
4869,"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
"
4870,"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:
"
4871,"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.
"
4872,"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:
"
4873,"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
"
4874,"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 ------
"
4875,"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 ------
"
4876,"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:
"
4877,"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.
"
4878,"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 ------
"
4879,"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:
"
4880,"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:
"
4881,"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.
"
4882,"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
"
4883,"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
"
4884,"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
"
4885,"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
"
4886,"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
"
4887,"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:
"
4888,"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:
"
4889,"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
"
4890,"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 ------
"
4891,"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
"
4892,"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
"
4893,"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
"
4894,"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
"
4895,"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 ------
"
4896,"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 ------
"
4897,"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
"
4898,"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
"
4899,"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.
"
4900,"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
"
4901,"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
"
4902,"[**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.


"
4903,"[**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.

"
4904,"[**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.




"
4905,"[**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.

"
4906,"[**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.



"
4907,"[**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.



"
4908,"[**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)

"
4909,"[**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.




"
4910,"[**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)

"
4911,"[**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)

"
4912,"[**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)

"
4913,"[**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.



"
4914,"[**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.


"
4915,"[**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.


"
4916,"[**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)

"
4917,"[**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.

"
4918,"[**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.



"
4919,"[**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)

"
4920,"[**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.



"
4921,"[**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.



"
4922,"[**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.


"
4923,"[**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)

"
4924,"[**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)

"
4925,"[**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.

"
4926,"[**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.






"
4927,"[**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)

"
4928,"[**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.

"
4929,"[**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.


"
4930,"[**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.


"
4931,"[**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.









"
4932,"[**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.

"
4933,"[**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.


"
4934,"[**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)


"
4935,"[**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.


"
4936,"[**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.


"
4937,"[**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.

"
4938,"[**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.

"
4939,"[**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.



"
4940,"[**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.


"
4941,"[**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.


"
4942,"[**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.



"
4943,"[**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.

"
4944,"[**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**].


"
4945,"[**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.



"
4946,"[**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)

"
4947,"[**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.


"
4948,"[**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**].


"
4949,"[**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.



"
4950,"[**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.



"
4951,"[**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)

"
4952,"[**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.



"
4953,"[**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


"
4954,"[**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.


"
4955,"[**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.

"
4956,"[**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.


"
4957,"[**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)

"
4958,"[**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.



"
4959,"[**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  21 year old man with
 reason for this examination:
  r/o inj
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: eez sat [**2185-1-29**] 12:58 am
  aorta ok. tiny, non-linear focus of decreased attenuation in posterior spleen,
  less than 1cm deep, too small to characterize by ct, but cannot exclude a
  small laceration. no perisplenic hematoma is present. no free fluid in abdomen
  or pelvis. no free air.
 ______________________________________________________________________________
                                 final report *abnormal!
 indication:    motor vehicle accident.

 technique: helically acquired axial images were obtained of the abdomen and
 pelvis from the lung bases to the pubic symphysis with 150 cc of optiray
 contrast.  there were no adverse reactions to contrast administration.
 multiplanar reformations were made.

 ct chest with contrast: the aorta is well opacified demonstrating no
 extravasation or contour abnormality. there is no aortic dissection or para
 aortic hematoma. age appropriate thymus tissue and a small pretracheal lymph
 node are present. evaluation of the lung parenchyma is limited due to
 respiratory motion but there are no gross consolidations or pulmonary
 contusions.  there is no pneumothorax. no rib fractures are seen.  there are
 no pleural or pericardial effusions.

 ct abdomen with contrast:  no hepatic lacerations or parahepatic hematoma is
 present.  there is no hematoma adjacent to the spleen but there is a tiny
 focal area of decreased attenuation along the posterior splenic border. no rib
 fractures are seen in this region.  there is no perisplenic hematoma. the area
 of decreased attenuation is too small to accurately characterize by ct, but
 overall depth is less than 1 cm.  the kidneys enhance symmetrically without
 evidence of obstruction or injury.  the adrenal glands, duodenum, pancreas and
 gallbladder are unremarkable.  intra abdominal loops are normal. there is no
 free air or free fluid within the abdomen or pelvis.

 ct pelvis with contrast: distal ureters are unremarkable. the bladder contains
 a foley catheter but is otherwise unremarkable. there is no free fluid in the
 pelvis or pelvic or inguinal lymphadenopathy.

 no fractures are seen.

 multiplanar reconstructions: coronal and sagittal reformats show no evidence
 of traumatic aortic injury.

                                                             (over)

 [**2185-1-29**] 12:13 am
 cta chest w&w/o c &recons; ct abdomen w/contrast                clip # [**clip number (radiology) 7931**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: mva,r/o internal injury
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report *abnormal!
 (cont)
 impression:
 1) no evidence of aortic injury.
 2) tiny focus of decreased attenuation in the posterior spleen, too small to
 characterize on ct.  there is no adjacent hematoma. overall depth of the area
 of decreased attenuation is less than 1 cm. a tiny laceration cannot be
 excluded.


"
4960,"[**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  59 year old man with
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications: trauma.

 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.  there were no adverse reactions to contrast administration.
 additional delay sequences of the superior mediastium and liver/spleen were
 acquired.

 ct of the chest with iv contrast: on the initial sequence, there is fluid
 density anterior to the distal ascending aorta.  on the delayed scan with a
 breath hold, this is not seen.  there is a small retrosternal hematoma, but
 the fat adjacent to the aorta is unremarkable. there is no evidence of
 extravasation of iv contrast from the aorta. on the reconstructed images, the
 aortic contours are smooth. there is no evidence of disssection.  there are
 areas of calcification in the aortic arch, and in the left subclavian artery.
 no pneumothorax is seen.  no focal pulmonary consolidations or contusions are
 seen.  there are no pleural or pericardial effusions.  no pathologically
 enlarged axillary, hilar, or mediastinal lymph nodes are seen.  no rib
 fractures are seen.  visualized portions of the clavicles and scapula appear
 intact.

 ct of the abdomen with iv contrast:  the liver and spleen are intact without
 focal laceration or adjacent hematoma.  the adrenal glands, pancreas, and
 kidneys show no evidence of acute traumatic injury.  there is no free
 intraabdominal air.  there is no free fluid within the abdomen or in the
 mesentery.  bowel loops are all normal in course and caliber.  the abdominal
 aorta is unremarkable.

 ct of the pelvis with iv contrast: the bladder contains a foley catheter with
 internal air.  there is no free fluid in the pelvis.  distal bowel is normal.

 bone windows: there is a comminuted fracture of the proximal right femur.
 within the proximal femoral diaphysis, there are three major fragments, one of
 which is anterior, the other lateral, and the final one is medial.  the
 lateral fragment is contiguous with the greater trochanter, femoral neck, and
 head. the anterior fragment is small and extends superiorly to the level of
 the femoral neck, where there is a small anterior cortical defect within the
 femoral neck, but no full thickness femoral neck fracture.  the smallest
 fragment is the medial fragment, which is highly comminuted, and it consists
 mostly of an avulsed lesser trochanter.  the left proximal femur is intact.
                                                             (over)

 [**2116-3-19**] 10:07 pm
 ct chest w/contrast; ct abdomen w/contrast                      clip # [**clip number (radiology) 8094**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: trauma
 field of view: 42 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 osseous structures of the pelvis appear intact.  no spinal fractures are seen.
 note is made of a likely healed left 11th rib fracture laterally. there is
 extensive costal cartilage calcinosis.

 ct reconstructions:  coronal and sagittal reformations show a normal aortic
 contour.

 impression:
 1.  no aortic extravasation, periaortic hematoma, or dissection.
 2.  no evidence of acute traumatic intraabdominal injury.
 3.  comminuted fracture of the proximal right femur as described above.


"
4961,"[**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  68 year old man pod#3 s/p r colectomy now with increasing o2 requirement,
  hypoxia, and tachycardia
 reason for this examination:
  evaluate for pulmonary embolism
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: oxygen requirement.  evaluate for pulmonary embolism.

 technique: axial images of the chest were aquired helically from the lung
 bases through 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 angiography of the pulmonary vessels.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:

 ct chest with iv contrast:  the pulmonary vasculature is well opacified and
 demonstrates no intraluminal filling defects suggestive of pulmonary emboli.
 there is extensive collapse/consolidation in both lower lobes. small bilateral
 pleural effusions are present. portions of the right lower lobe consolidation
 are more patchy, raising suspicion for pneumonia.  there is an additional
 dense consolidation in the dependent portion of the right upper lobe which is
 suspicious for aspiration or pneumonia.  there is fluid within the esophagus.
 numerous small mediastinal lymph nodes are seen which do not meet size
 criteria for pathological enlargement by ct scan. no pathologically enlarged
 axillar or hilar nodes are seen.  osseous structures are unremarkable. limited
 evaluation of upper abdominal structures shows possible fluid adjacent to the
 liver and a cystic structure immediately under the left hemidiaphragm which is
 not fully evaluated.

 ct reconstructions: multiplanar reformations show no evidence of pulmonary
 embolism.

 impression:
 1) no evidence of pulmonary embolism.

 2) bilateral pleural effusions with extensive consolidation in both lower
 lobes and the right upper lobe from aspiration or pneumonia.

 3) fluid filled esophagus. further evaluation with barium esophagram may be
 performed to evaluate for achalasia, stricture, or possible reflux.

 results were discussed with the surgical team at the time of interpretation.

                                                             (over)

 [**2201-1-5**] 5:48 pm
 cta chest w&w/o c &recons; ct 100cc non ionic contrast          clip # [**clip number (radiology) 70167**]
 reason: evaluate for pulmonary embolism
 admitting diagnosis: abdominal pain
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)










"
4962,"[**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
     66 year old man with persistent fevers, increasing abdominal pain, s/p
  ex-lap. also decreasing hematocrit.
 reason for this examination:
  evaluate for abscess/intra-abdominal infection, as well as source of bleeding.
  with po and iv contrast.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indications:  fevers, increasing abdominal pain after exploratory laparotomy,
 decreasing hematocrit.

 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
 secondary to the patient's debility history.  there were no adverse reactions
 to contrast administration.

 findings:  comparison is made to the prior torso ct from [**12-28**] and the
 gallbladder ultrasound from [**2119-1-6**].

 ct of the abdomen with iv contrast:  there are moderate-sized bilateral
 pleural effusions with associated bibasilar atelectasis.  again identified is
 a likely cyst within the right posterior hepatic lobe inferiorly (segment vi).
 there is stable intrahepatic biliary ductal dilatation.  the gallbladder
 contains calcified stones and asymmetrical areas of wall thickening consistent
 with the previously seen adenomyomatosis.  the common bile duct remains
 prominent extending into the duodenum.  there is no stranding around the
 gallbladder.  the pancreas is unremarkable.  the adrenal glands and kidneys
 are unchanged.  within the posterior aspect of the spleen is a wedge-shaped
 focal area of decreased attenuation, which likely reprents an infarct.  the
 spleen has progressively enlarged over the past two ct scans, now measuring
 over 13 cm. the appearance of the stomach is unchanged. there is no evidence
 of bowel obstruction.

 ct of the pelvis with iv contrast:  again, there is a small amount of fluid in
 the pelvis, but no loculated pockets with enhancing rims or internal air to
 indicate an abscess.  multiple cecal diverticula are seen.  the appendix is
 visualized, and is filled with oral contrast, and normal.  again, there is a
 suggestion of cecal, and transverse colonic wall thickening.  again, these
 segments are not fully distended, limiting evaluation.  there is some ascites
 in the right inguinal fat-containing hernia.

 osseous structures:  no suspicious lytic or sclerotic lesions are present.

 impression:
                                                             (over)

 [**2119-1-8**] 3:25 pm
 ct abd w&w/o c; ct pelvis w&w/o c                               clip # [**clip number (radiology) 4477**]
 ct 150cc nonionic contrast
 reason: evaluate for abscess/intra-abdominal infection, as well as s
 admitting diagnosis: hypothermia
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 1) no definite intraabdominal abscess.  moderate bilateral pleural effusions
 with associated bibasilar atelectasis.
 2) progressive splenic enlargment compared to [**2118-12-28**] and [**2118-12-16**]. the spleen
 now measures over 13cm. findings are suspicous for possible lymphoma in the
 absence of other etiologies for splenic enlargement.

 results were discussed with dr. [**last name (stitle) 4478**] at 9:55 pm on [**2119-1-8**].

"
4963,"[**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old woman with s/p intramural hemmorage in sigmoid
 reason for this examination:
  s/p intramural hemmorage in sigmoid-?resolved
 ______________________________________________________________________________
                                 final report
 indications:  status post intramural hemorrhage in sigmoid colon.  evaluate
 for resolution.

 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.  non-ionic contrast was used secondary to the patient's
 asthma history.  there were no adverse reactions to contrast administration.

 findings:  comparison is made with the study from [**2158-12-7**].

 ct of the abdomen with iv contrast:  no focal lung lesions are identified.
 there are no pleural or pericardial effusions.  no focal liver lesions are
 identified.  the spleen contains several punctate calcifications, likely
 calcified granulomas.  the adrenal glands, pancreas, stomach, and
 intraabdominal loops of small bowel are unremarkable.  there is a single focus
 of decreased attenuation in the lower pole of the left kidney which likely
 represents a simple cyst, and is unchanged in appearance since the prior
 study.  the kidneys otherwise enhance symmetrically without evidence of focal
 mass or obstruction.  there is no ascites or pathological mesenteric or
 retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast:  there has been marked reduction in the
 previously seen sigmoidal wall thickening.  extensive diverticular disease and
 likely muscular hypertrophy in the sigmoid colon, but there is no evidence of
 surrounding stranding to indicate acute diverticulitis.  the previously seen
 small amount of free fluid in the pelvis has also resolved. distal ureters and
 bladder are unremarkable.  there is no pathological pelvic lymphadenopathy.

 a small sclerotic focus is seen in the superior pubic ramus, which is likely a
 bone island.  additional sclerotic foci are seen in lower-thoracic vertebral
 bodies, which are also likely bone islands.  no suspicious lytic lesions are
 identified.

 impression:
 1) marked improvement in the previously seen sigmoidal wall thickening, and
 resolution of free fluid in the pelvis.  extensive diverticular disease is
 present, but there is no evidence of acute diverticulitis.

 2) tiny left renal cyst.

 3) multiple splenic granulomas.
                                                             (over)

 [**2159-1-4**] 1:22 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 53282**]
 ct 100cc non ionic contrast
 reason: s/p intramural hemmorage in sigmoid-?resolved
 field of view: 31 contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)



"
4964,"[**2146-12-28**] 7:12 am
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 8484**]
 ct 100cc non ionic contrast
 reason: trauma
 field of view: 36 contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  20 year old man with mva
 reason for this examination:
  trauma
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  trauma.

 technique:  axial images of the abdomen and pelvis were acquired helically
 from the lung bases through the pubic symphysis with 150 cc optiray contrast.
 there were no adverse reactions to contrast administration.

 findings:

 ct of the abdomen w/iv contrast:  there is a small focal area of consolidation
 in the right lower lobe, medial basal segment.  no pleural or pericardial
 effusions are seen.  there is periportal edema, consistent with vigorous fluid
 resuscitation.  the liver is intact without evidence of laceration.  the
 spleen appears intact.  the adrenal glands, kidneys, pancreas, and duodenum
 are all unremarkable.  the gallbladder is normal.  there is a general lack of
 intra-abdominal fat, limiting sensitivity for mesenteric injury.  there is no
 free fluid in the abdomen.  no free air is seen.

 ct of the pelvis w/iv contrast:  the bladder contains a foley catheter and
 air.  sigmoid colon and rectum are unremarkable.  there is no free fluid in
 the pelvis.

 no pelvic fractures are seen.  note is made of a densely sclerotic area in the
 left femoral neck, which likely represents a bone island.  there is a
 diminutive first right lumbar rib.  no rib fractures are seen.

 impression:

 1. no evidence of acute traumatic intra-abdominal injury.
 2. likely diminutive right first lumbar rib. no acute fracture.


"
4965,"[**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  62 year old woman with hx of bladder cancer with resection of tumor and
  retroperitoneal disection as well as chemotherapy.
 reason for this examination:
  pt with hx of bladder cancer with resection of right kidney and ureter as well
  as retroperitoneal dissection and has received chemotherapy now needs  ct of
  torso for staging.
 ______________________________________________________________________________
                                 final report
 indication:  renal cancer, status post resection of right kidney, ureter, and
 retroperitoneal dissection.

 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.

 comparison:  comparison is only able to be made to the study from [**2171-10-28**].  the more recent torso ct from [**2171-12-9**] is not available
 secondary to pacs malfunction.

 ct of the chest with iv contrast:  there are no pathologically enlarged
 axillary, hilar, or mediastinal lymph nodes.  there are no pleural or
 pericardial effusions.  again identified are multiple bilateral pulmonary
 nodules.  one previously seen nodule in the right lung base laterally is not
 visualized on the current study, but the largest nodule, in the left lung
 base, has increased in size.  the bronchi remain patent to the subsegmental
 levels.  the heart and great vessels is unremarkable.

 ct of the abdomen with iv contrast:  there has been marked progression of the
 patient's multiple hepatic masses.  there is some local biliary ductal
 dilatation adjacent to one of the masses in the right lobe.  surgical clips
 are seen in the right renal fossa from prior nephrectomy.  no soft tissue
 density suggestive of disease recurrence is present in this area.  there is a
 slight prominence of the first and second portion of the duodenum, but the
 bowel is not fully opacified, limiting evaluation.  the pancreas and adrenal
 glands, along with the spleen, and stomach are unremarkable.  the left kidney
 enhances uniformly.  there is no filling defect in the left renal pelvis or
 ureter.  no pathologically enlarged mesenteric or retroperitoneal lymph nodes
 are seen.  the descending aorta is calcified.  there is no ascites.

 ct of the pelvis with iv contrast:  the appearance of the cystic structure in
 the right adnexa is unchanged.  again seen is stranding in the presacral fat,
 likely post operative in nature, which is unchanged since [**2171-10-28**].
 the distal left ureter is unremarkable, with a normal appearing left ureteral
 jet.  the bladder is within normal limits.  there is no free fluid in the
 pelvis or pathological inguinal or pelvic lymphadenopathy, although multiple
                                                             (over)

 [**2172-3-3**] 10:40 am
 ct abd w&w/o c; ct chest w/contrast                             clip # [**clip number (radiology) 66187**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: pt with hx of bladder cancer with resection of right kidney
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 small pelvic nodes are seen which do not meet size criteria for pathological
 enlargement by ct scan.  the sigmoid colon and rectum are unremarkable.

 no new suspicious lytic or sclerotic osseous lesions are identified.

 impression:  progression of multiple intrahepatic masses, some of which are
 associated with localized biliary ductal dilatation.  no ascites.  enlargement
 of pulmonary nodule in left lung base.  findings all consistent with
 progression of disease.

"
4966,"[**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   42 year old man with pod#10 s/p ex-lap, small bowel resection x4, found to
  have celiac sprue, t-cell lymphoma on path, now w/ temps post-op, and new pus
  draining from ex-lap wound.
 reason for this examination:
  evaluate for perforations, fluid collections, wound infection.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication: celiac  sprue, multiple small bowel resections, now with post
 operative fevers, pus draining from exploratory laparotomy wound.  evaluate
 for intraabdominal abscess or perforation.

 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 contrast.  there were no adverse reactions to contrast
 administration.

 findings:  comparison is made to the study from [**2150-3-2**].

 ct abdomen with iv contrast: again seen is a rounded 4 mm nodule in the right
 lower lobe which is unchanged in appearance.  there is bibasilar atelectasis.
 no focal consolidations suggestive of pneumonia are present.  no focal hepatic
 lesions or splenic lesions are seen.  the pancreas and gallbladder are normal
 in appearance.  both adrenal glands and kidneys are unremarkable.  multiple
 surgical suture lines are seen throughout the small bowel.  there are multiple
 dilated small bowel loops, and enlarged mesenteric lymph nodes.  the
 appearance is unchanged since [**2150-3-2**]. there is no free intraperitoneal
 air. again seen is a heterogeneous area of attenuation in the anterior
 abdominal wall in between the rectus muscles, which measures 13 x 22 mm on
 today's study.

 ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and rectum
 are unremarkable.  again seen is a small amount of fluid adjacent to the
 sigmoid mesocolon which is slightly smaller than on the previous study.  no
 new intrapelvic abscess is present.  there is no pathologic inguinal or pelvic
 lymphadenopathy.

 impression: no new focal intraabdominal abscess.  stable appearance of
 multiple small bowel resections, with dilated small bowel loops and mesenteric
 lymphadenopathy.

                                                             (over)

 [**2150-3-9**] 2:47 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 9898**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: evaluate for perforations, fluid collections, wound infectio
 admitting diagnosis: intestinal lymphadenopathy
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

"
4967,"[**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  32 year old woman with ard and pancreatitis s/p multiple medication overdose
 reason for this examination:
  please check pancreas for necorsis by pancreatitis protocol and evaluate lungs
  for ards
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  multiple medication overdose, with pancreatitis and acute
 respiratory distress.

 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 patient's debility.  there were no adverse reactions to
 contrast administration.

 findings:  reference is made to the portable ap chest x-ray from [**2167-2-16**].

 ct of the chest with iv contrast:  again seen are sternal wires.  the
 orogastric and post-pyloric feeding tubes in appropriate positions.  the
 endotracheal tube is present in satisfactory position.  there are extensive
 bilateral areas of ground-glass opacity and consolidation consistent with
 ards.  there are small bilateral pleural effusions.  no pericardial effusion
 is seen.  oral contrast is seen within the thoracic esophagus, suggestive of
 possible aspiration. there are multiple prominent mediastinal lymph nodes,
 which are likely reactive.

 ct of the abdomen with iv contrast:  no focal hepatic lesions are identified.
 the spleen, adrenal glands, kidneys, stomach, and intra-abdominal loops of
 small and large bowel are unremarkable.  the gallbladder is mildly distended,
 but there is no adjacent stranding to suggest acute cholecystitis.  the
 pancreas enhances symmetrically without adjacent fluid collection.  there is
 minimal stranding adjacent to the pancreatic tail, consistent with the
 patient's known pancreatitis.  there is no ascites or pathological mesenteric
 or retroperitoneal lymphadenopathy.

 ct of the pelvis with iv contrast: the appendix, distal ureters, sigmoid
 colon, and rectum are within normal limits.  there is a small amount of free
 fluid within the pouch of [**location (un) **].  the bladder contains a foley catheter.
 there is no pathological inguinal or pelvic lymphadenopathy.

 no suspicious lytic or sclerotic osseous lesions are identified.

 impression:
                                                             (over)

 [**2167-2-16**] 11:18 am
 ct chest w/contrast; ct abd w&w/o c                             clip # [**clip number (radiology) 13979**]
 ct pelvis w/contrast; ct 150cc nonionic contrast
 reason: multiple medication overdose, ard, pancreatitis
 admitting diagnosis: adult respiratory distress syndrome
 field of view: 40 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 1)  stranding adjacent to the tail of the pancreas consistent with patient's
 known pancreatitis.  no peripancreatic fluid collection or hematoma or
 abnormal pancreatic perfusion.

 2)  ards.


"
4968,"[**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  44 year old man with all s/p allo-bmt with likely cmv colitis here with new,
  diffuse abdominal tenderness.
 reason for this examination:
  eval for evidence of perforation, other pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 history:  all s/p bone marrow transplant. diffuse abdominal tenderness, likely
 cmv colitis.

 comparison:  no prior ct studies.

 technique:  helically acquired contiguous axial images of the abdomen and
 pelvis were obtained with intravenous optiray per cte  protocol.  however,
 oral contrast was not administered secondary to the patient's inability to
 tolerate po intake or an ng tube, due to esophageal ulcers.  coronal
 reconstructions were performed.

 contrast: 122 cc  of intravenous optray were administered through a right
 antecubital iv catheter. during the initial injection, a few cc's of optiray
 squirted out between the external portion of the iv catheter and the power
 injector tubing. there was no subcutaneous infiltration of optiray. the
 intravenous line remained patent, allowing for normal drawing back of blood
 and flushing with saline.  the power injector was reconnected to the iv
 catheter, and injection of optiray was continued without further
 complications. the intravenous line was removed immediately after the study to
 reduce the risk of infection.  there was no adverse reaction to optiray during
 or immediately following the study.

 abdomen ct with intravenous contrast:  several subcentimeter nodular opacities
 are present at the visualized lung bases.  the largest opacity in the right
 lower lobe measures 8 mm, and the largest opacity in the left lower lobe
 measures  5 mm.  there are no pleural effusions.

 there is diffuse wall thickening in the proximal small bowel, with associated
 stranding and small lymph nodes in the proximal mesentery.  both the proximal
 and distal small bowel is distended with fluid.  however, there is no wall
 thickening in the distal small bowel, including the terminal ileum.  this
 appearance is consistent with enteritis, which may be due to graft-vs-host
 disease or infection.

 there is a 2 mm appendicolith within the appendix.  the appendix does not
 contain any air.  it measures 8 mm in cross-section diameter at the level of
 the appendicolith, but appears smaller distal to the stone. the cecal tip
 appears mildly thickened. there is some periappendiceal stranding, which is
                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)
 less advanced than the stranding in the proximal small bowel mesentery. there
 is no periappendiceal free air or fluid collection. these findings are
 equivocal regarding the presence of appendicitis. there may be mild typhlitis
 at the cecal tip , consistent with graft-vs-host disease. serial clinical
 exams are suggested. if clinically indicated, repeat imaging of the appendix
 may be helpful.

 the remainder of the ascending colon and the transverse colon are distended
 with fluid, without wall thickening.  the descending and sigmoid colon are
 collapsed. there is no free air or free fluid. in addition to the previously
 described proximal mesenteric stranding and small mesenteric lymph nodes,
 there is stranding and small lymph nodes in the para-aortic retroperitoneum.
 the liver, gallbladder, spleen, pancreas, kidneys, adrenal glands and ureters
 are unremarkable.

 pelvis ct with intravenous contrast:  calcifications are seen within the
 prostate gland.  the bladder, seminal vesicles and rectum are unremarkable.
 there is no pelvic or inguinal lymphadenopathy. there is no free fluid.

 bone windows:  there are no suspicious lytic or sclerotic lesions within the
 visualized osseous structures.

 ct reconstructions:  coronal reconstructions confirm the presence of wall
 thickening in the proximal small  bowel, with adjacent mesenteric stranding.

 the findings were discussed with dr. [**last name (stitle) 104418**] at 11:40 pm on [**2140-4-5**].

 impression:

 1)  proximal enteritis, which may represent graft-vs-host disease or
 infection.

 2)  appendicolith.  the appearance of the appendix is equivocal for
 appendicitis.  there may be mild typhlitis. serial abdominal exams are
 suggested. if clinically indicated, repeated imaging of the appendix may be
 helpful.

 3) subcentimeter peripheral nodular opacities at both lung bases, which are
 nonspecific. follow-up is suggested.





                                                             (over)

 [**2140-4-5**] 10:11 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 104417**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: eval for evidence of perforation, other pathology
 admitting diagnosis: post transplant\nausea;vomiting;diarrhea
 field of view: 36 contrast: optiray amt: 150
 ______________________________________________________________________________
                                 final report  (revised)
 (cont)




"
4969,"[**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  60 year old man with
 reason for this examination:
  fu aortic dissection and last week 4 d sx sob, chest pain radiating to back
 ______________________________________________________________________________
                                 final report
 indications: followup of aortic dissection. chest pain radiating to back.

 technique: contiguous axial images of the chest and abdomen were acquired
 helically from the lung apices through the proximal common iliac vessels,
 before and after administration of 150 cc of optiray contrast, secondary to
 the rapid bolus injection rate required for ct angiography of the aorta. there
 were no adverse reactions to contrast administration. coronal reformations
 were made.

 findings: comparison is made to the chest cta from [**2178-11-3**].

 ct chest with iv contrast:  again seen are changes from repair of a prior
 aortic dissection, with graft material extending from the aortic root to the
 proximal aortic arch. no extravasation is seen.  previously seen small amount
 of contrast in the false lumen and aortic arch is no longer present. the
 origins of the brachiocephalic, left common carotid, and subclavian arteries
 are all patent. no contrast is seen in the false lumen, until the dome of the
 right hemidiaphragm. there is a tiny circular area of contrast present which
 is not continuous with either the true lumen or the more inferiorly mixing
 contrast within the false lumen. there is symmetrical opacification of the
 true and false lumens by the level of the aortic hiatus in the diaphragm. the
 true lumen perfuses the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left renal artery is fed by both
 the true and false lumens.  the dissection flap extends into both common iliac
 vessels for a longer extent into the left than into the right. there is no
 peri-aortic hematoma or evidence of active extravasation. there are no pleural
 or pericardial effusions. emphysematous changes are seen in the lungs. again
 identified is a small, ill defined right middle lobe nodule which is unchanged
 in appearance. bibasilar atelectasis is seen.  no pathologically enlarged,
 axillary, hilar, or mediastinal lymph nodes are seen.

 ct abdomen with iv contrast: limited evaluation with only one phase of
 contrast shows no focal hepatic or splenic lesions. multiple bilateral renal
 cysts are present which are unchanged in appearance. visualized portions of
 intra-abdominal bowel loops are unremarkable.  the adrenal glands are normal.
 ct reconstructions: coronal reformats show a stable appearance of the aortic
 disection, without definite evidence of leak.

 impression:

 1. status post surgical repair of prior type a dissection. overall, appearance
                                                             (over)

 [**2179-3-30**] 2:21 pm
 cta chest w&w/o c &recons; ct abd w&w/o c                       clip # [**clip number (radiology) 11808**]
 ct 150cc nonionic contrast
 reason: fu aortic dissection and last week 4 d sx sob, chest pain ra
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 is unchanged compared to [**2178-11-3**].  the previously seen small amount of
 contrast in the false lumen in the aortic arch is no longer present.  the true
 lumen supplies the celiac access, superior mesenteric artery, inferior
 mesenteric artery and right renal artery. the left kidney is supplied from
 both the false and true lumen. there is a small rounded contrast pocket within
 the false lumen located slightly above the site of mixing, but this is not
 definitely connectable to either the true lumen, or to the mixing contrast.



"
4970,"[**2129-10-30**] 1:23 pm
 cta head w&w/o c & recons; ct 150cc nonionic contrast           clip # [**clip number (radiology) 85922**]
 reason: ? bleed and emboli
 admitting diagnosis: pulmonary edema,dm
  contrast: optiray amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
   74 year old man with history of somnolence, now w/ acute delta ma, lethargy

 reason for this examination:
  ? bleed and emboli
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report  (revised)
 indication:  acute mental status changes.  history of endocarditis.  evaluate
 for embolus or stroke.

 technique:  axial images of the brain were acquired before and after
 administration of 150 cc of optiray contrast.  nonionic contrast was used
 secondary to the rapid bolus infusion rate required for ct angiography.  there
 were no adverse reactions to contrast administration.  multiplanar
 reformations were made.

 findings:  comparison is made to the study from [**2129-10-16**].  again
 identified is an old left frontal lobe infarct.  there is no acute intra- or
 extra-axial hemorrhage, hydrocephalus, or shift of normally midline
 structures.  no areas of abnormal enhancement are present to suggest septic
 emboli.  there is no evidence of impending herniation.

 both internal carotid arteries are visualized.  there is moderate stenosis of
 the distal cervical portion of the right internal carotid artery, likely due
 to atherosclerotic disease, albeit this is a somewhat unusual locale.
 atherosclerosis seems more likely than dissection, as the vessel shows mural
 calcifications, and there is a history of diabetes as well. note is made of
 moderately stenotic left cavernous carotid artery.  the middle cerebral
 arteries to the level of the bifurcation, anterior communicating artery, and
 anterior cerebral arteries are unremarkable.  both vertebral arteries are
 patent.  the basilar artery is slightly small, but demonstrates good flow, and
 fills both posterior cerebral arteries, the proximal portions of which are
 normal.

 impression:  remote infarct of left frontal lobe.  atherosclerotic stenoses
 as noted above.


"
4971,"[**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  55 year old woman with
 reason for this examination:
  55 yo female.  change in bowel habits.  unable to do colonoscopy secondary to
  adverse reactions to sedations.  request ct colonography to screen for colon
  ca.
 ______________________________________________________________________________
                                 final report
 indication:  recent change in bowel habits, unable to tolerate conventional
 colonoscopy secondary to adverse reaction to conscious sedation.  assess for
 colon cancer.

 technique:  contiguous axial images were obtained from the lung bases to the
 pubic symphysis after insufflation of intrarectal air in the prone and supine
 positions.  iv contrast was not administered.

 comparison:  ct abdomen/pelvis of [**2180-9-28**].

 ct colonography:  no suspicious lesions are seen.  there is no evidence of
 polyps, masses, strictures, or inflammatory disease.  there is a small amount
 of fluid within the cecum, descending colon and sigmoid which displaces with
 repositioning.  there is minimal retained fecal matter.

 ct of abdomen w/o iv contrast:  the imaged portions of the lung bases again
 show a 1-2 mm noncalcified nodule of the peripheral right lower lobe.  the
 liver, spleen, pancreas, adrenal glands, kidneys, and unopacified loops of
 small bowel are unremarkable.  there is no free air, free fluid, or
 lymphadenopathy.  the patient has had a previous cholecystectomy.

 ct of pelvis w/o iv contrast:  the rectum, urinary bladder and adnexal regions
 are unremarkable.  there is no free air, free fluid, or lymphadenopathy.

 bone windows:  there are no suspicious osseous lesions.

 multiplanar reformatted images and full endoluminal navigation performed in
 the antegrade and retrograde direction confirm and aid in the above findings.

 conclusion:
 1)  no significant polyp or mass identified (greater than 1 cm).  please note
 that the sensitivity of ct colonography for polyps greater than 1 cm is
 85-90%.  the sensitivity for polyps 6-9 mm is about 60-70%.  flat lesions may
 be missed with ct colonography.

 2)  stable 1-2 mm noncalcified nodule within the right lower lobe, likely
 representing a benign granuloma.  in the absence of any known primary
 malignancies, no further follow up is needed.

                                                             (over)

 [**2181-8-28**] 7:28 am
 ct colon tech abd/pel w/oc                                      clip # [**clip number (radiology) 88237**]
 reason: 55 yo female.  change in bowel habits.  unable to do colonos
 ______________________________________________________________________________
                                 final report
 (cont)

"
4972,"[**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  36 year old man with cerebral palsy, epilepsy and history of recurrent
  aspiration pneumonias now with fever, rll cavitation
 reason for this examination:
  please assess for lung abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  cerebral palsy, epilepsy, and history of recurrent aspiration
 pneumonia.  now with fever, and right lower lobe cavitation on chest x-ray.
 please assess for lung abscess.

 comparison:  no prior chest ct.  chest radiograph of [**2191-11-7**] is
 available for comparison.

 technique:  axial multidetector ct images were obtained from the thoracic
 inlet through the adrenal glands without intravenous contrast.

 chest ct without contrast:  there is extensive consolidation in the right
 middle and lower lobes.  evaluation of these areas is somewhat limited by the
 patient's body habitus, lack of intravenous contrast enhancement, and streak
 artifact from surgical hardware in the spine.  there is a large rounded cavity
 with irregular margins and a fluid level in the right lower lobe, which
 appears most consistent with an abscess.  there are necrotizing areas in the
 adjacent lung in the right lower and middle lobes.  no definite pleural
 disease is seen in this area or in the remainder of the thorax.  there are
 patchy peribronchiolar ground-glass opacities in the dependent portions of the
 left lung, suggestive of aspiration.  paraseptal emphysema is noted in the
 medial left lower lobe.

 the airways appear patent to the level of segmental bronchi.  there is no
 mediastinal or axillary lymphadenopathy.  the heart and great vessels appear
 unremarkable.

 there is high-density material layering within the gallbladder, suggestive of
 previously administered intravenous contrast.  the patient did not have any
 radiology studies with intravenous contrast at our institution. alternatively,
 this finding may represent unusually dense sludge or stones. clinical
 correlation is suggested. there is a hiatal hernia.  there are gas-distended
 bowel loops in the upper abdomen.  clinical correlation is suggested.
 evaluation of the visualized portions of the liver, spleen, pancreas, adrenal
 glands, and kidneys is limited by streak artifact from the [**location (un) 1354**] rod in
 the spine. no abnormalities are detected.  marked scoliosis is noted.

 the findings were discussed with dr. [**last name (stitle) 25949**] at 10:50 a.m. on [**2191-11-8**].

 impression:
                                                             (over)

 [**2191-11-7**] 4:17 pm
 ct chest w/o contrast                                           clip # [**clip number (radiology) 81205**]
 reason: please assess for lung abscess
 admitting diagnosis: pneumonia
 field of view: 36
 ______________________________________________________________________________
                                 final report
 (cont)

 1.  necrotizing right middle and lower lobe pneumonia with a large abscess in
 the right lower lobe.

 2.  patchy ground-glass opacities in the left lung, with appearance suggestive
 of aspiration.

 3.  dense material in the gallbladder, which may represent intravenous
 contrast or unusually dense sludge or stones.  contrast in the gallbladder
 could represent an adverse reaction to intravenous contrast, or it may be seen
 in renal failure.

 4.  gas-distented bowel loops, incompletely assessed. consider dedicated
 abdominal radiograph series.

 5.  hiatal hernia.


"
4973,"[**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  72 year old woman pod4 from r. colectomy for cecal mass, now with fevers,
  tachycardia, incr abd distention, tenderness
 reason for this examination:
  assess for leak, collections
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  72-year-old female with abdominal distention.

 comparisons:  comparison is made to ct of the abdomen from [**2126-11-19**] and ct
 of the abdomen from [**2126-11-14**].

 technique:  ct of the abdomen and pelvis with oral and iv contrast.  150 cc of
 optiray 350 were administered without adverse reaction.

 coronal reconstructions were performed.

 ct of the abdomen with oral and iv contrast:  there are mild atelectatic
 changes in the right base.  there are no pleural effusions.  there is a small
 hiatal hernia.  there is no pericardial effusion.  the liver is slightly
 fatty.  however, there are no focal lesions.  there are two gallstones within
 the gallbladder.  there is no evidence of cholecystitis.  the spleen, adrenal
 glands are unremarkable.  there is a small hypodense area in the mid pole of
 the right kidney that was not completely evaluated in this study.  although
 statistically, it most likely represents a simple cyst, ultrasound could be
 performed to further evaluate this.

 there is a large transverse incision in the right aspect of the abdomen. there
 is fluid and air in the subcutaneous tissues, which could be postoperative.
 however, infection cannot be excluded on the basis of the ct scan.

 the proximal small bowel loops contain contrast and are dilated.  the distal
 small bowel loops are slightly decompressed.  however, there is contrast in
 the distal small bowel loops and the appearance most likely represents an
 ileus.  there are staples in the splenic flexure of the colon from prior right
 colectomy.  there are several slightly thickened small bowel loops, however,
 this appearance could be postoperative.  there is no evidence of free air or
 fluid collections within the abdomen.

 ct of the pelvis with oral and iv contrast:  there are multiple diverticula
 within the colon without evidence of diverticulitis.  as described above, the
 same postoperative changes are present in the pelvis.  there are also multiple
 mesenteric lymph nodes that are small and do not meet ct criteria for
 pathology.  there is no significant free fluid in the pelvis.  there is a
 foley catheter within the urinary bladder, which contains air.  the rectum is
                                                             (over)

 [**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
                                 final report
 (cont)
 unremarkable.

 bone windows:  there are no suspicious lytic or blastic lesions.

 impression:

 1.  postoperative changes as described above.  fluid and air in subcutaneous
 tissues could be postoperative, but infection cannot be excluded by ct scan.

 2.  mildly dilated loops of small bowel likely representing ileus.

 3.  multiple small mesenteric lymph nodes as described above.  they do not
 meet ct criteria for pathology and attention at followup is recommended.

 4.  multiple gallstones.

 5.  fatty liver without focal lesions in the liver.

 6.  diverticular disease without evidence of diverticulitis.

 7.  small hypodense area in the mid pole of the right kidney was not
 completely evaluated in this study.  although statistically, it most likely
 represents a simple cyst, ultrasound could be performed to further evaluate
 this.

"
4974,"[**2137-6-1**] 10:51 am
 mr hip w&w/o contrast left; mr 3d rendering w/post processing on independent wsclip # [**telephone/fax (1) 89222**]
 reason: preop planning - eval neurovascular structures, response to
  contrast: magnevist amt: 13
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  42 year old man with left posterior hip chondrosarcoma soft tissue recurrence
  s/p xrt/chemo
 reason for this examination:
  preop planning - eval neurovascular structures, response to tx
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  left posterior hip chondrosarcoma with soft tissue recurrence status
 post radiation therapy and chemotherapy.  preoperative evaluation.

 comparison:  mr thigh, [**2136-1-30**], and ct pelvis [**2137-4-29**].

 technique:  the following sequences of the pelvis and superior thighs were
 obtained on a 1.5 tesla magnet:  axial t1, axial t2, axial stir, coronal t1,
 axial 3d spgr pre- and post-contrast, coronal 3d spgr post-contrast, axial t1
 post-contrast with fat suppression.  gadolinium-dtpa was administered without
 adverse reaction.

 findings:

 the patient is status post left hip bipolar arthroplasty, and susceptibility
 artifact from the hardware slightly limits evaluation of the adjacent
 structures.

 again demonstrated centered within the gluteus muscles, especially the gluteus
 maximus, is a lobulated, multiseptated lesion which measures 14.0 x 7.2 x 18.2
 cm.  this lesion is predominantly hypointense on t1-weighted imaging with
 respect to the surrounding musculature and hyperintense on t2- weighted
 imaging.  post-contrast administration, there is predominantly peripheral rim
 enhancement with minimal internal enhancement of the septations.  given the
 lack of internal enhancement and predominantly fluid signal of the lesion, a
 large amount of necrosis is likely present in this mass.  no nodular
 enhancement is seen within the lesion.  this lesion drapes around the
 posterior aspect of the left ischial tuberosity, and extends along the course
 of the left sciatic nerve, which appears expanded and demonstrates
 heterogeneous high signal on t2-weighted imaging.  additionally, it appears
 that there is perineural extension of the tumor to involve the left s1, s2,
 and s3 nerve roots as they exit the neural foramina, as these nerve roots
 appear enlarged.  the extent of this mass overall appears grossly unchanged
 from the previous ct.

 subcutaneous edema is demonstrated within the scar in the left lateral
 proximal thigh.  edema is also seen along the superior fascial planes of the
 left hamstring muscles.  presacral edema is also present which crosses the
 midline and involves the right pelvis.

 there also appears to be abnormal signal involving the left piriformis and
                                                             (over)

 [**2137-6-1**] 10:51 am
 mr hip w&w/o contrast left; mr 3d rendering w/post processing on independent wsclip # [**telephone/fax (1) 89222**]
 reason: preop planning - eval neurovascular structures, response to
  contrast: magnevist amt: 13
 ______________________________________________________________________________
                                 final report
 (cont)
 obturator internus muscles, similar to the prior ct.

 visualized intrapelvic parenchymal structures appear grossly unchanged.  no
 pelvic or inguinal lymphadenopathy is demonstrated.

 the remaining bone marrow signal appears within normal limits.

 impression:

 1.  soft tissue recurrence involving the left pelvis and hip which appears
 predominantly necrotic in nature.  there is extension of tumor into the pelvis
 along the left s1 through s3 nerve roots to the left neural foramina, as well
 as along the entire course of the left sciatic nerve.

 2.  presacral edema extends to the right of midline.

"
4975,"[**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  81 year old man with s/p mvc, ct without contrast showing ? hemothorax osh
 reason for this examination:
  please eval r/o intra thoracic injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: ipf [**doctor first name 137**] [**2161-10-15**] 8:48 pm
  right hemothorax with active extravasation from a branch of interal mammary
  artery.
  stranding in the mediastinum.
 ______________________________________________________________________________
                                 final report
 ct of the chest with contrast, ct of the abdomen with contrast, ct of the
 pelvis with contrast, [**2161-10-15**] at [**2086**] hours

 history:  post-trauma from motor vehicle collision with outside hospital
 non-contrast ct demonstrating a large hemothorax.  assess for thoracic
 vascular injury.  the patient is now hypotensive with hematocrit drop.

 technique:  serial transverse images were acquired sequentially during the
 arterial phase administration of 80 ml of optiray 350.  no adverse reaction
 was encountered.  multiplanar reformatted images were generated.

 comparison:  non-contrast torso ct obtained earlier same day from outside
 hospital and uploaded to local pacs.

 findings:  similar to the prior study performed without contrast, there is a
 large anterior extrapleural collection in the right hemithorax.  with the
 benefit of contrast, it is markedly heterogeneous with large areas of fluid
 attenuation, a high-attenuation fluid-fluid level, surrounding rim
 enhancement, and multiple foci of active extravasation of vessels.  one of the
 larger foci of active extravasation is seen on series 2 image #74.  this is at
 the level of a non-displaced transverse fracture of the distal sternal body.
 foci of active extravasation are also seen at slightly more cephalad levels
 including at the inferior margin of the second sternocostal junction and at
 the inferior margin of the first sternocostal margin all along the course of
 the right internal mammary artery.  these are presumed extravasations off
 direct branches from that vessel, likely the proximal aspects of the
 corresponding intercostal vessels.  a component of this large extrapleural
 hematoma extends along the retrosternal space anterior to the mediastinum and
 heart.  a corresponding anterior mediastinal hematoma is also present.  no
 aortic injury is identified.  there is mass effect on the heart, specifically
 the anterior aspect of the heart, principally the right ventricle.

 in addition to the large extrapleural anterior hematoma, there is a relative
 large free-flowing dependent hemothorax with a hematocrit level layering
 posteriorly in the right hemithorax.  the combination of both of these
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)
 hematomas, results in significant mass effect on the underlying lobes of the
 right lung with compressive atelectasis seen both in the right upper, right
 middle and right lower lobes.  a small effusion is identified on the left.
 there is calcification over the apex of the right lung, presumably along the
 visceral pleura.  no pneumothorax is present.  there are no focal
 consolidations or areas of pulmonary contusion identified.

 the study was acquired predominantly in expiratory phase with inward bowing of
 the posterior membrane of the trachea and the major bronchi.  however,
 otherwise the major airways are widely patent.  incidental note is made of an
 aortic origin of the left vertebral artery, an anatomic variant.  the aorta
 otherwise is intact with normal contour, caliber and course.  there is
 scattered calcified plaque seen at multiple levels.  there is no apparent
 aortic injury.  there is fullness in the supraclavicular space on the right.
 this is incompletely evaluated on this chest ct protocol.

 timing was not optimized for solid organ evaluation given the concern for
 vascular injury.  however, grossly there are no discrete traumatic lesions of
 the solid abdominal organs of the upper abdomen.  a focal curvilinear
 calcification in the right hepatic lobe likely is reflective of prior
 granulomatous insult.  there is a high-attenuation focus in the most inferior
 tip of the right hepatic lobe.  this is most reminiscent of a flash-filling
 hemangioma although focal nodular hyperplasia or adenoma may also be
 considered.  gallbladder is present but otherwise unremarkable.  bilateral
 kidneys enhance symmetrically.  there are small cortical scars on both kidneys
 presumably due to prior infection.  conceivably, these may reflect prior small
 infarcts as well.  a 10 mm x 30 mm hypoattenuated lesion is identified
 anteriorly in the pancreatic body.  this is incidental and not related to
 trauma.  no pancreatic ductal dilatation is evident.

 the stomach and small bowel are largely collapsed.  no wall thickening or
 dilatation is evident.  a normal appendix is identified.  there is scattered
 stool throughout the colon.

 similar to the chest, there is scattered calcified and non-calcified plaque of
 the abdominal aorta and major branch vessels.  eccentric irregular plaque is
 identified at the bifurcation of the right common iliac artery.  no pathologic
 lymphadenopathy is seen within the abdomen or pelvis.  there is no free
 intraperitoneal fluid or air.

 the urinary bladder is markedly distended.  there is an enlarged prostate.
 the enlargement of the prostate is relatively non-uniform with an irregular
 focus of enlargement centered at left of midline causing mass effect on the
 base of the bladder.  there is no apparent invasion.  however, given the
 relative morphology of the enlarged prostate, an underlying mass lesion such
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)
 as prostate cancer cannot be excluded.  seminal vesicles image normally.

 osseous structures:  aside from the non-displaced horizontal fracture through
 the distal sternal body described above, no further fracture of the chest,
 abdomen, or pelvis is identified.  there are no suspicious osseous lesions.
 multilevel degenerative disease is seen principally in the upper lumbar spine
 and in the mid lower thoracic spine.

 impression:

 1.  there is active extravasation of the medial branches of the right internal
 mammary artery into a large presumed extrapleural anterior right hemithorax
 hematoma.  there is some element of tamponade of this hematoma and a portion
 of it does extend along the retrosternal space.  there is minimal at this
 point mass effect on the underlying heart.

 2.  no apparent aortic injury.  no obvious cardiac injury; however, the
 evaluation for such is limited on ct.

 3.  large layering hemothorax posteriorly in the right chest as well.  small
 pleural effusion on the left.

 4.  as above, a non-displaced transverse distal sternal body fracture.  this
 coincidentally occurs at the site of the largest focus of extravasation
 detailed above.

 5.  no evidence of acute solid organ injury in the abdomen or pelvis.  there
 may have been prior infections or infarcts of the kidneys as detailed above.

 6.  enlarged and irregularly shaped prostate.  underlying prostate cancer
 cannot be excluded.  appropriate workup after acute presentation is resolved,
 may be pursued.

 7.  hypoattenuated lesion of the pancreas, nontraumatic in etiology.  further
 evaluation after emergent conditon is addressed should be pursued with
 referral to pancreas center and likely abdominal mri (without
 contraindication).

 the emergent results of the study were immediately placed on the ed dashboard
 as a wet read.  the study was also reviewed in person with surgical consult,
 dr. [**first name4 (namepattern1) 1688**] [**last name (namepattern1) 2723**], of the trauma surgery team at approximately 9 p.m.
                                                             (over)

 [**2161-10-15**] 7:36 pm
 cta chest w&w/o c&recons, non-coronary; cta abd w&w/o c & reconsclip # [**telephone/fax (1) 19386**]
 cta pelvis w&w/o c & recons
 reason: please eval r/o intra thoracic injury
 field of view: 36 contrast: optiray amt: 80
 ______________________________________________________________________________
                                 final report
 (cont)

"
4976,"[**2165-10-27**] 2:52 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 50239**]
 reason: pe?
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  83 year old man with pleuritic chest pain and dyspnea, positive d-dimer.
  creatinine 1.6, baseline. hydrating.
 reason for this examination:
  pe?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sun [**2165-10-27**] 3:42 pm
  1. no pe or acute aortic syndrome.
  2. small (7-8 mm thick) pericardial effusion; may represent pericarditis in
  the setting of pleuritic chest pain; no compression of heart [**doctor last name 4473**] to
  suggest tamponade at this time.
  3. trace r and small l pleural effusions w/ associated atelectasis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with pleuritic chest pain and dyspnea.

 study:  chest cta.

 mdct images were generated through the chest without iv contrast.  subsequent
 mdct images were generated through the chest after administration of 100 cc of
 optiray intravenous contrast in the pulmonary arterial phase.  there is no
 adverse reaction or complication.  coronal, sagittal, and right and left
 oblique reformatted images were also generated.

 comparison:  v/q scan from [**2165-10-3**].

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.

 the aorta is of a normal caliber along its course without evidence of
 intramural hematoma or dissection.  minimal calcified atherosclerotic disease
 is seen in the aortic arch.  the pulmonary artery is of a normal caliber at
 its origin and there are no filling defects to the subsegmental level.
 coronary artery calcifications are seen bilaterally.  a small pericardial
 effusion is present, measuring up to 7 mm in thickness in the axial plane.
 subtle stranding is seen in the adjacent mediastinal fat.  the heart [**doctor last name 4473**]
 do not yet show evidence of compression.  bilateral pleural effusions are
 seen, trace on the right and small on the left, with associated atelectasis.
 otherwise, the lungs are clear.

 visualized portion of the upper abdomen shows no gross abnormality.  the
 previously described opacity in the posterior base of the lung still may
 represent an eventration versus a diaphragmatic hernia.

 the visualized bones demonstrate moderate degenerative changes of the thoracic
 spine, but there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2165-10-27**] 2:52 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 50239**]
 reason: pe?
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 1.  no pe or acute aortic syndrome.
 2.  pericardial effusion with surrounding inflammation, compatible with
 pericarditis.
 3.  small left and trace right pleural effusions with associated atelectasis.

"
4977,"[**2144-9-7**] 10:05 am
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 25226**]
 reason: r/o pe
 admitting diagnosis: pancreatitis
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  60 year old man with asthma, factor v leiden p/w etoh vs stone pancreatitis,
  transferred from osh with hypoxia, tachycardia
 reason for this examination:
  r/o pe
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2144-9-7**] 12:55 pm
  1.  pe involving the right lower lobe branch of the pulmonary artery without
  evidence right heart strain.  this finding was communicated to [**first name8 (namepattern2) 490**] [**last name (namepattern1) 1021**]
  at 12:27 p.m. on [**2144-9-7**] but [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
  2.  bilateral moderate pleural effusions with compressive atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with asthma, factor v leiden deficiency, now with
 pancreatitis; now with hypoxia and tachycardia.

 study:  chest cta; mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after the
 administration of 100 ml of intravenous contrast without complication or
 adverse reaction.  coronal, sagittal as well as right and left oblique
 reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.

 the pulmonary arterial trunk is of a normal caliber at its origin.  the
 pulmonary artery is of a normal caliber at its origin.  filling defect is
 noted at the right lower lobe branch of the pulmonary artery, which extends
 into the posterior basal, lateral basal, and anterior basal segments.

 the aorta is of a normal caliber along its course and shows no evidence of
 dissection or intramural hematoma.  there is no pericardial effusion. there is
 no inward bowing of the intraventricular septum into the left ventricle to
 suggest right heart strain.

 the visualized portion of the right lower lobe lung parenchyma shows no
 evidence of infarct.  a small area of ground-glass opacity is seen in the
 right upper lobe.  moderate bilateral simple pleural effusions are seen with
 associated compressive atelectasis.

 the visualized portion of the upper abdomen shows no overt abnormality.

 the visualized portion of the bones show no aggressive-appearing lytic or
 sclerotic lesions.
                                                             (over)

 [**2144-9-7**] 10:05 am
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 25226**]
 reason: r/o pe
 admitting diagnosis: pancreatitis
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 1.  pe involving the right lower lobe branch of the pulmonary artery without
 evidence right heart strain.  this finding was communicated to [**first name8 (namepattern2) 490**] [**last name (namepattern1) 1021**]
 at 12:27 p.m. on [**2144-9-7**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.
 2.  bilateral moderate pleural effusions with compressive atelectasis.
 3.  small right upper lobe opacity - inflammatory versus infectious etiologies
 may be considered.

"
4978,"[**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  45 year old man with group g strep sepsis and unknown source
 reason for this examination:
  abscess?  gi pathology which might cause bacteremia?
 contraindications for iv contrast:
  esrd, gets hd on mondays, needs to have hd after scan;esrd, hd on mondays
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh mon [**2186-7-31**] 11:56 pm
  1. no acute intra-abdominal process.
  2. ragged appearance of l4-l5 intervertebral disc endplates - this can be seen
  in discitis - correlate with patient's clinical condition.
 pfi version #1 jekh mon [**2186-7-31**] 12:59 pm
  no acute intra-abdominal process; specifically no evidence of a bacteremic
  source.
 ______________________________________________________________________________
                                 final report
 history:  45-year-old male with group g strep sepsis, an unknown source.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was given without complication or adverse reaction.
 coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  visualized portion of the lung bases appears unremarkable.

 the liver shows no focal lesion or biliary duct dilation.  the gallbladder is
 decompressed.  the spleen is normal in size and appearance.  pancreas shows no
 surrounding fluid collection.  the adrenal glands are normal appearing
 bilaterally.

 the kidneys enhance with and excrete contrast symmetrically without evidence
 of hydronephrosis or perinephric fluid collection.  in the inferior pole of
 the right kidney is a hypodensity that is too small to characterize but likely
 represents a simple cyst.

 the small and large intestine show no evidence of obstruction or wall edema.
 the appendix is visualized and is normal.  there is no free air, free fluid,
 or lymphadenopathy.

 pelvis:  the bladder, prostate, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.

 bones:  there are no aggressive appearing lytic or sclerotic lesions.
 moderate degenerative changes are seen throughout the lumbar spine.  anterior
                                                             (over)

 [**2186-7-31**] 10:14 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 72542**]
 reason: abscess?  gi pathology which might cause bacteremia?
 admitting diagnosis: sepsis
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 osteophytes are also noted throughout the lumbar spine.  at the l4-l5 level,
 there is enplate sclerosis, likely degenerative, however there is ragged or an
 erosive/destructive appearance to the adjacent endplates with mild soft tissue
 prominence anteriorly.

 impression:
 1. no acute intra-abdominal or intra-pelvic process.
 2. abnormal appearance of l4-l5 level, as described above, concerning for
 discitis/ostemyelitis - correlate with patient's clinical condition.

 findings discussed with [**first name8 (namepattern2) **] [**last name (un) 29352**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone at 8:49 am
 on [**2186-8-1**].

"
4979,"[**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old man with fall from roof, unequal bps
 reason for this examination:
  pls evaluate aortic arch
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2189-8-17**] 4:50 pm
  chest:
  1. 50% r anterior ptx w/ mediastinal shift and compressive effects on both
  lungs; r chest tube enters low and is oriented in posterior pleural space
  (away from ptx).
  2. no l ptx.
  3. no aortic or injury.
  4. extensive r chest wall emphysema.
  5. r posterolateral rib fx [**3-24**]; l posterolateral rib fx [**8-24**]; r clavicle fx.

  abdomen/pelvis:
  1. worsening hepatic and splenic lacerations w/ growing perihepatic and
  perisplenic hematomas - active extrav around spleen; small amt blood tracking
  along b paracolic gutters.
  2. prominent r adrenal gland - ? hematoma.
  3. no free intraabdominal air.
  4. extensive r abd/flank wall emphysema extending into r groin; early r flank
  hematoma.
  5. no spine or pelvic fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  75-year-old male with fall off roof of rv.

 study:  ct of the torso with contrast; 130 ml of optiray intravenous contrast
 was given without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  torso ct from [**2189-8-17**], from an outside hospital at
 1304.

 findings:

 chest:  the patient is intubated with the tube terminating in the mid trachea.
 there is a pneumothorax involving 50% of the right hemithorax and is situated
 mostly anteriorly.  a chest tube placed on the right exists in the posterior
 pleural space, but does not come in contact with this pneumothorax.  there is
 severe mass effect on the right lung, mediastinum and left lung, consistent
 with tension pneumothorax.  additionally, extensive pneumomediastinum and
 pneumopericardium is noted.  both lungs demonstrate extensive atelectasis
 primarily in their lower lobes.  the heart shows no pericardial effusion.
 there is no mediastinal hematoma.  the aorta demonstrates no evidence of
                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 dissection.  there is no contrast extravasation.  extensive chest wall
 emphysema is demonstrated.

 abdomen:  multiple liver lacerations are demonstrated in segments v, vi, vii
 and viii with surrounding dense fluid around the liver and tracking along the
 right paracolic gutter.  a single focus of peripheral contrast blush is
 demonstrated in segment viii (2; 41), concerning for active extravasation.
 this appearance appears worse and has progressed from prior ct.

 multiple splenic lacerations are demonstrated with a growing surrounding
 splenic hematoma.  additionally, multiple areas of contrast blush are noted,
 concerning for active extravasation.  this fluid tracks along the left
 paracolic gutter.  this too represents an increase from prior study.

 thickening of the head of the right adrenal gland is compatible with hematoma.

 the kidneys enhance with and excrete contrast symmetrically.  there are no
 perinephric fluid collections.  pancreas appears unremarkable.  the small and
 large intestine show no evidence of obstruction or wall thickening.  there is
 no free air.  the abdominal aorta is intact.

 continued subcutaneous emphysema and a developing right flank hematoma are
 demonstrated along the right abdominal wall.

 pelvis:  the bladder contains locules of gas and a foley balloon.  the
 prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.  gas tracking along the right abdominal wall tracks down into
 the right groin.

 bones:  multiple segmental fractures are demonstrated in the right
 posterolateral ribs from the third rib through the twelfth rib; there is
 additionally a fracture of the right clavicle.  multiple posterolateral rib
 fracture is also noted in the left ribs 9 through 12 although they appear to
 be older in age.  no acute left rib fracture is seen.  no spinal fracture is
 demonstrated.  the sternum is intact.  the pelvis is intact.  a total hip
 arthroplasty on the left is in place without evidence of periprosthetic
 fracture or loosening.

 impression:
 1.  right tension pneumothorax; right chest tube and posterior pleural space,
 not evacuating this pneumothorax; mediastinal deviation and compression of the
 right and left lungs are concerning for tension pneumothorax.
 pneumomediastinum and pneumopericardium is also present along with extensive
 right chest and abdominal wall subcutaneous emphysema extending into the
 groin.

                                                             (over)

 [**2189-8-17**] 3:33 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 24283**]
 reason: pls evaluate aortic arch
  contrast: optiray amt: 130cc
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  extensive hepatic and splenic lacerations with growing perihepatic and
 perisplenic hematomas with areas concerning for active extravasation.

 points 1 and 2 were called to or 15 at the time of dictation to make the
 operating team aware.

 3.  multiple segmental rib fractures on the right; the potential for flail
 chest exists.  right clavicular fracture.

 4.  right adrenal hematoma.

"
4980,"[**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  36 year old woman with hemorrhagic pancreatitis s/p ercp for choledochal cyst
  s/p ex-laps/washouts, perc drain drain removed on [**2129-10-10**].
 reason for this examination:
  please do a ct scan of the abdomen and pelvis w/ oral and iv contrast to assess
  for recurrent collection. patientis having ongoing pain. please page dr. [**first name8 (namepattern2) **]
  [**last name (namepattern1) 1350**] w/ a wet read, thanks.
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  36-year-old female with choledochal cyst status post ercp,
 complicated by hemorrhage pancreatitis and persistent fluid collection, now
 with percutaneous drain removed with recurrent abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; optiray 350 intravenous
 contrast was administered without complication or adverse reaction.  coronal
 and sagittal reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis with contrast from [**2129-8-26**].

 findings:

 abdomen:  the visualized portion of the lungs appears unremarkable.

 the liver demonstrates no defined hypodensity measuring 15 x 9 mm in the axial
 plane (4; 15), which is incompletely characterized but similar appearance to
 prior study.  again is seen fusiform aneurysmal dilatation of the cbd
 measuring 39 x 20 mm in the axial plane, compatible with a type 1 choledochal
 cyst.  the gallbladder is decompressed.  the spleen, pancreas and adrenal
 glands appear unremarkable.

 multiple fluid collections are seen in the abdomen.  two fluid collections
 just beneath the hepatic flexure of the colon are seen measuring 22 x 15 and
 44 x 11 mm in the axial plane (4; 33).  these are slightly decreased in size
 when compared to prior study.  further down in the right mid to lower abdomen
 is a larger fluid collection measuring 44 x 25 mm in the axial plane; two
 smaller fluid collections are seen lateral to it measuring 16 x 14 mm (4; 43)
 and 18 x 13 mm (4; 45).  these fluid collections are thick rimmed and
 peripherally enhancing.  there is extensive inflammatory fat stranding around
 them.  there is extensive right colonic wall thickening and pericolonic
 stranding, compatible with reactive change.  additionally, reactive fluid
 stranding around the right kidney represents reactive change.  there is no
 free air.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  no free fluid
 or lymphadenopathy is seen.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
                                                             (over)

 [**2129-10-18**] 2:52 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 59995**]
 reason: please do a ct scan of the abdomen and pelvis w/ oral and iv
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 impression:
 multiple abdominal fluid collections as described above, concerning for
 abscesses, the largest of which measures 4.4 x 2.5 cm in the axial plane and
 is amenable to percutaneous drainage from an anterior approach.  these
 findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 1350**] at 16:40 on [**2129-10-18**] by [**first name8 (namepattern2) 405**]
 [**last name (namepattern1) 406**] over the phone.

"
4981,"[**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  75 year old woman with ho diverticulitis with abd pain ttp llq
 reason for this examination:
  pls eval ro acute proc
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**hospital 5197**] fri [**2163-8-19**] 12:03 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 wet read version #1
 wet read version #2 [**first name9 (namepattern2) 5197**] [**doctor first name 73**] [**2163-8-18**] 8:16 pm
  s/p partial colectomy; no diverticulitis or abscess.

 ______________________________________________________________________________
 provisional findings impression (pfi): [**year (4 digits) 5197**] fri [**2163-8-19**] 12:02 am
  1.  status post sigmoid colectomy without evidence of complication.  no
  evidence of diverticulitis.
  2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
  factors (non-smoker and no cancer history), follow-up ct in one year is
  recommended to document stability.
  3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
  for further evaluation.
 ______________________________________________________________________________
                                 final report
 history:  75-year-old female with a history of diverticulitis, now with left
 lower quadrant abdominal pain.

 study:  ct of the abdomen and pelvis with iv contrast; 130 cc of optiray
 intravenous contrast was given.  there was no adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases demonstrate a 6 mm pulmonary nodule.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder is distended but shows no stones or wall edema.  the spleen is
 normal in size.  the pancreas shows no masses.  bilateral adrenal nodules,
 each about 1 cm, are incompletely characterized.  the kidneys enhance with and
 excrete contrast symmetrically.  at the superior pole of the left kidney is a
 well-circumscribed hypodensity measuring 3 cm in diameter, most compatible
                                                             (over)

 [**2163-8-18**] 5:42 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 5295**]
 reason: abd pain, h/o divertic.  eval
 field of view: 40 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 with a simple cyst.

 the small and large intestines show no evidence of obstruction.  the appendix
 is normal.  anastomosis is seen in the distal colon, most compatible with
 prior sigmoid resection.  there is no free air or free fluid.  scattered tiny
 fat-containing midline hernias are noted.

 pelvis:  the bladder and rectum appear unremarkable.  the patient is status
 post hysterectomy.  there is no free fluid or lymphadenopathy.  bilateral
 fat-containing inguinal hernias are noted.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  status post sigmoid colectomy without evidence of complication.  no
 evidence of diverticulitis.
 2.  right lower lobe pulmonary nodule, 6 mm.  in the setting of no risk
 factors (non-smoker and no cancer history), follow-up ct in one year is
 recommended to document stability.
 3.  bilateral adrenal nodules; a dedicated adrenal ct or mr may be considered
 for further evaluation.

 findings discussed with [**first name5 (namepattern1) 5296**] [**last name (namepattern1) 5297**] 12:05 am on [**2163-8-19**] by [**first name8 (namepattern2) 873**]
 [**last name (namepattern1) 5298**] over the phone.

"
4982,"[**2150-5-16**] 1:47 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 58728**]
 reason: evaluate for lymphadenopathy, abscess
  contrast: omnipaque amt: 70
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  60 year old man with aml s/p allo-transplant presenting with nasal congestion
  and severe sore throat
 reason for this examination:
  evaluate for lymphadenopathy, abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with aml status post allotransplant, now with
 severe sore throat.

 study:  ct of the neck with contrast; coronal and sagittal reformatted images
 were also generated.  75 cc of omnipaque intravenous contrast was administered
 without adverse reaction or complication.

 comparison:  [**2150-2-20**], [**2150-2-4**].

 findings:  the visualized portion of the brain is unremarkable.  the orbits
 and globes are intact.  the visualized paranasal sinuses demonstrate minimal
 mucosal thickening in the right maxillary sinus floor.

 no retropharyngeal or peritonsillar fluid collection is present, although
 streak artifact from dental amalgam somewhat limits assessment of finer detail
 in this area.

 the parotid glands are within normal limits.  no lymphadenopathy is present.
 the thyroid is normal in appearance.  a right-sided central venous catheter is
 in place.  the visualized lung apices are clear; the 6-mm right lower lobe
 pulmonary nodule described on the [**2150-2-4**] scan is not imaged on the
 current exam.  incidental note is made of a common origin of the
 brachiocephalic and left common carotid arterial branches off the aortic arch.

 impression:  no evidence of retropharyngeal or peritonsillar abscess; no
 lymphadenopathy.


"
4983,"[**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 46m with abd pain, n/v
 reason for this examination:
  r/o appy, other acute intraabdominal process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2200-3-29**] 7:08 pm
  inflammed duodenum w/ surrounding fluid and focal area of wall discontinuity,
  concerning for contained duodenal perforation; no free air; normal appendix

 wet read version #1
 wet read version #2 jekh sat [**2200-3-29**] 6:23 pm
  duodenitis; no free air; normal appendix

 ______________________________________________________________________________
                                 final report
 history:  46-year-old male with abdominal pain, nausea and vomiting.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the lung bases are clear.

 the liver contour is nodular with caudate and left lateral lobe hypertrophy
 and atrophy of the right posterior lobe of the liver, compatible with
 cirrhosis.  there is no intrahepatic biliary dilatation or definite focal
 hepatic lesion. portal vein is patent. calcified stones within the gallbladder
 fundus and neck are present.  there is no wall edema or pericholecystic
 stranding.  the spleen is normal in size and appearance.  the adrenal glands
 show no nodules.  the kidneys enhance with and excrete contrast symmetrically;
 subcentimeter hypodensities in both kidneys are too small to characterize,
 likely representing cysts; focal cortical scarring in the left kidney is
 compatible with prior infection or infarction.

 there is marked wall thickening and extensive surrounding fat stranding and
 mural edema involving the distal stomach and proximal duodenum, centered about
 the duodenal bulb.  a focal outpouching of the duodenal bulb is present,
 concerning for an ulcer, less likely a diverticulum.  no free air is seen,
 though a fluid collection is noted posterior to the distal stomach in the
 lesser sac measuring 19 x 19 mm.  the pancreatic head is adjacent to this
 inflammatory process and appears indistinct, although the pancreatic body and
 tail are also mildly atrophic.

 the remainder of the small and large bowel show no evidence of wall edema or
 obstruction.  the appendix is normal.  there is no lymphadenopathy or free
                                                             (over)

 [**2200-3-29**] 3:35 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 38045**]
 reason: r/o appy, other acute intraabdominal process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 air.

 pelvis:  gas is seen in the bladder and correlation with recent
 catheterization is recommended.  the prostate and rectum appear unremarkable.
 there is no free fluid or lymphadenopathy. small bilateral fat containing
 inguinal hernias are present.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. findings concerning for a contained perforation of a duodenal bulb ulcer
 with adjacent surrounding inflammation and associated duodenitis.  small focal
 fluid collection is present in the lesser sac. findings discussed with [**first name8 (namepattern2) **]
 [**known firstname **] at 19:00 [**2200-3-29**] by [**first name8 (namepattern2) 510**] [**last name (namepattern1) 5773**] over the phone.

 2. cirrhosis.

 3. cholelithiasis.

 4. gas within the bladder lumen. correlate with any history of recent
 instrumentation; otherwise, findings are concerning for an infectious process.

"
4984,"[**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  50 year old woman with pedestrain struck by tow truck. no obvious injury other
  than head lac
 reason for this examination:
  trauma?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2133-3-19**] 7:55 pm
  1. no intrathoracic injury.
  2. distended stomach but no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old female pedestrian struck by a tow truck.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of thyroid demonstrates a 5-mm hypodensity in
 the left lobe of the thyroid (2; 6).  there is no axillary, hilar, or
 mediastinal lymphadenopathy.  the aorta is of normal caliber along its course
 without evidence of dissection or injury.  no mediastinal hematoma is present.
 the pulmonary arterial tree shows no central filling defect.  there is no
 pleural or pericardial effusion.  the lungs show a subtle ground-glass opacity
 in the right lower lobe which may represent an area of contusion or
 aspiration.  there is no pneumothorax.

 abdomen:  an area of enhancement in the left lobe of the liver likely
 represents a hemangioma or perfusion anomaly (2;50).  the gallbladder, spleen,
 pancreas, and adrenal glands appear unremarkable.  there is no perihepatic,
 perisplenic, or pericolic fluid.  there is no free fluid or free air.  the
 kidneys enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; bilateral subcentimeter hypodensities are too small to
 characterize but likely represent cysts.  the aorta is of a normal caliber
 along its course without evidence of injury.  small and large bowels show no
 evidence of wall edema or obstruction; the stomach, however, is notably
 distended with gas.

 pelvis:  the bladder is decompressed.  the uterus and rectum appear
 unremarkable.

 bones:  there is no acute fracture; old left rib fractures are present.  there
                                                             (over)

 [**2133-3-19**] 7:05 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 84099**]
 reason: trauma?
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  small nonspecific area of ground glass in the right lung.  otherwise
 essentially unremarkable exam without acute intra-abdominal or intrathoracic
 injury; no acute fracture.
 2.  distended stomach may benefit from ng tube.

"
4985,"[**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 65f with clinical question:
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2142-3-17**] 11:09 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; surrounding hematoma but no pelvic free fluid; hematoma along l medial
  thigh as well; hairline fx through l iliac w/ probable involvement of l si
  joint, but no sacral fx.
 wet read version #1
 wet read version #2 jekh sat [**2142-3-17**] 10:25 am
  1. no intrathoracic for intraabdominal injury.
  2. acute l1 vertebral body burst fx w/ 8 mm of retropulsed fragments; fx
  through r l1 lamina; unstable; consider mr if concern for cord injury.
  3. minimally displaced fx of medial l inf pubic ramus and lateral l sup pubic
  ramus; hairline fx through l iliac w/ probable involvement of l si joint, but
  no sacral fx.
 ______________________________________________________________________________
                                 final report
 history:  65-year-old female pedestrian status post struck by suv.

 study:  ct of the torso with contrast; coronal and sagittal reformatted images
 were also generated.  130 cc of omnipaque 350 intravenous contrast was
 administered without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  the aorta is of normal caliber along its course without evidence of
 injury; incidental note is made of a common origin of the brachiocephalic and
 left common carotid arteries, a normal variant (2a; 14).  the pulmonary artery
 shows no central filling defects.  there is no pleural or pericardial
 effusion.  the lungs are clear without evidence of contusion.  there is no
 pneumothorax.

 abdomen:  a subcentimeter hypodensity in the dome of the liver is too small to
 characterize but likely represents a cyst rather than a contusion/laceration
 as there is no perihepatic fluid.  a subcentimeter hypodensity in the
 periphery of the spleen also likely represents a cyst or hemangioma rather
 than a contusion or laceration as there is no perisplenic fluid.  the pancreas
 and adrenal glands appear unremarkable.  the kidneys enhance with and excrete
 contrast symmetrically; a well-circumscribed 1-cm hypodensity in the mid pole
                                                             (over)

 [**2142-3-17**] 9:29 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30871**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 of right kidney is most compatible with a simple cyst.  there is no
 retroperitoneal fluid collection.  the small and large bowel show no evidence
 of obstruction or injury.  there is no free air or free fluid.  the abdominal
 aorta is of normal caliber along its course without evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  there is no
 free fluid or lymphadenopathy.  the left obturator musculature is thickened,
 likely representing intramuscular or contained hematoma.  additional
 incompletely image hematoma of the medial left thigh is present.

 bones:  there is a burst fracture of the l1 vertebral body with 8-mm
 retropulsed fragments into the central canal.  additionally, a minimally
 displaced fracture is present along the right aspect of the lamina of l1.  a
 small amount of adjacent hematoma is seen around the anterolateral aspects of
 the vertebral body.  loss of height is approximately 50%.

 additionally, minimally displaced fractures of the left superior and inferior
 pubic rami are present; the lateral aspect of the superior pubic rami is
 fractured while the medial aspect of the inferior pubic rami is fractured.
 additionally, a hairline fracture is present along the left iliac bone just
 adjacent to the si joint and extending into the si joint on the left.  the
 sacrum itself appears intact.

 impression:
 1.  no acute intra-abdominal or intrathoracic injury.
 2.  l1 burst fracture with retropulsed fragments and minimally displaced
 fracture of the right l1 lamina; these findings suggest an unstable fracture
 and if clinical concern for cord injury exists, mr would be recommended.
 3.  fracture of the left pelvis as described above.

 these findings were discussed with [**first name8 (namepattern2) **] [**last name (namepattern1) 7304**] in person at 10:00 a.m. and
 again at 11:05 a.m. by phone on [**2142-3-17**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
4986,"[**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  52m, h/o longstanding crohn's, started on [**first name9 (namepattern2) 22562**] [**2187-2-3**], has had better but
  incomplete control (all to remicaid).  has had a couple flares in the interum.
  returns today with s/s c/w flare.  c/o increased abd pain, esp in lrlq to deep
  palpation.  denies f/c/v, does c/o n/d which is normal for pt.  does report
  lrlq pain immidiately after eating or drinking nearly every time.  pt states
  otherwise, he feels well.  with dirty uaiv/po contrast pleaseplease eval
  kidneys and bowel,
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2188-3-22**] 6:43 pm
  1. s/p cholecystectomy, splenectomy, and total colectomy.
  2. l-sided loop of bowel w/ thickened wall and surrounding inflammation, c/w
  crohn's flare; no abscess.
  3. mild perinephric stranding but no e/o pyelonephritis or perinephric fluid
  collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with a history of crohn's disease, now with
 abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque 350
 intravenous contrast was administered without adverse reaction or
 complication.  oral contrast was also administered.

 coronal and sagittal reformatted images were also generated.

 comparison:  [**2186-11-29**].

 findings:

 abdomen:  the visualized portion of the lung bases are clear.  the liver shows
 no focal lesion or intrahepatic biliary dilatation.  clips in the gallbladder
 fossa compatible with prior cholecystectomy.  the spleen is surgically absent.
 pancreas shows no masses.  the adrenal glands show no nodules.  the kidneys
 enhance with and excrete contrast symmetrically without evidence of
 hydronephrosis; minimal perinephric stranding is present without an organized
 fluid collection or striated nephrogram.  patient is status post total
 colectomy without evidence of obstruction.  loops of bowel in the left abdomen
 demonstrate thickened wall with subtle surrounding fat stranding.  possible
 early phlegmon may be present in the left lower abdomen (2:54,601:38) without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude.  nearby scattered mesenteric lymph nodes are seen.  equivocal
 tethering of bowel loops in this area is also noted.  trace amount of reactive
 fluid is also seen in the mesentery.  there is no free air.  incidental note
                                                             (over)

 [**2188-3-22**] 5:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 22563**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 is made of ventral abdominal wall mesh.

 pelvis:  the bladder and prostate appear unremarkable.  there is a transition
 in the diameter of the lumen from the small bowel to the rectosigmoid colon
 region through which contrast is passing (2; 62).  there is no free fluid or
 lymphadenopathy in the pelvis.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 intervertebral discs
 primarily in the form of vacuum phenomenon and endplate sclerosis.

 impression:
 1. status post cholecystectomy, splenectomy, and total colectomy.
 2. left-sided bowel with wall thickening and surrounding inflammation; given
 patient history compatible with an inflammatory process such as the patient's
 known crohn's disease.  infection might have a similar appearance .
 possible early phlegmon may be present in the left lower abdomen without
 drainable fluid collection seen; however fistula in this location is difficult
 to exclude. mre is more sensitive and may be helpful for further evaluation.

"
4987,"[**2118-10-23**] 7:07 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 16327**]
 reason: r/o pe
 admitting diagnosis: pneumonia
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  53 year old man with acute hypoxia
 reason for this examination:
  r/o pe
 no contraindications for iv contrast
 ______________________________________________________________________________
 provisional findings impression (pfi): jekh sun [**2118-10-23**] 8:59 pm
  1.  no pe or acute aortic syndrome.
  2.  bibasilar opacities, likely reflecting components of early pneumonia and
  atelectasis.
 ______________________________________________________________________________
                                 final report
 history:  53-year-old male with acute hypoxia.

 study:  chest cta.  mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after the
 administration of 100 cc of optiray intravenous contrast without complication
 or adverse reaction.  this is dominant in the pulmonary arterial phase.
 coronal, sagittal, and right and left oblique reformatted images were also
 generated.

 comparison:  none.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar or mediastinal lymphadenopathy.

 the aorta is of a normal caliber along its course without evidence of
 dissection or intramural hematoma.  incidental note is made of a direct
 takeoff of the left vertebral artery between the origins of the left common
 carotid and left subclavian arteries, a normal variant (4; 10).

 the pulmonary arterial trunk is of a normal caliber and there are no filling
 defects down to the subsegmental level.

 trace pericardial fluid is noted anteriorly (4; 52).

 bibasilar opacities, as well as focal opacity in the posterior rul adjacent to
 the minor fissure (image 4:22) are seen within the lungs, likely representing
 more than just dependent atelectasis, but rather an additional superimposed
 infectious process.as part of the opacities have a nodular appearance,[e.g.
 rll (4:34), lll (4:55)] follow-up ct when symptoms resolve is recommended.

 the visualized portion of the upper abdomen shows no gross abnormality.

 the visualized bones demonstrated incidentally fusion of the right lateral
 fifth and sixth ribs.  additionally, there is a bony bridge between the
 posterior aspect of the left sixth and seventh ribs (501b; 36).  there are no
                                                             (over)

 [**2118-10-23**] 7:07 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 16327**]
 reason: r/o pe
 admitting diagnosis: pneumonia
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  no pe or acute aortic syndrome.
 2.  bibasilar opacities, likely reflecting components of early pneumonia and
 atelectasis.however, due to several nodular areas, follow-up chest ct when
 symptoms resolve is recommended.

"
4988,"[**2166-2-11**] 9:14 am
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 8970**]
 reason: melanoma
 ______________________________________________________________________________
                                 final report
 history:  49-year-old female with melanoma in need of assessment for
 metastatic disease.

 study:  ct of the neck with contrast; 50 ml of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  pet-ct from [**2165-11-12**] and ct of the torso from [**2-11**], [**2165**].

 findings:  the visualized portion of the brain shows no evidence of mass or
 abnormal enhancement; the circle of [**location (un) 501**] appears grossly intact.  the
 visualized portion of the globes and oribts appears within normal limits.

 the visualized paranasal sinuses and mastoid air cells are clear.  streak
 artifact is present, mildly limiting assessment of the mandible but it too
 appears intact.  cervical spine shows no evidence of malalignment or more
 aggressive-appearing lytic/sclerotic lesion.

 the parotid and submandibular glands appear normal.  no lymphadenopathy is
 present.  the jugular and carotid vasculature are patent.  a linear
 hypodensity in the right lobe of the thyroid measures 6 x 2 mm (2; 62).

 the visualized portion of the lung apices and upper mediastinum appears
 unremarkable.

 impression:  no evidence of lymphadenopathy or metastatic disease.

"
4989,"[**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  [**age over 90 **] year old woman with mcv, positive fast
 reason for this examination:
  bleeding?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2102-1-26**] 4:38 pm
  1. r [**5-21**] lateral rib fx and l [**3-22**] lateral rib fx (segmental fx in l 9 and
  10).
  2. splenic lac and contusion; possible small liver lac; hemoperitoneum.
  3. dense fluid near r colon may represent contusion; no active extrav seen to
  suggest vascular injury.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  [**age over 90 **]-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  outside hospital ct of the torso without contrast from [**1-26**], [**2101**] at 13:43.

 findings:

 chest:  the visualized portion of the thyroid gland shows bilateral
 hypodensities in each lobe for which ultrasound may be considered if
 clinically indicated.  there is no axillary, mediastinal, or hilar
 lymphadenopathy.  the aorta is of normal caliber along its course without
 evidence of dissection or mediastinal hematoma.  the pulmonary arterial trunk
 shows no central filling defect.  the heart size is within normal limits
 without pericardial effusion.  there is no significant pleural effusion.  the
 lungs demonstrate bibasilar atelectasis but no consolidation or contusion.  a
 small hiatal hernia is present.

 abdomen:  a hypodense streak along the dome of the liver is equivocal for
 laceration versus a lobulation (2; 32-39).  extensive dense fluid is seen
 around the liver and spleen.  the uppermost portion of the spleen demonstrates
 a vertically oriented hypodensity that may represent a laceration (601b; 32).
 more inferiorly in the spleen is a hypodensity oriented in the ap dimension
 that may represent either laceration or lobulation (2; 45 and 601b; 38).  at
 the very least, there is a splenic contusion (602b; 54).  a calcified splenic
 artery aneurysm is noted measuring 9 mm in diameter (2; 46 and 601b; 28).

 a duodenal diverticulum is present.  the pancreatic duct appears contiguous
 and there is no peripancreatic fluid; the pancreas is atrophic.  the right
 adrenal gland appears normal; the left adrenal gland demonstrates a rounded
                                                             (over)

 [**2102-1-26**] 3:23 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30865**]
 reason: bleeding?
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 soft tissue density measuring 13 mm in diameter that is incompletely
 characterized (2; 48) - ct or mr may be considered as clinically indicated.
 the kidneys enhance with contrast symmetrically without evidence of
 perinephric fluid.  incidental note is made of a calcified aneurysm of the
 left renal artery (2; 52) which measures 7 mm in diameter.

 the small bowel shows no areas of wall edema.  no free air is seen.  the large
 bowel demonstrates diverticulosis, but no evidence of bowel wall edema.
 complex fluid is seen sitting adjacent to the right colon (2; 61) within the
 mesentery (2; 62 and 601b; 26) and along a loop of jejunum.  a
 small-to-moderate amount of dense fluid is seen coursing throughout the
 mesentery and along the paracolic gutters.

 the aorta is of a normal caliber along its course without evidence of injury
 or active extravasation.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  dense free
 fluid seen in the pelvis, contiguous with that seen in the abdomen.  a
 left-sided [**doctor last name 13736**] hernia is present (2; 91).

 bones:  multiple minimally displaced fractures are present in the lateral
 aspects of the right ribs 6, 7, 8, 9, and 10 and in the left ribs 4 through
 11; of note, the fractures in left ribs 9 and 10 are segmental in nature.
 there does not appear to be an acute injury to the spine, although multilevel
 degenerative changes are present.  the clavicles are intact bilaterally.  the
 sternum is intact.  the pelvis and proximal femurs are intact.

 impression:  multiple rib fractures as described above with possible splenic
 (and less likely hepatic) lacerations with hemoperitoneum tracking along the
 right colon and jejunum concerning for bowel injury.  findings were discussed
 with [**first name4 (namepattern1) 9505**] [**last name (namepattern1) 612**] at 4 p.m. on [**2102-1-26**] in person by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**].

"
4990,"[**2123-1-3**] 9:35 am
 ct chest w/contrast                                             clip # [**clip number (radiology) 1645**]
 reason: placement of pigtail catheter [**1-2**], evaluation for improveme
 admitting diagnosis: pleural effusion;elev inr
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old man with lung adenoca and pleural effusion s/p pigtail catheter
  placement
 reason for this examination:
  placement of pigtail catheter [**1-2**], evaluation for improvement in lung volumes
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with lung cancer and pleural effusion status post
 pigtail catheter placement.

 study:  ct of the chest with contrast; 75 cc of omnipaque 350 intravenous
 contrast was administered without adverse reaction or complication.  images
 were generated using standard and lung algorithms.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2122-12-29**].

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 continues to be a large mass lesion occupying most of the region of the left
 upper lobe of the lung.  the left upper lobe bronchus and left upper lobe
 pulmonary vasculature continue to be occluded.  the left lower lobe superior
 segment pulmonary artery is narrowed but patent.  the left lower lobe bronchus
 is narrowed and even occluded over a short segment, but it is unclear if this
 is the result of mass effect or mucus plugging.  while the left upper lobe
 remains completely collapsed, there is minimally improved aeration of the left
 lower lobe.  the pigtail catheter is in place and there has been a decrease in
 the inferior portion of the left pleural effusion, the components of which are
 minimally complex fluid.  the upper portion of the left pleural effusion is
 also improved and the previously described pleural implants are unchanged.
 continued mediastinal lymphadenopathy is seen, most prominently in the
 subcarinal region where a 3 x 5 cm lymph node persists.  the aorta is of a
 normal caliber along its course and its arch branches are patent.  the heart
 and mediastinal have shifted into a more anatomically appropriate position
 compared to prior exam.  there is no pericardial effusion.  a small right
 simple pleural effusion persists on the right with small amount of dependent
 atelectasis.  additionally, a new focus of consolidation is present in the
 right upper lobe (4:45), which either represents a persistent area of
 atelectasis from the previous mediastinal shift versus an additional focus of
 consolidation/pneumonia.

 the visualized portion of the abdomen demonstrates widespread ascites, a
 nodular liver compatible with cirrhosis, a distended gallbladder, and an
 incompletely characterized hypodensity in the superior pole of right kidney.

 there are continued lytic lesions in the t10 through t12 vertebral bodies as
 well as in the t6 vertebral body.  the previously described pathologic
                                                             (over)

 [**2123-1-3**] 9:35 am
 ct chest w/contrast                                             clip # [**clip number (radiology) 1645**]
 reason: placement of pigtail catheter [**1-2**], evaluation for improveme
 admitting diagnosis: pleural effusion;elev inr
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture of the posterior right eighth rib persists.

 impression:
 1.  status post left pleural pigtail catheter placement with improvement in
 the volume of left pleural effusion and minimally improved aeration of the
 left lower lobe.  left lower lobe bronchus shows short segment occlusion,
 likely reflective of a mucus plug.
 2.  continued large left upper lobe mass with mass effect on the adjacent
 bronchus and artery; mediastinal lymphadenopathy, most prominent in the
 subcarinal stations.
 3.  new small consolidation in the anterior portion of the right lung apex may
 represent residual atelectasis versus a new focus of pneumonia; small right
 simple pleural effusion with minimal associated atelectasis.
 4.  ascites.
 5.  bone metastases as described above.

 findings were discussed with bracken [**last name (un) 1646**] at 10:48 a.m. on [**2123-1-3**]
 by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] over the phone.


"
4991,"[**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 43f with mvc, supobtimal fast,abrasion to abdomen, unrestrained
  driverclinical question: ? intrabdominal injury
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2150-3-5**] 5:33 pm
  1. bilateral dependent pulmonary edema.
  2. no intraabdominal injury.
  3. no fx.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  42-year-old female status post mvc.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  none.

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of normal caliber along its course without evidence of injury or
 mediastinal hematoma.  the pulmonary arterial tree shows no central filling
 defect.  the heart size is within normal limits and there may be trace
 pericardial fluid.  the lungs are clear of consolidation.  bibasilar
 ground-glass opacities, likely representing dependent edema. less likely
 contusions.  there is no pleural effusion or pneumothorax.

 abdomen:  the liver, spleen, adrenal glands, and pancreas appear normal.
 gallstones are present.  there is no perihepatic, perisplenic or pericolic
 gutter fluid.  there is no fluid in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically.  there is no free air or lymphadenopathy.
 the aorta is of normal caliber along its course of the abdomen without
 evidence of injury.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  foley catherter
 in place.  there is no free fluid or lymphadenopathy.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.  a wedge
 deformity in the t11 vertebral body is of indeterminate age but shows no
 retropulsed fragments or adjacent hematoma.

 impression:
 1.  dependent regions of ground glass in the lungs may represent edema, less
 likely contusion.  otherwise no evidence of intrathoracic or intra-abdominal
 injury.
                                                             (over)

 [**2150-3-5**] 5:01 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 29432**]
 reason: {see clinical indication field}
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  t11 wedge deformity of indeterminate age - correlate clinically.
 3.  cholelithiasis.

"
4992,"[**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  24 year old man with s/p mvc and was ejected from vehicle +etoh
 reason for this examination:
  ?intrathoracic or intraabdominal injury
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sat [**2186-1-28**] 6:33 am
  1. no intrathoracic injury.
  2. small subcapsular hematoma of liver (2:43 and 301b:25); no free fluid in
  abdomen or pelvis.
  3. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 wet read version #1
 wet read version #2 jekh sat [**2186-1-28**] 6:27 am
  1. no intrathoracic or intraabdominal injury.
  2. horizontally-oriented fx through posterior elements of t9 w/ minimal
  hematoma around right/anterior vertebral body column at that level (301b:33
  and 2:35); recommend mr [**first name (titles) **] [**last name (titles) 4247**] for ligamentous, disc, and cord injury.
 ______________________________________________________________________________
                                 final report
 history:  24-year-old male status post mvc and ejected from vehicle.
 left-sided upper extremity weakness.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.

 comparison:  none.

 findings:

 the visualized portion of the thyroid appears normal.  there is no axillary,
 hilar, or mediastinal lymphadenopathy.  the aorta is of a normal caliber along
 its course without evidence of mediastinal hematoma.  the pulmonary arterial
 trunk is of a normal caliber with no central filling defect.  the heart shows
 no pericardial effusion.  there is no pleural effusion or pneumothorax.  the
 lungs are clear.

 abdomen:  there is no free fluid around the liver or spleen or tracking along
 the paracolic gutters.  the spleen, pancreas, adrenal glands, and kidneys
 appear normal.  the bowel wall is not edematous.  there is no free air.

 pelvis:  a foley is in the bladder with excreted contrast within the bladder.
 the prostate and rectum appear unremarkable.  there is no free fluid or
 lymphadenopathy.

 bones:  horizontally oriented fractures are seen through the posterior
 elements of the t9 vertebra.  the vertebral body does not definitively show
                                                             (over)

 [**2186-1-28**] 5:37 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 30671**]
 reason: ?intrathoracic or intraabdominal injury
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 fracture, but a small right anterior hematoma is present in the soft tissue
 surrounding the vertebral body at that level.

 impression:
 1.  no intrathoracic injury.
 2.  horizontally oriented fracture of the posterior elements of t9 with right
 anterior surrounding soft tissue hematoma; mr is recommended to [**clip number (radiology) 4247**] for
 ligamentous, disc, and cord injury.

"
4993,"[**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 50m with h/o cirrhosis, fever and ams of unclear [**name2 (ni) 97919**]
  question: intraabd infection?
 reason for this examination:
  {see clinical indication field}
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2186-1-11**] 8:28 pm
  1. cirrhotic liver w/ small amt of perihepatic ascites, splenomegaly, and
  recannulized umbilical vein (a portion of which sits in a small umbilical
  hernia).
  2. small pericardial effusion.
  3. no organized intraabdominal fluid collection; normal appendix; no bowel
  wall edema; no hydronephrosis; no peripancreatic stranding/fluid collection.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  50-year-old male with cirrhosis, now with fever and altered mental
 status.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 abdomen:  the visualized lung bases are clear.  small pericardial effusion is
 present.

 the liver is shrunken and nodular compatible with cirrhosis.  small amount of
 perihepatic ascites is present.  the gallbladder is distended with a mildly
 thickened wall (likely secondary to hepatic disease).  small amount of
 pericholecystic fluid is also seen.  the spleen is enlarged measuring 14.8 cm
 in length.  the portal vein appears patent. there is a dilated recanalized
 umbilical vein, a portion of which has herniated through a small umbilical
 hernia (2; 60). the pancreas appears normal. the adrenal glands appear normal.
 the kidneys enhance and excrete contrast symmetrically without hydronephrosis.


 the small and large bowel show no evidence of ileus or obstruction.  there is
 no free air or lymphadenopathy.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  there is no pelvic free fluid or lymphadenopathy.  a
 small left buttock hematoma is present.

                                                             (over)

 [**2186-1-11**] 7:30 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 97918**]
 reason: {see clinical indication field}
 field of view: 50 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive appearing lytic or sclerotic lesions.

 impression:
 1.  cirrhotic liver with a small amount of ascites.
 2.  small pericardial effusion.
 3.  umbilical hernia containing a loop of the dilated, recannalized umbilical
 vein.

"
4994,"[**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  83 year old woman with paralysis of lower extremities
 reason for this examination:
  please eval for acute process - s/p fall, unable to move her lower extremities
  and no sensation
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2101-10-21**] 10:31 pm
  1. splaying of l1 and l2 spinous process w/ subtle malalignment of l2 and l3,
  concerning for ligametous injury, and in the setting of paralysis, consequent
  central canal injury - mr is recommended.
  2. herniation of stomach into thorax.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old female with lower extremity paralysis after fall.

 study:  ct of the torso with contrast; 130 cc of optiray intravenous contrast
 was given without adverse reaction or complication.

 comparison:  none.

 findings:

 chest:  there is no axillary, hilar, or mediastinal lymphadenopathy.  the
 aorta is of a normal caliber along its course with a few scattered areas of
 calcified atherosclerotic disease in the aortic arch and descending aorta;
 there is no evidence of intramural hematoma or dissection.  there is no
 central pulmonary arterial filling defect.  there is no pericardial or pleural
 effusion.  a small amount of fluid is seen in the pericardial recess adjacent
 to the ascending aorta.  the lungs are clear with bibasilar atelectasis.  the
 stomach has herniated into the thorax.

 abdomen:  there is no perihepatic fluid.  a non-specific hypodensity is seen
 in hepatic segment iv, too small to characterize but most likely a cyst.  the
 gallbladder is decompressed.  there is no perisplenic fluid.  the pancreas and
 adrenal glands are normal.  the kidneys enhance with and excrete contrast
 symmetrically.  small and large bowel show no obstruction or wall edema.
 there is no free fluid or free air.

 pelvis:  the bladder is decompressed around a foley.  the uterus and rectum
 appear unremarkable.  there is no free fluid or lymphadenopathy.

 bones:  there is splaying of the posterior elements at the level of l1-l2 with
 more subtle malalignment of l2 and l3 (602b; 36).  [**year (4 digits) **] material is seen
 within the spinal canal at this level and above.  otherwise, the pelvis and
 proximal femurs are intact.  no rib fractures are noted.

                                                             (over)

 [**2101-10-21**] 8:44 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 44901**]
 reason: please eval for acute process - s/p fall, unable to move her
 field of view: 36 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 impression:
 1.  splaying of the l1-l2 spinous processes is concerning for ligamentous
 injury and given the patient's history of paraplegia, mr should be performed.
 relatively [**name2 (ni) 3409**] material within the spinal canal is concerning for epidural
 hematoma.  findings were discussed with dr. [**last name (stitle) 3382**] in person at 22:00 on
 [**2101-10-21**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**] and [**first name8 (namepattern2) **] [**doctor last name 853**].
 2.  no intrathoracic or intra-abdominal injury.

"
4995,"[**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  31 year old woman with sudden onset abdominal pain, h/o cirrhosis
 reason for this examination:
  eval surgical pathology
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2180-9-8**] 3:18 am
  1. cirrhotic liver w/ tips; patent portal vessels.
  2. decompressed gb w/ wall edema, unchanged from [**2180-7-21**] ct; likely reflective
  of hepatic dysfunction.
  3. small amt of ascites, increased since [**2180-7-21**] ct; if clincial concern for
  pancreatitis, correlate w/ lipase.
  4. normal appendix.
  5. no obstruction or free air.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  31-year-old female with sudden onset of abdominal pain and history
 of cirrhosis.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of optiray
 intravenous contrast was used without adverse reaction and complication.
 coronal and sagittal reformatted images were also generated.

 comparison:  [**2180-7-21**].

 findings:

 abdomen:  the visualized lung bases are clear.  the liver demonstrates a
 portosystemic shunt.  the portal vein appears patent; assessment of the shunt
 is limited by the phase of the contrast although it also appears patent.  the
 liver demonstrates a nodular contour compatible with cirrhosis.  the
 gallbladder is decompressed although it shows small amount of wall edema.  the
 spleen is enlarged measuring 15.7 cm in its long axis (601b; 36).  coil
 material is seen in the region of the duodenum, likely to occlude varices.
 the splenic vein and sma are patent.

 the adrenal glands and pancreas show no masses.  subtle fluid-stranding is
 seen near the pancreatic tail and in the mesentery.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis.  the
 small and large bowel show no evidence of obstruction or wall edema.  there is
 no free air.  small amount of ascites is seen.  incidental note is made of a
 small fat-containing umbilical hernia.  the appendix is normal.

 pelvis:  the bladder, uterus and rectum appear unremarkable.  a small amount
 of fluid contiguous with the aforementioned ascites is seen.  there is no
 lymphadenopathy.

                                                             (over)

 [**2180-9-8**] 2:42 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 19453**]
 reason: eval surgical pathology
  contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1. cirrhotic liver with portosystemic shunt in place.  splenomegaly and small
 amount of ascites.  gallbladder wall edema most likely reflects sequela of
 hepatic dysfunction.
 2. if there is clinical concern for pancreatitis, correlate with lipase.

"
4996,"[**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with new onset rlq abdominal pain, nausea, and vomiting
  starting last night. hx of percutaneous gallbladder tube that was removed
  earlier this year. pt is on coumadin
 reason for this examination:
  please eval for intrabdominal infection, sbo, nephrolithiasis, intraperiotneal
  or retroperiotneal bleed.
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2167-9-3**] 3:31 pm
  no acute intraabdominal process - specifically, normal appendix, no
  obstruction, no stones, no retroperitoneal collection, no abscess.

 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  a 57-year-old male with new-onset right lower quadrant pain, nausea,
 and vomiting.  on coumadin, and history of percutaneous gallbladder tube
 removed earlier this year.

 study:  ct of the abdomen and pelvis with and without contrast; mdct images
 were generated through the abdomen without iv contrast; coronal and sagittal
 reformatted images were generated.  subsequent mdct images were generated
 through the abdomen and pelvis after the administration of 130 ml of optiray
 intravenous contrast without adverse reaction or complication.  coronal and
 sagittal reformatted images were again generated.

 comparison:  [**2167-7-6**].

 findings:

 abdomen:  the visualized portions of the lung bases are clear.  calcified
 atherosclerotic disease is seen in both coronary arteries.

 diffuse fatty infiltration of the liver is noted. the liver otherwise shows no
 focal lesion or intrahepatic biliary dilatation.  the gallbladder is normal
 without stones, wall edema, or pericholecystic fluid.  the spleen is normal in
 size.  the pancreas and adrenal glands show no masses.  the kidneys enhance
 and excrete contrast symmetrically.  there is no hydronephrosis,
 hydroureteral, renal or ureteral calculi, or perinephric inflammation.  the
 small and large bowel shows no evidence of obstruction or wall edema.  there
 is no free air, free fluid, or lymphadenopathy.  no retroperitoneal fluid
 collections are seen. small fat-containing umbilical hernia is present.

 pelvis:  the bladder, prostate, and rectum are unremarkable.  the appendix is
 normal.  there is no free fluid or lymphadenopathy in the pelvis.
 calcification of the vas deferens suggests diabetes.

                                                             (over)

 [**2167-9-3**] 2:56 pm
 ct abd & pelvis w/o contrast                                    clip # [**clip number (radiology) 100466**]
 reason: please eval for intrabdominal infection, sbo, nephrolithiasi
 field of view: 50 contrast: optiray amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 bones:  there are no aggressive-appearing lytic or sclerotic lesions.

 impression:  no acute intraabdominal process. fatty liver.
                                                                       dfddp

"
4997,"[**2171-10-23**] 7:35 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 15768**]
 reason: evidence of pe, mets, or other acute cp process?
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  63 year old man with active ca, acute hypoxia, tachycardia, rle edema.
 reason for this examination:
  evidence of pe, mets, or other acute cp process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2171-10-23**] 9:06 pm
  1. technically limited study - basal lungs excluded; no pe in visualized
  pulmonary arteries; no acute aortic syndrome.
  2. clear lungs; no pleural/pericardial effusion.
  3. r apical mass 30 x 24 mm; l 7th lateral rib lesion, 43 x 25 mm.
  4. r hilar and mediastinal lymphadenopathy.
  5. bony mets in t3 and t4 vertebral bodies.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  63-year-old male with hypoxia, tachycardia and right lower extremity
 edema.

 study:  chest cta; mdct images were generated through the chest without iv
 contrast.  subsequent mdct images were generated through the chest after
 administration of 100 cc of optiray intravenous contrast in the pulmonary
 arterial phase without adverse reaction or complication.  coronal, sagittal as
 well as right and left oblique reformatted images were generated.

 please note due to technical difficulties, the lower portion of the chest was
 not been completely imaged on the contrast-enhanced phase.

 comparison:  pet-ct from [**2171-8-16**].

 findings: the aorta is of a normal caliber along its course without evidence
 of dissection or intramural hematoma.  the pulmonary arterial trunk is normal
 in size and there are no filling defects in the visualized pulmonary arteries,
 though, the basal segments bilaterally are incompletely visualized on the
 contrast enhanced portions.  there is no pleural or pericardial effusion. the
 heart and remaining great vessels are unremarkable.

 there is no axillary lymphadenopathy.  extensive mediastinal lymphadenopathy
 is seen, including a pretracheal lymph node measuring 13 mm (3; 42) and a
 subcarinal lymph node conglomerate measuring 28 x 48 mm (3; 58).
 additionally, two right hilar lymph nodes are seen measuring 16 and 10 mm in
 their short axes (3; 49). prominent left hilar lymph nodes are also noted.
 these are similar compared to prior study.

 diffuse pulmonary nodules are visualized in both lungs, though comparison with
 the prior pet-ct is difficult given differences in technique. redemonstrated
 is nodularity along the right major and minor fissures, unchanged from prior
 study.  mucus plugging is seen in the left lower love bronchi.
                                                             (over)

 [**2171-10-23**] 7:35 pm
 cta chest w&w/o c&recons, non-coronary                          clip # [**clip number (radiology) 15768**]
 reason: evidence of pe, mets, or other acute cp process?
 field of view: 36 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)

 within the visualized upper abdomen, no gross abnormality is seen.

 an expansile lytic lesion arising from the second rib measures 30 x 24 mm (3;
 11) and extends into the posterior elements at that level including the lamina
 on the left; this represent progression compared to prior study.  a soft
 tissue mass expanding the left seventh lateral rib is seen measuring 43 x 25
 mm (3; 58), which has increased in size.  lytic lesions in t5 and t6 vertebral
 bodies have increased from the prior study.  lesions in t12 and l1 are not
 signficantly changed.  two new lytic lesions in the left scapula are noted.
 the lytic lesion in the sternum has not changed.

 impression:
 1.  limited assessment of the basal segmental pulmonary arteries. otherwise,
 no pulmonary embolism or acute aortic pathology seen.
 2.  multiple bony metastases, many of which have progressed as described
 above.
 3.  innumerable bilateral pulmonary nodules with persistent mediastinal and
 hilar lymphadenopathy.
 3.  left lower lobe bronchial mucus plugging.

"
4998,"[**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  84 yf presents from nursing home w/ dyspnea, tachypnea, tachycardia, otherwsie
  also complaining of abdominal pain, recently discharge from hospital with
  sepsis/bacteremia
 reason for this examination:
  ?pe, ?abscess
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2180-9-20**] 5:39 am
  1. no pe or acute aortic syndrome.
  2. moderate r and small l pleural effusions w/ compressive atlectasis.
  3. reflux of contrast from r heart into hepatic veins, indicative of heart
  failure.
  4. continued rectal inflammation - proctitis.
  5. no abscess.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  84-year-old female with dyspnea, tachycardia, tachypnea and
 abdominal pain.

 study:  chest cta and ct of the abdomen and pelvis with contrast.  mdct images
 were generated through the chest without iv contrast.  subsequent mdct images
 were generated through the chest after the administration of 130 ml of optiray
 intravenous contrast in the pulmonary arterial phase without adverse reaction
 or complication.  coronal, sagittal, and right and left oblique reformatted
 images were also generated.

 subsequent mdct images were generated through the abdomen and pelvis in the
 venous phase of the same contrast administration.  coronal and sagittal
 reformatted images were also generated.

 comparison:  ct of the abdomen and pelvis without contrast from [**2180-9-12**] and ct of the abdomen and pelvis without contrast from [**2180-9-5**].

 findings:

 chest cta:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course without evidence of intramural hematoma or
 dissection.  the pulmonary arterial trunk is of normal caliber, and there are
 no filling defects down to the subsegmental level.  there is no pericardial
 effusion.  bilateral simple pleural effusions are seen, moderate on the right
 and small on the left, with associated atelectasis; fluid is also tracking
 into the left major fissure.  fine assessment of the lung parenchyma is
 somewhat limited due to motion artifact.

 abdomen:  the liver shows minimal biliary prominence, an expected finding in a
                                                             (over)

 [**2180-9-20**] 4:46 am
 cta chest w&w/o c&recons, non-coronary; ct abd & pelvis with contrastclip # [**telephone/fax (1) 23584**]
 reason: ?pe, ?abscess
 field of view: 40 contrast: optiray amt:
 ______________________________________________________________________________
                                 final report
 (cont)
 post-cholecystectomy patient of this age.  the spleen is normal in size, and a
 hypodensity in its anterior [**doctor last name 39**] is too small to characterize but is unchanged
 from prior studies.  the pancreas demonstrates no masses or fluid collections.
 the adrenal glands are normal appearing bilaterally.  the kidneys enhance with
 and excrete contrast symmetrically; hypodensity in the right lower pole is too
 small to characterize, likely represents a cyst.  the small and large
 intestine show no evidence of obstruction or wall thickening.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta.  there is no
 lymphadenopathy, free air, or free fluid.

 pelvis:  the bladder is decompressed around a foley and a single locule of gas
 within the bladder is likely from that catheterization.  the uterus appears
 unremarkable.  the rectum demonstrates hyperenhancing mucosa with thickening
 of the wall and a small amount of stranding in the perirectal fat, all
 compatible with proctitis and similar in appearance to the prior two ct scans.

 bones:  severe degenerative changes are seen throughout the thoracolumbar
 spine; compression deformity of the t10 vertebral body is similar in
 appearance compared to the ct of the torso from [**2177-11-7**].

 impression:
 1.  no pe or acute aortic syndrome.
 2.  moderate right and small left pleural effusions with compressive
 atelectasis.
 3.  rectal wall inflammation compatible with proctitis.
 4.  no evidence of abscess.

"
4999,"continuation of previous note.
cv:  patient originally with low grade temp,  now afebrile.  patient on multiple cardiac medications thoughout the day with various adverse and not adverse reactions.  patient currently on esmolol for rate control, norepi for bp management, heparin, insulin and currently versed.  patient with poor [** **] pt on right foot and no dp on right foot.  [**name (ni) **] pt and dp on left foot.

resp: no vent changes made this shift, patient overbreathing on vent, with adequate oxygenation and good gases.  patient with minimal amounts of ett secreations.

gi:  patient started on insulin gtt for elevated blood sugars with multiple foul smelling bloody stools.

gu:  patient with patent foley voiding minimal amounts of urine.  please see flowsheets for all other information.  thank you
"
5000,"7p-7a
neuro: pt opens eyes, does not follow commands, does not [**name8 (md) 506**] rn in room, does not move any extremeties. perrla. morphine 2mg ivp given for pain shown by increase in bp.

cv: hr 80-90s in and out of afib. at present 80s sr no ectopy, lytes repleted prn. sbp labile, see carevue, on and off neo. at present time sbp 102, on 0.5mcg/kg/min. picc to right arm patent and [**name8 (md) 235**]. left radial arm [**name8 (md) 235**] reddened. dopplerable pedal pulses. generalized anasarca. bilat upper extremties oozy moderate amts of serous fluid. sternal sutures cdi, covered w/ gauze and abd. binder [**name8 (md) 235**] to sternal area. received 1 unit of prbcs, no adverse reactions, repeat hct 28.

resp: ls clear- coarse, diminished bases. sats >98%. rr 25-35. trial of cpap rr increased to 40's. on cmv rate 10, fio2 40% peep 5, see carevue for abgs. suctioned for small amts of thick yellow secretions via ett.

gi/gu: abd soft, round, hypoactive bs. tf residual at 0030 250cc, given back to pt, tf on hold, pa [**doctor last name **] aware. dophoff +placement. foley [**doctor last name 3447**] adequate amts of clear yellow urine.

skin: stg 2 2cm round to coccyx area, duoderm on and [**doctor last name 235**]. see carevue for further details.

endo: riss.

plan: monitor hemodynamcis. monitor pulmonary status. follow labs and treat as appropriate. pain control. monitor neuro status.
"
5001,"npn shift 1900-0700:

neuro: a&ox3, periods of restlessness, anxiety. non-compliant w/ activity restriction. perrla. mae, equal strength.

resp: b/l bs coarse w/ rales mid to lower bases bilaterally. upper airway congestion, wet, unprod cough. resp tachypneic, labored, discoordinate. chest x-ray revealed fluid volume overload. lasix 20mg iv at 0000 w/ good response.  tol 4l nc for most of night. resp distress at 0500, desat to 80's, audible expiratory wheezing, verbalized feeling sob. 100% nrb on w/ good effect. alb/atro neb given. pt refused o2 humi face mask, ho aware. place on high flow nasal cannula, able to wean to 6l at 0600 w/ good effect. pt more comfortable.

cv: st, rare pvc's, pac's. sbp 130-170's. no s/s of cardaic distress. on metoprolol at home. lopressor 5mg iv ordered as tsanding w/ good  effect. no edema. +pp, feet pale, cool, dusky toes. ho aware. pt hypernatremic, 151, ho aware. other electrolytes wnl.

hem: tx prbc x3 for hct of 20 from 26. tol tx well, no s/s of an adverse reaction. post hct x2 stable at 29.0. no s/s of active bleed. inr=1.2.

id: wbc up from 12 to 17. afebrile.

gi: abdomin distended, rounded, firm. +bs x4. pt coughing w/ small sips of h20. made npo until am, will further eval. no bm.

gu: good amts of yellow urine, w/ sediment. pt w/ chronic renal failure, bun/cr=52/3.6.

plan: wife and family to come in for meeting w/ ho to discuss course of care, adviced to fill out health care proxy forms. possible mri? pt declines surgey so far for aaa, 6x6cm. full code. resusitation status must be addressed w/ family.
"
5002,"[**2125-3-25**] 1:29 pm
 ct chest w/contrast                                             clip # [**0-0-**]
 reason: evaluate for abscess around surgery site. please extend to l
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 55m with recent rib r fractures, now with increasing pain around
  fracture site as well as pain
 reason for this examination:
  evaluate for abscess around surgery site. please extend to liver as he feels
  the liver is swollen and tender (murpy's sign negative)
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh sun [**2125-3-25**] 5:18 pm
  1. s/p fixation of r lateral [**6-25**] rib fx; adjacent pleural thickening raises
  question of repetitive irritation by hardware/screws.
  2. persisting fx of posterior r 8 & 9 rib fx.
  3. healing posterolateral r 10 rib fx.
  4. no chest wall/pleural fluid collection.
  5. no fluid around the visualized portion of the liver.
 wet read version #1
 wet read version #2 jekh sun [**2125-3-25**] 2:32 pm
  1. s/p fixation of r lateral [**6-25**] rib fx.
  2. persisting fx of posterior r 8 & 9 rib fx.
  3. healing posterolateral r 10 rib fx.
  4. no chest wall/pleural fluid collection.
  5. no fluid around the visualized portion of the liver.
 ______________________________________________________________________________
                                 final report
 history:  55-year-old male with recent right-sided rib fractures, now with
 pain around the fracture site.

 study:  ct of the chest with contrast; 70 cc of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  [**2125-2-4**] chest cta.

 findings:  the visualized portion of the thyroid appears unremarkable.  there
 is no axillary, hilar, or mediastinal lymphadenopathy.  the aorta is of normal
 caliber along its course.  the pulmonary arterial trunk is also of a normal
 caliber.  there is no mediastinal hematoma.  there is no pleural or
 pericardial effusion.  a small locule of fluid just anterior to the superior
 aspect of the heart measures approximately 2 cm in diameter and is most
 compatible with a pericardial cyst (2; 41).

 the lungs are clear of masses or consolidation.  small amount of
 atelectasis/scarring is present in the right lower lobe in the region of the
 rib fracture repair.

 the visualized portion of the upper abdomen shows no abnormality; specifically
 there is no fluid around the liver or in the superior portion of the
 retroperitoneum.
                                                             (over)

 [**2125-3-25**] 1:29 pm
 ct chest w/contrast                                             clip # [**0-0-**]
 reason: evaluate for abscess around surgery site. please extend to l
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)

 examination of the bones again demonstrates lateral fixation plates of the
 right seventh, eighth, and ninth ribs with the screw tips extending just
 beyond the inner cortical rib margins, of uncertain clinical significance.
 adjacent mild pleural thickening is also present.  non-united fracture of the
 posterior aspect of the right seventh and eight ribs are also present.  the
 posterolateral aspect of the right ninth rib demonstrates a non-displaced
 fracture with callus surrounding it (2; 61).  otherwise, the spine and sternum
 appear unremarkable.  no fluid collections are present in the soft tissues
 adjacent to the fracture fixation.

 impression:
 1. status post fixation of the right seventh through ninth lateral ribs with
 non-united posterior fractures of right ribs eight and nine.  adjacent pleural
 thickening raises the question of irriation from hardware/screws.  this
 finding was discussed with [**first name8 (namepattern2) 305**] [**last name (namepattern1) 1509**] at 17:17 on [**2125-3-25**] by [**first name8 (namepattern2) **] [**last name (namepattern1) 1647**]
 over the phone.
 2. healing posterolateral right 10th rib fracture.
 3. no evidence of chest wall or pleural fluid collection.
 4. limited views of the upper liver show no perihepatic fluid.

"
5003,"[**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 52m with new r pleural effusion
 reason for this examination:
  charac of fluiid?
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  52-year-old male with new right pleural effusion and abdominal pain.

 study:  ct of the torso with contrast; 150 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest radiograph from [**2164-8-17**] at 9:59 a.m.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  scattered
 axillary and mediastinal lymph nodes are present, although none meet
 pathologic size criteria.  multiple prominent bilateral hilar lymph nodes are
 present measuring 14 mm in their short axis on the right and 12 and 6 mm in
 their short axis on the left (601:45).  the aorta is of a normal caliber along
 its course with incidental note made of a common origin of the brachiocephalic
 and left common carotid arteries, a normal variant.  the pulmonary arterial
 trunk caliber is at the upper limits of normal, and there are no central
 filling defects.

 again is noted a large loculated effusion with minimally complex to simple
 fluid, unlikely to be hemorrhagic.  there is associated consolidation of
 nearly all the right lower and right middle lobes as well as compressive
 atelectatic effect on the right upper lobe.  portions of these collapsed lobes
 show variable enhancement, and multiple rounded hypodensities may in fact
 represent saccular bronchiectasis versus multiple foci of necrotizing
 pneumonia.  the left lung shows a clear upper lobe and saccular bronchiectasis
 of the lower lobe with diffuse bronchial wall thickenking in addition to some
 dependent atelectasis.  there is no pleural effusion on the left, and there is
 no pericardial effusion.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 subtle dense material in the neck of the gallbladder may represent small
 stones or sludge, but there is no pericholecystic fluid, wall edema or
 gallbladder distention.  the pancreas shows no masses or peripancreatic fluid
 collections.  the spleen is normal in size and appearance with a small 1-cm
 splenule noted anteroinferiorly.  the adrenal glands show no nodules.  the
 kidneys enhance with and excrete contrast symmetrically.  multiple
 well-circumscribed hypodensities are present in both kidneys, too small to
 characterize but likely representing simple cysts.  the small and large bowel
                                                             (over)

 [**2164-8-17**] 11:56 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 35326**]
 reason: charac of fluiid?
 admitting diagnosis: pneumonia
 field of view: 38 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 show no evidence of obstruction or wall edema.  the aorta, ivc and portal vein
 appear normal.  there is no free fluid, free air or lymphadenopathy.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  there is no
 pelvic lymphadenopathy or free fluid.

 bones:  a schmorl's node is present at the inferior endplate of l4 and t12.
 otherwise, there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  large loculated right pleural effusion; saccular bronchiectasis of the
 bilateral lower lobes and consolidation of the right middle and right lower
 lobes with heterogeneous hypoenhancement and rounded hypodensities that may
 represent either the underlying saccular bronchiectasis versus multifocal
 necrotizing pneumonia.
 2.  cholelithiasis without cholecystitis.
 3.  hilar lymphadenopathy may be reactive; follow up imaging after treatment
 is recommended to ensure resolution.

"
5004,"[**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  71 year old woman with pancreatic cancer s/p ex-lap with bx of periduodenal
  nodule, chole, [**last name (un) **], choledochojejunostomy, and gastrojejunostomy
 reason for this examination:
  for oncology staging
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 ct chest with contrast

 comparison:  none.  correlation is made with cta abdomen of [**2143-8-14**].

 technique:  multiple axial ct images were obtained through the chest following
 the administration of 75 cc of omnipaque iv contrast.  sagittal and coronal
 reconstructions were obtained.  no adverse reactions were reported.

 indication:  71-year-old female with pancreatic cancer, status post
 exploratory laparotomy with biopsy of peri-duodenal nodule, cholecystectomy,
 roux-en-y procedure, choledochojejunostomy, and gastrojejunostomy.  exam is
 done for oncology staging.

 findings:  right picc terminates at the superior atriocaval junction.  no
 supraclavicular, mediastinal, hilar, or retrocrural lymphadenopathy.  small
 right hilar lymph node measures 8 mm on short axis and does not meet criteria
 for pathologic enlargement by size.  scattered left hilar pulmonary calcified
 granulomas.  heart size is within normal limits without pericardial effusion.
 the thoracic aorta is normal in caliber without dissection or aneurysmal
 dilatation.  branches of the aortic arch are normal.  pulmonary trunk is
 within normal limits by size.  no central pulmonary thromboembolic disease is
 identified.  thyroid gland demonstrates homogeneous attenuation without focal
 lesions.

 there is a 4-mm nodule in the middle lobe and a 3-mm nodule in the subpleural
 right lower lobe (2:36).  no pulmonary mass is identified.  bilateral basilar
 subsegmental atelectasis.  small bilateral pleural effusions.  no
 pneumothorax.

 abdomen:  pneumobilia is likely related to recent changes of reported
 choledochojejunostomy. hypodensity in the gallbladder fossa with intrinsic air
 is compatible with surgicel packing although an abscess would have a similar
 appearance.  stable 0.9 x 1.3 cm hypodensity in the right hepatic lobe
 (segment vii).  small perihepatic and perisplenic ascites.  colonic
 diverticulosis without diverticulitis involving the visible splenic flexure.
 there is patchy fluid surrounding the splenic flexure, which may be due to
 post-surgical change.

 bones and soft tissues:  no acute fracture or destructive osseous process.
                                                             (over)

 [**2143-8-31**] 1:26 pm
 ct chest w/contrast                                             clip # [**clip number (radiology) 102050**]
 reason: for oncology staging
 admitting diagnosis: jaundice
  contrast: omnipaque amt: 75
 ______________________________________________________________________________
                                 final report
 (cont)
 multilevel degenerative disc disease.  advanced degenerative changes of the
 right and moderate degenerative changes of the left acromioclavicular joint.
 degenerative arthrosis of both humeral heads.  there is a calcific structure
 along the greater tuberosity of the left humerus which may relate to calcific
 tendinosis.  no acute fracture or destructive osseous process.

 impression:
 1.  indeterminate right middle lobe and lower lobe pulmonary nodules.  in a
 patient with history of prior malignancy, unenhanced ct chest is recommended
 in three months to monitor growth pattern and malignant potential.
 2.  no intrathoracic lymphadenopathy.
 3.  pneumobilia, abdominal ascites and pericolonic fluid involving the splenic
 flexure are likely related to recent surgery. hypoattenuation in gallbladder
 fossa with intrinsic air is compatible with surgicel packing, however an
 abscess would have a similar appearance and cannot be excluded.
 4.  scattered colonic diverticulosis.

"
5005,"[**2123-9-16**] 9:25 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 20502**]
 reason: please evlauate for occult malignancy
 admitting diagnosis: nausea;vomiting;liver tx
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  57 year old man with recent weight loss and dysphagia
 reason for this examination:
  please evlauate for occult malignancy
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  57-year-old male with recent weight loss and dysphagia concerning
 for occult malignancy.

 study:  ct of the neck with contrast; 70 cc of omnipaque intravenous contrast
 was administered without adverse reaction or complication.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:  the visualized portion of the brain is unremarkable.  please refer
 to the head ct report performed from the same day.

 the orbits and globes are intact.

 the paranasal sinuses are clear.  the mastoid air cells are clear.

 the nasopharynx and oropharynx demonstrate no evidence of masses; streak
 artifact from dental amalgam limits assessment of the tongue and adjacent soft
 tissues.  the parotid glands are normal appearing bilaterally.  the
 submandibular glands are normal appearing, although slight asymmetry is
 present with the left gland larger than the right.

 the carotid arteries and jugular veins are patent; a small amount of calcified
 atherosclerotic disease is present at both carotid artery bifurcations.  no
 lymphadenopathy is present.

 the thyroid appears unremarkable.

 the lung apices demonstrate scattered areas of ground-glass opacity,
 compatible with sites of infection or inflammation.  a moderate right pleural
 effusion is present, non-hemorrhagic in nature.

 the bones demonstrate mild to moderate multilevel degenerative changes in the
 spine, but no aggressive appearing lesion is present.

 impression:  no evidence of occult malignancy.
                                                             (over)

 [**2123-9-16**] 9:25 pm
 ct neck w/contrast (eg:parotids)                                clip # [**clip number (radiology) 20502**]
 reason: please evlauate for occult malignancy
 admitting diagnosis: nausea;vomiting;liver tx
 ______________________________________________________________________________
                                 final report
 (cont)

"
5006,"[**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 81m with sudden onset rlq pain at mcburney's point since yesterday.
  +rebound at pcp office
 reason for this examination:
  eval for appy, intra-abd process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh tue [**2194-9-23**] 11:02 pm
  1. no appendix seen, but no secondary signs of appendicitis.
  2. sigmoid diverticulosis w/o diverticulitis.
  3. l iliac vein [**year (4 digits) **]; early contrast phase limits evaluation of patency.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  81-year-old male with sudden-onset right lower quadrant pain
 yesterday.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2191-3-23**] ct of the torso with contrast.

 findings:

 abdomen:  visualized portion of the lung bases show minimal dependent
 atelectasis.  a moderate hiatal hernia is also present.  pacer leads are also
 present in the right ventricle.  the liver shows no focal lesion or
 intrahepatic biliary dilatation.  clips in gallbladder fossa are compatible
 with prior cholecystectomy.  the spleen is normal in size and appearance.  the
 adrenal glands show no nodules.  the pancreas shows no masses or fluid
 collections.  multiple hypodensities are present in both kidneys, too small to
 characterize, likely represents simple cysts.  the kidneys enhance with and
 excrete contrast symmetrically without evidence of hydronephrosis.  small and
 large bowel show no evidence of wall edema or obstruction.  diverticulosis is
 noted in the descending and sigmoid colon without diverticulitis.  there is no
 free air, free fluid or lymphadenopathy.  the appendix is not visualized.

 pelvis:  the bladder is unremarkable.  a left external iliac vein [**year (4 digits) **] is
 present, but due to early phase of contrast administration, its patency is not
 well evaluated on the current study.

 bones:  no aggressive-appearing lytic or sclerotic lesion is present.
 degenerative changes are present in the lower lumber spine, primarily in the
 form of facet joint hypertrophy and osteophytes.

 impression:
 1.  appendix not visualized, but no secondary signs of appendicitis.
                                                             (over)

 [**2194-9-23**] 8:49 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 37421**]
 reason: eval for appy, intra-abd process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 2.  descending and sigmoid diverticulosis without diverticulitis.
 3.  status post cholecystectomy.
 4.  left external iliac vein [**clip number (radiology) **], incompletely evaluated for patency.

"
5007,"[**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 80f with nausea/vomiting, diffuse abd pain
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh fri [**2188-10-10**] 5:17 am
  1. no acute intraabdominal process.
  2. cirrhosis, ascites, splenomegaly, and smv thrombosis w/ downstream
  reconstitution (similar to [**2188-6-8**] ct).
  3. stable panc tail ipmn.
  4. cholelithiasis w/o cholecystitis.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  80-year-old female with nausea, vomiting and diffuse abdominal pain.

 study:  ct of the abdomen and pelvis with contrast; omnipaque iv contrast was
 administered without adverse reaction or complication.  coronal and sagittal
 reformatted images were also generated.

 comparison:  [**2188-6-8**].

 findings:

 abdomen:  the lower portion of the chest demonstrates calcified
 atherosclerotic disease of the coronary arteries as well as mitral and aortic
 valve calcifications.  the central line tip sits in the upper part of the
 right atrium.

 again the liver demonstrates a shrunken nodular contour compatible with
 cirrhosis.  the portal vein is patent and thrombosis of the smv persists with
 downstream reconstitution, similar to prior exam.  the gallbladder is
 decompressed with dense layering material within it.  the spleen is large
 measuring 15.6 cm in its long axis (2:26).  the adrenal glands are normal
 appearing bilaterally.  again the pancreas demonstrates a 13 mm hypodensity in
 the tail that is circumscribed and stable from prior exam, likely an ipmn.
 kidneys enhance with contrast symmetrically but are noted to be atrophic in
 this patient with known end-stage renal disease.  incidental note is made of a
 circumaortic left renal vein.  the small and large bowel show no evidence of
 obstruction.  a thickened appearance of the wall is likely secondary to the
 large amount of ascites that is present.  there is no free air.  calcified
 atherosclerotic disease is seen throughout the abdominal aorta and into its
 major branches.

 pelvis:  streak artifact from bilateral hip hardware limits assessment of fine
 detail.  within that limitation, the bladder and rectum appear unremarkable.
 calcified uterine fibroids are present.
                                                             (over)

 [**2188-10-10**] 4:04 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 67022**]
 reason: r/o acute process
 field of view: 44 contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 degenerative disc disease is present at the l5-s1 level in the form of vacuum
 phenomenon as well as at the l3-l4 level in the form of narrowing, endplate
 sclerosis, and anterior osteophytes.  a hip arthroplasty is present on the
 right and repair of a proximal femoral fracture is evident on the left in the
 form of screw and plate fixation hardware.  old healed pubic rami and
 bilateral rib fractures are unchanged from prior exam.

 impression:
 1.  no acute intra-abdominal process.
 2.  cirrhosis, ascites, splenomegaly, and stable smv thrombosis with
 downstream reconstitution.
 3.  stable pancreatic tail ipmn.
 4.  cholelithiasis without cholecystitis.

"
5008,"[**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 79f with fever, leukocytosis, elevated lactate, abd ttp.pt is on
  dialysis; renal aware of contrast and plan for dialysis.
 reason for this examination:
  acute abd process?
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh wed [**2136-10-3**] 3:31 am
  1. no pe or aortic dissection.
  2. small b pleural effusions w/ mild pulmonary edema.
  3. cardiomegaly.
  4. nonspecific periportal edema in the liver.
  5. decompressed gb w/ mild wall edema - nonspecific but can be seen in chf,
  hypoproteinemia, or liver dysfunction.
  6. atrophic kidneys w/ multiple indeterminate lesions, some of which are
  cysts.
  7. sigmoid diverticulosis w/o diverticulitis.
  8. small amt of free fluid of unclear etiology, possibly reactive.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  79-year-old female with fever, leukocytosis, elevated lactate, and
 tenderness to palpation.

 study:  ct of the torso with contrast.  although the patient's creatinine was
 6.2, the patient is on dialysis and renal team is aware and plans for dialysis
 after the scan.  100 ml of omnipaque intravenous contrast was administered
 without adverse reaction or complication.  images were acquired in the
 arterial phase.

 images were then acquired in the chest, abdomen, and pelvis.  coronal and
 sagittal reformatted images were also generated.

 comparison:  none.

 findings:

 chest:  the visualized portion of the thyroid demonstrates a heterogeneous 1.8
 x 1.3 cm nodule in the left lobe of thyroid (2:7).  no axillary, hilar, or
 mediastinal lymphadenopathy is noted.  the aorta is of a normal caliber along
 its course without evidence of dissection or intramural hematoma; incidental
 note is made of a common origin of the brachiocephalic and left common carotid
 arteries, a normal variant.  the pulmonary arterial trunk is of a normal
 caliber and there are no filling defects to the subsegmental level.  the heart
 size is large, but there is no pericardial effusion.  small bilateral pleural
 effusions are present, but they are nonhemorrhagic in nature and minimal
 associated atelectasis is present.  scattered areas of ground-glass opacity
 are most compatible with pulmonary edema.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

 abdomen:  within the limits of early phase scan, the liver shows no focal
 lesion and mild-to-moderate periportal edema.  contrast is seen refluxing into
 the hepatic veins, raising the possibility of hepatic congestion.  the
 gallbladder is decompressed, but shows moderate wall edema/pericholecystic
 fluid.  no calcified stones are noted.  the spleen is normal in size.  the
 pancreas and adrenal glands show no masses or nodules.

 the kidneys enhance symmetrically but are atrophic.  both kidneys demonstrate
 multiple hypodense exophytic indeterminate lesions, some of which are cysts,
 but some of which have more mass-like or have more soft tissue-like densities.
 neither kidney demonstrates hydronephrosis.

 the small and large bowel shows no evidence of obstruction or wall edema.
 there is no pneumatosis or portal venous gas.  scattered diverticula are
 present along the descending and sigmoid colon.  there is no free air or
 lymphadenopathy.

 the abdominal aorta is of normal caliber along its course.  the celiac and sma
 are widely patent.  the renal arteries and [**female first name (un) 85**] are not narrowed.

 pelvis:  the bladder, uterus, and rectum appear unremarkable.  small amount of
 free fluid is present in the pelvis.  sigmoid diverticulosis is present
 without evidence of diverticulitis.  no lymphadenopathy is seen.

 bones:  a lucent lesion with a sclerotic rim is present in the right iliac
 bone measuring 15 x 13 mm in the coronal plane (601b:49), and is
 benign-appearing.  mild-to-moderate multilevel degenerative changes are
 present throughout the thoracolumbar spine.

 impression:
 1.  no pe or aortic dissection.
 2.  cardiomegaly and pulmonary edema.
 3.  heterogeneous nodule of the left lobe of the thyroid as described above.
 ultrasound may be considered as clinically indicated.
 4.  atrophic kidneys with multiple indeterminate lesions, some of which are
 cysts, but many of which are incompletely characterized, so rcc cannot be
 excluded; mr may be considered for further characterization.
 5.  descending and sigmoid colonic diverticulosis without diverticulitis.
 6.  periportal edema and decompressed gallbladder with wall edema, which is a
 nonspecific finding and may reflect chf, hyperproteinemia, or hepatic
 dysfunction.
 7.  small amount of free fluid in the pelvis, possibly reactive.
 8.  benign-appearing but indeterminate lytic lesion in the right iliac bone
 without evidence of cortical disruption.
                                                             (over)

 [**2136-10-3**] 2:05 am
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 109401**]
 reason: verbal order from [**first name4 (namepattern1) **] [**last name (namepattern1) **] due to pt renal function to rule out acute process
  contrast: omnipaque amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)

"
5009,"[**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  history: 83m with vomiting, fever, lethargy
 reason for this examination:
  r/o acute process
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: [**first name9 (namepattern2) 136**] [**doctor first name 137**] [**2191-7-28**] 3:33 am
  1. hiatal hernia.
  2. cholelithiasis w/o cholecystitis.
  3. nonspecific perinephric stranding.
  4. enlarged prostate.
  5. l fat-containing inguinal hernia, also containing a small portion of
  bladder, similar to prior ct in [**2188**].
  6. mild-to-moderate colonic fecal burden.
  7. no acute findings.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  83-year-old male with vomiting, fever, and lethargy.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  abdomen ct from [**2189-10-7**], and abdomen and pelvis ct from
 [**2188-10-2**].

 findings:

 abdomen:  bibasilar atelectasis is present as well as a small hiatal hernia.
 calcified atherosclerotic disease is present in the coronary arteries, and
 mitral valve calcifications are also present.

 the liver shows no focal lesion or intrahepatic biliary dilatation.  the
 gallbladder shows a single calcified layering stone, but no wall edema or
 pericholecystic fluid.  spleen is normal in size.  the pancreas is markedly
 atrophic with a punctate calcification, possibly representing a degree of
 chronic pancreatitis.  the adrenal glands are normal appearing bilaterally.

 the kidneys enhance with and excrete contrast symmetrically.  small
 subcentimeter hypodensities in each kidney are too small to characterize, but
 likely represents cysts.  mild urothelial thickening is present in the left
 renal pelvis.  non-specific perinephric stranding is present bilaterally.

 the small and large bowel show no evidence of wall edema or obstruction.  the
 colon demonstrates a moderate fecal burden.  the aorta is of a normal caliber
 along its course with areas of calcified and non-calcified atherosclerotic
 disease present.  scattered subcentimeter retroperitoneal lymph nodes are seen
                                                             (over)

 [**2191-7-28**] 2:49 am
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 78655**]
 reason: r/o acute process
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in the periaortic stations, but none meet pathologic size criteria.  there is
 no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley balloon with herniation of
 the left aspect of the bladder into the primarily fat-containing left inguinal
 hernia.  the prostate continues to be enlarged.  there is no pelvic
 lymphadenopathy or free fluid, and the rectum appears unremarkable.

 bones:  there are no aggressive-appearing lytic or sclerotic lesions.
 mild-to-moderate degenerative changes are seen throughout the thoracolumbar
 spine.

 impression:
 1.  no acute intra-abdominal process; moderate colonic fecal burden.
 2.  hiatal hernia.
 3.  enlarged prostate and left fat- and bladder-containing inguinal hernia.
 4.  mildly thickened left renal pelvis urothelium of unclear significance; no
 evidence of hydronephrosis or pyelonephritis.

"
5010,"[**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  85 year old woman s/p colectomy for bowel ischemia, now with rigid abdomen,
  fever
 reason for this examination:
  s/p colectomy, now with rigid abdomen, fever. please do ct abd/pelvis with po
  contrast
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2194-9-1**] 7:13 pm
  1. sbo w/ transition pt at ileostomy exit site; cause appears to be mass
  effect from herniated mesenteric fat adjacent to the ileostomy.
  2. s/p r colectomy w/ tiny locules of gas adjacent to colonic staple line -
  may be post-operative although leak cannot be excluded.
  3. small amt of complex free fluid in abdomen/pelvis - ddx includes blood or
  bowel leak contents - correlate w/ exam and hct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  85-year-old female status post right partial colectomy, now with
 rigid abdomen, and fevers.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2194-8-18**].

 findings:

 abdomen:  the visualized lung bases demonstrate a moderate right and small
 left pleural effusion with associated atelectasis.

 the previously described hemangioma in the left lobe of the liver is not well
 visualized on the current exam given difference in the phase of the contrast
 administration.  the gallbladder is distended, but shows no hyperdense stones
 or wall edema.  the spleen is normal in size.  no peripancreatic fluid
 collections are present.  the cbd again is still prominent with minimal
 central intrahepatic biliary dilatation as well as a prominent pancreatic
 duct.  the adrenal glands are normal appearing bilaterally.  multiple
 hypodensities within both kidneys are too small to characterize but compatible
 with simple cysts.  the kidneys enhance and excrete contrast symmetrically.
 the aorta is of a normal caliber along its course with scattered areas of
 calcified atherosclerotic disease.  there is no lymphadenopathy.

 the stomach and small bowel are distended with multiple air-fluid levels all
 the way to the ileostomy exiting from the right lower quadrant of ventral
 abdominal wall.  a locule of mesenteric fat has herniated through the ventral
 abdominal wall narrowing the lumen of the ileostomy, resulting in relative
                                                             (over)

 [**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 transition point.

 the patient is status post right colectomy; a small amount of right paracolic
 gutter fluid is present with adjacent peritoneal enhancement, potentially
 reflecting post-surgical changes in the resection bed (2:38).  a blind-ending
 left/transverse colon is present with gaseous distention of the transverse
 portion and apparent wall discontinuity/hypoenhancement at its posterior wall
 (2:38) and potentially involving the aterior wall as well.  near the staple
 line and at the anterior wall of the transverse colon are few small locules of
 intraperitoneal gas (2:39).  additionally, there is a small amount of gas
 within a ventral wall subcutaneous fat.  small amount of intra-abdominal free
 fluid is present and is of borderline complexity.

 pelvis:  the bladder is decompressed around a foley balloon.  uterus
 demonstrates multiple calcified fibroids.  the distal colon shows sigmoid
 diverticulosis with no evidence for diverticulitis.  minimally complex free
 fluid is present in the pelvis.  multiple inguinal lymph nodes are present,
 prominent in size but not meeting pathologic size criteria and are likely
 reactive in nature.  the right sided intramuscular hematoma is unchanged.

 bones:  no aggressive-appearing lytic or sclerotic lesions are present.
 degenerative disc disease is present at the l4-l5 level with endplate
 sclerosis and small anterior osteophytes.

 impression:
 1.  post operative changes of recent right hemicolectomy.  distended remaining
 transverse colonic pouch with apparent area of wall
 discontinuity/hypoenhancement; given the small locules of adjacent gas and
 minimal complex free fluid, colonic perforation potentially from ischemia is a
 possibility.
 2.  status post right colectomy with end ileostomy.  small bowel distnsion
 with relative transition point and mesenteric fat herniation through the
 ventral abdominal wall resulting in possible small-bowel obstruction vs ileus.
 3.  new bilateral effusions and adjacent atelectasis.

 findings raising possibility of ischemia/postoperative leak of the transverse
 colon were were discussed with [**first name8 (namepattern2) 4486**] [**last name (namepattern1) 30172**] at 19:52 by [**first name4 (namepattern1) 30173**] [**last name (namepattern1) 30174**] by
 phone.

"
5011,"[**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 4**] medical condition:
  history: 60m with hcc, abd pain and fever recently d/ced
 reason for this examination:
  1: eval for pe 2. ct abd for eval for fluid collection in ruq, possible
  hepatobilary etiology for ruq pain and fever
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2119-8-7**] 11:38 pm
  1. large porta hepatis mass invading the r portal vein w/ 2 crossing biliary
  stents, and multiple hepatic mets.
  2. 2 new (from [**2119-8-2**] ct) large dilated intrahepatic ducts (2: 16 and 22)
  that are more rounded and rim enhancing, appearing more abscess-like.
  3. stable collection near the pancreatic tail compared to [**2119-8-2**] ct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  60-year-old male with hepatocellular carcinoma, now with abdominal
 pain and fever after recent discharge.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2119-8-2**] abdominal ct.

 findings:

 abdomen:  the visualized portions of the lung bases demonstrate streaky
 atelectasis. right gynecomastia is incompletely imaged. no pleural effusion.
 prominent 9-mm right diaphragmatic lymph node is unchanged.

 the spleen is normal in size and appearance.  the adrenal glands show no
 nodules.  the kidneys enhance with and excrete contrast symmetrically without
 focal lesion or hydronephrosis. the small and large bowel show no evidence of
 obstruction or wall edema.  a lobulated low-attenuation peripancreatic
 collection adjacent to the tail, is redemonstrated and currently measures 4.6
 x 3.0 cm in greatest conglomerate axial dimensions, which is similar to the
 prior study where it measured approximately 4.3 x 2.8 cm at similar level. the
 pancreas is otherwise unremarkable.

 a dominant ill-defined enhancing hypodense mass involving segments [**last name (lf) 70637**], [**first name3 (lf) 751**],
 and ivb measuring 6.1 x 5.4 cm in the axial plane (2:20) is similar in size
 and appearance from the prior study and results in biliary obstruction in both
 hepatic lobes.  it has invaded the bifurcation of the main portal vein as well
 as the left and right portal veins, and has occluded the anterior right portal
 venous branch, unchanged. multiple stable-appearing ill-defined, peripherally
 enhancing satellite lesions are present primarily involving the right hepatic
 lobe, concerning for metastases.  incidental note is made of a fiducial seed
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 in segment [**clip number (radiology) 70637**] of the liver (2:22).  enlarged porta hepatis and
 paraesophageal lymph nodes are present, similar to the prior exam.

 since the prior study, there has been marked interval increase in size of
 lobulated tubular hypodensities with rim enhancement within segments vii and
 [**clip number (radiology) 70637**] compatible with marked worsening of biliary obstruction and cholangitis
 (2:16, 2:22). new rounded rim-enhancing hypodensities are noted adjacent to
 these dilated bile ducts compatible with abscesses (2:14), the largest
 discrete abscess measuring 12-mm which is located at the junctions of segments
 vii and [**clip number (radiology) 70637**] (2:14). additionally, the more inferiorly located blown-out
 intrahepatic bile duct in segment [**clip number (radiology) 70637**] demonstrates extension into the
 subcapsular space with a focal subcapsular abscess noted measuring 2.1 x 0.9
 cm (2:20).

 moderate intrahepatic biliary dilatation elsewhere in the right lobe as well
 as in the left lobe of the liver is not significantly changed. two metal
 biliary stents are seen coursing from the main left and right hepatic ducts
 through the common bile duct and terminate within the duodenum. as before, the
 left stent traverses the mass; the right stent terminates within the mass
 (2:23). a small amount of pneumobilia is present within the gallbladder and
 cystic duct, an expected finding in a patient with stents.

 there is no free air or free fluid.

 pelvis:  the bladder, prostate and rectum appear unremarkable.  the appendix
 is normal.  there is no pelvic lymphadenopathy or free fluid.

 bones:  there is degenerative disc disease at l5-s1 intervertebral disc.
 additionally, there is subtle grade i anterolisthesis of l4 on l5.  otherwise,
 there are no aggressive-appearing lytic or sclerotic lesions.

 impression:
 1.  worsening biliary obstruction in segments vii and [**clip number (radiology) 70637**] with peribiliary
 enhancement and multiple new adjacent rim enhancing round hypodensities
 compatible with cholangitis and abscess formation. the blown-out intrahepatic
 bile duct within the inferior aspect of segment [**clip number (radiology) 70637**] extends into the
 subcapsular space with a focal subcapsular abscess identified.

 2.  relatively unchanged appearance of dominant mass compatible with
 hepatocellular carcinoma within segments [**doctor first name 751**], ivb and [**doctor first name 70637**] with invasion into
 the portal venous system and biliary obstruction. numerous ill-defined lesions
 primarily within the right lobe of the liver which appear similar compared to
 the prior exam likely reflect metastases, although developing abscess
 formation cannot be completely excluded.

 3.  moderate left intrahepatic biliary dilatation is similar.
                                                             (over)

 [**2119-8-7**] 9:58 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 84146**]
 reason: 1: eval for pe 2. ct abd for eval for fluid collection in ru
 field of view: 36 contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)

 4.  no significant change in peripancreatic tail lobulated fluid collection.

"
5012,"[**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  43 year old man with new diagnosis of [**hospital 21613**] transferred from outside hospital
  with possible septic arthritis and pneumonia, still spiking fevers despite
  treatment with vanc/meropenem/azithro, and with worsening abdominal pain and
  distension
 reason for this examination:
  ? acute intra-abdominal infection, ? degree of pneumonia, ? other acute process
  to explain abdominal pain and fevers
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 history:  43-year-old male with new diagnosis of aml, now with fevers despite
 treatment with broad-spectrum antibiotics as well as worsening abdominal pain
 and distention.

 study:  ct of the torso with contrast; 130 cc of omnipaque intravenous
 contrast was administered without adverse reaction or complication.  coronal
 and sagittal reformatted images were also generated.

 comparison:  chest cta from [**2123-5-8**] from an outside hospital.

 findings:

 chest:  the visualized portion of the thyroid appears unremarkable.  a
 prominent lymph node in the right axilla measures 9 mm in its short axis (2;
 12).  scattered small mediastinal lymph nodes are present, the largest of
 which is in the precarinal station measuring 11 mm in its short axis (2; 25).
 additionally, a right hilar lymph node measures 10 mm in its short axis (2;
 34).  the aorta is of a normal caliber along its course.  an incidental note
 is made of the left vertebral artery filling directly off the aortic arch, a
 normal variant (2; 20).  the pulmonary arterial trunk shows no central filling
 defect.  the heart demonstrates a simple pericardial effusion measuring a
 maximum thickness of 11 mm in the axial plane (2; 38).  additionally, small
 amount of bilateral pleural effusions are present, simple in nature, with
 associated atelectasis.  additionally, scattered areas of airspace opacity in
 the right upper and superior segment of the right lower lobes are compatible
 with pneumonia.

 abdomen:  the liver shows no focal lesion or intrahepatic biliary dilatation.
 the gallbladder shows no stones or wall edema.  the spleen measures 14.8 cm in
 its long axis.  the adrenal glands show no nodules.  the kidneys enhance with
 and excrete contrast symmetrically without evidence of hydronephrosis or
 masses.  the aorta is of a normal caliber along its course; the celiac axis is
 mildly narrowed as it ducks beneath the diaphragmatic crus.  the small and
 large bowel show no evidence of obstruction or wall edema.  scattered
 retroperitoneal and mesenteric lymph nodes are noted although do not meet
 pathologic size criteria.  portions of the lower retroperitoneum have a
                                                             (over)

 [**2123-5-12**] 3:49 pm
 ct chest w/contrast; ct abd & pelvis with contrast              clip # [**clip number (radiology) 115110**]
 reason: ? acute intra-abdominal infection, ? degree of pneumonia, ?
 admitting diagnosis: pneumonia;septic arthritis;acute leukemia
  contrast: omnipaque amt: 150
 ______________________________________________________________________________
                                 final report
 (cont)
 ""[**doctor first name 2778**]"" appearance, of unknown clinical significance.  the appendix is
 visualized and is fluid filled but not dilated, nor is there adjacent
 inflammation (2; 106 and 301b; 33).  there is no free air or free fluid.

 pelvis:  the bladder is decompressed around a foley.  the prostate and rectum
 appear unremarkable.  bilateral inguinal lymph nodes are present measuring 9
 mm in their short axes (2; 124).  there is no free fluid.

 bones:  there is no aggressive-appearing lytic or sclerotic lesion.

 impression:
 1.  airspace opacity at the right upper lobe and superior segment of the right
 lower lobe compatible with pneumonia; small-to-moderate bilateral pleural
 effusions and small-to-moderate pericardial effusion, all of which fluid is
 simple in nature.
 2.  scattered areas of prominent lymph nodes and splenomegaly compatible with
 patient's known diagnosis of leukemia.

"
5013,"respiratory care note:
     received patient on ac as noted in carevue.  ett is secured and patent.  no changes have been made this shift.  for specific settings please refer to carevue.  bs are coarse throughout with occasional wheezes noted on the left side.  sx for small amounts of tan thick secretions, blood tinged at the beginning of the shift.  no rsbi this am due to increased fio2 and peep settings (.60 fio2 and 10 peep).  patient remained afebrile this shift.  mdi's administered as ordered with no adverse reactions noted.  spo2 remains 94-95%.  plan is to maintain current therapy and wean fio2 and peep as tolerated.
"
5014,"resp: pt placed back on mmv due to periods of apnea. psv 10/5/40% (see careview for mmv settings) bs are coarse to clear and suctioning for small to moderate amounts of thick white secretins. mdi's administered as ordered alb/atr with no adverse reactions. rsbi=50. no abg's this shift. 02 sats @ 99%. adequate tv's/ve's.
"
5015,"[**name (ni) 5986**] note
 pt arrived to sicu from ed with c/o n/v/d x3 days. pt a&ox3 upon arrival in ed, became agitated, recieved haldolx1, adverse reaction, intubated for airway protection. pt tachycardic and hypotensive, recieved a total of 6l ns in ed and 3 units of prbc's for hct of 23. placed on pressors and brought to ct for abd scan, showing ischemic bowel. pressors weaned off, maintaining sbp>100.

 upon arrival to unit, pt recieved 1 unit prbc's and 2 units ffp. pressors remain off. metabolic acidosis, recieving bicarb 150meq and 1 amp with some improvement. lactate increasing. lytes repleted. 40k in ns after bicarb finishes, 1l bolus ns inbetween.

neuro: pt remains sedated on prop gtt. sedation not shut off due to hemodynamic issues. pt able to mae, does not follow commands, withdraws to nailbed pressure, pupils equal and reactive. becomes agitated with increased activity.

resp: no vent changes made. ls clear bilat. suctioned prn for scant amount of thin white secretions.  svo2 in the 80's.

cv: remains in nsr, no ectopy. sbp wnl. fem aline placed at bedside upon arrival to unit. pressors remains off.

gi: abd firmly distended upon arrival. fib placed for lg amounts of melena stool, abd softer. ogt to lcs, scant output, flushed multiple times, placement checked.

gu: oliguric, clear yellow urine.

endo: blood sugars remain elevated. insulin gtt titrated per csru s/s.

plan:
 check abg, bs, and k q 1 hr. monitor lactate, monitor output. glucose control. provide pt and family with emotional support.
"
5016,"7a-7a
neuro: pt extubated at 11am, alert and oriented, following all commands. perrla. mae. morphine ivp and percocet prn for pain w/ fair relief.

cv: hr 80-100s sr/st, hr 100s st at beginning of shift, lopressor 12.5mg po started and digoxin 0.25mg started po bringing hr 80-90s sr. frequent pacs noted around 11am, mg 2 gm iv given, no ectopy noted since 12pm. sbp labile, as high as 120-130 while intubated and w/ activity, nipride as high as 1.2mcg, md [**doctor first name **] aware, at present 0.2mcg w/ bp 100/50. see carevue for details. ci [**3-20**], see carevue for filling pressures. cvp 10s. 1 unit of prbcs, no adverse reactions noted. +palpable pulses.

resp: ls clear, diminished bases- coarse. inhalers restarted. pt extubated at 11am, acidotic prior to extubation 7.29, 1 unit of prbcs given and 1 amp of bicarb as [**name8 (md) 20**] md [**last name (titles) **]. repeat ph 7.32. post abg 7.32/44/113/-3/24/98%, md [**doctor first name **] aware, no new orders. instructed how to use cough pillow and is. using is as high as 500-750cc. oob to chair.

gi/gu: abd softly distended, obese. +bs, no bm. ogt dc'd w/ extubation. tolerating clears. u/o low at beginning of shift, md [**doctor first name **] aware, blood given, lasix 20mg ivp started. foley draining adequate amt of yellow clear urine.

endo: insulin gtt restarted, as high as 9units/hr, at present at 2units/hr. see carevue for details of gtt.

social: many family members into see pt throughout day. spouse updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. pulmonary toilet. follow labs including blood glucose. wean nipride as pt tolerates.


"
5017,"social work note:

new trauma pt on t-sicu.  pt is a 23 year old man who is s/p fall/jump from 5 stories.  he has some head bleeds and an l2 burst fx.  pt was intubated this morning when this sw visited initially but has been extubated this afternoon.

[**name (ni) 25**] girlfriend, [**name (ni) 6199**] (misidentified as his sister initially) and pt's [**last name (lf) 344**], [**first name3 (lf) **] and les, are visiting this afternoon.  this sw met with pt and then his [**first name3 (lf) 344**], and then his girlfriend.  girlfriend's cell # is [**telephone/fax (1) 6200**] and work # is [**telephone/fax (1) 6201**].  she will likely return to work on thursday.

pt is a student at [**university/college 6202**].  he lives in [**hospital1 **] with his girlfriend, [**name (ni) 6199**].  [**name2 (ni) **] has one more semester of college.  family reports that only recent stressor is that their cat is quite ill and will likely be put down.

when this sw met with pt, he was alert and oriented to self and knew that he was in a hospital.  he was polite and engaged easily.  he was talking ""ragtime"" at various points and seemed concerned about getting in trouble legally.  he encouraged this sw to talk with his girlfriend for further information.  pt reports remembering being on a roof and that the people he was with were not strong enough to keep him from doing something that he wanted to do.  he referred to what happened as a ""dream"" and made reference to ""external reality"" and the involvement of his ""ego"" and the effect that had on his ""short term memory"".  pt denies wanting to hurt himself.  he feels comforted by his [**name2 (ni) 344**] and girlfriend's presence.

pt's [**name2 (ni) 344**] seem mutually supportive and expressed relief that pt is not more injured.  they report that they have been told that pt took some mushrooms last night and that his girlfriend has more information.  they said that one of pt's grandmothers had schizophrenia but that pt has no psychiatric hx himself.  he was evaluated during grade school and was found to have above-average intelligence and borderline add.  [**name2 (ni) **] said that pt does not use drugs and treats his body like ""a temple"".

[**name (ni) 25**] girlfriend reports that to her knowledge pt has never been suicidal and is generally quite ""happy"".  she said that pt tried mushrooms yesterday for the first time and had an ""adverse reaction"".  the friends that pt was with did not seek assistance for him (seemingly because they feared getting in trouble) and pt got away from them and got up to rooftop prior to fall/jump.  he left her a voicemail prior to fall/jump begging for help.  [**name (ni) 25**] girlfriend said that he does not otherwise use drugs.  the police have been involved and pt's [**name (ni) 344**] will be in contact with them.  [**name (ni) 25**] girlfriend does not think that there will be legal implication for pt from this incident following her conversation with police.

[**name (ni) **] and girlfriend given contact information for this sw for support as needed.  family given written information for themselves about emotional reactions to traumatic experiences.  pt is being evaluated by psychiatry and this sw met with them briefly to share above
"
5018,"resp:  [**name (ni) 257**] pt on [**last name (un) 33**] a/c 10/320/+5/30%.  alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds. suctioned small to moderate amount of thick yellow secretions.  mdi's administered q4 hrs alb/atr with no adverse reactions.  02 sats @ 100%.  rsbi performed without adequate results.  no further changes noted.
"
5019,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**2165-5-2**] to er wtih fever, decreased u.o., received 1x dose of gent and iv hydration at [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levofloxacin and flagyl. pt refused presep cath in er. lactate 1.8. pt treated for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy but was ordered to try meropenem per [**hospital unit name **] and id team. overnight pt had an adverse reaction within minutes to the meropenem developing audible wheezing with sob and +n/v- see care vue for details. ivabx changed to iv aztreonam with no adverse reaction. cvp remained low ranging [**3-6**] with bicarb ranging 18-20. pt was given a liter of d5w with 150 meq na bicarb. k of 3.1 was repleted with 40 meq kcl total. will draw repeat labs at 6am.

neuro: a&ox3, mae, pt with l aka with some stump discomfort this am which pt reports is tolerable and he doesn't take any medicine for it at home. he was given tylenol shortly prior to the complaint for fever. t max 102.6 po. pt given total of 650mg tylenol x2 with t current 101.6po. bld cx x2 and urine cx sent. central line was pulled back 2cm as was in too far via cxr per team. repeat cxr confirmed proper line placement. pt following commands appropriately. requires max assist with adls.

cv: hr ranging 80s-100s sr/st with no ectopy noted. bp ranging 100s-150s/60s-90s. +pp via doppler in r leg. l stump warm to touch.

resp: lungs cta except developed wheezing shortly after receiving iv meropenem. then after meropenem stopped, pt with no further wheezing. sp02 ranging 97-98% on rm air. pt had been placed on 2lnc during time when pt had a reaction to the meropenem with sob but within a few minutes after the meropenem was stopped, pt was weaned back to rm air with sats in high 90s.

gi/gu: abd soft, nt, +bs, had small loose brown bm x2 smeared on his pad unable to send for cdiff. +n/v with meropenem reaction but no further incident afterward. foley patent draining adequate amts yellow urine with sediment in it. u/a c&s sent along with urine tox screen.

skin: warm, dry, and intact.

comfort: c/o stump discomfort this am shortly after tylenol given for fever. states pain level acceptable.

lines: r ij tlcl patent and was pulled back by 2cm and reconfirmed via cxr per team. r piv was found pulled out by pt d/t discomfort at insertion site. some small amt swelling at insertion site but subsided with pressure and elevation. l piv intact.

social: has been living at the [**hospital3 **] recently but prior to that had lived in own home.

plan: monitor temp, tylenol prn, monitor micro data, ivabx, make note of new meropenem allergy (also allergic to pcn). f/u with am labs and need for more k and bicarb repletion. monitor cvp and need for more ivf.


"
5020,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**5-2**] to er with fever, decreased, u.o., received 1x dose of gent and iv hydration and [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levoflox and flagyl. pt refused presep cath in er. lactate 1.8. pt tx'd for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy and developed a meropenem [**last name (un) **] noc of [**5-2**]-5 with audible wheezing with sob and n/v. pt was switched to iv aztreonam with no adverse reaction. pt continues to spike temps with 3 sets bld cx sent since adm.

neuro: a&ox3 with cueing. mae, l aka with some stump discomfort that is his baseline ""phantom"" pain relieved without intervention. t max 103.9. given tylenol 650mg with temp down to 98.9.

cv: hr ranging 90s-110s sr with no ectopy. bp ranging 120s-160s/40s-90s. +pp via doppler in r leg. laka. no edema noted.

resp: lungs cta, sp02 ranging 97-99% on rm air.

gi/gu: abd soft, nt, +bs, small bm x2 brown loose. drinking water with meds with no difficulty swallowing. foley patent draining adequate amt clear yellow urine 40cc+/hr. pt approx .5 liters negative since mn and 4.2 l + los.

skin: raw areas on coccyx and testicle area. aloe vesta cream applied to areas.

lines: r ij tlcl patent.

social: no contact from family. pt a dnr.

plan: continue to monitor temp and provide tylenol prn. iv abx, monitor micro data. ? call out to floor later today.
"
5021,"7a-7p
neuro: pt [** **] and oriented x2, knows pt is at [**hospital1 **] and knows self. [**hospital1 **]. follows commands. mae,weakly. denies pain when asked.

cv: hr 90s-100s. sr rare pvcs. sbp >100. map>60. +[**hospital1 **] pedal pulses.

resp: ls coarse. sats >93% on 5lnc. nebs x2. productive cough, not bringing up sputum. talc to ct by thoracic resident.

gi/gu: abd obese, hypoactive bs. dophoff placed, cxr done + in stomach [**name8 (md) 20**] md [**last name (titles) **]. tf started at 1600 as ordered, continue tpn [**name8 (md) 20**] md [**last name (titles) **]. foley draining greenish yellow urine (intensivist aware on rounds)- from dye. draining adequate amts.

endo: per own's scale.

id: afebrile. antibiotics changed- meropenem started, no adverse reactions noted. bc sent from central line, need peripheral.

plan: monitor hemodynamics. monitor resp. status. skin care.




"
5022,"condition update
d: please see carevue flowsheet for specifics
 pt running [**name (ni) 10073**] temps all day with tmax 100.4. hr 60-80 in nsr with occassional pac's noted this afternoon. nmed goal is to maintain sbp 100-150 this am pt required neo which was weaned to off for a couple of hours and then pt required labetolol gtt to be started. all solutions are mixed in ns per request of nsurg. mannitol was restarted with no adverse reactions after dosing, and glycerin po was d/c'd.
 pt's neuro status has waxed and waned throughout the day. at most alert moments will open eyes on command-at other times won't even open to sternal rub. perrla but does not track/attend. pt consistently has purposeful movement and normal strength in left extremeties. rue has no movement to withdraws slightly and moves on bed to pain.
 no vent changes made today. pt remains on simv 600x16 with 5peep and 5ips and 50%. thick tan to blood frothy secretions-sputum spec sent for culture. patient is not breathing over the vent rr 16 except when stimulated.
 wife in and spoke to dr. [**last name (stitle) 10074**] who had been updated by nmed and nsurg service. wife's nephew was present during visit and due to wife's expressive aphasia it was agreed with wife and nephew that he would be the contact person-phone # in chart. social worker also met with wife/nephew.
plan:
 neuro checks
 sbp 110-150
 dose mannitol according to serum osmolality
 notify h.o. with any change
"
5023,"micu npn 7pm-7am
neuro: pt. received on ativan gtt @1mg/hr and fentanyl at 50mcg/hour. initially pt. appeared comfortable, able to obey commands, and would withdraw to pain. l pupil reactive to light. very weak cough and gag. pt's ativan gtt increased to 2mg/hr due to pt. stacking breaths with ventilator. pt. currently appears comfortable, does open eyes to pain, and flexing extremeties to nail bed pain.

resp: remains on ac16,+5 tv 500, 40%. am abg pending. lungs are coarse with crackles in the bases. at times pt. is very rhoncorous, and sounds like she has alot of secretions, however she has scant to no secretions when she is suctioned. secretions are rust colored. awaiting results of bronch.

cv: received on 8mcg/kg/min of dopamine. dopamine has been weaned to 3mcg/kg/min and will continue to wean as bp tolerates. nsr with occ pac's and pvc's.

gi: ogt to lis, draining guiac + bilious drainage. ogt clamped this am. active bowel sounds, no stool. ?feed pt. is bleeding has stopped.

gu: voiding adequate amounts of urine >40cc/hr. clear, yellow urine.

heme: hct stable, 30@mn.

misc: per pt's oncologist she received iv ig. pt. initally given a test dose of 5gms and she tolerated it well. bp stable, and temp stable, no signs of adverse reaction. pt. then given remaining dose. pt. tolerated well. see carevue for vss and temp.

social: family member stayed the night in the waiting room. plan is to find source of infection, wean dopamine as tolerated.
code status: dnr
see carevue for further data.
"
5024,"7p-7a
neuro: at beginning of shift pt alert,sleepy, following all commands,mae,perrla, nodded yes when asked if wants ""breathing tube out"" able to move head forward. pt resedated after re-intubation, on propofol,perrla, mae to painful stimuli. no indictions of pain.

cv: hr 70-100s. >100 during episode of re-intubation. sr/st. sbp labile on and off neo and ntg. currently off of neo and ntg. sbp 110s. [**md number(3) 5118**]/15-20s. cvp 7-16. svo2 52-64, md bridges aware. ci>2 by fick, see carevue. low svo2 treated w/ fluid bolus x3 and 2 units of prbcs,no adverse reactions, see carevue. epicardial wires attached and on ademand backup, see carevue for settings. +palpable pedal pulses, verified w/ doppler.


resp: at beginning of shift, pt following commands, acceptable abgs on cpap 5/5, md bridges at bedside before extubation and aware of svo2 57-60 before extubation. ok to extubate, extubated at [**2095**], pt sats to 55, pt in resp. distress, pt oxygenation w/ ambu and oral airway w/ improved sats to 90%, anesthesia called stat and at bedside re-intubated 7.5 tube, see carevue for vent settings and changes. abg after re-intubation 7.21/62/108, md bridges aware, rate on vent increased to 18, w/ improved abg 7.32/48/106, md bridges aware. presently on cmv rate 18 tv  700, fio2 70% w/ acceptable abgs, see carevue for details. ls clear diminished at bases. sats 94-100% at present time. suctioned for scant amts of thick white.

gi/gu: abd soft, abesent bs. ngt replaced after extubation draining bilious to brownish drainage. foley draining 40-60cc/hr of clear yellow urine, see carevue.

endo: gtt per protocol.

social: daughter updated w/ poc.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. once pt stabilizes, wean vent as pt tolerates.
"
5025,"1900-0700
see carevue for assessment and vital signs.

neuro: a&o. perl. mae. following commands. sleepy due to analegesia but easily rousable.

cv: sr 70's. no ectopy noted. sbp 97-125. always >100 when awake.

resp: maintaining sats 94-100% on ra. encouraged to deep breathe. ls clear.

gu: foley draining adequate volumes of clear urine.

gi: good diet tolerated. ssi coverage. made npo from midnight for possible or today. lr @ 125mlsph.

skin: intact. pin sites to l leg clean.

pain: ketamine infusion continues @ 7.5mls/15mg/hr. no adverse reactions/effects noted. dilaudid pca (double strength) continues. 0.5mg/6min lock/5mghr tot. used less since ketamine infusion commenced. pt slept for long periods and pain reported to be better controlled. sharp intermittent l leg pain continues. 2am morphine sulphate sr 130mg held as pt resp rate 12-13, pt comfortable/sleeping and also npo.

id: t max 100.5. 650mg acetaminophen given with effect.

plan: remain npo for possible or for l leg orif.
      monitor neuro status while on ketamine/dilaudid.
      maintain traction to l leg.
      emotional/psychological support of pt.
"
5026,"nursing progress note for 7p-7a:
neuro: pt is a&ox3, mae, follows commands.
pain: epidural gtt in infusing at 2ml/hr with good pain control and no adverse reactions noted.(changed dose, see [**month (only) **])
cv: hr is nsr 60-70's, rare pac noted. sbp 90-100's with maps 55-65.
skin is warm and dry, color pink, ppp. pt asymtomatic. remains on neo gtt at .4-.6 mcg/kg/min. bp does drop when attempts made to decrease neo gtt. lr at 10 ml per hour, cvp at 5. no fluid [**name8 (md) 52**] md's.
resp: pt's sats dropped to 88% while on 4l/nc, changed to 50% face mask with sats now 92-96%. wean non-productive cough. uses is with encouragement. 2 rt pleural [**last name (un) **] ct's to 20 cm sx. low amt of drainage. small airleak, no crepitus. md aware. dressing cdi.
gu/gi: npo, bs absent.  foley to bsd with adequate hourly o/u.

s/p thoracotomy with wedge resection, bx, lobectomy, esophageal mass removal and repair to trachea.  plan to keep pt dry to prevent re-intubation and attempt to wean neo gtt to off. encourage is.
"
5027,"12a-7a
pt is a 66 year old male readmitted from sinia w/ increased sob,
fever. s/p cabg x3 on [**2174-9-29**], wound dehiscence, trach on [**2174-11-4**]. vent dependent. wbc on readmit 42.

neuro: pt a+ox3, forgetful at times. mae. perrla. morphine 2mg iv prn.

cv: hr 90-110s st w/ rare pvcs. increased hr w/ aggitation. sbp 150, nitro gtt started keeping sbp 110-130 map >60. 1 unit of prbcs given for hct 26, no adverse reactions. + palpable pulses. left a line placed at bedside by dr. [**first name (stitle) **]. +csm. double port picc to left ac, flushing well.afebrile 96.4-98.0.

resp: ls coarse, diminished at bases. trach [**first name (stitle) 657**], fio2 50% on cmv mode rate 20 tv 600 peep 5. abgs drawn on admission, md [**doctor last name 2641**] aware. sats 99-100%. suctioning small thick yellow via trach.

gi/gu: abd soft slightly distended +bs. ngt patent and [**doctor last name 657**] from rehab. pt states foley was placed today. foley draining adequate amts of yellow urine. urine cx sent in er.

[**doctor last name **]: sternal wound open w/ wound vac dsg [**doctor last name 657**], last change on [**12-23**]. see carevue.

plan: monitor hemodynamics. pulmonary toilet. ? ct today. pending cultures. ? id consult.continue triple antibiotics.
"
5028,"npn 7a-7p
see carevue for specifics:

neuro status unchanged, quadraplegia, speaks both spanish & english attempts to mouth words, diff to understand, appears to nod approp to questions. denies pain. tmax 99.4, hr low 100s-120s, sbp 90s-140s, hct continued to drop 22.9, inr 1.7, 2 units ffp & 2 units prbc given without adverse reaction. to ir for ivc filter placement via r groin, tol procedure well. (+)fem & pps, site c/d/i. no vent changes, trached on ac 600x15, fio2 50%, peep 5, continues with mod amts of oral secretions needing freq mouth suctioning and oral care. ls coarse & diminished at bases spo2 99-100%. abd soft, nt/nd (+)bsx4, no bm this shift, tfs held for procedure, gt flushed without diff. foley with adequate u/o, bs qid with sc coverage. a/p stable,  continue with serial hcts if continue to trend down gi to repeat scope in am, monitor r groin/pulses may remove dsg in 24hrs per ir, pulmonary toileting with freq mouth care, ? restart tfs this evening vs am in case of need for repeat scope. provide emotional support.
"
5029,"7a-7p
neuro: a+ox2. mae. perrla. follows commands.

cv: hr 60-70s sr. converted to afib 100-110s at 1500 for approx. 15min, then converted back to nsr. sbp 100-130. weakly palpable dp/pt. 2+ generalized edema. aline positional, unable to draw blood from line, team aware. 1 unit of prbcs given, no adverse reactions noted.

resp: portex #7 trach site oozing w/blood. trach care done. trial on trach collar done, tolerated for 30 min., placed back on ventilator cpap. see carevue for details. ls clear. sats above 95%. suctioned for thick blood tinged secretions via trach. yellow thick secretions via [** **]. left sided pleural  effusion by xray, lasix ordered.
tolerated oob to chair x3hours.

gi/gu: abd soft, hypoactive bs. tf restarted at 20cc/hr. minimal residuals. bm x1 formed brown stool. foley draining adequate clear yellow urine.

skin: rash noted on back.team aware. cont. vanco.

plan: pulmonary toilet. rehab screening. diurese.
"
5030,"nursing care note
see careview for specifics.

neuro: propofol weaned to 50mcg/kg/min. pt arousable. oriented. follows commands. writing for communication. perl. strength in all four extremeties improving. lue remains weak. unable to lift and hold. unable to move neck, requiring repositioning of head.

resp: remains on cmv mode of ventilation. 40% 18x400, peep5. attempted a short trial of cpap +15ps. abg acceptable, obtained adequate tv's, but fatigued after 2 hours. suctioning for small amounts of thick yellow material. suctioned frequently for moderate amounts of oral secretions. lungs ctab.

cv: afebrile. vss.  rec'd ivig with no adverse reaction.

gi: abdomen soft with present bs. no bm this shift. ogt to lcws putting out moderate bilious material.

gu: autodiuresing.

labs: all noon lab results reported to dr [**last name (stitle) **].

plan: most iv meds changed to po as access is an issue. pt has 2 piv. provide support to pt & family. monitor neuro status. ? social work involvement.



"
5031,"npn7a-7p
neuro: pt using voc board to com. needs. dozing on & off all day, but easily arousable. anxious in am. tx'd w/ repos. 1mg ativan & 50mcg of fentanyl w/ good effect.
resp: recent abg's per pt's baseline. cont. to monitor sats & abg's as ordered. sxn' prn.
cv: hypotensive to sbp 80's following 50mg lopressor via ngt. team aware. bp corrected w/out need for ivf bolus & ivgtt. afebrile. nsr hr 90-106. no ectopy noted. +doppler bilat le pulses, cool to touch cyanotic in appearance. +2 edema r>l. rece'd ivig over 41/2 hr w/out adverse reactions.
gi/gu: npo. nepro tf @ goal of 40cc/hr. +bs +bm soft brown. foley draining adequate urine clear & yellow in color.
integ: skin tears w/ tegaderm drsgs reapplied over face & cocyx. staples in tact over lami inc site. no drainage noted.
endo: bs wnl. no coverage required w/ riss.
plan: goal for i/o negative to help prepare for possible extubation [**7-8**]. monitor hct, abg's as needed.
"
5032,"micu nursing progress note

pulm: pt to ct angio to eval pe. once on  ct table noted to have brb per ett, large thick amt. maintained o2 sats > 95%, airway remained patent. cont'd to sx moderate amts of bright red sputum during test. labs revealed hct drop from 35 to 30, inr 1.6-> rec'd ffp(2), vit k x 1. 4am labs revealed drop in hct to 26.2. cont to have bloody secretions overnight mod to large amts, appears to contain tissue, and to be less bright red than earlier in evening. now ordered for 2 additional units ffp (being thawed) and 2u prbc's typed and crossed. pt rec'd on a/c 450 x 20 peep 5, fio2 inc'd to 50% to maximize o2. am abg -> 195/31/7.45.

cv: sbp 80(sleeping)-126. hr 70's(nsr). repleted for k+, mgso4 and ca+. am labs drawn immediately after finishing repletion of lytes (md aware)

id/heme: spiked to 101.4 between rec-ing 2u of ffp. md [**doctor last name **] informed, bbank called. decision made to give apap and cont infusion d/t greater risk of bleeding vs probability(low) of adverse reaction. now ordered for 2 additional units-will pre medicate. pan cx'd, bc x 2 +fungal, urine sent. abx regimen un-changed.

gi/gu: no s or sx of bleeding via ogt. stool ob-. tolerating tf w/o difficulty though does cont to have large amt of diarrhea via mushroom cath. hypoactive bs. abd ^^girth though soft. u/o ~100-200cc/h.

skin: mediastinal,sternem dry and intact. r arm infiltrate site w/ some weeping, escar sloughing off.

social: aunt called for update, pt's mother has note been called by intern -needs to happen today.
"
5033,"resp care
pt remains on vent. changes made according to protocols. mdis given with good effect: decreased vent pressures.  no adverse reactions. will continue to mointor
"
5034,"npn 7a-2p

events:  pt. restarted on heparin (at 800u/hr), sent to cath lab for cardiac cathertization at 1400.  pt. with transient hypotension and low u/o today.  c/o of cp x 1 resolving without intervention.

neuro:  a+o x 3.  pleasant and cooperative.  anxious about cath.  medicated x 1 w/ 1 tab vicodin for lower back pain; [**8-23**].  pt. takes vicodin at home per her report despite hx. stating she has morphine allergy.  pt. without adverse reactions and pain dissapated; 0/10.  pt. decribes that her pcp believes her to have sleep apnea with insomnia; takes ambien at home as well for sleep.

resp:  sat's maintained >95% on 4l nc.  + smoker 1/2-1 pack/ day.  ls- clear/ diminished bases.  productive cough.

cv:  team describing weekends' events as ischemia, not infarction d/t unstable angina.  cp x 1 with no other associated symptoms; denied sob.  of note, pt. reported cp when asked.  30 minutes prior to onset of cp, pt. received vicodin for back pain.  no further narcotics were administered as pt. stated that cp or ""pressure"" was resolving on own.  no nitrates administered.  sbp 90's (manually/ doppler).  ho called immediately.  pt. started on heparin prior to onset of cp as well at 800u/hr with no bolus.  pt. sent to cath lab at 1400 after consent obtained by pt. and son.  [**name (ni) **] at bedside.    hr 60's.  bp 90's.  ivf started prior to cath at 125cc/hr of ns with 500cc fb.

gi:  pt. encouraged to drink po's d/t poor u/o, then made npo for cath.  abd wound dressings done at 8am; packed with several yards of nu-gauze; wounds tunnel.  wounds with serosanginous output.  no bm.  + bs.

gu:  u/o minimal.  ivf started prior to cath.

id:  pt. receiving pcn and flagyl rtc.  afebrile.

plan-  s/p cath care, hct s/p cath with wbc.  check ptt on 800u at 6:30pm.
"
5035,"1900-0700

general: pt remains sedated with cont'd mechanical ventilation. prbc transfusion completed with no adverse reactions: repeat hct-30.8,wbc-16.5. no changes made to vent through night, o2sat 92-97%.

neuro: pt reamins sedated, eye twitching noted to painful stimuli. minimal to no movement of ext noted. pupils 3mm bilaterally with r-brisk and l-sluggish.

resp: pt remains orally intubated with # 8.0 ett 24cm @ lip line. vent settings remain ac tv 600, 70% 35, peep 20. mv-22.o2sat 92-97%. suctioned for scant thick blood tinged secretions. abg 4am: 7.24, 69, 60, 27, lactic acid-2.2. lungs on r-rhonchi,l-coarse through lung field. oral cavity with bleeding gums and sinusitus noted.

cv: nsr-s.tachycardia with rare pacs noted. max temp 99.8 orally, bp 120-165/50's. hr 90-110. cvp-[**9-23**]. generalized edema noted to ext. pulses to lower ext by doppler. triadayne bed in use with rotation and percussion. compressive boots/foot drop splints on.

gu/gi: abd firmly distended with + bs noted. liquid diarrhea noted, occult neg-fecal incont bag applied with double skin barrier. ogt to liws draining bilious fluid, irrigated for questionable internal bleeding-negative. foley catheter to bsd draining clear yellow urine. lasix given at 2300. pt -800 at this point for 24hrs. na-152, bun-79, cr-1.7,

endo: insulin drip remains titrated to bs. bs 120-150.

iv: r radial aline zeroed and calibrated with sharp waveform. l ij tlc intact with [**month/year (2) **] @ 5mg/hr, fentanyl@ 80mcg/hr, lr@ 10cc/hr, insulin@3u/hr, [**e-mail address 6573**]/hr.

plan: continue supportive measures. family meeting today.

                       [**first name8 (namepattern2) 2641**] [**last name (namepattern1) 2642**] rn
"
5036,"npn 7a-7p

events-  abd ct done with gastrografin (not barocat), results pending, conts to stool (500 out this shift), transitioned to psv this afternoon, hct stable, wbc increasing again...

review of systems-

[**name (ni) **]  pt. nodding appropriately, eyes closed most of the shift, denying pain except x 1 when she was medicated with 2mg of mso4 w/ good effect.  family cautions use of versed/ ativan d/t adverse reactions to benzo's in the past- pt. reportedly becomes confused and disoriented.

resp-  received on a/c, transitioned to psv- will obtain evening abg.  ls- diminished throughout... sat's stable.  sx'd for thick white secretions.  would obtain sample if turns purulent- appears to be nasalpharyngeal ? sinusitis...

cv-  hr 80's-90's sometimes appears to be in nsr, others appears to be in aflutter- conts on amiodorone iv d/t poor tolerance of pos. bp stable via arterial line.  pm hct stable >32.  e-lytes repleted this am received 80meq of kcl, ca+ and mg+.  skin appears distressed and friable, oozing from extremeties.

gi-  abd conts to be firm and distended, tender to touch.  flexiseal device inserted and appears to be draining and containing stool well- 500cc output thus far.  no further go-lytely given today, would consider after ct results interpreted.  lactulose d/c'd as it could be causing increased flatus.

gu-  u/o adequate.  d5w changed to po 250cc q 4hours to save on input. tpn also adjusted to decrease sodium and improve e-lyte imbalance.  nutritionist recommending we not replete imbalance tom'row am as new bag of tpn should correct.

id-  afebrile.  off abx.  ? sinus drainage causing secretions.

[**name (ni) 4**]  husband and youngest dtr, [**name (ni) 169**] to visit and updated on plan of care.  also talked with dtr, [**name (ni) **] and plans to meet w/ fellow dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 5901**] tom'row to discuss timeline.
"
5037,"resp care

pt followed by respiratory for q6 neb treatments. atrovent given x2 via aerosol mask tol well with no adverse reaction. bs essentially clear/dim at the bases. no changes noted post tx, pt adequately oxygenating on 2l nc. will cint to follow as needed.
"
5038,"1600-1900
pt is a 70 year old female admitted s/p cabg x4, see admission h+p for details of history and details of events in or. oozy through chest tube on arrival, act 159,  np [**doctor last name **] and dr [**last name (stitle) 1348**] aware, protamine 50mg iv given,peep increased, labs sent, np [**doctor last name **] aware, plts ordered and given, no adverse reactions.

neuro: pt sedated on propofol gtt. perrla.

cv: received from or w/ hr sr 80-90s. epicardial wires work per anesthesia. ekg done. sbp 110-120s on ntg as high as 1.5, see carevue. goal sbp<130. ci>2. pa 20s/15, cvp 7-11. 1l of lr given and 468cc of plts given for volume. dopplerable pedal pulses. k repeted. np [**doctor last name **] aware of mg and phosphate, repeat phosphate sent.

resp: ls clear. see carevue and ccc for abgs and vent changes. presently on fio2 of 60%, rate 12,peep 10. sats 100%. ct draining sang. drainage on arrival 30-60cc q 15min, np [**name6 (md) **] and md [**doctor last name 1348**] aware, protamine and plts given, at present 10-20cc q15-30min.

gi/gu: abd soft absent bs. ogt +placement, draining bilious secretions. foley draining adequate amts of clear yellow urine.

endo: gtt started at 1845 for glucose 116.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. monitor for bleeding, once stable, wake and wean as pt tolerates.
"
5039,"respiratory care note:
     received patient of ac as noted in carevue.  patient trached with a #8.0 portex perc. trach.  no changes have been made this shift.  bs are coarse throughout.  sx for small to often moderate amounts of tan thick secretions via trach.  [** **]'s administered as ordered with no adverse reactions noted.  patient remains afebrile this shift.  positional cuff leak noted.  cuff pressure measured and continues to be 30.  team aware of high cuff pressures for trach.  spo2 remains 98-100%.  will continue to monitor respiratory status.
"
5040,"npn 7a-7p

events:
pt. spiked to 101.6 this am and 102.3 this afternoon.  pt. pan cx'd x stool and sputum this am.  with this afternoon spike, pt. had resp. distress with hypoxia on abg (70's), tachypnea, htn to 220 and rigors. treated with apap, lopressor 10mg ivp with 25mg po, 12.5 demerol.  currently stablized.

review of systems:

[**name (ni) **]  pt. more lethargic and less interactive today.  conts to follow commands with right hand squeezing.  no spontaneous movements noted on left side.  perrla 3-4mm.  or cancelled in light of fever.  rescheduled for tom'row if not febrile.

resp-  received on fio2 of 35% currently requiring fio2 50-70% to maintain sat's >92%.  abg at 1540.  cxr done at the time of resp. distress, results pending.  sx'd q 4 hours for minimal to no secretions.  no sputum spec. obtained.  ls- clear anterior, diminished bibasilar posteriorly.

cv-  hr 70-100 nsr.  mg of 1.5 repleted with 2g.  received 1u prbc in prep for the or d/t hct <30%.  tolerated transfusion well, no adverse reactions noted.  pt. received tyelenol prior to transfusion.  suture sites appear clean and dry.  lue significantly more edemedous and hot compared to right ? dvt.  however, pt. has [**location (un) 890**] filter in place and could not be anticoagulated.  team considering ultra sound.  no signs of cellulitis noted at this time.  elevated on pillows at this time.

gi-  abd soft/ distended.  no bm this shift.  tf restarted at 1pm d/t cancellation of or.  to be stopped at mn for questionable v/p shunt placement tom'row.  ? start ivf at that time, no order presently.

gu-  u/o adequate 40-60cc/hr.  receiving lasix 20mg po qd.

id-  fever spikes x 2 today with tmax 102.3.  conts on iv levoquin.

[**name (ni) 4**] husband and son in this am and plan to visit again tom'row before surgery... appear to be updated on plan of care.
"
5041,"respiratory care
patient remains trached with no leak noted.  no vent changes made this shift.  mdi's administered as ordered.  no adverse reactions noted.  sx'd for a small to moderate amount of thick tan secretions.  will continue to monitor as needed.

"
5042,"(continued)
 with gelfoam; no other obvious bleed.
gi: belly softly distended, active bs, no stool. nepro tf's at goal of 30cc/hr with no residuals.
endo: insulin gtt initiated for fsbs 180's; have achieved good control on current rate of 2u/hr (was as high as 5u/hr). cont's on hydrocortisone.
skin: bilateral ue's erythematous, edematous, weeping; elevated on pillows. no other skin breakdown.
social: several children and grandchildren visiting at start of shift; one dtr stayed the night in the room.

note: pt has doumented allergy to several drugs, including heparin and levoquin, both of which she is on. md's made aware, checked with family; apparently reactions not serious and pt wil remain on both, no adverse reactions noted.

a: remains critically ill with poor prognosis

p: continue all supportive measures; anticipate renal consult with possible initiation of cvvhd; support family; pt remains dnr but fill treat.
"
5043,"resp:  [**name (ni) 92**] pt on [**name (ni) **] a/c 14 600/70%/+15. alarms on and functioning. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which improve with suctioning.  suctioned x 3 for small to moderate amounts of thick bloody tinged secretions.  mdi's administered q 4 of alb/atr with no adverse reactions noted.  minimal air technique used to ^ maintain adequate cuff pressures.  02sats remain  in^ 90's 94-96% with no distress noted.  no rsbi performed dueto high peep pressures.  no further changes noted.
"
5044,"npn 7a-7p

[**name (ni) **]  pt. remains febrile with low grade temp 100.7 pr tmax.  conts on a/c without vent. wean today d/t febrile state [**name (ni) 87**] as well as cardiac decompensation considerations.  sx'ing needs are diminished compared to yesterday's descriptions. will attempt to turn off propofol gtt tom'row and wean to psv if remains stable [**name (ni) 87**].

review of systems-

neuro-  on 60mcg/kg/min of propofol easily arousable to voice, does not follow commands, makes eye contact, appears frustrated but unable to nod appropritately when interviewed.  moves all extremeties.  occasionally rigid when temps are higher.  will intiate weaning of prop/ventilator tom'row.

resp-  a/c 650 x 24 40% peep 10.  abg on 50% 7.45/36/178/26 this am.  mv 18.5l to maintain pco2.  considerable dead space ventilation.  ls cont to clear with some coarse rales heard bibasilar and crackles prominent on left side.  sat's remain stable.  sx'd q3-4 hours which is much less than yesterday's requirements.  will attempt psv tom'row.

cv-  hr 89-100's sinus rhythm.  bp 110-130's via nbp cuff.  conts on ntg gtt at 1.7mcg/kg/min, lopressor 20mg qid, heparin stable at 1600uhr with [**name (ni) 490**] ptt checks.  edema throughout lower extremeties and dependent regions +[**2-5**].  will be dialyzed tom'row and saturday to remove 4+ l in total.

gi-  abd soft/sl. distended.  sm. smearing of stool this am.  mushroom cath d/c'd d/t low volume of output.  reglan d/c'd d/t possible drug adverse reaction (fever) with consideration that pt. had 1100cc of stool out yesterday and already 300 today.  tf advanced to 20cc/hr and appears to be tolerating.  would consider increasing to 30 this evening.  tpn conts.  need to send next stool for c.diff- toxin b. ? colitis on ct scan.

gu-  minimal urine out.  hd tom'row and saturday as mentioned.

id-  fever w/u persists, all recent culture data negative to date, negative abd ct scan from yesterday.  id following.  restarted zosyn and vanco dosed by level yesterday (31.7 today).  lactate 1.5.

[**name (ni) 4**]  father in today and updated by nursing and sub-i.  would like to speak with cardiology about recent findings before he returns to [**country 8754**] on the 20th.  dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] emailed about this request and should meet with him tom'row.  sw and cm working closely with pt's father to find placement in home country.  father is staying at [**doctor first name 8762**] apt. in [**location 8763**] and is using public transit system- appears comfortable with accomodations.
"
5045,"admission note:

pt is a 83 yo healthy female admitted to [**hospital1 95**] with an embolic r stroke. pt was performing daily stretches this early am, felt weak and heavy on her left side, pt called her daughter then called ems, sent to er code stroke at 0945, ct scan showed embolic stroke to punctate areas of r parietal and frontal lobes (per er). tpa administered in er, focal sz activity noted in lle, mri obtained during sz activity, eeg leads placed after mri, 1 mg of ativan given---> resolution of focal sz activity, arrive in the tsicu at 1400.

neuro: alert and oriented to person place time and situation, slow to respond at times, l sided hemiparesis versus ataxia improving each hour, decreased l sided coordination and proprioception initially, decreasing l pronator drift, resolving l ptosis and facial droop, eom intact, no visual field deficits noted, impaierd sensation to light touch on l side but not deep pressure and pain, improving motor activity on l side in both ue and le, perrla 4mm, impaired cognition with simple addition and subtraction, clear speech.

cv: nsr, blp 120-160 systolic, goal bp between 110-180 systolic, easily palp pedal pulses on r, weak palp pedal pulses on l, afebrile, pneumoboot on, on anticoag for 24 hrs s/p tpa infusion, given 2 l ns bolus in er due to bradycardia during phenytoin administration, phuenytoin d/c'd.

resp: 98% o2 saturation on ra, blscta, on cough, + nasal congestion, nl rr and depth.

gi: last bm this am, active bs, soft abdomen.

gu: foley placed, adequate urine output > 100 cc per hour, on d5w with 150 meq of bicarb for 450 ml then ns at 100, labs sent for updated lytes.

endo: closely monitor bs q 2 hrs for elevated bs, 3 units og req insulin administrated for bs of 150.

skin: cdi with varicose veins.

id: afebrile, no wbc count.

assessment: s/p tpa admin for embolic stroke.

plan: monitor ns q 1 hour, maintain blood pressure 110-180 systolic, monitor bs frequently while on d5w, nursing treatments as indicated, watch for adverse reactions to tpa, cont to monitro and assess as ordered.



"
5046,"neuro: pt sedated with propofol 10 mcg/kg/min and haldol scheduled dose and prn. given 1 prn dose at 0330 for anxiety. any form of stimulus causes increased agitation. ? how much sleep pt has gotten as he moves around in the bed, appears uncomfortable  but denies pain. pt is more alert this morning. he wanted to watch tv, given tv control but has not used it to change the channel yet.

resp: cpap w/ps 12 peep 5 40%.. lungs clear but dim in the bases. sats 95-100%. abg's this am 7.44/53/92.

c/v: hr 80's to 90's with pvc's occasionally. map 60's to 80's but now lower with additional haldol. does require an occasional bolus of propofol of [**1-31**] ml.

gu/gi: foley patent, draining large amts pale yellow urine after 2 doses of lasix 40mg. abd is soft, distended. surgery in to consult on pt for a ?acute abd. pt was thought to be slightly uncomfortable with left abd palpation. pt is making urine and stool and his vs have been mostly stable, without indication of pain. they will be back to round on him in the am. tube feed infusing at goal. fecal incontinance bag in place with no additional stool noted.

social: daughter called last evening. she wanted to know how her father made it through his blood transfusions. she thought the pt was having an adverse reaction with the first xfusion.  assured her that pt was not having any problems, that he was pre medicated with benedryl and was also given lasix between the two units.

plan: labs drawn. repleat as necessary. surgery will round in the am. continue free h2o boluses until na+ under control. haldol when pt anxious and less propofol as pt shows less anxiety. pt is full code.


"
5047,"msicu npn 0700-1400
 a&o x3. more alert this am. states bed (1st step) has made a big difference in comfort level. plan was to try to give her pain meds atc. in a.m. we started with 2 tabs of darvocet and 4 mg dilaudid po but she was very sleepy all morning. for next dose, in ? 6hrs, we plan to decrease dilaudid to 2mg and depending on pain level and alertness, decrease darvocet to 1 tab. ketamine has been weaned off with no increase in pain at this time.
 given 1st dose of xeloda. had sm amt of emesis 2hrs post dose but no other adverse reactions noted. treated with 0.5 mg iv ativan with relief.
 uo ~30cc/hr. she remains very volume overloaded for los. currently recieving d5.45ns at 50cc/hr. her po intake is very poor and she can't take most of her oral medication. nutrition to consult for ?[** 1466**]. she does not have a clean line for tpn.
 afebrile.
 family very supportive and in most of day. aware of transfer to medical floor.
"
5048,"resp: [**name (ni) 97**] pt on psv 8/5/50%. bs reveal noted aeration. mdi's administered q4 hrs alb/atr with no adverse reactions. abg 7.46/35/91/26 on 40% fio2. rsbi=63, cuff check and adequate leak noted. continue to wean appropriately.
"
5049,"nsicu npn 0700-1500
see carevue for subjective/objective data.  neuro:  pupils 2mm, sluggish most of shift however at 1430 pupils 3mm, brisk.  does move all extremities on bed when propofol lightened, does withdraw to pain. purposeful movement-->consistently lifts left hand toward ett when un-
restrained.  icp drain in place, icp 12-22, drng blood tinged sec 11-24ml/hr.  spec obtained by md and sent to lab.  poor waveform--md aware.  icp flushed by md with minimal improvement in waveform.  +gag, +cough, +corneals.  dsg-->icp drain d+i.  one suture on icp drain out; again, md aware (not new).  to ct at 0800 for ct of head; results pending.

cv/pulm:  initially on neo--gradually weaned, turned to off at 1400 with bp 120's.  goal is to keep bp 120's-140's.  ekg done.  started on sq heparin.  hct=25; one unit prbc's hung at 1430 with no adverse reactions thus far.  mp=nsr, no vea noted.  maintenance iv kvo'd while prbc's infusing.  remains vented on ac10x600x50%x5peep.  peep was 10, decreased to 5, abg's pending.  suct for mod amts thick yel sec via ett and thick clear orally.  bs coarse bil.  no other vent changes made this shift.  ett rotated to l side mouth, [**name8 (md) 76**] md pulled back to 21cm lip line.  no rpt cxr done.

gi/gu:  ogt-->lcs drng 75ml coffee ground material.  tf started at 1430 fs promote with fiber at 10ml/hr.  goal=60ml/hr.  no bm, +flatus. hypoactive bs.  u/o qs q1h via foley.

integ:  no open areas noted.  changed to air mattress with 5assists tol well.  turned s/s but consistently left in supine position.

id:  tmax=100.1 po.  no change in abx.

psychosocial:  fam in to visit.  emotional support given to pt and fam.  per fam they will return this pm to visit again.
"
5050,"resp: [**name (ni) 97**] pt on [**last name (un) **] psv 12/+5/40%. ambu/syringe @ hob.  bs auscultated reveal bilateral coarse sounds which clear with suctioning.  suctioned x3 small to moderate thick yellow secretions.  pt is able to self suction oral cavity.  mdi's administered alb/atr with no adverse reactions.  02 sats remain between 98-100%, maintaining adequate tv during the noc @ 350-400. pt does continue to have periods of apnea during noc, but in no distress.  no [**name6 (md) 239**] performed rn suggests let pt rest.  will advise day therpist to perform when pt is more awake.  no further changes noted.
"
5051,"npn 1900-0700:

events: pt has required low-dose levo for bp management. crrt/uf resumed without complication.

ros:
neuro: pt remains on fentanyl 150mcg/hr and versed 1mg/hr with good effect. she is generally comfortable at rest and requires [** **] for turning. moving l arm only, weakly and without purpose. perrl, sluggish. did not appear to respond to her son.
resp: [**name2 (ni) **] vent changes made; most recent abg 7.33/43/121 on cmv .4/550/14/5. minimal thick tan, [**name2 (ni) **] blood-tinged secretions. although she has minimal secretions, her pp's increase significantly when she needs to be suctioned at all. ls: e wheezes, diminished lower. sats consistently 99-100%.
c-v: hypotensive at start of shift, requiring initiation of low-dose levo, which she has remained on. hr mostly 70's-90's, afib, with [**name2 (ni) **] pvc's. during the evening she had period of time during which she had intermittent slowing of hr with different-appearing qrs complex, representing a different conduction pathway. beats were well-perfused, with no significant drop in bp. she has been in her usual rhythm for the past several hours. ck's 218. 280, mb flat. troponin slightly elevated at .09, but pt has renal failure. cvp 20-21; lytes wnl.
gi: tf's continue at goal; belly obese but benign, no significant stool past several days.
gu: ampho bladder irrigation changed to continuous infusion; uo difficult to measure exactly, but seems to be running 10-30cc/hr. crrt/uf resumed at 0030, with current goal of -100cc/hr, which we are meeting without difficulty. please note that fluid balance on flow sheet is off by ~42cc/hr d/t ampho irrigant not accounted for in intake. ca gtt per sliding scale. bun/creat stable at 71/1.6.
id: afebrile, no need for bair hugger. wbc up to 18.8 (15.4). single dose of vanco given over 4 hours after pre-medication with benadryl. dose was well-tolerated with no evidence of adverse reaction.
heme: ptt therapeutic at 49.1; plt's wnl, hct stable at 30.3. no evidence of further bleeding.
endo: insulin gtt titrated prn.
skin: skin folds under breasts and in groin remain cracked/bleeding slightly. areas cleaned gently, double [**last name (un) **] and gauze applied. coccyx/perianal areas unchanged. upper l thigh blistering and draining now. l breast erythematous; both lower legs more red and blistering. ? if she has cellulitis in legs and breast.
access: r ij hd cath, r radial a-line, l sc mlc.
social: son [**name (ni) **] in to visit; he was updated on events of the day.

a: more stable night; tolerating crrt/uf once again.

p: current plan is to continue to remove fluid with goal of 3-4l/day off. would favor supporting bp as needed to facilitate this goal, as it appears to be about the only thing we can offer that might make a difference. per renal notes, plan to reassess when we have removed ~25kg (pt is ~55l positive for los, though this is improved from 59l a couple of days ago). otherwise, continue current management, ensuring pt comfort as a primary goal.
"
5052,"7a-7p
neuro: pt a+ox3,mae,perrla. dilaudid sc 2mg for pain.

cv: hr 80-100s sr no ectopy. sbp labile, on and off neo throughout day, see carevue for details. received one unit of prbcs, no adverse reactions. received lasix 20mg ivp after transfusion. +palpable pulses. generalized edema. at present to keep map >60, [**name8 (md) 9**] md [**last name (titles) 822**].

resp: ls wheezing throughout, audible at times especially w/ exertion. nebs q4 hours as scheduled. sats >97% on 4lnc.

gi/gu: abd soft,+bs,+flatus per pt. foley draining adequate amts of yellow urine-> light yellow after iv lasix.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. keep in unit overnoc, ? transfer to floor if remains off neo.
"
5053,"ccu nursing note 0700-1900

s/p r groin av fistual repair under conscious sedation; return to ccu @ 1130

neuro: pt neurologically intact, ao x3, speech clear, maew with equal strength, follows commands, denies pain, lightheadedness, sob or cp.  bedrest till 5 pm today.

cv: hr 60-80s nsr with rare pvcs.  sbp 120-140 map > 60.  new peripheral iv 18g placed in l fa by or staff.  no ivf ordered. old r ac iv dc'd with cathereting intact; drsg [**name5 (ptitle) **].  hct 24.3 this am; 1 unit rbc ordered and transfused; no adverse reactions noted.  repeat hct 27.3.  peripheral pulses palpable. r groin ecchymotic, or drsg [**name5 (ptitle) 819**].  l groin drsg [**name5 (ptitle) 819**].

pulm:  received pt from or on facemask.  o2 weaned to off; spo2 94%; resps even and unlabored; no acute distress noted.  lungs clear bilaterally. no cough.

gi:  pt tolerating ice chips without difficulty. abdomen benign; bs present.

gu: voids clear yellow urine per bedpan.

skin:  skin grossly intact; no breakdown noted;

social:  numerous family members have telephone and spoken with the patient following the procedures.  all family members updated on pt status and plan of care.

plan: transfer to floor today (?[**hospital ward name **] 9) and d/c home tomorrow.
"
5054,"pt update:

neuro: pt sedated. arouses to voice. mae on the bed. withdraws to painful stimuli. propofol weaned once precedex started @1300, and pt at comfortable level of sedation. pupils 3mm and reactive bilaterally. pt denies pain. ivig started @ 1400. no adverse reactions. rate advanced to 240cc/hr.

cv: hr 70-90s. nsr. no ectopy. sbp hypertensive in 190-200's in am. sbp max 210 @ 1200. treated with 10mg lasix and 15mg total hydralzine. htn continued until precedex given @ 0.7mcg/kg/hr. sbp came down to 120-140s where it remained through out rest of shift. ppp.

resp: attempt at ac early in shift. failed due to level of wob and increasing hr and bp. pt put back on cpap c/ ps. fio2 40, 5 and 5, 785 at 19. ls coarse with slight i/e wheeze. sxn'd for thick tan secretions.

gi: tf @ 20 via og tube. +bs. no bm.

gu: foley draining adequate amounts clear, yellow urine.

endo: iss.

plan: monitor for sbp htn. monitor infusion of ivig for fever, signs of adverse effect, etc.
"
5055,"0700-1900 npn
see carevue for subjective/objective data.
neuro:  remains sedated with fentanyl at 15mcg/hr and versed at 1mg/hr.  spontaneous movement of arms noted, no movements of legs noted.  no attempts to speak or communicate; does not open eyes.

cv/pulm:  mp=afib, isolated pvc noted.  remained on vasopressin until 1530 when vasopressin off.  remained off until 1700 when bp dropping  to 68/41, remainins 68-72/42.  vasopressin restarted, dr. [**first name (stitle) **] notified.  prbc' infusing at this time; will re-try to dc vasopressin once prbc's have infused.  prbc's infusing without evidence of adverse reactions thus far.  l tlc, l a-line unchanged.  remains vented on ps was on [**4-5**] until traveled to ct scan then placed on a rate for ct.  upon return placed back on [**4-5**] but pt not tolerating [**4-5**], rr increased to 40's-->placed on [**11-5**] with rr improved to 20's.  bs coarse, diminished bil.  ct of chest and abdomen done; results pending.

gi/gu:  abd soft, non-tender, bowel sounds hypoactive.  tol tf at goal rate of 60ml/hr via ogt.  tol baricat pre-ct; now stooling liquid golden stool via mushroom catheter and occasionally oozing around mushroom.  u/o 20-40ml/hr.

id/endo/integ:  afebrile.  sliding scale coverage for fingersticks.  skin continues to weep requiring soft-sorb changes q2h-->arms, legs, back and buttocks.  multiple open areas noted, multiple skin tears noted--see carevue.

psychosocial/plan:  fam in to visit.  no decisions made by family re: re-intubation of pt if she is extubated.  encouraged fam to make these decisions at this time/prior to extubation planned for am.  emotional support given to pt and fam.  plan is [**month/day (1) **]'d vent support, npo after mn for ? extubation in am.  complete prbc's and re-check hct.  monitor vs, i+o, breath sounds.  [**month/day (1) **] with q2h skin care, current nursing/medical regime.  pt is dnr at this time.
"
5056,"2200-0700

received pt from [**hospital ward name 54**] 7 for meropenem desensitization. pt has bc x2 with gram negative rods and requiring meropenem for iv abx coverage.  pt awake, alert, orientedx3. follows commands well. moves upper ext well, lower ext bka bilaterally. speech clear and pt appropriate. no confusion noted. no neuro deficits.

resp: resp easy and regular without difficulty. no sob noted. o2 sat remain stable. lungs clear/diminished at the bases bilaterally.

cv:nsr without ectopy noted. hr 70-80s, sbp 130-150, low grade temps noted. denies pain at this time. meropenem desensitization started at 0245am. pt tolerating well. no adverse reactions. piv x1 to larm 20g intact.

gi/gu: pt on [**doctor first name 602**] diet. abd flat soft + bs, no bm noted. denies nausea. [**name (ni) **] pt. r arm av fistula not yet matured for use, +thrill/bruit. pt last received hd [**12-4**].

endo: riss.

plan: pt to finish meropenem desensitization and transfer back to [**wardname 1699**]-bed being held for pt.
"
5057,"respiratory care note:
     patient remains trached with a #8.0 portex and on full vent support.  no changes have been made this shift.  bs are coarse throughout.  sx for small amounts of tan thick secretions via trach.  no rsbi this am due to fio2 of 60%.  patient remained afebrile.  mdi's administered as ordered, including 300mg of tobramycin at ~0200.  no adverse reactions noted.  spo2 remains 95-98%.  plan is to continue with current course of therapy.
"
5058,"npn
pt recieved from the er s/p 2 week history of headache, nausea, vomiting found [**5-29**] at home by friend lethargic. pt's daughter called by pt's friend and decided to call 911. pt taken to [**hospital 4223**] [**hospital 506**] hospital where a cxr and cat scan showed lung mass (l upper chest opacity) and ct head with l frontal mass with 5mml to r shift and hemnmorhagic l cerebellar mass causing tonsillar herniation. pt medflighted to [**hospital1 3**] for further eval/rx.
neuro deficit/pt disoriented to year will often respond ""[**2161**]"".
otherwise perrla 3mm each, mae with equal strength, no hand drift noted. tongue midline, smile symmetrical, no seizure activity. neuro sx = headache initially [**7-1**]. mri with and w/o contrast done. loading dose of dilantin 1000mg ordered in ew was given in icu. pt states allergy to steroids is increased hr, decadron given in ew without any adverse reaction and repeated x 1 in icu per dr [**last name (stitle) **]. pharmacy aware.
pain/as above [**7-1**] generalized h/a treated with dilaudid 0.5 mg ivp which decreased h/a pain to 3 then down to 1.
fluid deficit/pt c/o being thirsty, urine concentrated yellow, oral mucosa dry. pt recieved ns with kcl 40 meq at 250 cc/hr in the ew (1 liter). then iv changed to d5ns with 20meq kcl at 80ml/hr. pt is npo with exception of taking meds.
hypokalemic/k repleted in the ew as added to main iv for k 3.1. serum k level pending.
o2 sat 93%. at 12mn pt's o2 sat was 93% added 02 at 3lnp and sats improved to 97-98%.
icu prophylactics/h2blocker started, compression boots applied, sc heparin started.
psychosocial/pt,s sister [**name (ni) 2168**] in to see pt and with pt signed on as [**hospital **] healthcare proxy, form in chart. [**name (ni) 29**] brother has his phd and works with oncology research. pt has 2 young adult children who were in to visit. pt's family very concerned with recent developments in pt's health and decided to stay in hotel in [**location (un) 496**]. pt has hx of bipolar disease, anxiety disorder and depression. see [**month (only) **] for psych meds. pt is pleasant, calm and cooperative. she did ask for her xanax but neurosurg resident dr [**last name (stitle) **] did not want pt to take xanax. pain med as documented above has made pt comfortable and no further c/o anxiety after pain med given.
plan:nvs q1hr, notify neurosurg with changes.
emotional support for pt and her family.
monitor serum k's and replete as needed.
needs social work consult.


"
5059,"11p-0700
pt admitted from or at 2145 [**2186-8-24**], ( s/p aicd/ddd permanent pacer placed [**2186-8-24**] am, hypotension while on floor, back to or). see admission history for details.

neuro: pt sedated first on propofol, propofol weaned off and fentanyl 50mcg/hr and versed 1mg/hr gtts started d/t hypotension 88-90s/. opens eyes on verbal command, moves extremeties with hands on care, hx of right arm w/ steel rod placement. perrla. no facial grimacing noted.

cv: ddd permanent pacer hr 80-120s (120s while dopamine infusing). v paced, varying w/ own intrinsic and a paced beats. dopamine changed, secondary to hr, to neo gtt for sbp 90-100s. labile bp. goal 90-100s sbp. see carevue for details. cvp 5-8. + palpable pedal pulses. received 1 unit of prbcs, no adverse reactions. post hct 27. hct from ct 17.2, pa [**doctor last name 739**] aware. trauma line to left groin bleeding when received from or, pa [**doctor last name 739**] at bedside, stitched, no further bleeding. k repleted, order to replete k <4.0.

resp:ls clear. orally intubated, suctioned for scant blood tinged. sats >96% on fio2 40% rte 14 simv, see carevue for details.  left ct intact, no air leak, no crepitus, draining sang. minimal amts, see carevue.

gi/gu: abd soft, +bs. ogt + placement to intermittent wall suction, scant amt of blood via ogt after suctioning pt, pa [**name (ni) 739**] aware, no new orders at present. once bp stabilized, lasix 40mg ivp given. foley draining clear yellow urine adequate amts. see carevue.

endo: insulin gtt started for fs 150s, see carevue.

social: no contact from family this shift.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean vent as pt tolerates. monitor ct drainage. keep pt comfortable.
"
5060,"resp: [**name (ni) 516**] pt on psv 8/5/25%. pt has #8 portex. bs are coarse with decrease in aeration on ls. mucomyst/alb instilled as well as mdi's administered alb/atr with no adverse reactions. some green secretions oozing around trach site. bs reveal end exp. wheezing following administration of mucomyst. suctioned for small amounts of thick white/yellow secretions. episode of desaturation with ^ in ps & peep. weaned back to present settings in am. 02 sats @ 97% with adequate tv's. plan continue wean and attempt t/c trials if tolerates.
"
5061,"11p-7a
neuro: pt alert and oriented, mae, follows commands, perrla. medicated w/ toradol, tylenol po, and dilaudid 0.25mg ivp prn for c/o incisional pain.

cv: apacing most of shift, d/t sbp 80s w/ intrinsic rate of 60s. hr at present 65 sr, no ectopy, sbp 96/44 w/neo gtt at 1.25mcg/kg/min. [**md number(3) 2282**]/10s, cvp 5-8, ci > 2 by thermodilution. epicardial wires attached and intact, see carevue. right radial aline dampened, going by femoral aline for bp readings. received 1 unit of prbcs for hct 25 as ordered,no adverse reactions, repeat hct 30. +palpable pulses.

resp: ls clear diminished. sats >94% on 2lnc. rr wnl. encouraged coughing and deep breathing.

gi/gu: abd soft, hypoactive bs. foley draining adequate amts of clear light yellow urine, see carevue.

endo: received pt w/ fs 48, 1/2amp of d50 given iv. gtt restarted for fs>200, see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean neo as pt tolerates. follow intake and output, treat as appropriate.
"
5062,"npn 7a-7p
events: pt was acutely agitated and combative this am. pt climbing oob and swinging fists at this rn. pt was unable to re-orient and calm down. dr. [**last name (stitle) 3215**] to bedside. pt medicated with 2.5mg iv haldol with good effect. pt nnoted to have ?able previous reaction to haldol, but family does not know what this reaction was. there was no adverse reaction today when this dose was given and it actuallly had a good effect. later this afternoon pt appeared to be more wheezy and with labored breaths. abg wnl, atrovent nebs given w/o effect. pt given 10mg iv lasix with good effect.

neuro: pt has slept in naps since this mornings events, but remains only oriented to person and his family. when told that he is the hospital he states ""i know"". no c/o pain. pt remains in bilateral soft wrist restraints for safety.

cv: dilt gtt weaned off. hr 60s-80s in afib. bp 100s-130s/60s-80s. pt has difficult to palpate pulses. pt on standing po loressor.

resp: sats> 96% on 4.0l nc. abg wnl. ls with exp wheezes in bilateral upper lobes, crackles over right base. pt on standing nebs. rr 16-20s.

gi/gu: abd is softly distended, +bs. pt is ordered heart healthy diet, but has refused all meals today. pt takes his pills well. u/o adequate, foley draining clear yellow urine.

skin: rue more swollen than left with small bruised area below armpit. dr. [**last name (stitle) 3216**] made aware and will cont to monitor. r arm elevated with pillows.

id: pt has been afebrile. pt covered on ceftaz and vacno, also tamiflu.

social: [**name (ni) 4**] wife and three daughters int to visit today and updated by dr [**last name (stitle) 3216**] and this rn.

plan: cont to monitor resp status, prn lasix/nebs.
      monitor ms, prn haldol for acute confusion and pt now on standing olanzapine at night.


"
5063,"resp: [**name (ni) 516**] pt on a/c 20/500/+5/50%. bs are coarse to clear and suctioning for small amounts of thick tan secretions. mdi's administered alb/atr with no adverse reactions. am abg 7.34/38/187/21. rsbi=30. weaned to psv 10/5/50% tolerating well with adequate tv's/ve's. cvvhd discontinued. plan: continue to wean as tolerated.
"
5064,"cvs;hr 80-100 a-fib no ectopy abp 100-120/40-70 on vasopressin 1.2 u/hr anasarca pedal pulses are doppled,extrimities are warm,left toes are dusky.hct 27.5 @ 2100 one unit prbc transfused without any any adverse reactions.for access a-line and pa line remains intact.recieving regular dose of albumin q6h.

neuro;sedated with fentanyl 50 mcg/hr,pt is comfortable,nodding head and appropriate with answering.not moving extrimities.

resp;recieved on cmv 40/400/20/5 no vent changes over night,saturation probe is not sensing well frequent abg was done to confirm o2 sats,po2 >130.ls are coarse throughout,required occasional suction for thin whitish secretions.

gi;abdominal dressing was done by surgen yesterday with jp in place,connected to wall suction draining serous drain please carevue for details,getting tpn for nutrition.no bowel movement at this shift.

gu;draining adequate amounts of amber color urine via foley catheter.

skin;anasarca,multiple skin breakdown and oozing from extrimities.sacral dressing intact,positioned and back care given as needed.lower extrimities are warm positive pedal pulses.

id;core temperature 38.2,on antibiotics vanco/flagyl/levaquin

social;no contact from family at this shift.

plan;abdominal wound closure--add on, consent taken over phone by surgen and filed.
type and screen send yesterday
pain management,monitor lytes,replete lytes as needed
continue albumin
update with pt and family.
"
5065,"resp: [**name (ni) 516**] pt on psv 5/5/50%. pt has #7 portex trach. bs are coarse to clear and suctioning for small to moderate amounts of thick yellow/tan secretions. mdi's administered as ordered alb/atr with no adverse reactions. 02 sats maintained @ 98% with adequate tv's. rsbi=20. plan: continue wean/sbt with possible t/c trials.
"
5066,"npn 7p-7a (please also see carevue flownotes for objective data)

dx: neutropenia; fuo

49f admitted for neutropenia, fevers; pt went to clinic, received injection, initally felt her s/s were adverse reaction (per family...);
pt became hypotensive, started on levophed; started on several iv abx, required several electrolyte iv replacements; also received 1 unit prbc's;

at approx 12a, went to ct for abd/chest, drank bari-cat w/out difficulty; at end of ct pt c/o not being able to breath; icu resident paged to come down, also to bring lasix; pt returned to [**wardname **]4 w/out event; continued develop resp distress w/ audible rales, lasix/morphine/ativan received, pt finally became more comfortable w/ respirations, especially after mask ventilation applied;

pt received bedside u/s at approx 04:00, team looking to see if pt had perf'd gallbladder, found to be intact; (at approx. c/w md stated pt had pna and untreated strip recently; [**8-4**] bld cx's grew [**4-19**] bacteria in chains:)

team/ w. c/s input decided since pt's lactate now 3+, up from 1+ in er, that pt needed vigorous fluid resucuitation, and that pt would need to be intubated to prevent pulm edema/resp distress;

pt intubated at approx 05:00, started on versed/fent gtt for sedation, started on [**2-/2095**], not adequate, as of 07:00, on [**3-/2110**];
iv hydration restarted; a-line attemped left wrist, not accessed;

plan:
1) iv abx as ordered (likely to be consolidated at rounds)
2) iv hydration
3) update family prn
4) levophed to maintain b/p
5) pt states we can give information to her mother, as well as husband
"
5067,"npn:


2. infant remains on nco2 200cc flow, 30% fio2. rrs-40s-60s.
ls clear and equal, ic/sc rtxns noted upon exam. infant
remains on [** **] as ordered, no spells thus far. cont
towean fio2 as tolerated.

3. wgt-2070g, up 20g. tf remain @ 150cc/kg/d of bm30 with
promod. infant tolerating ng feeds well over 1hr. no attempt
to po feed made. abd benign, no spits, min aspirates. vdg
and stooling adaquate amts, stool heme neg. cont to monitor
wgt gain and feeding tolerance.

4. [**known lastname **] remains swaddled in an oac, temps remain stable.
alert and active with cares. bringing hands to face,
fontanels remain soft and flat. hep b vaccine administered
to infant this pm, no adverse reactions noted. consent
prsent in chart. cont to [**doctor last name 730**] dev needs.

5. mom and [**name (ni) 3809**] in tonight, updated @ bedside on infants
condition. mom independently participating in cares, held
infant x 1hr. asking appropriate questions. cont to update
and educate as needed.


"
5068,"respiratory care note
pt remains on imv 23/6 x 18 .40-.55.  bbs coarse w/crackles and positional leak around the tube.  sx'd for mod amt of cloudy thick white secretions.  1pm [** **] held due to tachycardia, given at 5pm.  pt started on dornase alpha (pulmozyme via minineb) 1.25mg [**hospital1 **], given at 5pm, well tolerated w/no adverse reaction.  oral ett resecured ~8.5 @ lip. 5pm cbg (drawn prior to [**hospital1 **]/neb):  7.38/62/25/38/+7, no [**hospital1 **] changes made.  continues on caffeine.  occ [**hospital1 182**], usually self resolved.  comfortable rr 35-50s.  nard.  will continue to follow and wean as tolerated.
                                  [**first name4 (namepattern1) 2693**] [**last name (namepattern1) 2694**], rrt
"
5069,"npn 1900-0700


resp:  infant in nasal [**doctor last name **] cpap 5, fio2 37-49%.  ls
clear/=, mild sc retractions.  rr 20-40s.  sxn'd mouth x1
for moderate amt clear secretions.  occ drifts, no spells
thus far this shift.  pt on iv [**doctor last name 775**] [**hospital1 **].  continue to
monitor.

fen:  cw 2185g (up 85g).  pt remains npo.  tf 130cc/k/day.
picc l ac patent and infusing pn d10 + il.  piv r hand
hep-locked.  repogle to cont lws.  4.2cc clear secretions
aspirated at 2100; discarded.  tube irrigated with 2cc
sterile h20 (asp entire volume back).  suction canister
changed at 2100 due to not maintaining proper suction.
repogle now appears to be draining secretions adequately.
abd soft, [**hospital1 **], round.  no loops, active bs.  ag stable,
27cm.  8hr uo= 3.0cc/k/hr, no stool thus far this shift, pt
is passing gas.  surgery fellow from tch in to consult.  no
plans for repeat kub as yet.  2 aloquots prbcs transfused
overnoc (20cc/k) for hct of 28.4.  consent present in chart.
 tolerated transfusion well, no adverse reactions.

par:  dad called x1 thus far this shift.  updated by this
rn.  asking [**hospital1 **] questions.  provided much support by this
rn.  continue to update and support as needed.

dev:  temps remain boarderline low; 97.8ax swaddled with
t-shirt, 2top blankets, hat.  [**hospital1 1**] aware.  a/a, irritable
with cares.  settles well with sucrose pacifier.  slept well
tonight in btwn cares.  moves hands to face.  [**last name (lf) 383**], [**first name3 (lf) 57**].

sepsis:  pt now day 3 of 14 with abx clinda and zosyn.  meds
admin as ordered.  temps boarderline low, will monitor
closely.  bc negative.  stool cultures: fecal culture
negative, campylobacter culture negative, prelim results of
viral culture negative.  will monitor for s/s sepsis
closely.


"
5070,"nicu nursing note 7p-7a


2.resp= o/remains intubated on hfov map 9, amp 15.  fio2
30-38%.  bscoarse, diminished bilaterally.  occas drifts in
o2sats to low- mid 80's. sxn'd small cloudy secretions via
ett.  orally sxn'd for mod thick cloudy secretions.  cbg
obtained 7.25, 44, 35, 20, -8.  no changes made.  cont on
vit a.  a/stable on hfov with current settings.  p/cont to
monitor for resp distress.

3.fen= o/bw= 717g current wgt= 711g (+34).  cont on tf=
160cc/kg/d.  enteral feeds @ 70cc/kg/d of bm 20 gavaged q3h
over 30min.  ivf @ 90cc/kg/d of pnd12 + lipids via central
picc in rarm.  received prbs via lfootpiv, infused without
difficulty.  no adverse reaction noted. abd benign, soft.
no loops.  + bowel sounds.  ag= stable.  uo= 4.8cc/kg/h x
12h.  having liquid yellow stools, heme(-).  a/tol feeds.
p/cont to monitor fen status.  plan to check lytes in with
next cares.

4.g&d= o/temp stable nested in servo isolette.  alert and
active. maew. afof.  a/aga. p/cont to support g&d needs.

5.[** **]= o/mom and dad visited for 2100 cares.  updated by
this rn and [** 7**].  p/cont to support and educate.


"
5071,"nursing progress note


#1. o: infant remains on hifi ventalation on unchanged
settings of map 7, delta p 14. fio2 overnight has been
29-32%. brief o2 sat drifts noted overnight. no bradycardia
noted thus far. ett suctioned for sm/mod white. breath
sounds are coarse and equal. ic/sc retractions noted. cbg
7.25-50-44-23--5. no changes made. last dose of indocin
given tonight.  a: stable on current settings. p: continue
to monitor resp status.

#2. o: infant transfused 2nd aloquot of 20cc/k transfusion
of prbc's tonight. no adverse reactions noted. last dose of
indocin given. no murmur heard tonight. infant [** 211**] and well
perfused. bp stable. a: s/p transfusion and indocin
treatment. p: continue to monitor cv status.

#4. o: infant remains on tf's of 150cc/k/d of d6.5pn and
il's infusing well via dluvc line. infant npo. abd soft and
flat with active bowel sounds. no loops. no meconium thus
far. infant voiding 3.8cc/k/hr today. d/s 219-226. wgt is up
41gms tonight to 450gms. a: npo. p: continue to monitor fen
status. check elec's on sunday morning.

#5. o: infant remains in heated isolette with stable temp.
he is alert and active with cares. maew. sucking on fingers
intermittently. a: aga. p: continue to assess and support
developmental needs.

#6. o: mom called x1 for brief update. apologized for not
showing up at 1600. she stated she will be in today. a:
involved mother. p: continue to inform and support.

#8. o: infant remains under single phototherapy. eye shieds
in place. a: hyperbili. p: continue to inform and support.


"
5072,"npn 1900-0700


resp:  infant remains on conv [** **] settings 18/5, r 18.  abg
2200: 7.23/46/105/20/-8; no changes made.  fio2 27-35%, incr
with cares.  ls coarse, sxn'd q3-4h thick cloudy secretions
via ett, small po and nares.  no bradys thus far this shift.
 caffeine held tonight for tachycardia.  pt continues on vit
a.  continue to monitor.

fen:  cw 852g (up 92g).  feeds restarted at 0100 at
100cc/k/day pe24.  picc infusing d10 ns + 0.5u hep/cc at
1.5cc/hr.  no spits, min asp.  abd full, soft.  ag noted to
be incr at 2200 (20.5cm with soft loops).  [** 41**] aware.  ag
now back to baseline at 18cm without loops.  uo improving.
8hr uo= 9.2cc/k/hr.  no stool thus far this shift.  lytes
sent 2200: 123/5.1/96/18.  na improving (up from 118 on
days).  lytes to be resent at 0500.  ds= 89.

par:  mom called x2 thus far this shift and in to visit with
dad at 2300.  updated at bedside by this rn, [** 41**] [**doctor last name **], and
md [**last name (titles) **].   mom expressed her concerns to this rn.  very
emotional and worried about her daughter.  much support
provided.  anxious to hear hus results this am.  continue to
support and update as needed.

dev:  temps stable while nested in servo isolette.  a/a with
cares, irritable at times btwn.  settles with hand
containment and pacifier.  moves hands to face.  anterior
font appears slightly full.  [**last name (titles) 41**] aware.  hus to be done in
am.  continue to monitor.

cv:  loud murmur auscultated.  pt tachycardic this shift,
170-190s (occ to 200s).  team aware.  caffeine therefore
held at 2100.  bp means stable (37-56).  most recent cuff
74/44 (56).  pt transfused 2nd aloquot (8cc) prbcs at 2330
over 4hrs.  consent signed in chart.  no adverse reactions
noted.  post-hct to be sent later today.  continue to
monitor cv status.


"
5073,"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**]

"
5074,"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**]"
5075,"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**]"
5076,"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**]
"
5077,"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.



"
5078,"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



"
5079,"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**]

"
5080,"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**]



"
5081,"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**]"
5082,"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**]"
5083,"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**]



"
5084,"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**]"
5085,"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**]"
5086,"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**]
"
5087,"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



"
5088,"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**]
"
5089,"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**]

"
5090,"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**]

"
5091,"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.



"
5092,"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



"
5093,"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**]"
5094,"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**]"
5095,"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**]
"
5096,"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**]
"
5097,"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**]"
5098,"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**]"
5099,"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**]"
5100,"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



"
5101,"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**]

"
5102,"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**]"
5103,"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**]
"
5104,"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**]

"
5105,"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**]"
5106,"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**]"
5107,"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**]"
5108,"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.



"
5109,"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**]"
5110,"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.



"
5111,"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.



"
5112,"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**]"
5113,"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).



"
5114,"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**]"
5115,"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**]"
5116,"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**]
"
5117,"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



"
5118,"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**]"
5119,"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**]"
5120,"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**]
"
5121,"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 **].



"
5122,"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**]"
5123,"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**].



"
5124,"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**]"
5125,"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**]



"
5126,"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**]"
5127,"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**]"
5128,"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



"
5129,"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.



"
5130,"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**]"
5131,"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



"
5132,"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



"
5133,"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**]"
5134,"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**]
"
5135,"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.


"
5136,"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) **].



"
5137,"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



"
5138,"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**]"
5139,"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) **].



"
5140,"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**]"
5141,"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



"
5142,"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



"
5143,"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**]
"
5144,"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**]

"
5145,"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 **]
"
5146,"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**]
"
5147,"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



"
5148,"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**]"
5149,"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.
"
5150,"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.
"
5151,"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.
"
5152,"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**]
"
5153,"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.
"
5154,"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.
"
5155,"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.
"
5156,"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 ------
"
5157,"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:
"
5158,"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
"
5159,"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
"
5160,"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
"
5161,"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.
"
5162,"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 ------
"
5163,"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:
"
5164,"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 ------
"
5165,"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:
"
5166,"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:
"
5167,"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:
"
5168,"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:
"
5169,"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 ------
"
5170,"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:
"
5171,"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 ------
"
5172,"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:
"
5173,"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:
"
5174,"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:
"
5175,"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.
"
5176,"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 ------
"
5177,"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
"
5178,"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:
"
5179,"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:
"
5180,"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:
"
5181,"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:
"
5182,"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 ------
"
5183,"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:
"
5184,"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 ------
"
5185,"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 ------
"
5186,"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:
"
5187,"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
"
5188,"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:
"
5189,"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.
"
5190,"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:
"
5191,"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
"
5192,"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
"
5193,"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
"
5194,"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
"
5195,"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
"
5196,"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
"
5197,"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
"
5198,"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.
"
5199,"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.
"
5200,"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
"
5201,"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
"
5202,"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
"
5203,"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
"
5204,"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
"
5205,"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
"
5206,"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:
"
5207,"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:
"
5208,"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:
"
5209,"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 ------
"
5210,"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:
"
5211,"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 ------
"
5212,"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:
"
5213,"[**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.









"
5214,"[**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)

"
5215,"[**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**].


"
5216,"[**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**].


"
5217,"[**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  72 year old woman pod4 from r. colectomy for cecal mass, now with fevers,
  tachycardia, incr abd distention, tenderness
 reason for this examination:
  assess for leak, collections
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 indication:  72-year-old female with abdominal distention.

 comparisons:  comparison is made to ct of the abdomen from [**2126-11-19**] and ct
 of the abdomen from [**2126-11-14**].

 technique:  ct of the abdomen and pelvis with oral and iv contrast.  150 cc of
 optiray 350 were administered without adverse reaction.

 coronal reconstructions were performed.

 ct of the abdomen with oral and iv contrast:  there are mild atelectatic
 changes in the right base.  there are no pleural effusions.  there is a small
 hiatal hernia.  there is no pericardial effusion.  the liver is slightly
 fatty.  however, there are no focal lesions.  there are two gallstones within
 the gallbladder.  there is no evidence of cholecystitis.  the spleen, adrenal
 glands are unremarkable.  there is a small hypodense area in the mid pole of
 the right kidney that was not completely evaluated in this study.  although
 statistically, it most likely represents a simple cyst, ultrasound could be
 performed to further evaluate this.

 there is a large transverse incision in the right aspect of the abdomen. there
 is fluid and air in the subcutaneous tissues, which could be postoperative.
 however, infection cannot be excluded on the basis of the ct scan.

 the proximal small bowel loops contain contrast and are dilated.  the distal
 small bowel loops are slightly decompressed.  however, there is contrast in
 the distal small bowel loops and the appearance most likely represents an
 ileus.  there are staples in the splenic flexure of the colon from prior right
 colectomy.  there are several slightly thickened small bowel loops, however,
 this appearance could be postoperative.  there is no evidence of free air or
 fluid collections within the abdomen.

 ct of the pelvis with oral and iv contrast:  there are multiple diverticula
 within the colon without evidence of diverticulitis.  as described above, the
 same postoperative changes are present in the pelvis.  there are also multiple
 mesenteric lymph nodes that are small and do not meet ct criteria for
 pathology.  there is no significant free fluid in the pelvis.  there is a
 foley catheter within the urinary bladder, which contains air.  the rectum is
                                                             (over)

 [**2127-1-12**] 12:48 pm
 ct abdomen w/contrast; ct pelvis w/contrast                     clip # [**clip number (radiology) 37105**]
 ct 150cc nonionic contrast; ct reconstruction
 reason: r. colectomy for cecal mass, now with fevers, abdominal distention, tenderness, assess for leadk, collections
 admitting diagnosis: cecal mass/sda
 field of view: 50 contrast: optiray amt: 150cc
 ______________________________________________________________________________
                                 final report
 (cont)
 unremarkable.

 bone windows:  there are no suspicious lytic or blastic lesions.

 impression:

 1.  postoperative changes as described above.  fluid and air in subcutaneous
 tissues could be postoperative, but infection cannot be excluded by ct scan.

 2.  mildly dilated loops of small bowel likely representing ileus.

 3.  multiple small mesenteric lymph nodes as described above.  they do not
 meet ct criteria for pathology and attention at followup is recommended.

 4.  multiple gallstones.

 5.  fatty liver without focal lesions in the liver.

 6.  diverticular disease without evidence of diverticulitis.

 7.  small hypodense area in the mid pole of the right kidney was not
 completely evaluated in this study.  although statistically, it most likely
 represents a simple cyst, ultrasound could be performed to further evaluate
 this.

"
5218,"[**2100-8-24**] 11:19 am
 ct t-spine w/ contrast                                          clip # [**clip number (radiology) 31907**]
 reason: pls perform with and without contrast to r/o infection/abces
 admitting diagnosis: pancoast tumor/sda
  contrast: optiray amt: 100
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  60 year old man with t1-3 lami and removal of pancoast tumor w/ chest wall
  reconstruction.
 reason for this examination:
  pls perform with and without contrast to r/o infection/abcess include cervical
  spine c6 thru t6 s/p t1-3 lami pod#8
 no contraindications for iv contrast
 ______________________________________________________________________________
                                 final report
 study:  ct c-spine with contrast and reconstructions.

 indication:  60-year-old male with t1 through t3 laminectomy and removal of
 pancoast tumor with chest wall reconstruction.  please evaluate for infectious
 process, fever.

 comparison:  ct thoracic spine without contrast [**2100-8-17**], mri
 thoracic spine [**2100-8-4**].

 technique:  multidetector ct axially acquired images were obtained of the
 thoracic spine after the uneventful intravenous administration of contrast
 material.  multiplanar reformatted images were obtained.

 contrast:  100 cc optiray 350 is administered without adverse reaction.

 findings:  soft tissue with minimal enhancement is present within the
 postoperative bed status post right partial laminectomies from t1 through t3.
 the soft tissue findings obliterate the right paraspinal musculature, however,
 not appreciably changed since comparison study from [**8-17**].

 two new right apically oriented chest tubes are present.  an endotracheal tube
 is present in standard position approximately 5 cm from the [**month (only) 5381**].  ng tube
 courses through the mediastinum into the stomach and out of the field of view.
 a surgical drain is noted in the right mediastinum in between the azygos vein
 and right pulmonary artery.  the medial aspect of the right pleural effusion
 demonstrates a new loculated appearance (2a:51).  overall, the right
 pleural effusion is slightly larger with little change to a tiny effusion on
 the left. there is a mild increase in the degree of atelectasis on the left.

 impression:

 1.  no appreciable change in soft tissue appearance within the post-surgical
 bed. findings are difficult to distinguish between purely postoperative change
 versus superimposed infection; however, no findings specific to infection are
 detected. mri with gadolinium versus labled white blood cell nuclear medicine
 scan may be of use as necessary.

 2.  right pleural effusion is slightly larger with appearance of new medial
                                                             (over)

 [**2100-8-24**] 11:19 am
 ct t-spine w/ contrast                                          clip # [**clip number (radiology) 31907**]
 reason: pls perform with and without contrast to r/o infection/abces
 admitting diagnosis: pancoast tumor/sda
  contrast: optiray amt: 100
 ______________________________________________________________________________
                                 final report
 (cont)
 loculated component.



"
5219,"condition update:
d/a:  t max 99.9 most of day, spike to 102.6 in ct.

neuro:  pt lethargic, [**name (ni) 759**] to voice, perl, at times will attempt to answer questions, at times no verbal response.  will locate painful stimuli, and mae's minimally on bed, not to command.  denies pain.  oriented x1 only.  pt with rigors at times, tremulous however no s+s of seizure activity.

cv:  hr 70's when afebrile to 120's when febrile.  neo titrated for [**name (ni) **] map > 60, [**name (ni) **] >90.  cvp 3-17.  fluid balance mn-1630 + 1111 cc's.  scant generalized edema, + ascitic abdomen.

resp:  ls clear, diminished.  when stimulated, pt rr increases and becomes wheezy at times.  ? if administration of meropenum contributes to overall worsening picture so benadryl now given before meropenum administration and it is given over 1 hour.  no s+s of adverse reaction noted today with x2 doses of meropenum.  pt on [**name (ni) 3674**] cool mist with am abg:  7.42, 46, 134, 31, 5.

gi:  abdomen distended, ascitic.  + bs.  no bm. tube feeds @ [**name (ni) **] via post-pyloric tube stopped this morning in preparation for procedure.  ivf started.  pt to angio and then to ct scan for ct guided placement of catheter.  pt remains in ct at this time intubated, with anesthesia, radiologist, and nursing in room.

gu:  foley-bsd with clear amber urine/icteric.

sx:  [**name (ni) **] [**name (ni) 731**] was [**name (ni) **] for consents.

r:  septic, dependent on pressors, currently in ct scan for drain placement.

p:  continue to titrate neo for [**name (ni) **] > 90, map > 60.  tobramycin levels due with next dose.  continue current close monitoring and management.




"
5220,"[**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
 [**hospital 3**] medical condition:
  85 year old woman s/p colectomy for bowel ischemia, now with rigid abdomen,
  fever
 reason for this examination:
  s/p colectomy, now with rigid abdomen, fever. please do ct abd/pelvis with po
  contrast
 no contraindications for iv contrast
 ______________________________________________________________________________
 wet read: jekh mon [**2194-9-1**] 7:13 pm
  1. sbo w/ transition pt at ileostomy exit site; cause appears to be mass
  effect from herniated mesenteric fat adjacent to the ileostomy.
  2. s/p r colectomy w/ tiny locules of gas adjacent to colonic staple line -
  may be post-operative although leak cannot be excluded.
  3. small amt of complex free fluid in abdomen/pelvis - ddx includes blood or
  bowel leak contents - correlate w/ exam and hct.
 wet read version #1
 ______________________________________________________________________________
                                 final report
 history:  85-year-old female status post right partial colectomy, now with
 rigid abdomen, and fevers.

 study:  ct of the abdomen and pelvis with contrast; 130 cc of omnipaque
 intravenous contrast was administered without adverse reaction or
 complication.  coronal and sagittal reformatted images were also generated.

 comparison:  [**2194-8-18**].

 findings:

 abdomen:  the visualized lung bases demonstrate a moderate right and small
 left pleural effusion with associated atelectasis.

 the previously described hemangioma in the left lobe of the liver is not well
 visualized on the current exam given difference in the phase of the contrast
 administration.  the gallbladder is distended, but shows no hyperdense stones
 or wall edema.  the spleen is normal in size.  no peripancreatic fluid
 collections are present.  the cbd again is still prominent with minimal
 central intrahepatic biliary dilatation as well as a prominent pancreatic
 duct.  the adrenal glands are normal appearing bilaterally.  multiple
 hypodensities within both kidneys are too small to characterize but compatible
 with simple cysts.  the kidneys enhance and excrete contrast symmetrically.
 the aorta is of a normal caliber along its course with scattered areas of
 calcified atherosclerotic disease.  there is no lymphadenopathy.

 the stomach and small bowel are distended with multiple air-fluid levels all
 the way to the ileostomy exiting from the right lower quadrant of ventral
 abdominal wall.  a locule of mesenteric fat has herniated through the ventral
 abdominal wall narrowing the lumen of the ileostomy, resulting in relative
                                                             (over)

 [**2194-9-1**] 4:59 pm
 ct abd & pelvis with contrast                                   clip # [**clip number (radiology) 30171**]
 reason: s/p colectomy, now with rigid abdomen, fever. please do ct a
  contrast: omnipaque amt: 130
 ______________________________________________________________________________
                                 final report
 (cont)
 transition point.

 the patient is status post right colectomy; a small amount of right paracolic
 gutter fluid is present with adjacent peritoneal enhancement, potentially
 reflecting post-surgical changes in the resection bed (2:38).  a blind-ending
 left/transverse colon is present with gaseous distention of the transverse
 portion and apparent wall discontinuity/hypoenhancement at its posterior wall
 (2:38) and potentially involving the aterior wall as well.  near the staple
 line and at the anterior wall of the transverse colon are few small locules of
 intraperitoneal gas (2:39).  additionally, there is a small amount of gas
 within a ventral wall subcutaneous fat.  small amount of intra-abdominal free
 fluid is present and is of borderline complexity.

 pelvis:  the bladder is decompressed around a foley balloon.  uterus
 demonstrates multiple calcified fibroids.  the distal colon shows sigmoid
 diverticulosis with no evidence for diverticulitis.  minimally complex free
 fluid is present in the pelvis.  multiple inguinal lymph nodes are present,
 prominent in size but not meeting pathologic size criteria and are likely
 reactive in nature.  the right sided intramuscular hematoma is unchanged.

 bones:  no aggressive-appearing lytic or sclerotic lesions are present.
 degenerative disc disease is present at the l4-l5 level with endplate
 sclerosis and small anterior osteophytes.

 impression:
 1.  post operative changes of recent right hemicolectomy.  distended remaining
 transverse colonic pouch with apparent area of wall
 discontinuity/hypoenhancement; given the small locules of adjacent gas and
 minimal complex free fluid, colonic perforation potentially from ischemia is a
 possibility.
 2.  status post right colectomy with end ileostomy.  small bowel distnsion
 with relative transition point and mesenteric fat herniation through the
 ventral abdominal wall resulting in possible small-bowel obstruction vs ileus.
 3.  new bilateral effusions and adjacent atelectasis.

 findings raising possibility of ischemia/postoperative leak of the transverse
 colon were were discussed with [**first name8 (namepattern2) 4486**] [**last name (namepattern1) 30172**] at 19:52 by [**first name4 (namepattern1) 30173**] [**last name (namepattern1) 30174**] by
 phone.

"
5221,"nursing update
   temp dropped 100-96.1.  hr stable nsr, no ectopy or arrythmias.  co/ci stable 6.45/3.52 @ 0400. pap's and cvp stable.
   plts 20 @ [**2141**], heparin stopped @ 2230 and 10-pack platelets tx @ 2300.  rec'd cmvig 3.2g @ 2330 - no adverse reactions.  hct 24.7 @ 2400, ho notified, recheck @ 0300 25.3. no new orders @ this time. continues to bleed from nasal to oral cavity.
   not retaining ca+, ica repleted with ca gluc 4g x4.  glucose rx per s/s, tolerating post-pyloric tf's well, green bile only draining per ngt.   stooling large amount loose green bile colored stool.
   abg's stable, weaned off nitrous oxide.

"
5222,"msicu nsg note: 19:00-7:00
this is an 81 y.o. man adm [**2165-5-2**] to er wtih fever, decreased u.o., received 1x dose of gent and iv hydration at [**hospital3 **] and transferred to er for eval-pt received 3l ivf, levofloxacin and flagyl. pt refused presep cath in er. lactate 1.8. pt treated for presumed urosepsis and transferred to [**hospital unit name **] for close monitoring. pt with a pcn allergy but was ordered to try meropenem per [**hospital unit name **] and id team. overnight pt had an adverse reaction within minutes to the meropenem developing audible wheezing with sob and +n/v- see care vue for details. ivabx changed to iv aztreonam with no adverse reaction. cvp remained low ranging [**3-6**] with bicarb ranging 18-20. pt was given a liter of d5w with 150 meq na bicarb. k of 3.1 was repleted with 40 meq kcl total. will draw repeat labs at 6am.

neuro: a&ox3, mae, pt with l aka with some stump discomfort this am which pt reports is tolerable and he doesn't take any medicine for it at home. he was given tylenol shortly prior to the complaint for fever. t max 102.6 po. pt given total of 650mg tylenol x2 with t current 101.6po. bld cx x2 and urine cx sent. central line was pulled back 2cm as was in too far via cxr per team. repeat cxr confirmed proper line placement. pt following commands appropriately. requires max assist with adls.

cv: hr ranging 80s-100s sr/st with no ectopy noted. bp ranging 100s-150s/60s-90s. +pp via doppler in r leg. l stump warm to touch.

resp: lungs cta except developed wheezing shortly after receiving iv meropenem. then after meropenem stopped, pt with no further wheezing. sp02 ranging 97-98% on rm air. pt had been placed on 2lnc during time when pt had a reaction to the meropenem with sob but within a few minutes after the meropenem was stopped, pt was weaned back to rm air with sats in high 90s.

gi/gu: abd soft, nt, +bs, had small loose brown bm x2 smeared on his pad unable to send for cdiff. +n/v with meropenem reaction but no further incident afterward. foley patent draining adequate amts yellow urine with sediment in it. u/a c&s sent along with urine tox screen.

skin: warm, dry, and intact.

comfort: c/o stump discomfort this am shortly after tylenol given for fever. states pain level acceptable.

lines: r ij tlcl patent and was pulled back by 2cm and reconfirmed via cxr per team. r piv was found pulled out by pt d/t discomfort at insertion site. some small amt swelling at insertion site but subsided with pressure and elevation. l piv intact.

social: has been living at the [**hospital3 **] recently but prior to that had lived in own home.

plan: monitor temp, tylenol prn, monitor micro data, ivabx, make note of new meropenem allergy (also allergic to pcn). f/u with am labs and need for more k and bicarb repletion. monitor cvp and need for more ivf.


"
5223,"micu npn 7pm-7am
neuro: pt. received on ativan gtt @1mg/hr and fentanyl at 50mcg/hour. initially pt. appeared comfortable, able to obey commands, and would withdraw to pain. l pupil reactive to light. very weak cough and gag. pt's ativan gtt increased to 2mg/hr due to pt. stacking breaths with ventilator. pt. currently appears comfortable, does open eyes to pain, and flexing extremeties to nail bed pain.

resp: remains on ac16,+5 tv 500, 40%. am abg pending. lungs are coarse with crackles in the bases. at times pt. is very rhoncorous, and sounds like she has alot of secretions, however she has scant to no secretions when she is suctioned. secretions are rust colored. awaiting results of bronch.

cv: received on 8mcg/kg/min of dopamine. dopamine has been weaned to 3mcg/kg/min and will continue to wean as bp tolerates. nsr with occ pac's and pvc's.

gi: ogt to lis, draining guiac + bilious drainage. ogt clamped this am. active bowel sounds, no stool. ?feed pt. is bleeding has stopped.

gu: voiding adequate amounts of urine >40cc/hr. clear, yellow urine.

heme: hct stable, 30@mn.

misc: per pt's oncologist she received iv ig. pt. initally given a test dose of 5gms and she tolerated it well. bp stable, and temp stable, no signs of adverse reaction. pt. then given remaining dose. pt. tolerated well. see carevue for vss and temp.

social: family member stayed the night in the waiting room. plan is to find source of infection, wean dopamine as tolerated.
code status: dnr
see carevue for further data.
"
5224,"tsicu nursing admit note
pt s/p unwitnessed fall at home, possible mechanical cause.  no loc per family.  pt taken to [**hospital3 **] where scans revealed c1, c2 fx.  transfered to [**hospital1 41**].  initially given steroid bolus, stopped per trauma.  head ct revealed possible evolving stroke, to be evaluated by mri.  bilateral shoulder injury to be evaluated by ct.

pt with extensive hx including dementia (etoh vs alzhiemers), cad s/p ami, chf controlled with dialysis, htn, a-fib, copd, gi-bleed, esrd with hd 3x per week.  pt with multiple hospitalizations with fistula problems, line sepsis, now with graft.  baseline dementia generally exacerbated with delerium during hospitalizations.  pt with code purple previous hospitalization.  adverse reaction to haldol in past.  given sl zyprexa.

pt stating he has considered stopping dialysis treatments and ""throwing in the towel.""  he stated that he does not want to continue to live this way.  family will need to discuss pts wishes in light of significant dementia.

dr. [**last name (stitle) 898**] in to meet with family.  discussed collar vs. halo vs. surgery.  family does not believe collar is an option as pt would remove it.  family is requesting rehab placement as pt requires extensive care from wife at baseline.  dr. [**last name (stitle) 898**] to continue to discuss options.

ros:

neuro - aao x2.  pt knows name and that he is in the hospital.  [**name (ni) **] unclear why he is hospitalized.  unclear as to date.  asking to go home, easily redirected discussing x-rays planned before he can go.  mae with equal stregth.  sensation intact.  collar on with good fit, pt has not tried to remove collar over noc.  no restraints needed.  pt c/o right shoulder pain, reports good relief with tylenol.

cv - sr with [**name (ni) **] pvcs, pacs.  rate 60s to low 70s.  hypertensive at times with sbp 120s to 170s.  given po antihypertensives.  toprol held per dr. [**last name (stitle) 1859**].  peripheral pulses stronger in rle vs lle.

resp - lungs cta.  eupnic.  o2 sat dipped to 91% with deep sleep.  placed on 2l nc with o2 sats >97%.

gi - abdomen soft, flat, + bs.  tolerated sips of water with meds.

gu - does not make urine.  missed dialysis today because of fall.  will have dialysis today.  hold antihypertensives until after dialysis.

endo - elevated blood sugar since admission.  no known hx.  riss.

social - wife, [**name (ni) 1736**], is caregiver [**first name (titles) **] [**last name (titles) **].  family is caring and appear to have reasonable expectations.  they will continue to talk with neurosurgery re: plan for cervical fracture.  await plan of care for shoulder injury.  family requesting case management input re: rehab placement.  upon chart review, pt was dnr/dni during previous hospitalization.

a - neuro status intact, stable s/p c1, c2 fx.  dementia apparently at baseline.  good pain relief with tylenol.

p - continue serial exams.  mri of head to evaluate stroke.  ct to evaluate shoulder injury.  consult case management.  discuss code status with family.  dialysis treatment as needed.  sw consult for family coping in light of pt's statements re: quality o
"
5225,"ccu progress note!  7a-7p
delayed transfusion reaction:
   pt began to feel uncomfortable around 930am, stating he was feeling 'awful'.  at 10am, team in to assess pt on rounds, pt feeling nauseous. droperidol 0.625mg given total of 3 times today w/ little effect. ekg done w/ no changes noted. labs sent, cks flat. pt sob resp rate 20-30s, laboured at times. ls clear, crackles to bases. tmax 100.4. st 1320-130s. milrinone gtt d/c'd d/t ?adverse reaction to drug. pt con't all afternoon w/ nauseous feeling and stating he felt awful. slept in naps most of afternoon. hematuria - u/a sent. unknown about why pt was feeling so awful.
  around 5pm, house staff notified by blood bank that pt recieved blood + for minor antigens that pt has antibodies for.(1 unit prbcs given [**2130-1-10**], checked via ccc and w/ 2 nurses and given over 4hrs - hung 10am-down 2pm. benedryl 25mg po and tylenol prior to transfusion.) blood bank stated that due to missmatch he may have a delayed transfusion reaction.  pt had temp of 100.4 today, nausea, resp distress and hematuria (signs of a transfusion reaction). labs sent. ivf d5w w/3amp naco3 @ 250cc/hr x 1l.


neuro: a+ox3 today. pleasant + cooperative. pt napped most of late morning/afternoon d/t feeling awful. moves self in bed.

cardiac: st 110-130s today. occ pvcs noted. integrillin d/c'd at 11am. post cath fluids stopped at 8am. milrinone d/c'd at noon. ekg showed no changes today. no c/o chest pain. rij swan intact, pad 28-32, pcwp 31->23. co 3.3->4.7, ci 2.2->3.1, svr [**2127**]->1200. dobutamine @ 15mcg/k/min, nitro @ 180mcg/min. for cath lab in am to fix lad, to recieve pre cath fluids tonite.

resp: ls clear, crackles to bases. rr 20-30s, o2 3l n/c. laboured breathing at times this afternoon. cxr unchanged. sats 94-100%.

gu: foley changed today d/t ?clotted catheter. u/a sent. con't w/ hematuria, pink urine w/ clots. poor u/o, noting decrease in u/o since ivf d/c'd at 8am. lasix gtt decreased to 5mg/hr. ns bolus given this afternoon w/ no results. currently recieving d5w w/ 3amps bicarb @ 250cc/hr x 1l to flush out patient (d/t transfusion reaction). last cr 2.6!

gi: abd soft, distented. bm this evening. nauseated most of day, droperidol given x 3 w/ little effect. took small amt dinner this evening since he has started to feel a bit better. npo at midnite for cath in am.


plan: monitor resp status d/t ^ivf. monitor for further delayed transfusion reactions. con't to monitor vs and do cardiac calcs q4h. npo @ midnite for am cath. start pre-cath ivf tonite.
"
5226,"npn 7a-7p

events:
pt. spiked to 101.6 this am and 102.3 this afternoon.  pt. pan cx'd x stool and sputum this am.  with this afternoon spike, pt. had resp. distress with hypoxia on abg (70's), tachypnea, htn to 220 and rigors. treated with apap, lopressor 10mg ivp with 25mg po, 12.5 demerol.  currently stablized.

review of systems:

[**name (ni) **]  pt. more lethargic and less interactive today.  conts to follow commands with right hand squeezing.  no spontaneous movements noted on left side.  perrla 3-4mm.  or cancelled in light of fever.  rescheduled for tom'row if not febrile.

resp-  received on fio2 of 35% currently requiring fio2 50-70% to maintain sat's >92%.  abg at 1540.  cxr done at the time of resp. distress, results pending.  sx'd q 4 hours for minimal to no secretions.  no sputum spec. obtained.  ls- clear anterior, diminished bibasilar posteriorly.

cv-  hr 70-100 nsr.  mg of 1.5 repleted with 2g.  received 1u prbc in prep for the or d/t hct <30%.  tolerated transfusion well, no adverse reactions noted.  pt. received tyelenol prior to transfusion.  suture sites appear clean and dry.  lue significantly more edemedous and hot compared to right ? dvt.  however, pt. has [**location (un) 890**] filter in place and could not be anticoagulated.  team considering ultra sound.  no signs of cellulitis noted at this time.  elevated on pillows at this time.

gi-  abd soft/ distended.  no bm this shift.  tf restarted at 1pm d/t cancellation of or.  to be stopped at mn for questionable v/p shunt placement tom'row.  ? start ivf at that time, no order presently.

gu-  u/o adequate 40-60cc/hr.  receiving lasix 20mg po qd.

id-  fever spikes x 2 today with tmax 102.3.  conts on iv levoquin.

[**name (ni) 4**] husband and son in this am and plan to visit again tom'row before surgery... appear to be updated on plan of care.
"
5227,"nursing admission note:

pt is a very pleasant 51yo man admitted to micu a for pcn desensitization. please see fhpa for further details of pmh, hpi.

all: pcn (rash, ""throat tightenening""), last dose when he was in his 20's.

valuables: pt has cell phone, wallet w/id, watch and some clothing in his room. offered opportunity to lock valuables in safe, but he declined.

ros:
neuro: pt a&o x 3, very pleasant and cooperative. no neuro deficits. pt has intermittent ha which he presented with, which responds well to tylenol. he also has ""spinal ha"" post-lp. he describes this as pain at the back of his neck, radiating up the back of his head. this pain occurs when he is sitting up and is relieved by lying flat.
id: afebrile, wbc 3.1 (4.8). pt given escalating doses of pcn per desensitization protocol. recieved 5 doses without any evidence of reaction. within a couple of minutes of starting the 6th dose (50,000 units), he suddenly began to vomit bilious material, about 300cc's total. dose was immediately stopped, and within a couple of minutes he stopped vomitting. no treatment needed. team notified of this event; after consultation with allergist, doses 4, 5, and 6 were repeated. at this writing, dose 6 is infusing without difficulty, and pt is asymptomatic. plan is to give 7th (full) dose, then start on standing doses if he continues to do well (order not yet written for standing doses).
c-v: hemodynamically very stable; hr 70's, bp 90's-100's. lytes wnl.
resp: pt is on ra with no complaints. ls cta, sats high 90's, rr teens. slight brief desaturation noted at times when sleeping.
gu: voiding clear yellow urine in urinal. bun/creat wnl.
gi: belly benign, no stool. episode of vomitting as described under id.
endo: no issues
heme: hct stable at 31; plt's wnl. no evidence of bleeding.
skin: intact; faint rash on palms and soles of feet.
access: piv x 1.
social: married. wife is spokesperson.

a: tolerating pcn desensitization thus far

p: if he is able to complete desensitizatin protocol, anticipate return to cc7 and continuation of pcn for presumed neurosyphilis. if he has any adverse reaction, will need further desensitization.
"
5228,"npn: s/p cabg

neuro: drowsy and lethargic at times. easily arouses. oriented to self,hospital,or family. occ sl confused to day/time. mae with equal strength. knees sl buckling with oob to chair. perrl. visited with husband and [**name2 (ni) 2585**]. [**name (ni) 2586**] hopes to be back to work in 4 weeks.
cv: 100-70's sr-st with occ to freq pac's-rare pvc's seen-triplet x2. on/off neo to .75 to keep map>60. ci>2.5. swan dc'd.  k repleted. lytes wnl. pacer set a s a demand at 60. pedal pulses by doppler. hct stable 32.6.
id: tmax 99. wbc 9. cont on postop vanco.
resp: lungs diminished in bases. cough prod of bloody to blood tinged secretions early. requiring 4l nc and 40% ftneb especially when dozing. ct/mt to sxn-no airleak-serosang dng decreasing. sats > 95%. gu: foley to gd with initially good uo-now trending low0500cc ns given. cr .5.
gi: abd obese,soft, nt, nd. periods of nausea especially with movement which pt states happens r/t her meniere's. reglan given x1. tol small amt clears.
endo: on insulin gtt per cts protocol-gl to 71-gtt now off.
comfort: dilaudid .5 mg iv q 2-3 hrs for pain with effect. pt cont to state multiple allergies to everything you try to give her. no adverse reactions seen. to have vicodin ordered for po pain med.
activity: oob to ch with 2 assists-tol well but very slow-c/o knees buckling and very tired.
incisions: sternum and ct with original dsd-old staining on sternum-d/i. l leg ace wrapped d/i.
a: stable -still requiring volume and +/- neo
p: wean neo as tol, 500cc ns bolus, monitor uo-? lasix later if needed. po pain med, replete lytes.
"
5229,"7p-7a
neuro: pt attempts to open eyes w/ stimuli, perrla, random movements of hands and toes, not to command. medicated prn w/ morphine for pain noted by pt's grimacing.

cv: hr 100-110s. st. sbp >90 while on levo gtt. weaning levo gtt as pt tolerates, goal map>65 per vascular team, see carevue. cvp 12-14. lopressor held d/t levophed and hypotension, md bridges aware. k 5.4-5.3, md bridges aware, k gtt stopped from cvvhd.  received 2 units of prbcs, no adverse reactions. fingers and toes dusky. + palpable pulses.

resp: ls coarse. orally intubated, ps decreased to 18, w/ acceptable abgs, see carevue. rr 20s. tv 500-600 on cpap [**6-22**], fio2 50%. see carevue for further details. sats 94-100%, poor waveform at times. ct w/ no-> scant serosang drainage, flushed as ordered.

gi/gu: abd firmly distended, hypoactive bs. tf nutren renal at goal of 10cc/hr, w/ minimal residuals. flexiseal intact, draining loose brown stool. foley draining 8-15cc/hr of clear yellow urine. cvvhdf running pt even as pt's bp tolerates. see carevue for details.

endo: per pt's scale.

social: wife and son into visit at beginning of shift. vascular md [**doctor last name 2261**] spoke to son [**name (ni) 351**] re: pt and ct results.

skin: see carevue.

plan: monitor hemodynamics. monitor resp. status. follow labs and treat as appropriate. wean levophed to off, then start to remove fluid via cvvhdf slowly. skin care. keep pt comfortable.
"
0,"admission date:  [**2108-6-26**]              discharge date:   [**2108-7-2**]

date of birth:  [**2049-2-6**]             sex:   f

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2108-6-26**]: laparascopic sleeve gastrectomy


history of present illness:
[**known firstname **] has class iii extreme morbid obesity with weight of
364.3 pounds as of [**2108-5-29**] (her initial screen weight on [**2108-5-22**]
was 368 pounds), height of 65 inches and bmi 60.6.  her previous
weight loss efforts have included hmr for one year in [**2104**]
losing 20 pounds, off-label prescription weight loss medication
combination of fenfluramine/phentermine (""fen/phen"") in [**2092**] for
one year losing 70 pounds and [**street address(1) 41635**] visits on/off over
the past 5 years with very little weight loss.  she has exercise
for two years at curves for women losing 50 pounds and one year
of [**location (un) 86**] sports club in [**2106**] to [**2107**] losing 20 pounds. in all
of her efforts whatever weight she loss she was unable to
maintain from no more than one year.  she denied taking
over-the-counter ephedra-containing appetite suppressant/herbal
supplements.  her weight at age 21 was 150 pounds with her
lowest adult weight 125 pounds and her highest weight being 377
pounds earlier this year (2/[**2108**]).  she weighed 192 pounds at
age 33, 200 pounds at age 38, 286 pounds at age 46 and 325
pounds at the age of 50.  she stated she developed a significant
[**last name 4977**] problem at the age of 35 and has been struggling with
weight since birth of her second child and quit  smoking in
[**2081**].  factors contributing to her excess weight include large
portions, genetics, too many carbohydrates and emotional eating.
 for exercise she does water aerobics 60 minutes 5 days per week
since [**month (only) 359**] and lap swimming 90 minutes 5 days per week.  she
denied history of eating disorders and does have depression but
has not been followed by a therapist nor has she been
hospitalized for mental health issues and she is on psychotropic
medication (sertraline).


past medical history:
past medical history:  notable for fatty liver, rotator cuff
tendinitis, right shoulder, obstructive sleep apnea, type 2
diabetes with a1c of 6%, dyslipidemia, gastroesophageal reflux,
osteoarthritis of the knees, aortic valve regurgitation, past
depression.

past surgical history:  c-section x 2, carpal tunnel, right hand

social history:
she smoked one to two packs a day for 25 years quit [**2091**], no
recreational drugs, has occasional alcohol, drinks caffeinated
beverages.  she is a retired teacher, is divorced and has two
adult children

family history:
her family history is noted for father deceased age 58 with
heart disease, hyperlipidemia and obesity; mother living with
hyperlipidemia; sister deceased at 36 years of age secondary to
bulimia; maternal and paternal grandparents with heart
disorders.

physical exam:
vs: t 98, hr 86, bp 149/65, rr 18, o2 97%ra

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd: soft, appropriate peri-incisional tenderness, no rebound
tenderness/guarding
wounds: abd lap sites with steri-strips cdi, no periwound
erythema, + periwound ecchymosis
ext: no edema

pertinent results:
labs:
[**2108-6-27**] 07:40am blood hct-36.2
[**2108-6-26**] 04:21pm blood hct-38.4
[**2108-6-28**] 09:38am blood type-art po2-70* pco2-47* ph-7.40
caltco2-30 base xs-2
[**2108-6-30**] 06:40am blood wbc-5.6 rbc-4.21 hgb-11.3* hct-36.6
mcv-87 mch-26.7* mchc-30.7* rdw-15.2 plt ct-184 neuts-81.0*
lymphs-12.6* monos-3.6 eos-2.7 baso-0.1

imaging:
[**2108-6-27**]:
ugi sgl contrast w/ kub:
impression:  no evidence of obstruction or leak.


brief hospital course:
the patient presented to pre-op on [**2108-6-26**]. pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparascopic sleeve gastrectomy. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout
hospitalization; pain was initially managed with a pca and then
transitioned to oral roxicet once tolerating a stage 2 diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient was triggered on pod2 for desaturations
with an increased oxygen requirement.  the patient was
subsequently transferred to the tsicu on pod2 where she was
weaned to 3l nasal cannula; vancomycin was initiated as empiric
therapy.  she was subsequently transferred back to the general
surgical [**hospital1 **] on pod3 and weaned completely from o2 on pod5.
good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization. the pt was
maintained on cpap overnight for known sleep apnea.
gi/gu/fen: the patient was initially kept npo.  on pod1, an
upper gi study, which was negative for a leak, therefore, the
diet was advanced sequentially to a bariatric stage 2 diet,
which was well tolerated. however, on pod2, during period of
acute oxygen desaturation, the pt was made npo.  a methylene
blue dye test was performed without change in character of drain
output which remained serosanguinous throughout the admission.
the patient's diet was resumed and she was able to tolerate a
stage 3 diet without incident. patient's intake and output were
closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none; empiric treatment with
vancomycin was administered from pod2 through pod5 as described
above.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
metformin 500 mg [**hospital1 **]
omeprazole 20 mg daily
sertraline 50 mg daily
simvastatin 20 mg daily
vitamin d3 5000 units daily
multivitamin with minerals 1 tablet daily

discharge medications:
1. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*
2. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day
for 1 months.
disp:*600 ml* refills:*0*
3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**6-21**] ml
po every four (4) hours as needed for pain.
disp:*250 ml* refills:*0*
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day.
disp:*250 ml* refills:*0*
5. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable/crushable; no gummy.
6. metformin 500 mg tablet sig: 0.5 tablet po twice a day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule;
sprinkle contents onto applesauce, swallow whole.
8. sertraline 50 mg tablet sig: one (1) tablet po once a day.
9. simvastatin 20 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
morbid obesity


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except:
1.  please decrease your metformin to 250 mg twice daily.
please continue to monitor blood sugars and report elevated or
low readings to your prescribing provider.

crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:15 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:30 am
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2108-7-2**]"
1,"unit no:  [**numeric identifier 44622**]
admission date: [**2113-4-17**]
discharge date: [**2113-4-24**]
date of birth:  [**2091-7-11**]
sex:  m
service:


history of present illness:  the patient is a 21-year-old
male with a history of end-stage renal disease (on
hemodialysis) secondary to reflux nephropathy, and focal
segmental glomerulosclerosis who presented with fevers to 102
and a facial rash.

initially, he had a temperature of 100.6 at [**location (un) 4265**]
hemodialysis unit on [**2113-3-27**].  there, he received
vancomycin which was complicated by red man syndrome.  this
consisted of a fever and rash from the forehead down to his
waistline.  he was given benadryl and tylenol and sent home.

he received hemodialysis on [**2113-4-12**] uneventfully.  at
hemodialysis on [**2113-4-14**] he had a temperature to 102.7.
blood cultures were taken from his hemodialysis line.  he was
given 1 gram of kefzol and referred to the emergency
department.

in the emergency department, a chest x-ray showed no
pneumonia.  laboratories with a white blood cell count of
5.4.  urinalysis had small leukocyte esterase, but no
nitrites.  therefore, he was started empirically on
ciprofloxacin 500 mg twice per day times seven days for a
possible urinary tract infection.  urine culture ultimately
returned negative.  he began taking ciprofloxacin in the
morning of [**2113-4-15**].  he woke up on [**2113-4-16**] with
""dots"" all over and pruritus.  he took his last dose of
ciprofloxacin on [**2113-4-16**] in the evening.  his rash was
not relieved with benadryl or tylenol, so he came to the
emergency department for further evaluation.

in the emergency department - on [**2113-4-17**] - he was
noted to have a temperature of 98.8, his blood pressure was
128/64, his pulse was 98, his respiratory rate was 16, and
his oxygen saturation was 100 percent on room air.  in the
emergency department, he was pan-cultured and given one dose
of vancomycin intravenously and ceftriaxone intravenously.
laboratories at that time showed a potassium of 6.3 with
questionable peaked t waves on his electrocardiogram.
therefore, he also received calcium gluconate 1 gram, 10
units of regular insulin, 1 ampule of dextrose, 1 ampule of
bicarbonate, and kayexalate 60 grams.  before leaving to the
emergency department, he spiked a temperature to 103.6.
therefore, tylenol was given.

of note,  he had a recent admission in [**month (only) 956**] after two
generalized tonic-clonic seizures.  at that time he was
started on dilantin.  also during that admission, he
completed a 3-day course of ciprofloxacin for a urine culture
that grew out acinetobacter.

during this admission, review of systems was significant for
fevers, sore throat, and generalized malaise.  he denied any
rigors, night sweats, or weight loss.  he denied chest pain,
shortness of breath, palpitations, orthopnea, or paroxysmal
nocturnal dyspnea.  there was no cough, wheezing, or
hemoptysis.  there was no dysuria, abdominal pain, or
suprapubic tenderness.  no nausea, vomiting, diarrhea, or
constipation.  no recent travel.  no recent medication
changes.  no outdoor activities or camping.  no recent
vaccinations.  no pets or tic exposures.  no recent sexual
contacts other than his longtime girlfriend with whom he is
in a monogamous relationship.

past medical history:  end-stage renal disease (on
hemodialysis) secondary reflux, nephropathy, and focal
segmental glomerulosclerosis.  he is dialyzed on monday,
wednesday, and friday.  he started hemodialysis on [**2113-3-1**].  reflux nephropathy resulted in recurrent ascending
escherichia coli infections.  he is status post placement of
a right subclavian perm-a-cath on [**2113-3-15**] and an
arteriovenous fistula was placed on [**2113-3-17**].

spina bifida; status post repair as an infant - complicated
by bowel and bladder incontinence, with a history of straight
catheterization three times daily - complicated by numbness
in the soles of the feet and backs of both thighs as well as
left foot weakness and hyperreflexive bilateral lower
extremities.

newly diagnosed seizure disorder on [**2113-3-14**] for two
generalized tonic-clonic seizures - started on dilantin on
[**2113-3-26**].  seizures characterized by initial head
deviation toward to the right followed by generalized tonic-
clonic movements.  his first seizure on [**2113-3-14**] was
felt to be secondary to hypercalcemia in the setting of a
calcium level of 6.  his second seizure took place on
[**2113-3-26**] and was felt to be idiopathic.  at that
time, he was loaded on dilatation 300 mg three times per day.
he erroneously continued on dilantin 300 mg three times per
day until a follow-up appointment on [**2113-4-6**].  at that
time, he was switched to a regimen of 300 mg in the morning
and 200 mg in the evening.

hypoparathyroidism.

history of multiple urinary tract infections; last diagnosed
in [**2113-2-26**] and treated with ciprofloxacin.

anemia of chronic disease.

allergies:  the patient reports no known drug allergies.

medications prior to admission:
1. dilantin 300 mg by mouth in the morning alternating with
   200 mg by mouth in the evening.
2. lisinopril 10 mg by mouth once per day.
3. epogen subcutaneously every week.
4. sodium bicarbonate tablets four tablets by mouth twice per
   day.
5. oxybutynin 5 mg by mouth twice per day.
6. tums 500 mg by mouth three times per day.
7. calcitriol at each hemodialysis session.
8. nephrocaps once per day.


social history:  the patient is a sophomore at [**university/college 5130**]
[**location (un) **].  he lives in a dormitory.  he is originally from
[**location (un) 17004**], [**state 531**].  he denies any tobacco or illicit drug use,
but he reports occasional social alcohol intake.  he is in a
monogamous sexual relationship with a longstanding
girlfriend.

family history:  the patient reports no family history of
seizures or kidney disease.

physical examination on presentation:  generally, this was
well-developed, well-nourished, thin, young male.  he was
uncomfortable and ill-appearing, but nontoxic.  vital signs
revealed his temperature was 99.8, his blood pressure was
128/64, his heart rate was 98, his respiratory rate was 16,
and his oxygen saturation was 100 percent on room air.  head
and neck examination was remarkable for normocephalic and
atraumatic.  the pupils were equal, round, and reactive to
light.  the mucous membranes were moist.  the posterior
oropharynx was erythematous, but there were no lesions
exudates.  the neck was supple with no masses or
lymphadenopathy.  the chest wall had hemodialysis catheter
site bandaged with no evidence of edema, fluctuance or
purulent discharge.  the lungs were clear to auscultation
bilaterally.  there were no rhonchi, rales, or wheezes.
cardiovascular examination revealed a regular rate and rhythm
with normal first and second heart sounds auscultated.  there
were no murmurs, rubs, or gallops.  the abdomen was soft,
nontender, and nondistended.  there were positive normal
active bowel sounds.  there was no hepatosplenomegaly.
examination of the back revealed no spinal or costovertebral
angle tenderness.  the extremities were warm and well
perfused.  there was no clubbing, cyanosis, or edema.  the
left forearm arteriovenous fistula had some serous drainage;
but no erythema, edema, or fluctuance.  a bruit was
auscultated over the arteriovenous fistula.  his skin
demonstrated erythematous, raised, maculopapular rash
diffusely, but concentrated mostly on the face, abdomen,
extremities, palms, and soles.  the lesions were
approximately 1 cm in diameter.  on the face, the eyelids
were spared.  otherwise, the rash was confluent, pruritic,
blanching, nonconfluent on the body with a questionable
appearance of wheels.  there were no bullae formation.  no
target lesions.  the skin examination was also remarkable for
a tuft of hair on his back and a scar overlying his previous
spina bifida surgery site.  neurologically, he was alert and
oriented times three with no tremor or asterixis.

pertinent laboratory values on presentation:  a complete
blood count on admission revealed his white blood cell count
was 5.1 (with 61 percent neutrophils, 26 percent lymphocytes,
5 percent monocytes, 7.2 percent eosinophils - 2.9 percent on
[**2113-3-26**] - and 0.5 percent basophils), his
hematocrit was 41.6, and his platelets were 194.  chemistries
showed his sodium was 138, potassium was 6.3, chloride was
95, bicarbonate was 27, blood urea nitrogen was 58,
creatinine was 13.5, and his blood glucose was 87.  his
calcium was 10.6, his phosphorous was 4.4, and his magnesium
was 2.5.  coagulation profile revealed his prothrombin time
was 12.7, his partial thromboplastin time was 26.4, and his
inr was 1.1.  hemolysis studies on [**2113-4-18**] showed a
haptoglobin of 87, his fibrinogen was 253, and his d-dimer
was elevated at 2274.  an additional workup for his rash and
fever revealed a throat swab with culture negative for beta
streptococcal infection.  stool culture was negative.  mono
spot was negative.  aso titer from [**4-19**] demonstrated a
positive aso screen with a titer positive to 200 to 400.
rapid plasma reagin nonreactive.  [**doctor last name 3271**]-[**doctor last name **] virus titer
showed the patient to be igg positive and igm negative.
urine culture from [**2113-4-14**] was also negative for
growth.

brief summary of hospital course:  fever issues:  a concern
over line source of fevers in the emergency department, the
patient received a vancomycin.  he was started on ceftriaxone
for gram-negative coverage given his history of multiple
urinary tract infections and a history of straight
catheterization use.  prior to antibiotic initiation, he was
pan-cultured.  on the night of admission, he spiked a
temperature to 103.7 which decreased to 101.5 with tylenol.

on the morning of [**2113-4-18**] he went to hemodialysis and
there spiked a temperature to 105.  he was cultured from his
hemodialysis line and sent back to the general medicine
floor.  as the fever started after hemodialysis sessions and
appeared to worsen with accessing his hemodialysis line, the
interventional radiology service was contact[**name (ni) **] for removal of
the patient's tunnel catheter.  initially, the interventional
radiology service did not feel the catheter needed to be
removed.  thereafter, the patient himself refused removal.
later on the day of [**2113-4-18**] he was dialyzed via his
arteriovenous fistula with no adverse events.

he was seen in consultation by the infectious disease service
who recommended holding vancomycin, ciprofloxacin, and
dilantin.  an exhaustive workup; including pan cultures,
liver function tests, mono spot, cytomegalovirus, [**doctor last name 3271**]-
[**doctor last name **] virus, mycoplasma, and titers, rapid plasma reagin, aso,
throat swab, antineutrophil cytoplasmic antibody, rheumatoid
factor, and sedimentation rate was initiated out of concern
for drug fevers, viral infection, line infection, vasculitis,
toxic shock syndrome, primary human immunodeficiency virus
infection.

the patient was covered initially with aztreonam after he
spiked a fever to 107.3 in the setting of a normal blood
pressure of 140/90 and a heart rate of 120.  in addition to
aztreonam during this temperature spike he also received 1
gram of tylenol and benadryl.  he was moved from the floor to
the medical intensive care unit for further monitoring.

out of continued concern for a line infection in spite of
negative culture data, the patient's tunneled port-a-cath was
removed on [**2113-4-19**].  he continued to have dialysis and
was dialyzed on [**2113-4-20**] through his arteriovenous
fistula.  about one hour into that hemodialysis session, he
had rigors.  there was some question of whether his fevers
and rigors could be secondary to a membrane issue.

as all of the patient's culture data was negative, and his
fevers subsided status post discontinuation of vancomycin and
dilantin, it was felt that his fevers were most likely
secondary to an acute drug reaction.  it is therefore
recommended that he avoid exposure to vancomycin and dilantin
in the future.

rash issues:  it was unclear whether the patient's rash was
drug related versus infectious in etiology.  the onset
occurred after therapy with ciprofloxacin and had an
urticaria appearance and peripheral eosinophilia which was
suggestive of a drug related process.  however, in light of
the high fevers ________ was maintained for infectious
sources as well.

an exhaustive workup (as outlined above) was undertaken in
order to help delineate the source of the patient's fevers.
an infectious workup was negative.  for symptoms, he was
continued on benadryl and an h2 blocker to decrease histamine
release.  he was not initially treated with steroids out of
concern for infection.

on [**2113-4-18**] he was noted to have cracking and peeling
as well as a edema of his lips and a question ulcerative
lesion in his oropharynx and conjunctivae.  this was
concerning for [**doctor last name **]-[**location (un) **] syndrome.  he was seen in
consultation by the dermatology, infectious disease, and
ophthalmology services.  ophthalmology saw only mild
conjunctivitis on their examination and recommended
artificial tears and lacri-lube.  per dermatology, the likely
culprits for the patient's rash included vancomycin and
dilantin.  however, there was really no way to delineate
which of these two agents were the cause of this.  with
conservative and symptomatic therapy, the patient's rash
improved.

end-stage renal disease issues:  on the day of his admission,
the patient had discontinuation of his tunneled port-a-cath.
he started hemodialysis via an arteriovenous fistula.  he
tolerated this well with the exception of intermittent fever
spikes.  he was continued on nephrocaps, calcium acetate,
epogen, and calcitriol per the renal team.

seizure disorder issues:  in light of the suspicion of
dilantin as an etiologic [**doctor last name 360**] for the patient's fevers and
rash, dilantin was discontinued.  he was monitored closely in
the setting of fevers due to the fact that fevers can
decrease seizure threshold.  he was started on gabapentin
after consultation with the neurology service.  outpatient
neurology followup was arranged as well.

code status issues:  the patient was a full code.

condition on discharge:  good - afebrile times 36 hours and
hemodynamically stable.  dilantin and vancomycin levels were
trending down.  skin rash was improving.  all culture data
was negative for acute infection.

discharge status:  the patient was discharged to home.

discharge diagnoses:  drug fever and reaction secondary to
vancomycin or dilantin.

end-stage renal disease (on hemodialysis).

history of recurrent urinary tract infections.

history of a seizure disorder.

history of spina bifida; status post surgical repair.

bowel and bladder incontinence.

anemia of chronic disease.

medications on discharge:
1. gabapentin 300 mg by mouth at hour of sleep.
2. lisinopril 20 mg by mouth once per day.
3. epogen injections subcutaneously at hemodialysis.
4. oxybutynin 5 mg by mouth twice per day.
5. calcium acetate 670 mg two tablets by mouth three times
   per day (with meals).
6. nephrocaps one capsule by mouth every day.
7. artificial tears 1 drop each eye q.2h.
8. lacri-lube one application each eye at hour of sleep.
9. benadryl 25 mg one capsule by mouth q.4-6h. as needed (for
   itching).
10.      calcitriol.


follow-up plans:  the patient was instructed to call his
primary care physician or visit [**name initial (pre) **] local emergency room if he
experienced recurrent fevers, shaking chills, headaches,
chest pain, confusion, recurrent skin rash, or any other
worrisome symptoms.  he was instructed if he feels fevers and
rash, the most likely reaction was medications; however, we
could not ascertain whether the reaction was due to dilantin
or vancomycin.  we strongly suggested that he absolutely
avoid both of these agents in the future.  he was instructed
to discontinue his dilantin and sodium bicarbonate.

additionally, he had follow-up appointments with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] in the neurology department on [**2113-6-6**].  he was
instructed to call both dr. [**last name (stitle) 44623**] and dr. [**last name (stitle) **] from the
renal division for follow-up appointments after discharge.


                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 20314**]

dictated by:[**last name (namepattern1) 14378**]
medquist36
d:  [**2113-7-6**] 16:30:22
t:  [**2113-7-6**] 22:13:09
job#:  [**job number 44624**]

cc:[**last name (namepattern1) 44625**]



"
2,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
3,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
4,"admission date:  [**2130-4-26**]              discharge date:   [**2130-5-3**]

date of birth:  [**2048-7-7**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 3223**]
chief complaint:
incarcerated right inguinal hernia
left lower extremity cellulitis


major surgical or invasive procedure:
[**2130-4-26**]: right inguinal herniorraphy with mesh


history of present illness:
81m with right inguinal hernia with non-reducible bulge since
noon today.  pain in right groin since then. noted some
discomfort as early as this morning. has had some nausea
throughout day as well.  no vomiting or other abdominal pain.
has not noted a hernia before.  additionally left leg has been
red for a couple of weeks; has been using cream and has not seen
a physician for it.  did not notice that it was swolen.


past medical history:
past medical history: hearing impaired (fluent with sign
language), chronic 1st degree heart block, recurrent atrial
fibrillation/ atrial flutter, s/p dccv [**2120-1-24**], s/p dccv
[**2121-8-8**], bradycardia, elevated psa, htn, hyperlipidemia, m.r.,
basal cell ca s/p excision

past surgical history: none


social history:
lives alone. works for [**company 2318**], independent in adls. no tobacco,
rare etoh.


family history:
mother breast cancer, leg cancer, stomach cancer. father cva.
brother w/ cabg at 64yrs.


physical exam:
on admission:
vitals:97.2 95 182/91 16 100%
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: rrr, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds. right groin with palpable
non-reducible
large hernia, hernia contents extending into scrotum as well,
ttp.
dre: normal tone, no gross or occult blood
ext: no le edema, le warm and well perfused


pertinent results:
[**2130-4-29**]
labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3*
mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93
urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12
[**2130-4-29**] 05:30am blood calcium-8.5 phos-2.4* mg-2.0

[**2130-4-28**]:
chest (portable ap):
severe bilateral opacities appear to be unchanged with no change
in the element of pulmonary edema. cardiomegaly is severe. known
pericardial effusion is most likely present. consolidations in
the left lower lobe are slightly asymmetric and might represent
superimposed abnormality such as infectious process, please
correlate clinically.

[**2130-4-27**]:
echo: impression: mildly depressed left ventricular systolic
function. moderately dilated right ventricle. focal asymetric
hypertrophy of the basal antero-septum. heavily calcified aortic
valve. moderate amount of pericardial effusion with no evidence
of tamponade physiology.

ecg: atrial fibrillation with rapid ventricular response and
probable ventricular premature beats. slight intraventricular
conduction delay may be incomplete left bundle-branch block.
delayed r wave progression may be due to intraventricular
conduction delay, left ventricular hypertrophy or possible prior
septal myocardial infarction, although is non-diagnostic. st-t
wave abnormalities are non-specific but cannot exclude
myocardial ischemia. clinical correlation is suggested. since
the previous tracing of [**2130-4-26**] the rate is faster and lateral
lead st-t wave changes appear more prominent.

chest (portable ap): findings: as compared to the previous
radiograph, there is unchanged massive cardiomegaly. in
addition, there is evidence of mild to moderate pulmonary edema.
presence of co-existing pneumonia cannot be excluded. no
pneumothorax.

bilat lower ext veins port: impression: no dvt in the right or
left lower extremity.

labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30*
11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm
blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33*

[**2130-4-26**]:
ecg: atrial fibrillation. slight intraventricular conduction
delay may be incomplete left bundle-branch block. delayed r wave
progression with late precordial qrs transition may be due to
intraventricular conduction delay, left ventricular hypertrophy
or possible prior anterior wall myocardial infarction, although
is non-diagnostic. st-t wave abnormalities are non-specific.
since the previous tracing of [**2130-3-28**] the ventricular rate is
faster and the qtc interval is shorter.

labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1*
mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1
inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98
hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 [**2130-4-26**] 05:50pm
blood ctropnt-<0.01


brief hospital course:
the patient presented to the emergency department on [**2130-4-26**] due to a non-reducible right groin bulge with associated
pain and nausea.  additionally, the patient reported left leg
erythema which had been present for a few weeks without fevers.
given physical findings consistent with incarcerated hernia, the
patient was taken to the operating room where he underwent a
laparoscopic right inguinal hernia repair with mesh. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

shortly following transfer to the general surgical [**hospital1 **], the
patient was triggered for lethargy, hypoxia and atrial
fibrillation with rapid ventricular response.  intravenous
metoprolol and lasix were administered and the patient was
maintained on a non-rebreather with improved oxygenation.  he
was subsequently transferred to the trauma intensive care unit
for further management.

neuro: the patient was somnolent post-operatively, which was
deemed post-operative baseline by the als interpreter, who
reportedely knew patient well.  the somnolence resolved by pod1
and he remained alert and oriented throughout the remainder of
his hospitalization.  the patient is deaf at baseline and was
able to communicate via an als interpreter.  pain was well
controlled with oral tylenol and intermittent intravenous
hydromorphone.
cv: the patient has baseline rate controlled atrial fibrillation
on warfarin.    however, as described above, he developed a fib
with rvr on pod 0, which responsed to intravenous metoprolol
without recurrence.  additionally, an ekg obtained upon transfer
to the icu revealed st changes; cycled cardiac enzymes were
negative.  an echocardiogram was obtained and revealed mildly
depressed left ventricular systolic function, a moderately
dilated right ventricle, focal asymetric hypertrophy of the
basal antero-septum, heavily calcified aortic valve and a
moderate amount of pericardial effusion with no evidence of
tamponade physiology.  his home medication regimen was resumed
and the patient remained stable from a cardiovascular standpoint
for the remainder of his hospitalization; vital signs were
routinely monitored.
pulmonary: as described above, the patient experienced an
episode of hypoxia on pod 0, likely due to pulmonary edema.
intravenous lasix was administered with immediate effect.  upon
arrival to the icu, the patient was placed on bipap, which was
weaned to nasal cannula on pod 1.  the patient remained stable
from a pulmonary standpoint for the remainder of his
hospitalization and was weaned off supplemental oxygen entirely
on pod 3. good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
gi/gu/fen: the diet was advanced to regular on pod 1, which was
well tolerated.   patient's intake and output were closely
monitored; electrolytes were repleted routinely.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.  the left lower extremity
cellulitis improved on intravenous cefazolin and treatment was
transitioned to oral antibiotics on pod 4, which will continue
for an additional seven days.
skin: a deep tissue injury to the sacrum was identified while in
the icu.  aggressive skin care was provided via nursing without
evidence of further skin breakdown.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to
ambulate early and often.  additionally, given the events of
pod0, a lower extremity ultrasound was obtained and was negative
for a dvt.
rehab: the patient received physical therapy while hospitalized
due to deconditioning, but was deemed unsuitable for discharge
to home.  short term rehabilitation was recommended to maximize
independence and regain conditioning and independence.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating with a walker and physical therapy, voiding
without assistance, and pain was well controlled.  the patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
he will be discharged to a rehab facility for additional
physical therapy.


medications on admission:
atenolol 25mg daily
finasteride 5mg daily
simvastatin 20mg daily
verapamil er 240mg daily
coumadin 1mg daily
vitamin d2 1,000 units daily
vitamin e 400 units daily

discharge medications:
1. verapamil 240 mg tablet extended release sig: one (1) tablet
extended release po q24h (every 24 hours).
2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every
8 hours).
3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm.
4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five
(5) ml po q6h (every 6 hours) as needed for cough.
5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day): hold for loose stool.
6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily).

7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
8. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
9. bisacodyl 10 mg suppository sig: one (1) suppository rectal
hs (at bedtime) as needed for constipation.
10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).

11. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every
6 hours) for 7 days.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - [**location (un) 550**]

discharge diagnosis:
incarcerated right inguinal hernia
left lower extremity cellulitis


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 an incarcerated right
inguinal hernia and subsequently underwent surgical repair with
mesh.  additionally, you were noted to have cellulitis on the
lower aspect of your left leg, which was treated with
antibiotics.  during your stay, you also received treatment from
a physical therapist, who recommended discharge to a
rehabiliation facility to furhter improve your conditioning and
independence.  you are now preparing for disharge to a
rehabiliation facility with the following instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service at [**telephone/fax (1) 600**] to make a
follow-up appointment within 2 weeks.
please contact your primary care provider to make [**name initial (pre) **] follow-up
appointment within 1 week from discharge from the rehabilitation
facility.
provider: [**first name11 (name pattern1) 5445**] [**initial (namepattern1) **] [**last name (namepattern4) 5446**], dpm phone:[**telephone/fax (1) 543**]
date/time:[**2130-5-22**] 3:50
provider: [**first name8 (namepattern2) 6118**] [**last name (namepattern1) 6119**], rn,ms,[**md number(3) 1240**]:[**telephone/fax (1) 1971**]
date/time:[**2130-6-16**] 10:00


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

completed by:[**2130-5-3**]"
5,"admission date:  [**2146-6-15**]              discharge date:   [**2146-6-28**]

date of birth:  [**2081-10-25**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1556**]
chief complaint:
colon cancer
s/p jejunoileal bypass in [**2109**]

major surgical or invasive procedure:
[**2146-6-15**]: rt hemicolectomy, reversal of jejunoileal bypass, liver
biopsy (tru-cut needle).
[**2146-6-27**]: exploratory laparotomy with washout, repair of
perforation in ileum, placement of vacuum-assisted closure
dressing.


history of present illness:
64-year-old man with a history of colonic polyps, who on
screening colonoscopy ([**2146-5-17**]) demonstrated an ulcerated,
clamshell, nonobstructing mass in the cecum.  the length was
approximately 3 cm.  biopsy confirmed invasive
adenocarcinoma grade ii.  otherwise, he has had no change in his
health. no blood per rectum, no weight loss, no abdominal pain.
he currently has [**12-24**] formed bowel movements per day.  he does
experience loose bowel movements if he eats fatty foods or
cheese.

past medical history:
past medical history:
1.  myocardial infarction, [**2143**].
2.  right-sided nephrolithiasis.
3.  morbid obesity (bmi 44.3 kg/m2).
4.  hypertension.
5.  history of colonic polyps.

past surgical history:
1.  jejunoileal bypass, [**2109**] (16 inches of jejunum anastomosis
    to the last 6 inches of ileum) appendectomy was performed at

    that time.
2.  open cholecystectomy with choledochostomy tube and
    gastrostomy tube for acute gallstone pancreatitis, [**2109**].
3.  ureteroscopy with stenting, 05/[**2144**].  this was complicated
    by bradycardia into the 20s.
4.  cardiac pacemaker placement, [**2145-4-6**].
5.  right flank incision with stone extraction, [**2145-5-5**].
6.  cystoscopic attempted stone extraction and stenting,
    [**2145-5-21**].
7.  surgical extraction of right renal stone, [**2145-6-4**].
8.  cardiac stents (drug-eluting), [**2143**].
9.  right shoulder surgery, [**2140**], no metallic implants.

social history:
he does not smoke, drink excessively or use
drugs.  he manages an insurance firm.  he is accompanied by his
wife and daughter today.


family history:
significant for mother with [**name (ni) 2481**] disease,
father with [**name (ni) 5895**] disease.


physical exam:
bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi:
44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99.

physical examination:  general:  he is alert, oriented, in no
acute distress.  heent:  pupils are equal, round and reactive to
light.  sclerae anicteric.  oropharynx is clear.  neck:  supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly or nodules.  trachea is midline.  lungs:  clear to
auscultation bilaterally.  heart:  regular.  abdomen:  obese.
he
has a right subcostal incision (cholecystectomy).  he has a
right
lower abdominal transverse incision (intestinal bypass).  he has
a right flank incision (renal surgery).  there are no obvious
hernias.  there is no tenderness.  genitourinary:  penis is
circumcised.  testicles are descended bilaterally.  extremities:

without edema.  neurologic:  grossly nonfocal.


pertinent results:
[**2146-6-15**] 04:50pm   glucose-187* urea n-12 creat-1.0 sodium-141
potassium-4.1 chloride-104 total co2-27 anion gap-14
[**2146-6-15**] 04:50pm   estgfr-using this
[**2146-6-15**] 04:50pm   calcium-9.2 phosphate-3.9 magnesium-1.4*
[**2146-6-15**] 04:50pm   wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6*
mcv-77* mch-23.8* mchc-30.8* rdw-15.5
[**2146-6-15**] 04:50pm   plt count-102*
[**2146-6-15**] 12:44pm   type-art rates-/12 tidal vol-700 po2-330*
pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 12:44pm   glucose-153* lactate-2.1* na+-135 k+-3.8
cl--101
[**2146-6-15**] 12:44pm   hgb-10.7* calchct-32 o2 sat-97
[**2146-6-15**] 12:44pm   freeca-1.19
[**2146-6-15**] 10:53am   type-art rates-/12 tidal vol-700 po2-84*
pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 10:53am   na+-135
[**2146-6-15**] 10:53am   hgb-10.3* calchct-31 o2 sat-94

brief hospital course:
the patient presented to pre-op on [**2146-6-15**]. pt was evaluated by
anaesthesia and taken to the operating room where a laparoscopic
adjustable gastric band placement was performed. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout the
hospitalization; until her was intubated and sedated. pain was
well controlled with iv pain medications.
cv: vital signs were routinely monitored. the patient remained
stable from a cardiovascular standpoint until he developed
tachycardia and hypotension on [**2146-6-27**]. following that the
patient was placed on multiple pressors by the icu team. cardiac
enzymes were initially negative, a tee revealed a hyperdynamic
myocardium.
pulmonary: vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. the patient remained
stable from a pulmonary standpoint until [**2146-6-27**] when he
developed shortness of breath, new and increasing oxygen
requirement and desaturation. cta of the chest revealed no
evidence of pe, but the patient had evidence of worsening
pulmonary function and ards. he was intubated and his peep was
optimized using an intraesophageal balloon. he remained
intubated until the decision of comfort measures only was
executed terminally extubating the patient.

gi/gu/fen: he was kept npo with ng tube to suction. the patient
was initially putting out about 7-8 liters of bilious fluid a
day. this was adequately replaced with iv fluids. the patient
was later decreasing his ng tube outputs to 4 liters by day 6
post-operatively. the patient passed gas on the 5th day
post-operatively, and bowel movements pod6. tpn was started due
to the elevated ng outputs (dark green bile). patient's intake
and output were closely monitored.
 pod#12, the patient decompensated with sudden onset chest and
shoulder pain, shortness of breath, tachypnea, new oxygen
requirement, ekg new right bundle branch block, and transient
abdominal pain.
the patient was taken to the or and exploration revealed a total
of 5 liters of fluid non bilious. he was found to have one small
hole at the proximal anastomosis and purulent pocket. 3 drains
were placed. subsequently the patient developed multiple organ
system failure, with acute renal failure requiring continuous
venovenous hemodialysis. worsening refractory metabolic acidosis
requiring multiple boluses and iv drip bicarbonate. acute liver
failure was also noted with inr>3 and liver transaminases >[**2133**].


id: the patient's fever curves were closely watched for signs of
infection. the
patient developed sepsis as discussed above with multiple
organisms (k. pneumonia, b. fragilis,...) the patient was placed
on broad spectrum iv antibiotics.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

 the patient was showing signs of multiple organ system collapse
with refractory hypotension and acidosis despite maximal medical
therapy. a family meeting was conducted with the family deciding
that the patient's wishes would be to withdraw care at that
point. the patient was extubated terminally and the patient
passed away shortly after on [**2146-6-28**] at 17:37.

medications on admission:
medications - prescription
atorvastatin -  (prescribed by other provider) - 40 mg tablet -
1
tablet(s) by mouth once a day
hydrochlorothiazide -  (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth once a day
sildenafil [viagra] -  (prescribed by other provider) - dosage
uncertain
valsartan [diovan] -  (prescribed by other provider) - 80 mg
tablet - 1 tablet(s) by mouth once a day

medications - otc
aspirin -  (prescribed by other provider) - 81 mg tablet,
chewable - 1 tablet(s) by mouth once a day
cholecalciferol (vitamin d3) [vitamin d] -  (prescribed by other
provider) - dosage uncertain


discharge medications:
none

discharge disposition:
expired

discharge diagnosis:
cecal cancer with positive lymph node
reversal of jejunoileal bypass
liver cirrhosis secondary to jejunoileal bypass
acute respiratory distress syndrome
acute liver failure
acute renal failure
intraabdominal severe septic shock

discharge condition:
dead

discharge instructions:
na

followup instructions:
na


completed by:[**2146-7-26**]"
6,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
7,"admission date:  [**2155-7-12**]              discharge date:   [**2155-7-16**]

date of birth:  [**2097-9-7**]             sex:   m

service: medicine

allergies:
simvastatin / tape / hydrochlorothiazide / eptifibatide /
cellcept / [**year (4 digits) **]

attending:[**first name3 (lf) 14820**]
chief complaint:
transfered from [**hospital 18112**] hospital for inferior myocardial
infarction.

major surgical or invasive procedure:
cardiac catheterization
rca stent


history of present illness:
this is a 57 year old man, with a past medical history of cabg
and pfo closure in [**12-24**], s/p renal transplant secondary to
wegeners vasculitis, who was transferred from an outside
hospital for an inferior myocardial infarction.  pt was having
chest pain and an electrocardiogram showed st segment changes in
the inferior leads which was consistent with an inferior mi.
patinet underwent cardiac catheterization ([**2155-7-13**]) with
stenting for an inferior mi. he had some vagal symptoms towards
the end of the procedure and was treated with zophrin and
atropine.  pt was then transerred to the ccu.

past medical history:
-paroxysmal atrial fibrillation, not on coumadin
-esrd s/p living donor (sister) renal transplant in [**5-/2154**]
-cad:
   - s/p acute mi [**2143**] with palmaz lad and rca stents
   - s/p rotablation and hepacoat stent to the d1 in [**6-/2149**],
treated with brachytherapy for instent restenosis in [**10/2149**]
   - s/p taxus stent in rpl in [**10/2151**]
   - s/p two cypher stents placed in the rca [**10/2152**]
   - cath in [**7-24**] with 60-70% ostial stenosis of lad, moderate
diffuse disease of lcx, 60% proximal of rca with in stent
restenosis with a 70% in the pl branch taxus stent(for latest
cath, see pertinent results)
-denies h/o dm; however, sugars have been elevated in past
-chronic angina
-hypertension
-hypercholesterolemia
-wegener's granulomatosis (renal/pulmonary involvement)
diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, anca neg.
since (chronic proteinuria); now s/p renal transplant in [**5-/2154**]

-idiopathic pericarditis [**2150**]
-gerd
-anxiety, endorses dysthymic symptoms but not depression
-gout
-umbilical hernia repair
-restless leg syndrome
.
outpatient cardiologist:  [**first name4 (namepattern1) **] [**last name (namepattern1) **]
nephrologist:  dr. [**last name (stitle) 1366**]
transplant nephrologist:  [**doctor first name **] [**doctor last name **]
pcp: [**first name8 (namepattern2) 3788**] [**last name (namepattern1) **]
.
allergies:
[**last name (namepattern1) **]--rash
simvastatin--myalgia
tape--rash
hctz--unkown reaction

social history:
 social history is significant for the absence of current
tobacco use; quit 25 years ago. there is no history of alcohol
abuse; he endorses rare etoh. no illicit drugs. married with 3
children, lives w/ wife and youngest daughter.


family history:
there is no family history of premature coronary artery disease
or sudden death. mother had cva at 46. sister with scleroderma
and another sister with [**name (ni) 18109**].

physical exam:
vitals: vital signs stable, patient afebrile
gen: no acute distress
heent: mmm, perrl
neck: no jvd
heart: s1+, s2+ no murmurs.
lungs: clear to auscultation bilaterlly.
abd: soft, non tender, non distended, bowel sounds present
ex: no edema, distal pulses present bilarerally.
neuro: aaox3

pertinent results:
blood:
[**2155-7-16**] 06:05am blood wbc-8.2 rbc-3.70* hgb-10.2* hct-29.8*
mcv-81* mch-27.5 mchc-34.1 rdw-14.1 plt ct-129*

electrolytes:
[**2155-7-16**] 06:05am blood glucose-130* urean-22* creat-1.6* na-140
k-4.0 cl-106 hco3-25 angap-13

cardiac enzymes:
[**2155-7-14**] 05:30am blood ck(cpk)-987*
[**2155-7-13**] 05:15pm blood ck(cpk)-[**2153**]*
[**2155-7-13**] 06:19am blood ck(cpk)-2779*
[**2155-7-13**] 01:50am blood ck(cpk)-2132*
[**2155-7-14**] 05:30am blood ck-mb-76* mb indx-7.7* ctropnt-5.85*
[**2155-7-13**] 01:50am blood ck-mb-403* mb indx-18.9*
[**2155-7-16**] 06:05am blood calcium-8.3* phos-3.7 mg-1.9

transplant meds:
[**2155-7-16**] 06:05am blood tacrofk-8.2
[**2155-7-15**] 09:19am blood tacrofk-4.4*
[**2155-7-14**] 05:30am blood tacrofk-4.6*

blood gas:
[**2155-7-12**] 10:27pm blood type-art po2-116* pco2-33* ph-7.42
caltco2-22 base xs--1 intubat-not intuba

brief hospital course:
patient was admitted to ccu for medical management post
myocardial infarction and stent placement.  he remained stable.
he did develop an eight centimeter pseudoaneurysm and a-v
fistula on his left groin site.  [**month/day/year **] surgery was consulted
and said it was to small to intervene.  he will follow up with
surgery for another ultrasound to assess the size. he was seen
by transplant team for management of his transplant medications.
 renal was consulted for management of his wegeners
granulomatosa.  as patient had a stent placed and had a history
of an allergy to [**month/day/year **], he was desensitized to [**month/day/year **].  the
desensitization was successful without any adverse events.  ent
was consulted for epistaxis prophylaxis while on [**month/day/year **], patient
started on saline nasal spray.  he was transferred out of the
ccu to the floor and discharged on [**2155-7-16**].

problem [**name (ni) **]:

# cad/ischemia: history of cad (cabg in [**2154**]), pt had st
elevations on ecg in inferior leads with st elevation in v3r,
which are 90% sensitive for rv infarct. cath complicated by
vagal symptoms towards end of procedure treated with zofran and
atropine. pt. desensitized to [**year (4 digits) **] on [**2155-7-14**].
- continue [**last name (lf) **], [**first name3 (lf) **], statin
- patient monitored on telemetry
- as pt had rv infarct (by ekg, no right heart cath performed),
avoid nitroglycerin for chest pain as rv infarct patients are
preload dependent.
.
# pump: current echo lvef 35-40%, lv apical dyskinesis and lv
inferior/inferior-lateral hypokinesis. pt with some orthopnea.
- fluid status closely monitored.
- pt started on lasix 40 po.
.
# rhythm:  pt having runs of nsvt on telemetry. likely secondary
to hypokalemia, also possibly due to reperfusion. history of
paroxysmal a-fib, has  cardioversion.
- monitor on telemetry
- on metoprolol 50 [**hospital1 **] for rate control, titrate up to home dose
as bp tolerates
- will stop amiodarone as nsvt was peri mi and did not recur
.
# hypertension: it was noted in a prior note on omr that pt's
blood pressure should be managed with beta blocker, a small dose
of acei and nifedipine. if necessary nifedipine should be
titrated up as it is safe in the renal transplant setting.
- c/w bb and acei as bp tolerates.
- nitrates were held as blood pressure stable.  can be
re-assessed as outpatient.
- pt should have bp check by pcp or np within 1-2 weeks of d/c
.
# valves: +2 mr, mitral valve leaf thickening.  mild aortic
valve thickening.
.
# left femoral bruit: bruit over left groin where venous and
arterial access lines were pulled. systolic and diastolic bruit
likely due to av fistula. l groin u/s showing 8mm
pseudoaneurysm.
- per [**hospital1 1106**] surgery, pseudoaneurysm is to small to treat
(<2cm).  f/u with dr. [**last name (stitle) **] in [**last name (stitle) 1106**] clinic.
.
# wegeners granulomatosis: has been in remission for 10+ yrs.
stable.
- monitor respiratory status
- monitor hct
- follow ent recs re: epistaxis prevention:  saline nasal
flushes three times a day.
.
# renal transplant: end-stage renal disease secondary to
wegener's granulomatosis, received a living related renal
transplant from his sister on [**2154-5-14**]. baseline cr 1.7. pt.
back to baseline cr.
- continue tacrolimus and myfortic
- dose meds for crcl of 50.
.
# dm: sliding scale insulin.
.
# fen: cardiac/heart-healthy low salt diabetic diet
.
# prophylaxis: [**year (4 digits) **]
.
# code:  full

medications on admission:
1. allopurinol 100 mg tablet daily
2. atorvastatin 10mg daily
3. astelin 137 mcg ns
4. fluticasone 50 mcg ns
5. lisinopril 30mg daily
6. metoprolol 100mg sr 1.5 tabs daily
7. myfortic 360mg 2 tabs daily
8. nifedipine 90mg daily
9. protonix 40mg daily
10. actos 15mg daily
11. prednisone taper.
12. requip 3mg daily
13. zoloft 100mg daily
14. prograf 0.5mg daily
15. bactrim 400/80mg daily
16. aspirin 325 mg daily


discharge medications:
1. pioglitazone 15 mg tablet sig: one (1) tablet po twice a day.

2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
3. atorvastatin 10 mg tablet sig: one (1) tablet po daily
(daily).
4. fluticasone 50 mcg/actuation spray, suspension sig: [**12-18**]
sprays nasal daily (daily).
5. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1)
tablet po daily (daily).
6. sertraline 100 mg tablet sig: one (1) tablet po daily
(daily).
7. mycophenolate sodium 360 mg tablet, delayed release (e.c.)
sig: two (2) tablet, delayed release (e.c.) po twice a day.
8. ropinirole 3 mg tablet sig: one (1) tablet po twice a day.
9. sodium chloride 0.65 % aerosol, spray sig: [**12-18**] sprays nasal
tid (3 times a day) 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily): please do not miss a dose, take for at least 1 year, do
not stop taking unless your cardiologist tells you to. .
disp:*90 tablet(s)* refills:*3*
12. astelin 137 mcg aerosol, spray sig: two (2) puffs nasal
twice a day.
13. toprol xl 100 mg tablet sustained release 24 hr sig: 1.5
tablet sustained release 24 hrs po once a day.
disp:*135 tablet sustained release 24 hr(s)* refills:*3*
14. furosemide 40 mg tablet sig: one (1) tablet po daily
(daily).
15. tacrolimus 1 mg capsule sig: 1.5 capsules po bid (2 times a
day).
16. lisinopril 30 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
non-st elevation myocardial infarction
acute on chronic systolic congestive heart failure
secondary diagnosis:
chronic renal insufficiency
wegenner's vasculitis
epistaxis


discharge condition:
stable


discharge instructions:
weigh yourself every morning before breakfast, call doctor if
weight > 3 lbs in 1 day or 6 pounds in 3 days.
adhere to 2 gm sodium/heart healthy diet.
.
you had an inferior myocardial infarction with 5 drug eluting
stents placed in your right coronary artery. you need to take
[**month/day (2) 4532**] every day for one year, do not miss [**first name (titles) 691**] [**last name (titles) 4319**] unless dr. [**doctor last name 11723**] tells you to. you were seen by pt who gave you a
activity prescription until you see dr.[**name (ni) 3733**].
.
stop taking your nifedipine.

while you were inpatient, you had [**name (ni) 4532**] desensitization. you
were started on a daily dose of [**name (ni) 4532**] after the
desensitization.  this medication should be taken daily, if at
any time 36 hours lapses between [**name (ni) 4319**] of [**name (ni) 4532**], the
desensitization process will have to be repeated.
.
you need repeat angiogram in 2 weeks, you should speak to your
cardiologist regarding this. you should also have a holter
monitor in 2 weeks that will monitor your heart rhythm and track
any irregular heart beats.

followup instructions:
primary care:
provider: [**first name11 (name pattern1) 198**] [**last name (namepattern4) 199**], m.d. phone: [**telephone/fax (1) 250**] date/time:
[**7-29**] at 4:20pm.
provider: [**first name11 (name pattern1) 198**] [**last name (namepattern4) 199**], m.d. phone: [**telephone/fax (1) 250**]
date/time:[**2155-11-4**] 1:00
cardiologist:
provider: [**first name4 (namepattern1) **] [**name initial (nameis) **], md phone: [**telephone/fax (1) 62**]. date/time:
[**7-22**] at 10:40am. [**hospital ward name 23**] clinical center, [**location (un) 436**].
[**location (un) **] follow-up for left femoral pseudoaneurysm:
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2155-8-13**] 8:00
provider: [**name10 (nameis) 251**] [**last name (namepattern4) 1490**], md phone:[**telephone/fax (1) 1237**]
date/time:[**2155-8-13**] 9:15



"
8,"admission date:  [**2108-6-26**]              discharge date:   [**2108-7-2**]

date of birth:  [**2049-2-6**]             sex:   f

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2108-6-26**]: laparascopic sleeve gastrectomy


history of present illness:
[**known firstname **] has class iii extreme morbid obesity with weight of
364.3 pounds as of [**2108-5-29**] (her initial screen weight on [**2108-5-22**]
was 368 pounds), height of 65 inches and bmi 60.6.  her previous
weight loss efforts have included hmr for one year in [**2104**]
losing 20 pounds, off-label prescription weight loss medication
combination of fenfluramine/phentermine (""fen/phen"") in [**2092**] for
one year losing 70 pounds and [**street address(1) 41635**] visits on/off over
the past 5 years with very little weight loss.  she has exercise
for two years at curves for women losing 50 pounds and one year
of [**location (un) 86**] sports club in [**2106**] to [**2107**] losing 20 pounds. in all
of her efforts whatever weight she loss she was unable to
maintain from no more than one year.  she denied taking
over-the-counter ephedra-containing appetite suppressant/herbal
supplements.  her weight at age 21 was 150 pounds with her
lowest adult weight 125 pounds and her highest weight being 377
pounds earlier this year (2/[**2108**]).  she weighed 192 pounds at
age 33, 200 pounds at age 38, 286 pounds at age 46 and 325
pounds at the age of 50.  she stated she developed a significant
[**last name 4977**] problem at the age of 35 and has been struggling with
weight since birth of her second child and quit  smoking in
[**2081**].  factors contributing to her excess weight include large
portions, genetics, too many carbohydrates and emotional eating.
 for exercise she does water aerobics 60 minutes 5 days per week
since [**month (only) 359**] and lap swimming 90 minutes 5 days per week.  she
denied history of eating disorders and does have depression but
has not been followed by a therapist nor has she been
hospitalized for mental health issues and she is on psychotropic
medication (sertraline).


past medical history:
past medical history:  notable for fatty liver, rotator cuff
tendinitis, right shoulder, obstructive sleep apnea, type 2
diabetes with a1c of 6%, dyslipidemia, gastroesophageal reflux,
osteoarthritis of the knees, aortic valve regurgitation, past
depression.

past surgical history:  c-section x 2, carpal tunnel, right hand

social history:
she smoked one to two packs a day for 25 years quit [**2091**], no
recreational drugs, has occasional alcohol, drinks caffeinated
beverages.  she is a retired teacher, is divorced and has two
adult children

family history:
her family history is noted for father deceased age 58 with
heart disease, hyperlipidemia and obesity; mother living with
hyperlipidemia; sister deceased at 36 years of age secondary to
bulimia; maternal and paternal grandparents with heart
disorders.

physical exam:
vs: t 98, hr 86, bp 149/65, rr 18, o2 97%ra

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd: soft, appropriate peri-incisional tenderness, no rebound
tenderness/guarding
wounds: abd lap sites with steri-strips cdi, no periwound
erythema, + periwound ecchymosis
ext: no edema

pertinent results:
labs:
[**2108-6-27**] 07:40am blood hct-36.2
[**2108-6-26**] 04:21pm blood hct-38.4
[**2108-6-28**] 09:38am blood type-art po2-70* pco2-47* ph-7.40
caltco2-30 base xs-2
[**2108-6-30**] 06:40am blood wbc-5.6 rbc-4.21 hgb-11.3* hct-36.6
mcv-87 mch-26.7* mchc-30.7* rdw-15.2 plt ct-184 neuts-81.0*
lymphs-12.6* monos-3.6 eos-2.7 baso-0.1

imaging:
[**2108-6-27**]:
ugi sgl contrast w/ kub:
impression:  no evidence of obstruction or leak.


brief hospital course:
the patient presented to pre-op on [**2108-6-26**]. pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparascopic sleeve gastrectomy. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout
hospitalization; pain was initially managed with a pca and then
transitioned to oral roxicet once tolerating a stage 2 diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient was triggered on pod2 for desaturations
with an increased oxygen requirement.  the patient was
subsequently transferred to the tsicu on pod2 where she was
weaned to 3l nasal cannula; vancomycin was initiated as empiric
therapy.  she was subsequently transferred back to the general
surgical [**hospital1 **] on pod3 and weaned completely from o2 on pod5.
good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization. the pt was
maintained on cpap overnight for known sleep apnea.
gi/gu/fen: the patient was initially kept npo.  on pod1, an
upper gi study, which was negative for a leak, therefore, the
diet was advanced sequentially to a bariatric stage 2 diet,
which was well tolerated. however, on pod2, during period of
acute oxygen desaturation, the pt was made npo.  a methylene
blue dye test was performed without change in character of drain
output which remained serosanguinous throughout the admission.
the patient's diet was resumed and she was able to tolerate a
stage 3 diet without incident. patient's intake and output were
closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none; empiric treatment with
vancomycin was administered from pod2 through pod5 as described
above.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
metformin 500 mg [**hospital1 **]
omeprazole 20 mg daily
sertraline 50 mg daily
simvastatin 20 mg daily
vitamin d3 5000 units daily
multivitamin with minerals 1 tablet daily

discharge medications:
1. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*
2. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day
for 1 months.
disp:*600 ml* refills:*0*
3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**6-21**] ml
po every four (4) hours as needed for pain.
disp:*250 ml* refills:*0*
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day.
disp:*250 ml* refills:*0*
5. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable/crushable; no gummy.
6. metformin 500 mg tablet sig: 0.5 tablet po twice a day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule;
sprinkle contents onto applesauce, swallow whole.
8. sertraline 50 mg tablet sig: one (1) tablet po once a day.
9. simvastatin 20 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
morbid obesity


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except:
1.  please decrease your metformin to 250 mg twice daily.
please continue to monitor blood sugars and report elevated or
low readings to your prescribing provider.

crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:15 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:30 am
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2108-7-2**]"
9,"unit no:  [**numeric identifier 44622**]
admission date: [**2113-4-17**]
discharge date: [**2113-4-24**]
date of birth:  [**2091-7-11**]
sex:  m
service:


history of present illness:  the patient is a 21-year-old
male with a history of end-stage renal disease (on
hemodialysis) secondary to reflux nephropathy, and focal
segmental glomerulosclerosis who presented with fevers to 102
and a facial rash.

initially, he had a temperature of 100.6 at [**location (un) 4265**]
hemodialysis unit on [**2113-3-27**].  there, he received
vancomycin which was complicated by red man syndrome.  this
consisted of a fever and rash from the forehead down to his
waistline.  he was given benadryl and tylenol and sent home.

he received hemodialysis on [**2113-4-12**] uneventfully.  at
hemodialysis on [**2113-4-14**] he had a temperature to 102.7.
blood cultures were taken from his hemodialysis line.  he was
given 1 gram of kefzol and referred to the emergency
department.

in the emergency department, a chest x-ray showed no
pneumonia.  laboratories with a white blood cell count of
5.4.  urinalysis had small leukocyte esterase, but no
nitrites.  therefore, he was started empirically on
ciprofloxacin 500 mg twice per day times seven days for a
possible urinary tract infection.  urine culture ultimately
returned negative.  he began taking ciprofloxacin in the
morning of [**2113-4-15**].  he woke up on [**2113-4-16**] with
""dots"" all over and pruritus.  he took his last dose of
ciprofloxacin on [**2113-4-16**] in the evening.  his rash was
not relieved with benadryl or tylenol, so he came to the
emergency department for further evaluation.

in the emergency department - on [**2113-4-17**] - he was
noted to have a temperature of 98.8, his blood pressure was
128/64, his pulse was 98, his respiratory rate was 16, and
his oxygen saturation was 100 percent on room air.  in the
emergency department, he was pan-cultured and given one dose
of vancomycin intravenously and ceftriaxone intravenously.
laboratories at that time showed a potassium of 6.3 with
questionable peaked t waves on his electrocardiogram.
therefore, he also received calcium gluconate 1 gram, 10
units of regular insulin, 1 ampule of dextrose, 1 ampule of
bicarbonate, and kayexalate 60 grams.  before leaving to the
emergency department, he spiked a temperature to 103.6.
therefore, tylenol was given.

of note,  he had a recent admission in [**month (only) 956**] after two
generalized tonic-clonic seizures.  at that time he was
started on dilantin.  also during that admission, he
completed a 3-day course of ciprofloxacin for a urine culture
that grew out acinetobacter.

during this admission, review of systems was significant for
fevers, sore throat, and generalized malaise.  he denied any
rigors, night sweats, or weight loss.  he denied chest pain,
shortness of breath, palpitations, orthopnea, or paroxysmal
nocturnal dyspnea.  there was no cough, wheezing, or
hemoptysis.  there was no dysuria, abdominal pain, or
suprapubic tenderness.  no nausea, vomiting, diarrhea, or
constipation.  no recent travel.  no recent medication
changes.  no outdoor activities or camping.  no recent
vaccinations.  no pets or tic exposures.  no recent sexual
contacts other than his longtime girlfriend with whom he is
in a monogamous relationship.

past medical history:  end-stage renal disease (on
hemodialysis) secondary reflux, nephropathy, and focal
segmental glomerulosclerosis.  he is dialyzed on monday,
wednesday, and friday.  he started hemodialysis on [**2113-3-1**].  reflux nephropathy resulted in recurrent ascending
escherichia coli infections.  he is status post placement of
a right subclavian perm-a-cath on [**2113-3-15**] and an
arteriovenous fistula was placed on [**2113-3-17**].

spina bifida; status post repair as an infant - complicated
by bowel and bladder incontinence, with a history of straight
catheterization three times daily - complicated by numbness
in the soles of the feet and backs of both thighs as well as
left foot weakness and hyperreflexive bilateral lower
extremities.

newly diagnosed seizure disorder on [**2113-3-14**] for two
generalized tonic-clonic seizures - started on dilantin on
[**2113-3-26**].  seizures characterized by initial head
deviation toward to the right followed by generalized tonic-
clonic movements.  his first seizure on [**2113-3-14**] was
felt to be secondary to hypercalcemia in the setting of a
calcium level of 6.  his second seizure took place on
[**2113-3-26**] and was felt to be idiopathic.  at that
time, he was loaded on dilatation 300 mg three times per day.
he erroneously continued on dilantin 300 mg three times per
day until a follow-up appointment on [**2113-4-6**].  at that
time, he was switched to a regimen of 300 mg in the morning
and 200 mg in the evening.

hypoparathyroidism.

history of multiple urinary tract infections; last diagnosed
in [**2113-2-26**] and treated with ciprofloxacin.

anemia of chronic disease.

allergies:  the patient reports no known drug allergies.

medications prior to admission:
1. dilantin 300 mg by mouth in the morning alternating with
   200 mg by mouth in the evening.
2. lisinopril 10 mg by mouth once per day.
3. epogen subcutaneously every week.
4. sodium bicarbonate tablets four tablets by mouth twice per
   day.
5. oxybutynin 5 mg by mouth twice per day.
6. tums 500 mg by mouth three times per day.
7. calcitriol at each hemodialysis session.
8. nephrocaps once per day.


social history:  the patient is a sophomore at [**university/college 5130**]
[**location (un) **].  he lives in a dormitory.  he is originally from
[**location (un) 17004**], [**state 531**].  he denies any tobacco or illicit drug use,
but he reports occasional social alcohol intake.  he is in a
monogamous sexual relationship with a longstanding
girlfriend.

family history:  the patient reports no family history of
seizures or kidney disease.

physical examination on presentation:  generally, this was
well-developed, well-nourished, thin, young male.  he was
uncomfortable and ill-appearing, but nontoxic.  vital signs
revealed his temperature was 99.8, his blood pressure was
128/64, his heart rate was 98, his respiratory rate was 16,
and his oxygen saturation was 100 percent on room air.  head
and neck examination was remarkable for normocephalic and
atraumatic.  the pupils were equal, round, and reactive to
light.  the mucous membranes were moist.  the posterior
oropharynx was erythematous, but there were no lesions
exudates.  the neck was supple with no masses or
lymphadenopathy.  the chest wall had hemodialysis catheter
site bandaged with no evidence of edema, fluctuance or
purulent discharge.  the lungs were clear to auscultation
bilaterally.  there were no rhonchi, rales, or wheezes.
cardiovascular examination revealed a regular rate and rhythm
with normal first and second heart sounds auscultated.  there
were no murmurs, rubs, or gallops.  the abdomen was soft,
nontender, and nondistended.  there were positive normal
active bowel sounds.  there was no hepatosplenomegaly.
examination of the back revealed no spinal or costovertebral
angle tenderness.  the extremities were warm and well
perfused.  there was no clubbing, cyanosis, or edema.  the
left forearm arteriovenous fistula had some serous drainage;
but no erythema, edema, or fluctuance.  a bruit was
auscultated over the arteriovenous fistula.  his skin
demonstrated erythematous, raised, maculopapular rash
diffusely, but concentrated mostly on the face, abdomen,
extremities, palms, and soles.  the lesions were
approximately 1 cm in diameter.  on the face, the eyelids
were spared.  otherwise, the rash was confluent, pruritic,
blanching, nonconfluent on the body with a questionable
appearance of wheels.  there were no bullae formation.  no
target lesions.  the skin examination was also remarkable for
a tuft of hair on his back and a scar overlying his previous
spina bifida surgery site.  neurologically, he was alert and
oriented times three with no tremor or asterixis.

pertinent laboratory values on presentation:  a complete
blood count on admission revealed his white blood cell count
was 5.1 (with 61 percent neutrophils, 26 percent lymphocytes,
5 percent monocytes, 7.2 percent eosinophils - 2.9 percent on
[**2113-3-26**] - and 0.5 percent basophils), his
hematocrit was 41.6, and his platelets were 194.  chemistries
showed his sodium was 138, potassium was 6.3, chloride was
95, bicarbonate was 27, blood urea nitrogen was 58,
creatinine was 13.5, and his blood glucose was 87.  his
calcium was 10.6, his phosphorous was 4.4, and his magnesium
was 2.5.  coagulation profile revealed his prothrombin time
was 12.7, his partial thromboplastin time was 26.4, and his
inr was 1.1.  hemolysis studies on [**2113-4-18**] showed a
haptoglobin of 87, his fibrinogen was 253, and his d-dimer
was elevated at 2274.  an additional workup for his rash and
fever revealed a throat swab with culture negative for beta
streptococcal infection.  stool culture was negative.  mono
spot was negative.  aso titer from [**4-19**] demonstrated a
positive aso screen with a titer positive to 200 to 400.
rapid plasma reagin nonreactive.  [**doctor last name 3271**]-[**doctor last name **] virus titer
showed the patient to be igg positive and igm negative.
urine culture from [**2113-4-14**] was also negative for
growth.

brief summary of hospital course:  fever issues:  a concern
over line source of fevers in the emergency department, the
patient received a vancomycin.  he was started on ceftriaxone
for gram-negative coverage given his history of multiple
urinary tract infections and a history of straight
catheterization use.  prior to antibiotic initiation, he was
pan-cultured.  on the night of admission, he spiked a
temperature to 103.7 which decreased to 101.5 with tylenol.

on the morning of [**2113-4-18**] he went to hemodialysis and
there spiked a temperature to 105.  he was cultured from his
hemodialysis line and sent back to the general medicine
floor.  as the fever started after hemodialysis sessions and
appeared to worsen with accessing his hemodialysis line, the
interventional radiology service was contact[**name (ni) **] for removal of
the patient's tunnel catheter.  initially, the interventional
radiology service did not feel the catheter needed to be
removed.  thereafter, the patient himself refused removal.
later on the day of [**2113-4-18**] he was dialyzed via his
arteriovenous fistula with no adverse events.

he was seen in consultation by the infectious disease service
who recommended holding vancomycin, ciprofloxacin, and
dilantin.  an exhaustive workup; including pan cultures,
liver function tests, mono spot, cytomegalovirus, [**doctor last name 3271**]-
[**doctor last name **] virus, mycoplasma, and titers, rapid plasma reagin, aso,
throat swab, antineutrophil cytoplasmic antibody, rheumatoid
factor, and sedimentation rate was initiated out of concern
for drug fevers, viral infection, line infection, vasculitis,
toxic shock syndrome, primary human immunodeficiency virus
infection.

the patient was covered initially with aztreonam after he
spiked a fever to 107.3 in the setting of a normal blood
pressure of 140/90 and a heart rate of 120.  in addition to
aztreonam during this temperature spike he also received 1
gram of tylenol and benadryl.  he was moved from the floor to
the medical intensive care unit for further monitoring.

out of continued concern for a line infection in spite of
negative culture data, the patient's tunneled port-a-cath was
removed on [**2113-4-19**].  he continued to have dialysis and
was dialyzed on [**2113-4-20**] through his arteriovenous
fistula.  about one hour into that hemodialysis session, he
had rigors.  there was some question of whether his fevers
and rigors could be secondary to a membrane issue.

as all of the patient's culture data was negative, and his
fevers subsided status post discontinuation of vancomycin and
dilantin, it was felt that his fevers were most likely
secondary to an acute drug reaction.  it is therefore
recommended that he avoid exposure to vancomycin and dilantin
in the future.

rash issues:  it was unclear whether the patient's rash was
drug related versus infectious in etiology.  the onset
occurred after therapy with ciprofloxacin and had an
urticaria appearance and peripheral eosinophilia which was
suggestive of a drug related process.  however, in light of
the high fevers ________ was maintained for infectious
sources as well.

an exhaustive workup (as outlined above) was undertaken in
order to help delineate the source of the patient's fevers.
an infectious workup was negative.  for symptoms, he was
continued on benadryl and an h2 blocker to decrease histamine
release.  he was not initially treated with steroids out of
concern for infection.

on [**2113-4-18**] he was noted to have cracking and peeling
as well as a edema of his lips and a question ulcerative
lesion in his oropharynx and conjunctivae.  this was
concerning for [**doctor last name **]-[**location (un) **] syndrome.  he was seen in
consultation by the dermatology, infectious disease, and
ophthalmology services.  ophthalmology saw only mild
conjunctivitis on their examination and recommended
artificial tears and lacri-lube.  per dermatology, the likely
culprits for the patient's rash included vancomycin and
dilantin.  however, there was really no way to delineate
which of these two agents were the cause of this.  with
conservative and symptomatic therapy, the patient's rash
improved.

end-stage renal disease issues:  on the day of his admission,
the patient had discontinuation of his tunneled port-a-cath.
he started hemodialysis via an arteriovenous fistula.  he
tolerated this well with the exception of intermittent fever
spikes.  he was continued on nephrocaps, calcium acetate,
epogen, and calcitriol per the renal team.

seizure disorder issues:  in light of the suspicion of
dilantin as an etiologic [**doctor last name 360**] for the patient's fevers and
rash, dilantin was discontinued.  he was monitored closely in
the setting of fevers due to the fact that fevers can
decrease seizure threshold.  he was started on gabapentin
after consultation with the neurology service.  outpatient
neurology followup was arranged as well.

code status issues:  the patient was a full code.

condition on discharge:  good - afebrile times 36 hours and
hemodynamically stable.  dilantin and vancomycin levels were
trending down.  skin rash was improving.  all culture data
was negative for acute infection.

discharge status:  the patient was discharged to home.

discharge diagnoses:  drug fever and reaction secondary to
vancomycin or dilantin.

end-stage renal disease (on hemodialysis).

history of recurrent urinary tract infections.

history of a seizure disorder.

history of spina bifida; status post surgical repair.

bowel and bladder incontinence.

anemia of chronic disease.

medications on discharge:
1. gabapentin 300 mg by mouth at hour of sleep.
2. lisinopril 20 mg by mouth once per day.
3. epogen injections subcutaneously at hemodialysis.
4. oxybutynin 5 mg by mouth twice per day.
5. calcium acetate 670 mg two tablets by mouth three times
   per day (with meals).
6. nephrocaps one capsule by mouth every day.
7. artificial tears 1 drop each eye q.2h.
8. lacri-lube one application each eye at hour of sleep.
9. benadryl 25 mg one capsule by mouth q.4-6h. as needed (for
   itching).
10.      calcitriol.


follow-up plans:  the patient was instructed to call his
primary care physician or visit [**name initial (pre) **] local emergency room if he
experienced recurrent fevers, shaking chills, headaches,
chest pain, confusion, recurrent skin rash, or any other
worrisome symptoms.  he was instructed if he feels fevers and
rash, the most likely reaction was medications; however, we
could not ascertain whether the reaction was due to dilantin
or vancomycin.  we strongly suggested that he absolutely
avoid both of these agents in the future.  he was instructed
to discontinue his dilantin and sodium bicarbonate.

additionally, he had follow-up appointments with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] in the neurology department on [**2113-6-6**].  he was
instructed to call both dr. [**last name (stitle) 44623**] and dr. [**last name (stitle) **] from the
renal division for follow-up appointments after discharge.


                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 20314**]

dictated by:[**last name (namepattern1) 14378**]
medquist36
d:  [**2113-7-6**] 16:30:22
t:  [**2113-7-6**] 22:13:09
job#:  [**job number 44624**]

cc:[**last name (namepattern1) 44625**]



"
10,"admission date:  [**2130-10-16**]       discharge date:  [**2130-10-24**]


service:  ccu

history of present illness:  this is an 83-year-old white
male with history of coronary artery disease status post
coronary artery bypass graft times three vessels in [**2121**], end
stage renal disease on hemodialysis three times a week,
diabetes mellitus and hypertension transferred from [**hospital 1474**]
hospital for cardiac catheterization.

the patient initially presented to [**hospital 1474**] hospital with
complaints of increased dyspnea on exertion, weakness and
dizziness.  in the emergency department their he was found to
have new ekg changes, new t wave depressions in v2 through v3
and more depressed t wave depressions in v4 through v6 and
atrial fibrillation.  the patient was ruled out for mi by
serial enzymes, although he did have an initial ck mb index
of 3.2 and had an echocardiogram which showed lv enlargement
with akinesis of the inferior and posterior walls.  also with
hypokinesis of other lv walls and ejection fraction of 30%,
mitral tricuspid regurgitation with a pulmonary artery
systolic pressure of 45 mg of mercury, mild mr with
significant left atrial enlargement.  patient then had a
persantine mibi which showed a small lateral wall ischemia
and small inferior wall infarct.

decision was then made to transfer to [**hospital1 190**] for cardiac catheterization.  cardiac
catheterization showed a pulmonary capillary wedge pressure
of 22 mg of mercury, right atrial pressure of 25 mg of
mercury, pa pressure of 46/17, right ventricular pressure
48/9.  a totally occluded lad with positive collateral flow,
70% stenosis of the left circumflex.  the svg to om graft was
totally occluded.  svg to dm graft was patent and lima to lad
graft was patent.  overall severe three vessel disease.  two
out three grafts had moderately decreased left ventricular
ejection fraction of 40%, moderate mitral regurgitation and
moderately diffuse hypokinesis.

during the procedure, the patient became hypertensive with a
210/110 and intravenous prior to nitroglycerin was started.
patient also had flash pulmonary edema after a
................. load of about 500 cc and was electively
intubated for increased shortness of breath and agitation.
the patient was then transferred to the ccu for nipride wean
and extubation.

medications on transfer:
1.  tylenol p.r.n.
2.  ambien p.r.n.
3.  metoprolol 25 mg p.o. b.i.d.
4.  captopril 6.25 mg p.o. t.i.d.
5.  ec-asa 325 mg p.o. q.d.
6.  coumadin 5 mg h.s. then 2 mg h.s.
7.  nitroglycerin drip 0.052.2 mcg per kilogram per minute.
8.  nephrocaps one cap p.o. q.d.
9.  regular insulin sliding scale.
10. glipizide xl 10 mg p.o. q.d.
11. propofol drip.

past medical history:
1.  coronary artery disease status post coronary artery
bypass graft for three vessels in [**2121**].
2.  end stage renal disease on hemodialysis on tuesday,
thursday and saturday.
3.  hypertension.
4.  diabetes mellitus.
5.  anemia.
6.  prostate ca.
7.  new onset atrial fibrillation.

social history:  not obtainable.

family history:  not obtainable.

initial ekg showed atrial fibrillation at 65 beats per
minute, normal axis, qrs mildly elongated, left ventricular
hypertrophy by voltage, t wave inversions in v2 through v5,
st depressions in i and l, unchanged from outside hospital
ekgs.

physical examination:  vital signs with a temperature of 97.6
f, blood pressure 106/45, heart rate 68.  pulmonary artery
pressure 37/11.  in general elderly, sedated, intubated male
lying still in bed.  head, eyes, ears, nose and throat:
normocephalic, atraumatic.  pupils are 2 mm bilaterally,
equal, round, reactive to light.  endotracheal tube in place.
neck:  no jugular venous distention.  cardiovascular:  iv/vi
systolic murmur loudest at the apex radiating to the axilla
into the back, irregular.  pulmonary:  loud bronchial sounds
bilaterally.  abdomen:  soft, nondistended with normal
abdominal bowel sounds, no hepatosplenomegaly.  positive
abdominal bruit.  extremities:  warm, no edema, no hematoma
at right groin.  neuro:  patient sedated.  withdraws from
touching of feet.

initial laboratory results:  white blood cell count of 5.7,
hematocrit 32.7, platelets 134.  differential was 72.4%
neutrophils, 18.2% lymphocytes, 8.2% monocytes, 1.0%
eosinophils, 0.2% basophil.  inr was 1.3. potassium 5.5,
calcium 8.3, magnesium 2.7, phosphorus was 9.7.

abg done was 7.45, 73 and 345 on 100% oxygen.

initial assessment:  this is an 83-year-old male with history
of coronary artery disease, diabetes mellitus, end stage
renal disease on hemodialysis transferred from outside
hospital for cardiac catheterization secondary to abnormal p
mibi with dyspnea and hypertension in cath lab.  started on
nipride and nitroglycerin drips, intubated and electively
transferred to ccu for extubation and drip weaning.

hospital course:
1.  cardiac:  patient is being kept on the nitroglycerin drip
throughout the entire course when he was on the ventilator
and it was discontinued once he had been weaned.  the patient
was started on imdur 50 mg p.o. q.d. for approximately six
hours prior to stopping the nitroglycerin drip with no ill
effects.

patient was noted to have a moderately decreased left
ventricular ejection fraction of 30 to 40%.  the patient was
started on an ace inhibitor and was gradually titrated up,
however two days into ace inhibitor therapy with captopril,
the patient developed an erythematous rash which was
pruritic.  at this point, it was assumed that the rash was
secondary to the sulfur group of the captopril and patient
was switched to lisinopril 40 p.o. q.d. with eventual
clearing of rash and no other ill effects.

the patient was switched over from nitroglycerin drip to
imdur with no ill effects.  patient remained moderately
hypertensive throughout the hospital course with blood
pressures up to 160 mg of mercury systolic were tolerated as
this patient is on hemodialysis.

2.  rhythm:  patient was noted to have new onset atrial
fibrillation.  patient was maintained on telemetry and had
frequent episodes of nonsustained ventricular tachycardia as
well as ventricular tachycardia throughout the first two days
of hospitalization with gradual clearing of these.  the
patient was tried on a beta blocker and pr prolongation was
noted.  at this point, the beta blocker was discontinued and
patient had a pacemaker placed so that he would be able to
tolerate amiodarone therapy.

patient had a dual chamber rate responsive pacemaker placed
and was started on amiodarone loading 400 mg p.o. b.i.d.  at
pacemaker placement, the patient received a dose of
vancomycin.  the patient tolerated the pacemaker placement
and was kept on telemetry for 24 hours after pacemaker was
placed with no adverse events noted.

the patient was also restarted on coumadin for
anticoagulation after pacemaker placement.  the decision of
how long to continue coumadin will be left up to the pcp.
[**name10 (nameis) **] patient's amiodarone loading should be 400 mg p.o. b.i.d.
times one week then 400 mg p.o. q.d. times one week and then
200 mg p.o. q.d.  the patient should be seen at [**hospital **]
clinic in one week.

3.  coronaries:  patient with status post coronary artery
bypass graft in [**2121**], lima to lad, svg to lpda, and svg to om
which is totally occluded, 70% stenotic lesion in mid
circumflex.  patient was started on lipitor 10 mg p.o. q.d.
and was kept on aspirin throughout hospital course.  the
patient should continue to take these two drugs indefinitely.


4.  pulmonary:  patient had an initial weaning trial
approximately 12 hours after admission to the ccu.  the
patient became tachypneic as he was initially weaned from the
ventilator and it was decided to rest him for another day.
the patient was switched over to pressure support and
successfully weaned on hospital day #2.  the patient
initially required oxygen, but soon was able to tolerate room
air with o2 saturations of 95% and above.  there were no
further pulmonary issues in the hospital course.

5.  renal:  patient was continued on hemodialysis throughout
hospital course and initially started on amphojel and phos-lo
as patient had increased phosphorus on presentation.
eventually, amphojel was able to be discontinued after four
hospital days as per renal's recommendation.  patient to
continue hemodialysis as an outpatient on tuesdays, thursdays
and sundays.

6.  endocrine:  the patient was noted to become hypoglycemic
with blood sugars as low as 48.  patient had his glipizide
discontinued and had some hypoglycemia for one day after
discontinuation and subsequently high blood sugars of 160s to
200s while continuing regular insulin sliding scale.  it was
decided to reinitiate glipizide at a lower dose of 2.5 mg
q.d. and further watch for hypoglycemia as an outpatient.

7.  dermatologic:  patient developed an erythematous
maculopapular and some areas ................ pruritic rash
over the trunk and upper thighs and back on day #2 of
captopril.  a dermatology consult was called and a skin
biopsy was performed.  the patient was switched from
captopril to lisinopril.  skin biopsy confirmed a lymphocytic
infiltrate with rare eosinophils, focal rbc extravasation
consistent with systemic hypersensitivity reaction, no
leukocytoclastic vasculitis was seen.

the patient's rash eventually cleared, although not
completely after lisinopril was initiated.  the patient was
given sarna lotion, [**doctor first name **] and benadryl p.r.n. for itching
with moderate effect.

8.  prophylaxis:  patient received aspirin, lipitor, coumadin
and protonix for gi prophylaxis during hospital course.

discharge diagnosis:
1.  new onset atrial fibrillation status post dual chamber
pacemaker placement, initiation of amiodarone therapy.
2.  coronary artery disease.
3.  end stage renal disease on hemodialysis tuesday, thursday
and saturday.
4.  hypertension.
5.  diabetes mellitus type 2.
6.  anemia.
7.  prostate ca.

discharge medications:
1.  warfarin 2 mg p.o. q.h.s.
2.  amiodarone 400 mg p.o. b.i.d. times seven days started
[**2130-10-23**] then 400 mg p.o. q.d. times seven days then
200 mg p.o. q.d.
3.  lisinopril 40 mg p.o. q.d.
4.  imdur 60 mg p.o. q.d.
5.  lipitor 10 mg p.o. q.h.s.
6.  enteric coated aspirin 325 mg p.o. q.d.
7.  benadryl 25 mg p.o. q. six hours p.r.n.
8.  docusate 100 mg p.o. b.i.d.
9.  [**doctor first name **] 60 mg p.o. b.i.d.
10. sarna tp p.r.n.
11. phos-lo three caps p.o. t.i.d.
12. [**doctor last name **] two tabs p.o. b.i.d. p.r.n.

condition on discharge:  good.

discharge status:  to short term rehab.  patient to follow up
with own cardiologist to arrange pulmonary function test as
patient is now being started on amiodarone and also to follow
up tsh and lfts.




                            [**first name11 (name pattern1) **] [**last name (namepattern4) 1008**], m.d.  [**md number(1) 1009**]

dictated by:[**name8 (md) 45172**]
medquist36

d:  [**2130-10-24**]  16:26
t:  [**2130-10-24**]  14:35
job#:  [**job number 45173**]
"
11,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
12,"admission date:  [**2150-4-16**]              discharge date:   [**2150-4-21**]


service: medicine

allergies:
nsaids / bactrim

attending:[**first name3 (lf) 358**]
chief complaint:
angioedema

major surgical or invasive procedure:
intubation

history of present illness:
pt is an 85 y/o f with a h/o gave s/p argon treatment last on
[**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc, portal
htn/grade 1 varices but no hx of bleeding varices, cri (baseline
cr = 1.2-1.5) who is transfered from [**hospital3 **] intubated
s/p angioedema. by report the pt has some mild abdominal pain
and some irritation in her throat a day prior to admission to
[**hospital3 **]. the following morning she called her son with
complaints of oral swelling; son states that her speach was
garbled. the son reports that the patient denies having had any
sob, no wheezing, no hives. he called an abmulance who
transported the pt to [**hospital3 **].
.
per omr, the patient present to [**hospital1 18**] pheresis unit on [**2150-4-10**]
for blood transfusion for chronic slow upper gi bleeding. she
had no pretreatment medications given and no adverse events;
vitals on leaving the unit were 97.4 - 67 - 119/55. she has also
been recently treated for a uti with bactrim started on [**2150-4-3**].

.
at st elizabeths', she was hd stable but had a large, edematous
tongue. she recevied decadron, epinephrine, benadryl, famotidine
and hydroxazine in the ed. the ed was unable to intubate and she
was taken to the or. laryngeal edema was noted, but the et tube
was passed successfully. she was then transfered to the ccu. she
received hydroxazine tid and her tongue swelling improved. sbt
was attempted early on but failed likely secondary to sedation.
per report, pt did have a cuff leak. family requested transfer
to [**hospital1 18**] as pt receives all her care here.
.
on arrival in the micu she passed an sbt and was successfully
extubated. she did well throughout the day but continued to have
an o2 requirement. by the time of transfer to the floor she was
on 2l of nc o2 satting 94%. on the floor she is alert and
oriented. she does not know what caused her swelling. she denies
new pills, new medications, or new foods. she feels well and has
no sob, itching, or complaints.
.


past medical history:
# gave - s/p argon treatment, last on last on [**2150-3-11**]
# hepatitis c
# cirrhosis
- child's class a, portal htn, grade 1 varices
- no h/o ascites, encephalopathy, variceal bleeding, synthetic
function intact
# dm type ii
# htn
# iron deficiency anemia
# s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
# hypercholesterolemia
# osteopenia
# insomnia
# angioedema [**3-26**] possibly due to bactrim but as yet not proven

social history:
lives alone in [**location (un) 583**] in [**hospital3 4634**] complex. is widowed.
has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
holidays). worked in food business in sales.


family history:
no family history of allergic diseases

physical exam:
gen: pleasant elderly lady in nad, speaking comfortably, no
cyanosis, jaundice, or dyspnea
vs: 99.4 124/58 82 18 94% on 2l nc
heent: mmm, no op lesions, tongue nl size, neck supple, no lad
or thyromegaly
cv: rr, nl s1 s2 no s3 s4 mrg
pulm: roncherous breath sounds with scattered wheezes and
crackles 1/4 up the lung fields
abd: bs+, nt, ventral hernia, gas on percussion, no masses or
hsm, no fluid wave, + collaterals and angiomata
limsb: no le edema, + clubbing
neuro: perrla, eomi, moving all limbs, reflexes 2+ of the biceps
and petellar tendons.


pertinent results:
admission labs:
[**2150-4-17**] 05:15am blood wbc-7.4 rbc-3.41* hgb-10.2* hct-31.4*
mcv-92 mch-29.9 mchc-32.5 rdw-16.7* plt ct-139*
[**2150-4-17**] 05:15am blood glucose-132* urean-27* creat-1.1 na-143
k-4.3 cl-112* hco3-24 angap-11
[**2150-4-18**] 08:30am blood alt-112* ast-59* ld(ldh)-203 alkphos-99
totbili-1.7*
[**2150-4-17**] 05:15am blood calcium-8.6 phos-2.8 mg-2.4
.
discharge labs:
[**2150-4-21**] 05:50am blood wbc-5.0 rbc-3.13* hgb-9.6* hct-28.4*
mcv-91 mch-30.7 mchc-33.8 rdw-16.9* plt ct-200
[**2150-4-21**] 05:50am blood glucose-91 urean-34* creat-1.4* na-137
k-3.9 cl-103 hco3-24 angap-14
[**2150-4-20**] 05:40am blood alt-55* ast-34 ld(ldh)-182 alkphos-83
totbili-1.3
[**2150-4-20**] 05:40am blood albumin-2.6* calcium-8.3* phos-3.5 mg-2.0

brief hospital course:
85f with a h/o gave s/p argon laser treatment last on [**2150-3-11**],
iron deficiency anemia due to chronic ugib, cirrhosis [**1-19**] hcv,
portal htn with grade 1 varices but no history variceal
bleeding, cri (baseline cr = 1.2-1.5) who is s/p prolonged
intubatation for angioedema of unknown etiology - possibly due
to bactrim. she is doing very well on s/p extubation at this
point. all antihistamines have been discontinued at this point.
she was progressively be restarted on her home meds.
.
# angioedema: resoved. lack of hives, bronchospasm or
hypotension suggests that this was not allergic angioedema but
rather bradykinin related. c3 and c4 were low. c1 esterase
inhibitor pending, [**doctor first name **] neg. per allergy consult at [**hospital 7302**] prior to transfer, non-allergic angioedema
is due to complement depletion (either hereditary or ca related)
or complement activation (infection or transfusion). the patient
did have a transfusion recently which may be related.
medications would also be high on the list of etiologies. common
offenders are nsaids and aceis, but arbs have also been
implicated.  it was discovered that the pt was taking bactrim
when the reaction leading to her admission. this is a possible
offender and has been added to her allergy list. restarted home
meds one by one. all but felodipine have been restarted. had
hives and itching the day prior to discharge which did not
generalize and seemed more of a contact dermatitis on the l arm.
no new medications were started so it is unclear what initiated
this. responded to hydroxyzine x1. also of note, the patient
refused to shower or be washed down this admission which may
contribute to her itchiness.
.
# chronic ugib: received regular blood transfusions as an
outpatient for any hct < 30. in the past she only needed them
infrequently but her transfusion requirements have increased
lately. transfused prior to discharge. [**month (only) 116**] need outpatient
follow up with gi (dr [**first name8 (namepattern2) 1158**] [**last name (namepattern1) 679**] has been recommended by her
outpatient gastroenterologist [**first name4 (namepattern1) 2127**] [**last name (namepattern1) 10113**]).
.
# wheezes and ronchi: related to angioedema and volume overload
most likely. resolved with diuresis and nebulizers.
.
# hx hcv complicated by cirrhosis. no evidence of encephalopathy
now, but is at risk. continued lactulose. continued
spironolactone [aldactone] - 50 mg daily. continue furosemide
[lasix] - 40 mg daily. continue nadolol - 80 mg daily as ppx
against variceal bleeding.
.
# htn: holding home ccb as normotensive. on nadolol as above.
.
# cri: baseline 1.5, was elevated on admission to [**hospital3 5097**] to
1.7. at baseline on discharge.
.
# diabetes: iss in house. discharged on metformin.

medications on admission:
home medications:
felodipine - 10 mg qam and 5 mg qpm
folic acid - 1 mg daily
furosemide [lasix] - 40 mg daily
hydrocortisone acetate [anusol-hc] - 25 mg daily
lactulose 10 gram/15 ml daily
metformin - 1000 mg qam and 500 mg qpm
mupirocin - 2 % ointment [**hospital1 **]
nadolol - 80 mg daily
pantoprazole - 40 mg [**hospital1 **]
spironolactone [aldactone] - 50 mg daily
sucralfate - 1 g tid
zolpidem - 5 mg tablet - [**12-21**] qhs prn
calcium carbonate-vitamin d2 - 500 mg-375 unit [**hospital1 **]
cyanocobalamin - 500 mcg daily
ferrous gluconate - 325 mg 5 times a day
sarna ultra [**hospital1 **]


discharge medications:
1. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one
(1) tablet po twice a day.
disp:*60 tablet(s)* refills:*11*
2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*11*
3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
4. anusol-hc 25 mg suppository sig: one (1) suppository rectal
once a day.
disp:*30 suppositories* refills:*6*
5. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po once a
day.
disp:*450 ml(s)* refills:*11*
6. metformin 500 mg tablet sig: two (2) tablet po qam.
disp:*60 tablet(s)* refills:*5*
7. metformin 500 mg tablet sig: one (1) tablet po qpm.
disp:*30 tablet(s)* refills:*5*
8. nadolol 80 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*5*
10. spironolactone 50 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*5*
11. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
disp:*30 tablet(s)* refills:*0*
12. b-12 dots 500 mcg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*11*
13. ferrous gluconate 325 mg tablet sig: one (1) tablet po five
times a day.
disp:*150 tablet(s)* refills:*11*


discharge disposition:
home

discharge diagnosis:
angioedema

discharge condition:
stable vital signs, at baseline

discharge instructions:
you were admitted at [**first name8 (namepattern2) 1495**] [**hospital **] hospital with angioedema,
or swelling in your mouth and throat. you had a breathing tube
placed for this. you were then transfered to [**hospital1 771**] where you had the breathing tube taken
out. you improved clinically and were discharged to home.
.
please continue to take your medications as ordered. because you
had a likely medication reaction that led to your angioedema you
should throw out your old medications. do not take any
supplements. here is your updated medication list list:
1. stop taking felodipine for now
2. calcium + vitamin d twice daily
3. vitamin b12 daily
4. folic acid daily
5. furosimide 40mg daily
6. anusol daily as needed for hemorrhoids
7. metformin 1000mg (2 pills) in the morining and 500mg (1 pill)
in the evening
8. lactulose 15ml daily to 3 bowel movements per day
9. nadolol 80mg daily
10. pantoprazole (protonix) 40mg twice daily
11. spironolactone 50mg daily
12. zolpidem (ambien) 5mg at night as needed for insomnia
13. iron 5 times daily
.
please attend your follow up appointments.
.
please call your doctor or come to the emergency room if you
experience swelling of you face or tongue, chest pain,
palpitations, shortness of breath, wheezing, bleeding, or other
concerning symptoms.

followup instructions:
md: [**name6 (md) 10160**] [**name8 (md) 10161**], np
specialty: priamry care
date and time: [**last name (lf) 766**], [**5-4**] at 4pm
location: [**hospital3 **]
phone number: [**telephone/fax (1) 250**]
special instructions if applicable: booked with russain
interpreter


completed by:[**2150-4-22**]"
13,"admission date:  [**2124-12-15**]     discharge date:  [**2124-12-16**]

date of birth:   [**2068-7-22**]     sex:  m

service:  micu

history of present illness:   this is a 56 year old man with
a history of lung cancer status post radiation therapy and
chemotherapy and chronic obstructive pulmonary disease, who
presents with acute dyspnea and oropharynx swelling.  the
patient states that he was in his usual state of health when
three hours after eating a dinner of shrimp and scallops,
began to develop burning and warmth of his posterior cervical
neck and forehead.  he went to cvs to get some benadryl and
on the way became progressively short of breath and
complained of upper and lower lip swelling.  the emergency
medical services was activated.  he was found to be
stridorous with a blood pressure of 60/palpation complaining
of his throat closing up.

the patient received epinephrine 0.3 subcutaneously and
benadryl 50 mg intravenous en route to the hospital and his
blood pressure normalized.  the patient was saturating at 98%
on room air.  he received intravenous solu-medrol and
intravenous cimetidine.

the patient reported a history of swelling after a bee sting
30 years ago for which he went to the emergency room and
received intravenous benadryl.  he consumes shellfish
regularly and has had no adverse events in the past.  the
patient is currently on chemotherapy, the cycle beginning in
[**month (only) 359**].  his last dosage of medication being approximately
two weeks prior to presentation.

past medical history:
1.  nonsmall cell lung cancer status post chemotherapy and
radiation therapy found to be non-surgical on thoracotomy.
evidence of metastases to the left adrenal gland.
2.  emphysema.
3.  depression.
4.  status post tonsillectomy.

medications:
1.  chemotherapy.
2.  combivent two puffs four times a day p.r.n.
3.  wellbutrin 150 mg twice a day.

allergies:   no known drug allergies.

physical examination:   vital signs were afebrile.  blood
pressure 94/48; pulse 109; respirations 20; saturation of 98%
on room air.  in general, in no apparent distress, alert and
oriented times three.  the patient is speaking in full
sentences.  no respiratory distress.  heent:  normocephalic,
atraumatic.  pupils are equal, round and reactive to light.
extraocular movements intact.  sclerae anicteric.  there is
swelling of the upper and lower lips and question of swelling
of the tongue; no airway compromise, no lymphadenopathy.
chest is clear to auscultation bilaterally.  cor:
tachycardia, normal s1, s2, no murmurs, rubs or gallops.
abdomen is soft, nontender, nondistended.  no
hepatosplenomegaly or masses.  positive bowel sounds.
extremities are warm and well perfused.  positive for
clubbing.  no cyanosis of edema.  neurological:  cranial
nerves ii through xii are intact.  he moves all extremities.
strength is five out of five.

laboratory:  white blood cell count 3.9, hematocrit 30.4,
platelets 494.  sodium 143, potassium 4.4, chloride 107,
bicarbonate 29, bun 13, creatinine 0.7, glucose 130.  serum
toxicology screen negative.

ekg with sinus tachycardia at the rate of 114.

chest x-ray with ill defined density overlying the right
superior hilum suggestive of a mass.  right lateral pleural
thickening, rib fractures and atelectatic changes consistent
with post surgical change.

hospital course:
1.  anaphylaxis:  the patient was started on intravenous
hydrocortisone, intravenous famotidine and intravenous
diphenhydramine,.  he was admitted and observed in the
medical intensive care unit given his history for previous
anaphylaxis in the setting of p.o. allergen.

the patient remained hemodynamically stable and his
angioedema resolved.  it seemed unusual that the patient
would develop an allergy to shellfish at the age of 56.  it
was suspected that the patient's history of chemotherapy may
have put him at risk for this allergic reaction.

the patient will be discharged with the plan to follow-up
with his primary care physician on [**name9 (pre) 766**], [**12-18**].  he
will be referred to an allergist and is instructed in the use
of an epinephrine pen which he will carry with him at all
times, keeping one in the glove compartment of his car and
one in his house.

the patient will complete a rapid steroid taper.

2.  lung cancer:  this is followed by the patient's
oncologist at the [**hospital3 328**].

3.  tachycardia:  the patient remained in sinus tachycardia
in the low 100s throughout his hospital course.  this was
felt to represent the physiologic response to the patient's
anemia.  this will be followed up at the patient's primary
care physician.

4.  the patient's anemia was felt to be secondary to
chemotherapy.  further evaluation is deferred to the
patient's primary care physician.

condition on discharge:   good.

discharge status:   to home.

discharge diagnoses:
1.  anaphylaxis to shellfish.
2.  nonsmall cell lung cancer.
3.  resting tachycardia.

discharge medications:
1.  prednisone taper, 40 mg times one day, then 20 mg times
one day.
2.  albuterol ipratropium mdi one to two puffs q. six hours
p.r.n.
3.  bupropion 150 mg p.o. twice a day.
4.  benadryl 50 mg p.o. q. six hours p.r.n.
5.  epinephrine pen 1/[**numeric identifier 4856**] syringe, one injection
intramuscular p.r.n. anaphylaxis.

discharge instructions:
1.  the patient will follow-up with his primary care
physician, [**last name (namepattern4) **]. [**last name (stitle) 6512**], at the southern [**hospital 12162**] health center on
[**12-18**], at 11:30 a.m.
2.  the patient will be referred to an allergist for further
evaluation.




dictated by:[**name8 (md) 96586**]

medquist36

d:  [**2124-12-16**]  12:15
t:  [**2124-12-16**]  19:17
job#:  [**job number 96587**]
"
14,"admission date:  [**2160-6-15**]     discharge date:  [**2160-6-22**]


service:

chief complaint:  ""i've been feeling bad for the last few
days and since yesterday i have been nauseous and vomiting.""

history of present illness:  the patient is a 77-year-old man
who presents with the above chief complaint and his past
medical history includes numerous medical problems including
non q wave mi times two, status post cabg in [**2139**],
hypertension, insulin dependent diabetes mellitus,
hypercholesterolemia, history of tias, history of lower gi
bleed and diverticulosis.  the patient was in his usual state
of health until approximately 4-5 weeks ago when his
degenerative joint disease and disc disease of his lumbar
spine began causing shooting right lower extremity pains.  at
that time the patient was treated with steroid injections and
po prednisone which caused an increase in his blood sugars.
for this increase in blood sugars he was started on humalog
approximately 3-5 days ago as his sugars have been in the
300-400's on his previous regimen.  approximately one week
ago the patient began feeling bad and run down.  the
patient's primary care doctor believed it was due to the high
blood sugars and started the humalog 3-5 days ago.  yesterday
the patient reports the onset of nausea and vomiting after
eating.  he tolerated lunch as his last meal and he has not
taken any po today.  also today he reports the onset of loose
stools times three.  he denied any fevers, abdominal pain,
weight change or urinary symptoms.  he does acknowledge night
sweats and chills at night over the last two days.  he has a
chronic cough secondary to post nasal drip which is
unproductive of sputum.  there is no erythema over the skin
where he injects his insulin.  his exercise tolerance is
approximately one flight of stairs and he is limited by right
lower leg pain.  he also denies any chest pain, shortness of
breath, palpitations or diaphoresis.  he has no pnd.  the
patient finally came to the er as he was not able to take
anything by mouth.

past medical history:  1) insulin dependent diabetes
mellitus.  2) hypertension, poorly controlled.  3) chronic
renal insufficiency.  4) status post non q wave mi times two.
5) status post cabg in [**2139**].  6) hypercholesterolemia.  7)
history of tia.  8) gout.  9) lower gi bleed status post
polyp removal.  10) diverticulosis.  11) allergies and post
nasal drip.

medications:  [**doctor first name **] 60 mg po q d, lopressor 20 mg po q d,
multivitamin, doxazosin 4 mg q h.s., lipitor 20 mg po q d,
allopurinol 300 mg po q d, ranitidine 150 mg po q h.s.,
glyburide 10 mg po bid, diovan 80 mg po q d, enteric coated
aspirin 325 mg po q d, quinine as needed, nph 20-30 units q
a.m., 10-15 units q p.m., humalog sliding scale started three
days ago.

social history:  the patient lives with his wife.  [**name (ni) **] denies
any tobacco or alcohol use.

family history:  noncontributory.

allergies:  morphine makes him nauseous.

physical examination:  vital signs, temperature 99.5, heart
rate 83, blood pressure 170/125, respiratory rate 18, satting
100% on two liters nasal cannula.  in general he is an
elderly man lying in bed in no acute distress.  heent:  he
has alopecia, pupils are equal, round and reactive to light
from 3 to 2 mm, sclera are anicteric.  mucus membranes are
moist.  neck supple, no jugulovenous distension, no
lymphadenopathy, no bruits.  cardiac exam, irregularly
irregular, s1 and s2 normal, no murmurs, gallops or rubs.
lungs are clear to auscultation bilaterally. abdomen, mild
tenderness to deep palpation of the left lower quadrant.  he
is non distended, bowel sounds present and normal.  abdomen
is soft.  gu, normal male genitalia, trace guaiac positive on
exam.  prostate without any nodules, regular and smooth.
extremities, no clubbing, cyanosis or edema. neuro, he is
alert and oriented times three, cranial nerves ii through xii
normal.  reflexes 2+ bilaterally biceps and achilles
strength, [**3-29**] upper extremities bilaterally, in the left
lower extremity is 4+/5 strength in his right big toe and
plantar and dorsiflexion of his foot.  gait and coordination
were not tested.

laboratory data:  white count 14.6, differential with 84
neutrophils, 1 band, 10 lymphs, hematocrit 44.4, platelet
count 134,000, pt 11.7, ptt 21.4, inr 0.9.  sma 7, 137, 5.2
which was hemolyzed, 100, 21, 40, 1.4, glucose 297.  calcium
8.4, phosphorus 4.7, magnesium 2.1, ast 24, alt 28, total
bilirubin 0.9, ck 54, troponin 0.3, alkaline phosphatase 59,
amylase 114, lipase 41, albumin 3.3, uric acid 4.3, tsh is
pending at this time.  chest x-ray showed no signs of
pulmonary edema and no infiltrate.  ekg was irregularly
irregular at 92, axis -30, occasional p waves, looking like
flutter but there are also absent p waves.  intervals are
normal.  there is a q in 3 and f, no st changes, poor r wave
progression.  an echocardiogram from [**2160-4-25**] showed mild
left atrial dilatation, non obstructive focal septal
hypertrophy, depressed lv function 1+ aortic regurg, mild mr
[**first name (titles) **] [**last name (titles) **] fraction could not be estimated at that time.

impression:  this is a 77-year-old man with multiple ongoing
medical problems who presents with generalized complaints of
the last week and a [**11-27**] day history of nausea and vomiting
and loose stool.  he was found to be in new onset atrial
fibrillation in the er.  physical exam was remarkable for the
atrial fibrillation with guaiac positive stool and mild left
lower quadrant tenderness.  labs revealed an increased white
blood cell count with left shift and low albumin.  chest
x-ray and ekg are normal and unchanged respectively.

plan:
cardiac:  the patient has known cad.  his aspirin, beta
blocker, lipitor and [**last name (un) **] will be continued.  his hypertension
will be aggressively controlled.  although ischemia is
unlikely without any changes in ekg, cks will be followed.
the patient is in new onset atrial fibrillation but lopressor
will be increased to 50 mg [**hospital1 **] for rate control.  tsh is
pending after weighing the risks and benefits of heparin.
given the patient's trace guaiac positive stool, history of
lower gi bleed, the decision was made to start the patient on
heparin as he had multiple risk factors for stroke elevating
him into a higher level of category including his past
history of tias.

infectious disease:  he has an elevated white count with a
left shift.  he has night sweats, chills times two days.
cultures of urine, stool and blood will be sent.  blood
cultures will be obtained when the patient's fever curve is
greater than 101.  no empiric antibiotics will be started at
this time.

endocrine:  the patient has poor glucose control.  he will be
written for an insulin sliding scale while in the hospital
and fingersticks will be checked qid.  his oral hypoglycemics
will be held for now.

gi:  he is trace guaiac positive with left lower quadrant
tenderness and a history of diverticulosis.  diverticulitis
is certainly a possibility although given the benign
presentation of his abdomen on exam, it is unlikely.
however, we will continue to follow his abdominal exam.  we
will guaiac all stools and we will follow hematocrit q d on
heparin.  the patient will be given antiemetics as needed to
control the nausea and vomiting.

renal:  the patient has a creatinine of 1.4 with an elevated
bun to creatinine ratio.  he is most likely dehydrated given
his nausea and vomiting and slightly prerenal and will be
hydrated.

musculoskeletal and neuro:  he has decreased strength in his
right lower leg consistent with his past medical history of
djd and disc disease of his lumbar spine.  his pain will be
controlled with non opioids as much as possible as opioids
have given him bad reactions in the past.  the patient was
admitted and this plan was pursued.

hospital course:  on hospital day #2 the patient had no
adverse events overnight.  the stool samples and the tsh are
still pending.  the patient is maintained on heparin and the
plan will be to transition him to coumadin, then to discharge
the patient and bring him back at 1-2 months for tee and
cardioversion at that time after anticoagulation, as it is
unknown how long patient has been in atrial fibrillation.
also on this admission the plan is to control his blood
sugars, hopefully the combined approach will lead to a
resolution of his nausea and vomiting and he can go home.  on
hospital day #3 the patient complained of some right thigh
swelling.  he was neurovascularly intact and this was thought
to be secondary to a muscle pull the patient experienced
approximately five days prior to admission.  there was a
small hematoma.  this is most likely exacerbated because of
the heparin the patient has been on, but the team was not so
concerned about this.  also on the third hospital day the
patient became tachycardic and hypotensive with blood
pressure in the 60's/30's.  the patient was somnolent at this
time.  exam was unchanged from prior.  iv fluids were given
and ekg was done that was unchanged.  the heparin was
discontinued and an ng lavage was performed that showed dark
brown fluid in the stomach with occasional clots which were
gastroccult positive.  with the lavage, the red fluid did not
clear.  a stat hematocrit came back at 26 which was down from
44 on admission, although this is partly due to rehydration,
this is significantly due to an upper gi bleed.  the patient
was transferred to the ccu at that time and transfused two
units of packed red blood cells.  the patient underwent
emergent egd that showed clotted blood in the lower third of
the esophagus and multiple non bleeding diffuse erosions in
the lower third of the esophagus.  the stomach was normal.
in the duodenum there were multiple acute crater ulcers in
the bulb and in the second part of the duodenum.  pigmented
material coating these ulcers suggested recent bleeding in
one of the ulcers.  the patient was treated with proton pump
inhibitor [**hospital1 **], discontinuation of all nsaids and
anticoagulation.  hematocrits were continually followed and
an h. pylori antibody was checked.  the tsh level came back
as normal at this time.  on the fourth hospital day the
patient was transferred back to the floor from the unit after
the egd and the 2 units of packed cells when patient was
stabilized.  on hospital day #5 the patient's main complaint
was his right thigh swelling leading to right thigh weakness
when he stood up.  he denied anymore episodes of
lightheadedness, dizziness, chest pain, shortness of breath,
bright red blood per rectum, melena or vomiting of blood.  at
this time his aspirin was changed to 81 mg from 325 mg and
the patient was not on either heparin or coumadin.  the
patient's hematocrit post transfusion rose to 31 and has
continued to rise since then.  his creatinine and bun bumped
transiently during the patient's hypovolemia episodes.  they
are now trending down.  the nph and regular insulin sliding
scale is controlling the patient's blood sugars.  [**initials (namepattern4) **] [**last name (namepattern4) **]
consult was obtained because the patient is usually followed
in [**last name (un) **], to further optimize the patient's insulin regimen.
the plan is to treat the patient for one month with proton
pump inhibitors, to follow-up the results of the h. pylori,
treat that if positive and to allow the ulcers one month to
heal.  the patient will return for a repeat upper endoscopy
in one month.  at that time if the ulcers are healed,
anticoagulation will be pursued with the eventual goal of
performing a tee and cardioversion either chemical or
electrical, once the patient has been on stable
anticoagulation for one month.  hospital day #6 the patient's
diet was advanced as tolerated.  physical therapy saw the
patient who agreed he was safe for discharge home.  on
hospital day #7 the patient slowly was regaining his strength
in his right leg and mobility.  he was starting to ask to go
home.  on hospital day #8 he was discharged home.  he will
follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 1313**], dr. [**last name (stitle) 19862**] from endocrine
and dr. [**first name (stitle) 1104**] from cardiology.  all of those attendings are
aware of the [**hospital 228**] hospital course.  the patient's
lopressor dose at the time of discharge is 37.5 mg po tid.
the h. pylori result came back positive.  he will be treated
for h. pylori infection.  he will follow-up with gi in [**2-29**]
weeks for repeat upper endoscopy.




                          [**first name11 (name pattern1) **] [**last name (namepattern4) 31943**], m.d.  [**md number(1) 31944**]

dictated by:[**last name (namepattern1) 8228**]

medquist36

d:  [**2161-1-28**]  12:05
t:  [**2161-1-28**]  14:07
job#:  [**job number **]
"
15,"admission date:  [**2125-10-8**]              discharge date:   [**2125-10-19**]

date of birth:  [**2055-7-28**]             sex:   f

service: omed

allergies:
codeine / carboplatin / cisplatin

attending:[**last name (namepattern1) 5062**]
chief complaint:
fatigue, acute hematocrit drop

major surgical or invasive procedure:
none

history of present illness:
initial hx prior to icu admission:
this is a 70 yo f w/ h/o relapsing papillary serous ovarian
cancer last first diagnosed in [**2117**].  she was last admitted to
this hospital for her 7th cycle of cisplatin.  she was given
[**doctor last name **]/taxol once in [**2117**], and was changed to [**doctor last name **]-cytoxan for
low counts in 01/[**2118**].  she tne received six cycles of cisplatin
started in [**1-/2125**] and administered in the hospital because of
the questionable history of allergic reaction to carboplatin.
-
since that admission, she showed signs of fluid retention, both
in her legs and in her ascites but she did not have any evidence
of congestive heart failure based on exam with normal lungs and
flat jvd. there was concern that perhaps her cancer was
progressing and that is the reason for her tense ascites, but
consideration was also given to worsening renal failure as
explanation for increased ascites.  ct scan taken [**2125-9-21**] showed increased ascites, but otherwise stable exam with
mesenteric masses and evidence of peritoneal carcinomatosis that
appear unchanged when compared to [**2125-7-25**].
-
her husband reported some recent confusion during their clinic
visit on [**9-26**].  due to her creatinine clearance of about
20ml/min, the decision was made during this visit to switch the
patient to weekly gemzar despite the stability of dz achieved
w/cisplatin.  due to her decreased creatinine clearance, a
reduced dose of 500 mg per meters squared was chosen.  she was
started on this dose on [**10-3**] and acutely tolerated it well.  the
plan was for weekly gemzar, three weeks on and one week off.
-
the patient first felt different from her normal self on
saturday, when she ""started to feel lousy.""  she saw an
accupuncturist on sat. for posterior neck pain; needles were
inserted into her head, back and ankles.  on sunday, her
weakness progressed to the point that she could no longer stand.
 her husband noted a bloodshot left eye ealier today, now
resolved.  she recently fell on her left buttock.
-
on ros, the patient notes moderate to severe abdominal pain for
the past several days, especially before meals and sometimes
resolved with food.  she sleeps with three pillows.
-
today, the patient's fellow contact[**name (ni) **] her.  she reported the
above symptoms and was told to come to clinic.  her hematocrit
has decreased from 33 to 17 and so she was admitted to omed and
immediately transferred to icu as inr>60.

on transfer back to omed from icu:

mrs. [**known lastname 1661**] is a 70 y/o f with recurrent ovarian ca, s/p cabg,
s/p mv repair, and hypothyroid, presented from onc clinic on
[**2125-10-8**] with weakness, nausea, and decreased po intake since
gemcitabine tx on [**2125-10-3**] and on clinic visit [**10-8**] was found to
be hyptotensive, decrease hct (from 33.0 to 17.1), and inr>60.
patient was initially admitted to omed service, but transferred
to micu for further evaluation. please see micu admit note for
more information on past medical hx and course during stay. in
brief, patient was admitted for hemodynamic stability and work
up of coagulopathic state. mrs. [**known lastname 1661**] denied diarrhea,
hematuria but did report very slight brbpr on toilet paper. she
was trace guiac positive on admission. she had diffuse
ecchymosis over lower extremities, back, and buttocks. she
received 6 units of prbc's with appropriate bump in hct to 34.1
on [**10-16**].  in terms of her coagulopathy, it is thought that a
combination of coumadin (for h/o dvt), decrease po intake, and
recent administration of gemcitabine were instigating factors.
coumadin held on admission. she received 1 unit ffp and was
initially treated with po vitamin k while in micu, with decrease
in inr to 3.0 on morning of [**10-17**]. on [**10-17**] she received 1 mg iv
vitamin k. her initial mixing studies were negative for
inhibitors. shortly after receiving the 6 units of blood,
patient became sob secondary to fluid overloaded state. she was
diuresed and responded well to lasix; however, creatinine began
rising (above baseline of ~2.6) likely because of hypovolumia
and decrease blood flow to kidneys. patient was subsequently
gently hydrated, with impoved renal status.  creatinine 2.8 on
[**10-16**]. during fluid overloaded state, mrs. [**known lastname 1661**] also developed
afib, which per family was new onset. after cardiology consult
and discussion with primary oncology team, it was decided to
cardiovert patient. she tolerated well and is now in nsr.
nutrition is still an issue for patient, as she has decrease
appetite. also, she was seen by pt for gait instability/[**month (only) **]
balance. mrs [**known lastname 1661**] appears well and states that she is feeling
good. she is anxious to get up and walk around the floor.
patient currently denies and n/v/dizziness. no f/c/ns/sob/cp.
she has not urinated since foley d/c'ed this morning but feels
that she might be able to go soon. urinary retention was not a
problem for her prior to admission.


past medical history:
1.relapsing papillary serous ovarian ca as above--hx onc
therapy:
she was diagnosed in [**2117**].

she is status post carboplatin and taxol times one in [**2117**],
changed to [**doctor last name **]- cytoxan because of low counts in 01/[**2118**].

status post cytoxan and cisplatin times two and then cytoxan and

carboplatin times four from [**6-/2119**] to 09/[**2119**].
status post [**doctor last name **] times six until 05/[**2121**].
status post taxol times eight from [**3-/2123**] to 10/[**2123**].
status post oral etoposide times one, discontinued because of
mouth sores in 11/[**2123**].
status post carboplatin times two, discontinued because of an
allergic reaction that occurred in 12/[**2123**].
status post cisplatin times three from [**1-/2124**] to [**4-/2124**],
discontinued because of rising creatinine.
status post weekly taxol but discontinued because of disease
progression.
started on cisplatin 50 mg/m2 in [**9-/2124**] status post two cycles
at that time, discontinued because of rising creatinine.
status post two cycles with navelbine, discontinued because of
disease progression.
status post seven cycles of cisplatin started in [**1-/2125**] and
administered in the hospital because of the questionable history

of allergic reaction to this medication given the fact that she
had an allergic reaction to carboplatin in the past. cisplatin
was discontinued due to rising cr.
status post gemzar treatment last wednesday, [**2125-10-3**]
-
2. yeast infection [**2125-8-29**]
-
3.cad s/p cabg and mvr
-
4. h/o le dvt
-
5.cri
-
6. hyperchol.
-
7. gout
-
8. hypothyroidism


social history:
married, 30 pack yr tob, quitx20 years, no etoh, no ivda.

family history:
mother=[**name (ni) **]
father:prostate ca
brother:pd
m aunt=ovarian ca
cousin=ovarian ca


physical exam:
[**10-8**]:
vitals: 99.4  76-80 (76)  94/42
gen: pale woman relaxing in bed in nad, brighter appearing than
yesterday evening or this morning
neck: supple, perrl, eomi, conjunctivae remain pale, mouth and
oropharynx clear
lungs: ctab
heart: rrr
abd: soft, distended, nt
ext: warm x 4 with pulses x 4
skin: left large ecchymosis on buttocks slighly increased in
size and color since yesterday, bil hands, abdomen

[**10-16**]:
pe:t:98.0  p: 68-75   bp: 86-128/44-99   rr:24 o2:93-98%
gen: patient is pleasant, pale appearing elderly female, nad
heent: perrl - consenusally, eomi, sclerae anicteric; supericial
ulcer on r side of tongue, blood blister on back l tongue; neck:
supple, from, no lad
lungs: cta with bibasilar crackles
cardiac: rrr, no m/g/r
abd: moderate distention-but not firm, no peritoneal signs,
nontender, no masses appreaciated, +bs, resolving ecchymosis on
luq of abd.
ext: 2+ pitting edema of le bilat. diffuse ecchymosis of b/l
buttocks r>l, and upper thighs, mostly resolved on l left
extremity; few small ecchymosis on l wrist. resolving per micu
notes.
neuro: a&ox3; responding appropriately, very talkative, cn2-12
intact with no focal deficit. strength 5/5 throughout.


pertinent results:
crit: baseline mid 20s; [**10-3**] 33  [**10-5**] 17.1  9/21@1430 following
3u 28.6
pt: [**9-5**] 13.7  [**10-8**] >100  [**10-9**] following 1u ffp 24.8, 32.6
ptt: [**9-5**] 23.6  [**10-8**]  150, 143 [**10-9**] following 1u ffp 61.7, 48.8
platelets: [**10-8**] 263 [**10-9**] 162

ct of the chest without iv contrast: there are minor dependent
atelectatic
changes. extensive atherosclerotic changes of the aorta and
coronary arteries
are evident. multiple prominent but nonpathologically enlarged
mediastinal
lymph nodes are identified. there is a large hiatal hernia. no
pleural or
pericardial effusions are present.

ct of the abdomen without iv contrast: there is a
moderate-to-large amount of
ascites within the abdomen, but no evidence of an intra- or
retroperitoneal
hematoma. allowing for the limitations of a noncontrast exam,
the liver,
gallbladder, spleen, pancreas, adrenal glands, and kidneys are
within normal
limits. extensive aortic calcifications are again noted. no
pathologically
enlarged retroperitoneal or mesenteric lymph nodes are
identified in this
limited study. there is no free air.

ct of the pelvis without iv contrast: a large volume of ascites
is present
within the pelvis. the urinary bladder is unremarkable. there is
sigmoid
diverticulosis without diverticulitis.

bone windows: no suspicious lytic or blastic leions are
identified.

impression: moderate-to-large volume of ascites, but no evidence
of intra- or
retroperitoneal hemorrhage.

[**10-9**] chest ap:
portable ap chest: comparison is made with a chest ct scan from
[**2125-10-8**]. again seen is a left subclavian port with the tip in the
svc, in
satisfactory position. there is no pneumothorax. there are
multiple
mediastinal clips and a prosthetic mitral valve. there is stable
cardiomegaly
with mild upper lung zone redistribution. there is a large
hiatal hernia with
associated atelectasis in the left lower lobe. there is
worsening right lower
lobe atelectasis.


brief hospital course:
a/p: mrs. [**known lastname 1661**] is a 70 yo female with h/o recurrent ovarian
cancer who recieved first dose of gemcitabine on [**2125-10-3**] and
presented to clinic on [**10-8**] with hypotension, drop in hct
(33-->17), and inr>30, admitted to icu. icu course c/b fluid
overload, acute on chronic renal fl., and afib. transferred to
omed on [**10-16**] hemodynamically stable, inr 3.0 and 34.1.

1. coagulopathy - patient admitted with an inr >60, 3.0 on [**10-16**].
thought to be [**2-19**] combination of decrease po intake, coumadin,
and gemcatabine.  continue to hold coumadin. as per hpi, treated
with ffp and vitamin k in icu with inr decrease to 3.0. given
1gm vitamin k iv [**10-16**] prior to transfer to floor. inr 2.1 day
prior to discharge and 2.9 on day of discharge. per primary
oncology team, she was given 10mg po vitamin k prior to
discharge and will f/u in clinic in 3 days to have inr
rechecked. coumadin was held on discharge.
2. anemia - patient with chronic anemia, but acute blood loss
internally to buttocks thighs in setting of coagulopathic state.
responded appropriately to 6 units prbc's in icu with hct
remained stabe once transferred to oncology service. she was
receiving procrit about once a week prior to admission to
hospital and received injection 3x/week during admisison. she is
to f/u with primary team on monday to discuss continuation of
procrit.
3. htn: blood pressures had been fluctuating while in icu and
initially holding of metoprolol. outpatient dose of metoprolol
25mg [**hospital1 **] and was restarted and switched to 12.5mg tid for while
in the icu. her blood pressures were well controlled on this
dose and she was discharged on 12.5 mg tid.
4. acute on chronic renal insufficiency - patient with baseline
creatinine of 2.4-2.7. creatinine had increased [**2-19**] to prerenal
azotemia while being diuresed in icu. trending to baseline on
transfer to floor. creatinine was 2.7 on day of discharge.
nephrotoxic medications were avoided during admission.
5. ovarian cancer -  s/p gemcitabine treatment [**10-3**], preceeding
admission and onset of previoulsy discussed adverse events. will
discuss with primary oncologist future treatment plans.
6. nutrition - mrs [**known lastname 1661**] has had poor appetite for some time,
which may have attributed to coagulopathic state.  seen and
evaluated by nutrition service. patient notes that her appetite
is slowly increasing and appeared to be eating about [**date range (1) 5082**] of
food on tray. discussed importance of eating green vegetables -
ie broccoli- but encouraged any po intake for now.
7. constipation - mrs. [**known lastname 1661**] has had difficulty moving bowels
x 1 week despite aggressive treatment. she was managed on senna
and colace and responded well to .5l of golytely to get bowels
started and then occassional miralax.
8. pt: physical therapy evaluated patient today and suggested
3-5 visits/wk to help with balance, gait, and transfers.
suggested possible rehab on discharge, but patient refused and
stated that she preferred home pt. also with ot evaluation with
suggestion of home aide to supervise shower transfers and home
safety evaluations.
9. cad/hyperlipidemia - continue atorvastatin during admission
and on dsicharge.
10. hypothyroid - continued outpatient dose of levothyroxil
during admission and on discharge.
11. episode of afib - patient was noted to be in afib during icu
stay (as per hpi). because of the desire to avoid need for
anticoagulation (if need for cardioversion if in afib >48 hours)
she was successfully  cardioverted on [**10-12**]. nsr throughout rest
of hospitalization.
12. fen: continue protonix, phosphagel, tums, and pneumoboots.
13. code: dnr/dni


medications on admission:
levoxyl 75 mcg p.o. daily, prilosec, coumadin 1mg qd,
lipitor, atenolol, anzemet, celexa, oxycontin b.i.d., iron,
procrit, renagel 40mg qd and ativan daily.

discharge medications:
1. levothyroxine sodium 75 mcg tablet sig: one (1) tablet po qd
(once a day).
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 q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*2*
3. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po
qd (once a day).
disp:*30 tablet(s)* refills:*2*
4. sevelamer hcl 400 mg tablet sig: one (1) tablet po tid (3
times a day).
disp:*90 tablet(s)* refills:*2*
5. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2
times a day).
disp:*120 capsule(s)* refills:*2*
6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day).
disp:*60 tablet(s)* refills:*2*
7. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
8. calcium carbonate 500 mg tablet, chewable sig: one (1)
tablet, chewable po tid w/meals (3 times a day with meals).
disp:*30 tablet, chewable(s)* refills:*2*
9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3
times a day).
10. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as
needed for anxiety.


discharge disposition:
home with service

facility:
[**hospital 119**] homecare

discharge diagnosis:
primary diagnosis:
1. coagulopathy
secondary diagnosis
1. ovarian cancer
2. malignant ascities
3. chronic renal insufficiency
4. congestive heart failure
5. h/o dvt
6. s/p mvr


discharge condition:
stable.

discharge instructions:
please call your pcp or come to the ed if you have notice
worsening bruising, bloody stools, shortness of breath, chest
pain, feves/chills, or other worrisome symptoms.
please follow up on monday in the [**hospital **] clinic to have your
labs drawn.
do not restart coumadin on discharge. please discuss restarting
this medication with your doctor when you return to the [**hospital **]
clinic on [**10-22**].


followup instructions:
1. please return to the oncology clinic on monday, [**2125-10-22**] to have your labs drawn.
2. please call your oncologist for an appointment in [**1-19**] weeks.
3. please call your pcp, [**last name (namepattern4) **]. [**first name (stitle) **] at ([**telephone/fax (1) 95873**] for an
appointment in [**1-19**] weeks.



"
16,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
17,"admission date:  [**2130-4-26**]              discharge date:   [**2130-5-3**]

date of birth:  [**2048-7-7**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 3223**]
chief complaint:
incarcerated right inguinal hernia
left lower extremity cellulitis


major surgical or invasive procedure:
[**2130-4-26**]: right inguinal herniorraphy with mesh


history of present illness:
81m with right inguinal hernia with non-reducible bulge since
noon today.  pain in right groin since then. noted some
discomfort as early as this morning. has had some nausea
throughout day as well.  no vomiting or other abdominal pain.
has not noted a hernia before.  additionally left leg has been
red for a couple of weeks; has been using cream and has not seen
a physician for it.  did not notice that it was swolen.


past medical history:
past medical history: hearing impaired (fluent with sign
language), chronic 1st degree heart block, recurrent atrial
fibrillation/ atrial flutter, s/p dccv [**2120-1-24**], s/p dccv
[**2121-8-8**], bradycardia, elevated psa, htn, hyperlipidemia, m.r.,
basal cell ca s/p excision

past surgical history: none


social history:
lives alone. works for [**company 2318**], independent in adls. no tobacco,
rare etoh.


family history:
mother breast cancer, leg cancer, stomach cancer. father cva.
brother w/ cabg at 64yrs.


physical exam:
on admission:
vitals:97.2 95 182/91 16 100%
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: rrr, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds. right groin with palpable
non-reducible
large hernia, hernia contents extending into scrotum as well,
ttp.
dre: normal tone, no gross or occult blood
ext: no le edema, le warm and well perfused


pertinent results:
[**2130-4-29**]
labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3*
mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93
urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12
[**2130-4-29**] 05:30am blood calcium-8.5 phos-2.4* mg-2.0

[**2130-4-28**]:
chest (portable ap):
severe bilateral opacities appear to be unchanged with no change
in the element of pulmonary edema. cardiomegaly is severe. known
pericardial effusion is most likely present. consolidations in
the left lower lobe are slightly asymmetric and might represent
superimposed abnormality such as infectious process, please
correlate clinically.

[**2130-4-27**]:
echo: impression: mildly depressed left ventricular systolic
function. moderately dilated right ventricle. focal asymetric
hypertrophy of the basal antero-septum. heavily calcified aortic
valve. moderate amount of pericardial effusion with no evidence
of tamponade physiology.

ecg: atrial fibrillation with rapid ventricular response and
probable ventricular premature beats. slight intraventricular
conduction delay may be incomplete left bundle-branch block.
delayed r wave progression may be due to intraventricular
conduction delay, left ventricular hypertrophy or possible prior
septal myocardial infarction, although is non-diagnostic. st-t
wave abnormalities are non-specific but cannot exclude
myocardial ischemia. clinical correlation is suggested. since
the previous tracing of [**2130-4-26**] the rate is faster and lateral
lead st-t wave changes appear more prominent.

chest (portable ap): findings: as compared to the previous
radiograph, there is unchanged massive cardiomegaly. in
addition, there is evidence of mild to moderate pulmonary edema.
presence of co-existing pneumonia cannot be excluded. no
pneumothorax.

bilat lower ext veins port: impression: no dvt in the right or
left lower extremity.

labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30*
11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm
blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33*

[**2130-4-26**]:
ecg: atrial fibrillation. slight intraventricular conduction
delay may be incomplete left bundle-branch block. delayed r wave
progression with late precordial qrs transition may be due to
intraventricular conduction delay, left ventricular hypertrophy
or possible prior anterior wall myocardial infarction, although
is non-diagnostic. st-t wave abnormalities are non-specific.
since the previous tracing of [**2130-3-28**] the ventricular rate is
faster and the qtc interval is shorter.

labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1*
mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1
inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98
hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 [**2130-4-26**] 05:50pm
blood ctropnt-<0.01


brief hospital course:
the patient presented to the emergency department on [**2130-4-26**] due to a non-reducible right groin bulge with associated
pain and nausea.  additionally, the patient reported left leg
erythema which had been present for a few weeks without fevers.
given physical findings consistent with incarcerated hernia, the
patient was taken to the operating room where he underwent a
laparoscopic right inguinal hernia repair with mesh. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

shortly following transfer to the general surgical [**hospital1 **], the
patient was triggered for lethargy, hypoxia and atrial
fibrillation with rapid ventricular response.  intravenous
metoprolol and lasix were administered and the patient was
maintained on a non-rebreather with improved oxygenation.  he
was subsequently transferred to the trauma intensive care unit
for further management.

neuro: the patient was somnolent post-operatively, which was
deemed post-operative baseline by the als interpreter, who
reportedely knew patient well.  the somnolence resolved by pod1
and he remained alert and oriented throughout the remainder of
his hospitalization.  the patient is deaf at baseline and was
able to communicate via an als interpreter.  pain was well
controlled with oral tylenol and intermittent intravenous
hydromorphone.
cv: the patient has baseline rate controlled atrial fibrillation
on warfarin.    however, as described above, he developed a fib
with rvr on pod 0, which responsed to intravenous metoprolol
without recurrence.  additionally, an ekg obtained upon transfer
to the icu revealed st changes; cycled cardiac enzymes were
negative.  an echocardiogram was obtained and revealed mildly
depressed left ventricular systolic function, a moderately
dilated right ventricle, focal asymetric hypertrophy of the
basal antero-septum, heavily calcified aortic valve and a
moderate amount of pericardial effusion with no evidence of
tamponade physiology.  his home medication regimen was resumed
and the patient remained stable from a cardiovascular standpoint
for the remainder of his hospitalization; vital signs were
routinely monitored.
pulmonary: as described above, the patient experienced an
episode of hypoxia on pod 0, likely due to pulmonary edema.
intravenous lasix was administered with immediate effect.  upon
arrival to the icu, the patient was placed on bipap, which was
weaned to nasal cannula on pod 1.  the patient remained stable
from a pulmonary standpoint for the remainder of his
hospitalization and was weaned off supplemental oxygen entirely
on pod 3. good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
gi/gu/fen: the diet was advanced to regular on pod 1, which was
well tolerated.   patient's intake and output were closely
monitored; electrolytes were repleted routinely.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.  the left lower extremity
cellulitis improved on intravenous cefazolin and treatment was
transitioned to oral antibiotics on pod 4, which will continue
for an additional seven days.
skin: a deep tissue injury to the sacrum was identified while in
the icu.  aggressive skin care was provided via nursing without
evidence of further skin breakdown.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to
ambulate early and often.  additionally, given the events of
pod0, a lower extremity ultrasound was obtained and was negative
for a dvt.
rehab: the patient received physical therapy while hospitalized
due to deconditioning, but was deemed unsuitable for discharge
to home.  short term rehabilitation was recommended to maximize
independence and regain conditioning and independence.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating with a walker and physical therapy, voiding
without assistance, and pain was well controlled.  the patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
he will be discharged to a rehab facility for additional
physical therapy.


medications on admission:
atenolol 25mg daily
finasteride 5mg daily
simvastatin 20mg daily
verapamil er 240mg daily
coumadin 1mg daily
vitamin d2 1,000 units daily
vitamin e 400 units daily

discharge medications:
1. verapamil 240 mg tablet extended release sig: one (1) tablet
extended release po q24h (every 24 hours).
2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every
8 hours).
3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm.
4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five
(5) ml po q6h (every 6 hours) as needed for cough.
5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day): hold for loose stool.
6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily).

7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
8. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
9. bisacodyl 10 mg suppository sig: one (1) suppository rectal
hs (at bedtime) as needed for constipation.
10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).

11. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every
6 hours) for 7 days.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - [**location (un) 550**]

discharge diagnosis:
incarcerated right inguinal hernia
left lower extremity cellulitis


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 an incarcerated right
inguinal hernia and subsequently underwent surgical repair with
mesh.  additionally, you were noted to have cellulitis on the
lower aspect of your left leg, which was treated with
antibiotics.  during your stay, you also received treatment from
a physical therapist, who recommended discharge to a
rehabiliation facility to furhter improve your conditioning and
independence.  you are now preparing for disharge to a
rehabiliation facility with the following instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service at [**telephone/fax (1) 600**] to make a
follow-up appointment within 2 weeks.
please contact your primary care provider to make [**name initial (pre) **] follow-up
appointment within 1 week from discharge from the rehabilitation
facility.
provider: [**first name11 (name pattern1) 5445**] [**initial (namepattern1) **] [**last name (namepattern4) 5446**], dpm phone:[**telephone/fax (1) 543**]
date/time:[**2130-5-22**] 3:50
provider: [**first name8 (namepattern2) 6118**] [**last name (namepattern1) 6119**], rn,ms,[**md number(3) 1240**]:[**telephone/fax (1) 1971**]
date/time:[**2130-6-16**] 10:00


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

completed by:[**2130-5-3**]"
18,"admission date:  [**2146-6-15**]              discharge date:   [**2146-6-28**]

date of birth:  [**2081-10-25**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1556**]
chief complaint:
colon cancer
s/p jejunoileal bypass in [**2109**]

major surgical or invasive procedure:
[**2146-6-15**]: rt hemicolectomy, reversal of jejunoileal bypass, liver
biopsy (tru-cut needle).
[**2146-6-27**]: exploratory laparotomy with washout, repair of
perforation in ileum, placement of vacuum-assisted closure
dressing.


history of present illness:
64-year-old man with a history of colonic polyps, who on
screening colonoscopy ([**2146-5-17**]) demonstrated an ulcerated,
clamshell, nonobstructing mass in the cecum.  the length was
approximately 3 cm.  biopsy confirmed invasive
adenocarcinoma grade ii.  otherwise, he has had no change in his
health. no blood per rectum, no weight loss, no abdominal pain.
he currently has [**12-24**] formed bowel movements per day.  he does
experience loose bowel movements if he eats fatty foods or
cheese.

past medical history:
past medical history:
1.  myocardial infarction, [**2143**].
2.  right-sided nephrolithiasis.
3.  morbid obesity (bmi 44.3 kg/m2).
4.  hypertension.
5.  history of colonic polyps.

past surgical history:
1.  jejunoileal bypass, [**2109**] (16 inches of jejunum anastomosis
    to the last 6 inches of ileum) appendectomy was performed at

    that time.
2.  open cholecystectomy with choledochostomy tube and
    gastrostomy tube for acute gallstone pancreatitis, [**2109**].
3.  ureteroscopy with stenting, 05/[**2144**].  this was complicated
    by bradycardia into the 20s.
4.  cardiac pacemaker placement, [**2145-4-6**].
5.  right flank incision with stone extraction, [**2145-5-5**].
6.  cystoscopic attempted stone extraction and stenting,
    [**2145-5-21**].
7.  surgical extraction of right renal stone, [**2145-6-4**].
8.  cardiac stents (drug-eluting), [**2143**].
9.  right shoulder surgery, [**2140**], no metallic implants.

social history:
he does not smoke, drink excessively or use
drugs.  he manages an insurance firm.  he is accompanied by his
wife and daughter today.


family history:
significant for mother with [**name (ni) 2481**] disease,
father with [**name (ni) 5895**] disease.


physical exam:
bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi:
44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99.

physical examination:  general:  he is alert, oriented, in no
acute distress.  heent:  pupils are equal, round and reactive to
light.  sclerae anicteric.  oropharynx is clear.  neck:  supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly or nodules.  trachea is midline.  lungs:  clear to
auscultation bilaterally.  heart:  regular.  abdomen:  obese.
he
has a right subcostal incision (cholecystectomy).  he has a
right
lower abdominal transverse incision (intestinal bypass).  he has
a right flank incision (renal surgery).  there are no obvious
hernias.  there is no tenderness.  genitourinary:  penis is
circumcised.  testicles are descended bilaterally.  extremities:

without edema.  neurologic:  grossly nonfocal.


pertinent results:
[**2146-6-15**] 04:50pm   glucose-187* urea n-12 creat-1.0 sodium-141
potassium-4.1 chloride-104 total co2-27 anion gap-14
[**2146-6-15**] 04:50pm   estgfr-using this
[**2146-6-15**] 04:50pm   calcium-9.2 phosphate-3.9 magnesium-1.4*
[**2146-6-15**] 04:50pm   wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6*
mcv-77* mch-23.8* mchc-30.8* rdw-15.5
[**2146-6-15**] 04:50pm   plt count-102*
[**2146-6-15**] 12:44pm   type-art rates-/12 tidal vol-700 po2-330*
pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 12:44pm   glucose-153* lactate-2.1* na+-135 k+-3.8
cl--101
[**2146-6-15**] 12:44pm   hgb-10.7* calchct-32 o2 sat-97
[**2146-6-15**] 12:44pm   freeca-1.19
[**2146-6-15**] 10:53am   type-art rates-/12 tidal vol-700 po2-84*
pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 10:53am   na+-135
[**2146-6-15**] 10:53am   hgb-10.3* calchct-31 o2 sat-94

brief hospital course:
the patient presented to pre-op on [**2146-6-15**]. pt was evaluated by
anaesthesia and taken to the operating room where a laparoscopic
adjustable gastric band placement was performed. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout the
hospitalization; until her was intubated and sedated. pain was
well controlled with iv pain medications.
cv: vital signs were routinely monitored. the patient remained
stable from a cardiovascular standpoint until he developed
tachycardia and hypotension on [**2146-6-27**]. following that the
patient was placed on multiple pressors by the icu team. cardiac
enzymes were initially negative, a tee revealed a hyperdynamic
myocardium.
pulmonary: vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. the patient remained
stable from a pulmonary standpoint until [**2146-6-27**] when he
developed shortness of breath, new and increasing oxygen
requirement and desaturation. cta of the chest revealed no
evidence of pe, but the patient had evidence of worsening
pulmonary function and ards. he was intubated and his peep was
optimized using an intraesophageal balloon. he remained
intubated until the decision of comfort measures only was
executed terminally extubating the patient.

gi/gu/fen: he was kept npo with ng tube to suction. the patient
was initially putting out about 7-8 liters of bilious fluid a
day. this was adequately replaced with iv fluids. the patient
was later decreasing his ng tube outputs to 4 liters by day 6
post-operatively. the patient passed gas on the 5th day
post-operatively, and bowel movements pod6. tpn was started due
to the elevated ng outputs (dark green bile). patient's intake
and output were closely monitored.
 pod#12, the patient decompensated with sudden onset chest and
shoulder pain, shortness of breath, tachypnea, new oxygen
requirement, ekg new right bundle branch block, and transient
abdominal pain.
the patient was taken to the or and exploration revealed a total
of 5 liters of fluid non bilious. he was found to have one small
hole at the proximal anastomosis and purulent pocket. 3 drains
were placed. subsequently the patient developed multiple organ
system failure, with acute renal failure requiring continuous
venovenous hemodialysis. worsening refractory metabolic acidosis
requiring multiple boluses and iv drip bicarbonate. acute liver
failure was also noted with inr>3 and liver transaminases >[**2133**].


id: the patient's fever curves were closely watched for signs of
infection. the
patient developed sepsis as discussed above with multiple
organisms (k. pneumonia, b. fragilis,...) the patient was placed
on broad spectrum iv antibiotics.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

 the patient was showing signs of multiple organ system collapse
with refractory hypotension and acidosis despite maximal medical
therapy. a family meeting was conducted with the family deciding
that the patient's wishes would be to withdraw care at that
point. the patient was extubated terminally and the patient
passed away shortly after on [**2146-6-28**] at 17:37.

medications on admission:
medications - prescription
atorvastatin -  (prescribed by other provider) - 40 mg tablet -
1
tablet(s) by mouth once a day
hydrochlorothiazide -  (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth once a day
sildenafil [viagra] -  (prescribed by other provider) - dosage
uncertain
valsartan [diovan] -  (prescribed by other provider) - 80 mg
tablet - 1 tablet(s) by mouth once a day

medications - otc
aspirin -  (prescribed by other provider) - 81 mg tablet,
chewable - 1 tablet(s) by mouth once a day
cholecalciferol (vitamin d3) [vitamin d] -  (prescribed by other
provider) - dosage uncertain


discharge medications:
none

discharge disposition:
expired

discharge diagnosis:
cecal cancer with positive lymph node
reversal of jejunoileal bypass
liver cirrhosis secondary to jejunoileal bypass
acute respiratory distress syndrome
acute liver failure
acute renal failure
intraabdominal severe septic shock

discharge condition:
dead

discharge instructions:
na

followup instructions:
na


completed by:[**2146-7-26**]"
19,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
20,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
   demographics
   attending md:
   [**location (un) **] [**doctor first name **] a.
   admit diagnosis:
   tongue swelling
   code status:
   full code
   height:
   admission weight:
   58.6 kg
   daily weight:
   allergies/reactions:
   nsaids
   please avoid du
   precautions:
   pmh:  anemia, diabetes - oral [**doctor last name **], gi bleed, hepatitis
   cv-pmh:  hypertension
   additional history: hep c cirrhosis, portal htn w/ grade i varices,
   ascites, encephalopathy, variceal bleeding, dm 2, right renal
   nephrectomy for renal cell ca (15 yrs ago), hypercholesterolemia,
   osteopenia, insomnia,
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:122
   d:54
   temperature:
   98.7
   arterial bp:
   s:
   d:
   respiratory rate:
   22 insp/min
   heart rate:
   85 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   nasal cannula
   o2 saturation:
   96% %
   o2 flow:
   3 l/min
   fio2 set:
   50% %
   24h total in:
   655 ml
   24h total out:
   415 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2150-4-17**] 05:15 am
   potassium:
   4.3 meq/l
   [**2150-4-17**] 05:15 am
   chloride:
   112 meq/l
   [**2150-4-17**] 05:15 am
   co2:
   24 meq/l
   [**2150-4-17**] 05:15 am
   bun:
   27 mg/dl
   [**2150-4-17**] 05:15 am
   creatinine:
   1.1 mg/dl
   [**2150-4-17**] 05:15 am
   glucose:
   132 mg/dl
   [**2150-4-17**] 05:15 am
   hematocrit:
   31.4 %
   [**2150-4-17**] 05:15 am
   finger stick glucose:
   159
   [**2150-4-17**] 06:00 pm
   valuables / signature
   patient valuables: none
   other valuables:
   clothes:  sent home with:
   wallet / money:
   no money / wallet
   cash / credit cards sent home with:
   jewelry:
   transferred from: micu-7
   transferred to: [**hospital ward name 4126**]
   date & time of transfer:  [**2150-4-17**] 1830
"
21,"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
"
22,"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
"
23,"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
"
24,"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
"
25,"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:
"
26,"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
"
27,"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:
"
28,"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
"
29,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension; one ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: ercp [**2179-2-13**]
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   90% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 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:
"
30,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   patient started on clear liquid diet this am [**2-14**], tol well. pt
   remains alert/ oriented, denies pain. vss. afebrile. ambulates in room,
   tol well, steady gait. wbc trending down, cont on ns at 100ml/hour per
   surgery. cont unasyn iv. voids per urinal , 1bm this am.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension, 1ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: [**2179-2-13**] ercp
   latest vital signs and i/o
   non-invasive bp:
   s:123
   d:53
   temperature:
   97
   arterial bp:
   s:
   d:
   respiratory rate:
   13 insp/min
   heart rate:
   66 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   96% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   2,520 ml
   24h total out:
   825 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2179-2-14**] 04:09 am
   potassium:
   3.5 meq/l
   [**2179-2-14**] 04:09 am
   chloride:
   113 meq/l
   [**2179-2-14**] 04:09 am
   co2:
   18 meq/l
   [**2179-2-14**] 04:09 am
   bun:
   23 mg/dl
   [**2179-2-14**] 04:09 am
   creatinine:
   0.8 mg/dl
   [**2179-2-14**] 04:09 am
   glucose:
   66 mg/dl
   [**2179-2-14**] 04:09 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 am
   valuables / signature [**2179-2-14**]
   patient valuables: wristwatch
   other valuables:
   clothes:  jacket, jeans, tshirt, underwear, hat, belt, boots,
   toiletries
   wallet / money:  brown leather wallet, no money, one bankcard
   cash / credit cards sent home with:
   jewelry:
   transferred from: [**hospital ward name **] 4
   transferred to: 917
   date & time of transfer:  [**2179-2-14**] 1300
"
31,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   patient started on clear liquid diet this am [**2-14**], tol well. pt
   remains alert/ oriented, denies pain. vss. afebrile. ambulates in room,
   tol well, steady gait. wbc trending down, cont on ns at 100ml/hour per
   surgery. cont unasyn iv. voids per urinal , 1bm this am.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension; one ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy, [**doctor first name **]-[**doctor last name **] 2 [**2140**],
   aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: ercp [**2179-2-13**]
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   97
   o2 flow:
   ra
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 am
   valuables / signature
   patient valuables: wristwatch
   other valuables:
   clothes:  jacket, jeans, tshirt, underwear, hat, belt, boots,
   toiletries
   wallet / money:  brown leather wallet, no money, one bankcard
   cash / credit cards sent home with:
   jewelry:
   transferred from: [**hospital ward name **] 4
   transferred to: 917
   date & time of transfer:
"
32,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   90% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 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:
"
33,"ccu nursing progress note
please see nursing admission summary

s:  denies c/o itching.  asking many questions re: asa desensitization therapy

o:  see flow sheet for objective data.

pt. premedicated with 25 mg po benadryl 45 minutes prior to start of asa desensitization. patient received progressively increasing doses of asa according to protocol.  rn in room continuously throughout protocol and for 45 minutes after the last dose.  patient without vs changes, no wheezing, no edema, no rash.  patient instructed to immediately notify nurse of any itching, or change in sensation through the night.

pt. given info and explained the purpose of health care proxy.    [**name (ni) **] does not wish to complete the form this evening, but says that he might be willing to do it tomorrow (""doesn't want to jinx himself."")  does state that he would designate his wife as proxy anyways, so legally, he's not sure if it makes any difference.  have explained that not all patients designate their spouse to be proxy, and it gives the health care providers a more clear indication of his wishes.

pt is pre-cath for tomorrow.  pt. does not have any further questions re:  cath procedure.

a:  s/p successful completion of asa desensitization protocol without adverse events.

p:  monitor for delayed allergic reaction. follow pre cath orders.  re-assess wishes regarding health care proxy tomorrow.
"
34,"admission date:  [**2170-5-17**]     discharge date:  [**2170-5-22**]

date of birth:   [**2112-6-10**]     sex:  m

service:

chief complaint:  shortness of breath.

history of present illness:  this is a 57-year-old male with
a history of pe in [**2156**], obstructive sleep apnea and prostate
cancer, who presented with shortness of breath starting four
days prior to admission, but becoming acutely worse on the
morning of admission.  the patient went to his primary care
physician and was sent to the emergency department.  he had
no chest pain, no pleuritic chest pain, no new lower
extremity edema, although the patient does have chronic
stable lower extremity edema bilaterally.  the patient had
recently flown to [**location (un) **] and returned five days ago.  no
fevers or chills were noted, no recent illnesses, no melena,
no hematochezia.

past medical history:  1. pe in [**2156**].  2. status post
orthopedic surgery.  3. obstructive sleep apnea with cpap at
12 mm of water.  4. hyperglycemia history without a diagnosis
of diabetes mellitus, last a1c 6.5 in [**2167**].  5. obesity.  6.
prostate cancer status post prostatectomy.  7. ankle
fracture.  8. glaucoma.  9. hypertension.  10.
diverticulosis.  11. chronic lower extremity edema.

allergies:  sulfa give the patient a rash.

medications:  1. aspirin.  2. multivitamin.  3. timolol.  4.
hydrochlorothiazide started three days prior to admission.

social history:  the patient is the chief of anesthesiology
at [**hospital6 1708**].  he does not smoke, drinks
occasional alcohol.

family history:  mother died of pe.

physical examination:  temperature was 97.2, blood pressure
135/93, pulse 85, respirations 16, saturating 98% on five
liters, 88% on room air.  general:  obese male, mildly
tachypneic with nasal cannula on.  alert and oriented x 3 in
no acute distress.  heent:  pupils were equal, round, and
reactive to light and accommodation.  mucous membranes were
moist.  extraocular movements intact, anicteric sclerae,
benign oropharynx.  neck:  no lymphadenopathy, no jugular
venous distension appreciated.  chest:  clear to auscultation
bilaterally.  cardiac:  regular rate and rhythm, split s2, no
rubs, gallops or murmurs, no heave.  abdomen:  obese,
nontender, nondistended, normal active bowel sounds, no
organomegaly.  extremities:  2+ pitting edema bilaterally and
equal.  neurologic:  no focal neurologic deficits.  the
patient reports a rectal examination was done in the primary
care physician's office and was negative.

laboratory data:  white blood cell count 8.5, 69% polys, 21%
lymphocytes, hematocrit 42.9, platelet count 203, mcv 87,
sodium 136, potassium 4.4, chloride 93, bicarbonate 23, bun
17, creatinine 0.9, glucose 141, inr 1.2.

spiral cta showed large left main pulmonary artery embolus
and large right pulmonary embolus slightly smaller than left;
both are in the main pulmonary arteries.

ekg:  normal sinus rhythm at 90, question of right atrial
abnormality, otherwise normal axis, no s1, q3, t3, no st
changes, no old ekg for comparison.

echocardiogram done in the emergency department showed an
ejection fraction of greater than 60% but increased pulmonary
artery pressures 48-56 mmhg.  he has a dilated right
ventricle with decreased right ventricular function, abnormal
septal motion consistent with right ventricular volume
overload and left apical sparing consistent with [**last name (un) **]
sign.  there was mild symmetric left ventricular hypertrophy.

hospital course:  this is a 57-year-old male with past pe
presenting with massive bilateral pulmonary emboli and
hemodynamically stable.  the echocardiogram does show signs
of right ventricular strain.

1. pulmonary emboli:  massive bilateral pes with right
ventricular strain but hemodynamic stability.  the patient
was initially admitted to the intensive care unit after being
started on heparin in the emergency department.  he was
observed in the intensive care unit for two days without
adverse events.  he was then called out to the floor and
continued on his heparin gtt with coumadin dosing.  he was
then switched from heparin to lovenox in anticipation for
discharge.  he gradually was weaned from his nasal cannula
and the patient was saturating 98% on room air with
ambulation upon discharge.

lower extremity duplex was performed to look for potential
source of his pe.  this examination showed a nonobstructive
left popliteal dvt.  because the patient was hemodynamically
stable throughout his hospitalization and improving on
anticoagulation, he was not given thrombolysis treatment for
his massive pe.  his anticoagulation will be managed by his
primary care physician, [**first name8 (namepattern2) **] [**last name (namepattern1) 3306**], [**name initial (nameis) **].d.

2. diabetes mellitus:  the patient was hyperglycemic
throughout his hospital admission.  his fasting blood sugars
were repeatedly greater than 126 and he was diagnosed with
type 2 diabetes mellitus.  he was started on glucophage 500
mg p.o. q.d.  a hemoglobin a1c level was drawn which was 7.8
consistent with his suspected diabetes mellitus.

3. gout:  the patient had a flare of gout in his left great
toe, podagra.  he was treated with indomethacin 50 mg p.o.
t.i.d. with mild improvement upon discharge.

4. obstructive sleep apnea:  the patient was continued on his
cpap of 13 mm of water at night.

the patient was discharged home stable on room air with
coumadin and lovenox bridging.  he will follow up at the
office of dr. [**last name (stitle) 3306**] on friday [**2170-5-25**] for an inr draw
and follow-up appointment.

discharge diagnoses:
1. massive pulmonary embolism.
2. diabetes mellitus.
3. gout.
4. obstructive sleep apnea.

discharge medications:
1. lovenox 120 mg subcutaneous b.i.d. until therapeutic inr
as instructed by dr. [**last name (stitle) 3306**].
2. coumadin 10 mg p.o. q.d. until appointment with dr.
[**last name (stitle) 3306**] and then doses according to her instructions.
3. timolol eyedrops 0.25% b.i.d. bilaterally.
4. latanoprost 0.005% drops bilateral eyes q.h.s.
5. indomethacin 50 mg p.o. t.i.d. until gout relieved.
6. glucophage 500 mg p.o. q.d.
7. multivitamin one p.o. q.d.





                          [**name6 (md) 251**] [**name8 (md) **], m.d.  [**md number(1) 1197**]

dictated by:[**dictator info **]

medquist36

d:  [**2170-5-31**]  14:50
t:  [**2170-6-6**]  08:03
job#:  [**job number 14081**]
"
35,"admission date:  [**2155-7-12**]              discharge date:   [**2155-7-16**]

date of birth:  [**2097-9-7**]             sex:   m

service: medicine

allergies:
simvastatin / tape / hydrochlorothiazide / eptifibatide /
cellcept / [**year (4 digits) **]

attending:[**first name3 (lf) 14820**]
chief complaint:
transfered from [**hospital 18112**] hospital for inferior myocardial
infarction.

major surgical or invasive procedure:
cardiac catheterization
rca stent


history of present illness:
this is a 57 year old man, with a past medical history of cabg
and pfo closure in [**12-24**], s/p renal transplant secondary to
wegeners vasculitis, who was transferred from an outside
hospital for an inferior myocardial infarction.  pt was having
chest pain and an electrocardiogram showed st segment changes in
the inferior leads which was consistent with an inferior mi.
patinet underwent cardiac catheterization ([**2155-7-13**]) with
stenting for an inferior mi. he had some vagal symptoms towards
the end of the procedure and was treated with zophrin and
atropine.  pt was then transerred to the ccu.

past medical history:
-paroxysmal atrial fibrillation, not on coumadin
-esrd s/p living donor (sister) renal transplant in [**5-/2154**]
-cad:
   - s/p acute mi [**2143**] with palmaz lad and rca stents
   - s/p rotablation and hepacoat stent to the d1 in [**6-/2149**],
treated with brachytherapy for instent restenosis in [**10/2149**]
   - s/p taxus stent in rpl in [**10/2151**]
   - s/p two cypher stents placed in the rca [**10/2152**]
   - cath in [**7-24**] with 60-70% ostial stenosis of lad, moderate
diffuse disease of lcx, 60% proximal of rca with in stent
restenosis with a 70% in the pl branch taxus stent(for latest
cath, see pertinent results)
-denies h/o dm; however, sugars have been elevated in past
-chronic angina
-hypertension
-hypercholesterolemia
-wegener's granulomatosis (renal/pulmonary involvement)
diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, anca neg.
since (chronic proteinuria); now s/p renal transplant in [**5-/2154**]

-idiopathic pericarditis [**2150**]
-gerd
-anxiety, endorses dysthymic symptoms but not depression
-gout
-umbilical hernia repair
-restless leg syndrome
.
outpatient cardiologist:  [**first name4 (namepattern1) **] [**last name (namepattern1) **]
nephrologist:  dr. [**last name (stitle) 1366**]
transplant nephrologist:  [**doctor first name **] [**doctor last name **]
pcp: [**first name8 (namepattern2) 3788**] [**last name (namepattern1) **]
.
allergies:
[**last name (namepattern1) **]--rash
simvastatin--myalgia
tape--rash
hctz--unkown reaction

social history:
 social history is significant for the absence of current
tobacco use; quit 25 years ago. there is no history of alcohol
abuse; he endorses rare etoh. no illicit drugs. married with 3
children, lives w/ wife and youngest daughter.


family history:
there is no family history of premature coronary artery disease
or sudden death. mother had cva at 46. sister with scleroderma
and another sister with [**name (ni) 18109**].

physical exam:
vitals: vital signs stable, patient afebrile
gen: no acute distress
heent: mmm, perrl
neck: no jvd
heart: s1+, s2+ no murmurs.
lungs: clear to auscultation bilaterlly.
abd: soft, non tender, non distended, bowel sounds present
ex: no edema, distal pulses present bilarerally.
neuro: aaox3

pertinent results:
blood:
[**2155-7-16**] 06:05am blood wbc-8.2 rbc-3.70* hgb-10.2* hct-29.8*
mcv-81* mch-27.5 mchc-34.1 rdw-14.1 plt ct-129*

electrolytes:
[**2155-7-16**] 06:05am blood glucose-130* urean-22* creat-1.6* na-140
k-4.0 cl-106 hco3-25 angap-13

cardiac enzymes:
[**2155-7-14**] 05:30am blood ck(cpk)-987*
[**2155-7-13**] 05:15pm blood ck(cpk)-[**2153**]*
[**2155-7-13**] 06:19am blood ck(cpk)-2779*
[**2155-7-13**] 01:50am blood ck(cpk)-2132*
[**2155-7-14**] 05:30am blood ck-mb-76* mb indx-7.7* ctropnt-5.85*
[**2155-7-13**] 01:50am blood ck-mb-403* mb indx-18.9*
[**2155-7-16**] 06:05am blood calcium-8.3* phos-3.7 mg-1.9

transplant meds:
[**2155-7-16**] 06:05am blood tacrofk-8.2
[**2155-7-15**] 09:19am blood tacrofk-4.4*
[**2155-7-14**] 05:30am blood tacrofk-4.6*

blood gas:
[**2155-7-12**] 10:27pm blood type-art po2-116* pco2-33* ph-7.42
caltco2-22 base xs--1 intubat-not intuba

brief hospital course:
patient was admitted to ccu for medical management post
myocardial infarction and stent placement.  he remained stable.
he did develop an eight centimeter pseudoaneurysm and a-v
fistula on his left groin site.  [**month/day/year **] surgery was consulted
and said it was to small to intervene.  he will follow up with
surgery for another ultrasound to assess the size. he was seen
by transplant team for management of his transplant medications.
 renal was consulted for management of his wegeners
granulomatosa.  as patient had a stent placed and had a history
of an allergy to [**month/day/year **], he was desensitized to [**month/day/year **].  the
desensitization was successful without any adverse events.  ent
was consulted for epistaxis prophylaxis while on [**month/day/year **], patient
started on saline nasal spray.  he was transferred out of the
ccu to the floor and discharged on [**2155-7-16**].

problem [**name (ni) **]:

# cad/ischemia: history of cad (cabg in [**2154**]), pt had st
elevations on ecg in inferior leads with st elevation in v3r,
which are 90% sensitive for rv infarct. cath complicated by
vagal symptoms towards end of procedure treated with zofran and
atropine. pt. desensitized to [**year (4 digits) **] on [**2155-7-14**].
- continue [**last name (lf) **], [**first name3 (lf) **], statin
- patient monitored on telemetry
- as pt had rv infarct (by ekg, no right heart cath performed),
avoid nitroglycerin for chest pain as rv infarct patients are
preload dependent.
.
# pump: current echo lvef 35-40%, lv apical dyskinesis and lv
inferior/inferior-lateral hypokinesis. pt with some orthopnea.
- fluid status closely monitored.
- pt started on lasix 40 po.
.
# rhythm:  pt having runs of nsvt on telemetry. likely secondary
to hypokalemia, also possibly due to reperfusion. history of
paroxysmal a-fib, has  cardioversion.
- monitor on telemetry
- on metoprolol 50 [**hospital1 **] for rate control, titrate up to home dose
as bp tolerates
- will stop amiodarone as nsvt was peri mi and did not recur
.
# hypertension: it was noted in a prior note on omr that pt's
blood pressure should be managed with beta blocker, a small dose
of acei and nifedipine. if necessary nifedipine should be
titrated up as it is safe in the renal transplant setting.
- c/w bb and acei as bp tolerates.
- nitrates were held as blood pressure stable.  can be
re-assessed as outpatient.
- pt should have bp check by pcp or np within 1-2 weeks of d/c
.
# valves: +2 mr, mitral valve leaf thickening.  mild aortic
valve thickening.
.
# left femoral bruit: bruit over left groin where venous and
arterial access lines were pulled. systolic and diastolic bruit
likely due to av fistula. l groin u/s showing 8mm
pseudoaneurysm.
- per [**hospital1 1106**] surgery, pseudoaneurysm is to small to treat
(<2cm).  f/u with dr. [**last name (stitle) **] in [**last name (stitle) 1106**] clinic.
.
# wegeners granulomatosis: has been in remission for 10+ yrs.
stable.
- monitor respiratory status
- monitor hct
- follow ent recs re: epistaxis prevention:  saline nasal
flushes three times a day.
.
# renal transplant: end-stage renal disease secondary to
wegener's granulomatosis, received a living related renal
transplant from his sister on [**2154-5-14**]. baseline cr 1.7. pt.
back to baseline cr.
- continue tacrolimus and myfortic
- dose meds for crcl of 50.
.
# dm: sliding scale insulin.
.
# fen: cardiac/heart-healthy low salt diabetic diet
.
# prophylaxis: [**year (4 digits) **]
.
# code:  full

medications on admission:
1. allopurinol 100 mg tablet daily
2. atorvastatin 10mg daily
3. astelin 137 mcg ns
4. fluticasone 50 mcg ns
5. lisinopril 30mg daily
6. metoprolol 100mg sr 1.5 tabs daily
7. myfortic 360mg 2 tabs daily
8. nifedipine 90mg daily
9. protonix 40mg daily
10. actos 15mg daily
11. prednisone taper.
12. requip 3mg daily
13. zoloft 100mg daily
14. prograf 0.5mg daily
15. bactrim 400/80mg daily
16. aspirin 325 mg daily


discharge medications:
1. pioglitazone 15 mg tablet sig: one (1) tablet po twice a day.

2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
3. atorvastatin 10 mg tablet sig: one (1) tablet po daily
(daily).
4. fluticasone 50 mcg/actuation spray, suspension sig: [**12-18**]
sprays nasal daily (daily).
5. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1)
tablet po daily (daily).
6. sertraline 100 mg tablet sig: one (1) tablet po daily
(daily).
7. mycophenolate sodium 360 mg tablet, delayed release (e.c.)
sig: two (2) tablet, delayed release (e.c.) po twice a day.
8. ropinirole 3 mg tablet sig: one (1) tablet po twice a day.
9. sodium chloride 0.65 % aerosol, spray sig: [**12-18**] sprays nasal
tid (3 times a day) 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily): please do not miss a dose, take for at least 1 year, do
not stop taking unless your cardiologist tells you to. .
disp:*90 tablet(s)* refills:*3*
12. astelin 137 mcg aerosol, spray sig: two (2) puffs nasal
twice a day.
13. toprol xl 100 mg tablet sustained release 24 hr sig: 1.5
tablet sustained release 24 hrs po once a day.
disp:*135 tablet sustained release 24 hr(s)* refills:*3*
14. furosemide 40 mg tablet sig: one (1) tablet po daily
(daily).
15. tacrolimus 1 mg capsule sig: 1.5 capsules po bid (2 times a
day).
16. lisinopril 30 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
non-st elevation myocardial infarction
acute on chronic systolic congestive heart failure
secondary diagnosis:
chronic renal insufficiency
wegenner's vasculitis
epistaxis


discharge condition:
stable


discharge instructions:
weigh yourself every morning before breakfast, call doctor if
weight > 3 lbs in 1 day or 6 pounds in 3 days.
adhere to 2 gm sodium/heart healthy diet.
.
you had an inferior myocardial infarction with 5 drug eluting
stents placed in your right coronary artery. you need to take
[**month/day (2) 4532**] every day for one year, do not miss [**first name (titles) 691**] [**last name (titles) 4319**] unless dr. [**doctor last name 11723**] tells you to. you were seen by pt who gave you a
activity prescription until you see dr.[**name (ni) 3733**].
.
stop taking your nifedipine.

while you were inpatient, you had [**name (ni) 4532**] desensitization. you
were started on a daily dose of [**name (ni) 4532**] after the
desensitization.  this medication should be taken daily, if at
any time 36 hours lapses between [**name (ni) 4319**] of [**name (ni) 4532**], the
desensitization process will have to be repeated.
.
you need repeat angiogram in 2 weeks, you should speak to your
cardiologist regarding this. you should also have a holter
monitor in 2 weeks that will monitor your heart rhythm and track
any irregular heart beats.

followup instructions:
primary care:
provider: [**first name11 (name pattern1) 198**] [**last name (namepattern4) 199**], m.d. phone: [**telephone/fax (1) 250**] date/time:
[**7-29**] at 4:20pm.
provider: [**first name11 (name pattern1) 198**] [**last name (namepattern4) 199**], m.d. phone: [**telephone/fax (1) 250**]
date/time:[**2155-11-4**] 1:00
cardiologist:
provider: [**first name4 (namepattern1) **] [**name initial (nameis) **], md phone: [**telephone/fax (1) 62**]. date/time:
[**7-22**] at 10:40am. [**hospital ward name 23**] clinical center, [**location (un) 436**].
[**location (un) **] follow-up for left femoral pseudoaneurysm:
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2155-8-13**] 8:00
provider: [**name10 (nameis) 251**] [**last name (namepattern4) 1490**], md phone:[**telephone/fax (1) 1237**]
date/time:[**2155-8-13**] 9:15



"
36,"admission date:  [**2164-7-13**]              discharge date:   [**2164-7-16**]

date of birth:  [**2089-3-5**]             sex:   f

service: medicine

allergies:
atenolol / diltiazem / lisinopril / verapamil

attending:[**first name3 (lf) 443**]
chief complaint:
sob, chest pain

major surgical or invasive procedure:
cardiac catherization


history of present illness:
ms. [**known lastname 18582**] is a 75 [**last name (un) **] with htn, hyperlipidemia, depression,
gerd, hypothyroidism and osetoporosis who was admitted today for
an elective cath.  she had been complaining of one year of
fatigue and sob.
.
she was taken to the cath lab where she had lad with 40%
stenosis after the diagonal. the proximal d1 had a 90% stenosis
in which a bms was placed. the pt had some cp on leaving the
cath lab which persisted and then worstened on [**hospital ward name 121**] 3. pt with
st elevations in i, avl and was sent for rpt cath
.
on repeat cath, she had restenosed the stent placed earlier in
the day so it was restented proximally and distally with 2 more
bms's. of note, she recieved a total of 465cc iv contrast.
.
on arrival in the icu, she has no complaints initially but then
c/o mild headache.
.
on ros, she denies any fevers, nausea, vomitting, pain, sob,
lightheadedness or any other sx.


past medical history:
gerd
h pylori [**2156**]
lower gi bleed r/t diverticulitis
polyps removed
chronic headaches
hypertension
osteoporosis
depression
intermittent blurry vision-unclear etiology
pneumonia
ep study [**2161**] d/t bradycardia
eye surgery for growth
hypothyroid
pernicious anemia


social history:
retired [**hospital1 18**] ekg tech. widow. lives alone. has
5 daughters. denies tobacco and etoh.

family history:
father died of an mi at age 52. mother died at age [**age over 90 **]


physical exam:
general: nad
heart: rrr, no m/r/g
pulm: ctab, no w/r/r
ext: no edema
neuro: grossly intact

pertinent results:
admission labs:
[**2164-7-13**] 04:06pm blood wbc-13.1* rbc-4.68 hgb-13.1 hct-38.8
mcv-83 mch-28.0 mchc-33.7 rdw-13.8 plt ct-308
[**2164-7-13**] 04:06pm blood pt-15.4* ptt-47.6* inr(pt)-1.4*
[**2164-7-13**] 04:06pm blood glucose-165* urean-12 creat-0.6 na-137
k-3.4 cl-99 hco3-25 angap-16
[**2164-7-13**] 04:06pm blood calcium-8.3* phos-4.9* mg-1.7
[**2164-7-14**] 06:04am blood triglyc-97 hdl-49 chol/hd-3.8 ldlcalc-120
.
cardiac enzymes:
[**2164-7-13**] 07:12pm blood ck-mb-33* mb indx-14.5*
[**2164-7-13**] 07:12pm blood ck(cpk)-228*
[**2164-7-14**] 06:04am blood ck-mb-42* mb indx-11.0*
[**2164-7-14**] 06:04am blood ck(cpk)-383*
[**2164-7-14**] 02:35pm blood ck-mb-24* mb indx-8.0* ctropnt-0.66*
[**2164-7-14**] 02:35pm blood ck(cpk)-300*
[**2164-7-15**] 05:35am blood ck-mb-8 ctropnt-0.53*
[**2164-7-15**] 05:35am blood ck(cpk)-118
[**2164-7-16**] 06:05am blood ck-mb-3 ctropnt-0.72*
[**2164-7-16**] 06:05am blood ck(cpk)-49
.
discharge labs:
[**2164-7-16**] 06:05am blood glucose-97 urean-12 creat-0.8 na-140
k-4.9 cl-102 hco3-30 angap-13
[**2164-7-16**] 06:05am blood calcium-9.3 phos-4.3 mg-2.1
.
[**2164-7-14**] echo:
the left atrium is dilated. there is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
distal septal, anterior and apical hypokinesis. the remaining
segments contract normally (lvef = 45%). 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 (1+) aortic regurgitation is seen. mild (1+)
mitral regurgitation is seen. there is mild pulmonary artery
systolic hypertension. there is no pericardial effusion.
impression: mild regional left ventricular systolic dysfunction,
c/w cad. mild mitral and aortic regurgitation.
compared with the prior study (images reviewed) of [**2164-7-13**],
the findings are similar.
.
[**2164-7-13**] echo:
there is mild symmetric left ventricular hypertrophy with normal
cavity size. there is regional left ventricular systolic
dysfunction. there is no pericardial effusion.
impression: no pericardial effusion identied.
.
[**2164-7-13**] 2nd cath:
comments:
1- limited selective coronary angiography of the lmca sysrtem
showed
acute occlusion of the entire d1 system. this vessel underwent
ptca and
stening with a 2.25x12 mm minivision bms 2 hours prior. the
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- the lmca, lad (known mid vessel lesion that was negative by
ffr
earlier), and lcx were unchanged.
3- successful emergent ptca and stenting of the d1 with two
additional
stents: a 2.0x8 mm distally overlapping and a 2.25x12 proximally

overlapping with the old (placed this am) 2.25x12 mm minivision
bms.
final angiography showed timi 3 flow thrroughout the d1 system
without
vresidual stenosis, dissection or distal emboli.
4- resting hemodynamic assessment showed stable hemodynamics
compared to
earlied rhc except for severe systemic arterial hypertension
(required
ntg gtt at doses as high as 200 mcg per min). the left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- bedside echocardiography showed absence of pericardial
effusion

final diagnosis:
1. acute closure of the d1, two hours after pci and stenting
2. [**name (ni) 18583**] ptca and stenting of the d1 with two additional
bms (one
distal and the second proximal to the earlier placed bms, all
overlapping).
3. ccu admission for observation
4. continue integrilin gtt for 18 hours
5. plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. asa 325 mg po indefinitely
7. 2d echocardiogram
8. global cardiovascular risk reduction strategies
.
[**2164-7-13**] 1st cath:
comments:
1- limited selective coronary angiography of the lmca sysrtem
showed
acute occlusion of the entire d1 system. this vessel underwent
ptca and
stening with a 2.25x12 mm minivision bms 2 hours prior. the
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- the lmca, lad (known mid vessel lesion that was negative by
ffr
earlier), and lcx were unchanged.
3- successful emergent ptca and stenting of the d1 with two
additional
stents: a 2.0x8 mm distally overlapping and a 2.25x12 proximally

overlapping with the old (placed this am) 2.25x12 mm minivision
bms.
final angiography showed timi 3 flow thrroughout the d1 system
without
vresidual stenosis, dissection or distal emboli.
4- resting hemodynamic assessment showed stable hemodynamics
compared to
earlied rhc except for severe systemic arterial hypertension
(required
ntg gtt at doses as high as 200 mcg per min). the left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- bedside echocardiography showed absence of pericardial
effusion

final diagnosis:
1. acute closure of the d1, two hours after pci and stenting
2. [**name (ni) 18583**] ptca and stenting of the d1 with two additional
bms (one
distal and the second proximal to the earlier placed bms, all
overlapping).
3. ccu admission for observation
4. continue integrilin gtt for 18 hours
5. plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. asa 325 mg po indefinitely
7. 2d echocardiogram
8. global cardiovascular risk reduction strategies


brief hospital course:
ms. [**known lastname 18582**] is a 75 [**last name (un) **] with htn, hyperlipidemia, depression,
gerd, hypothyroidism and osetoporosis who was admitted today for
an elective cath, had bms to 1st diag which thrombosed acutely
on the floor and had rpt stent x2
.
# cad: patient was chest pain free after 2nd catherization. she
was started on aspirin 235, plavix 75, and pravastatin 40mg po
qday. patient was hesitant to start new medications but was
counseled extensively that especially stopping aspirin and
plavix could lead to another mi. she was not started on a
beta-blocker given her history of complete heart block on
beta-blocker. she was not started on ace-i or [**last name (un) **] [**3-6**] h/o
adverse events and patient refusal to start those medications.
echo showed ef of 45% and regional systolic dysfunction c/w cad.
she will follow up with dr. [**last name (stitle) **].
.
# rhythm- patient was in sinus rhythm throughout
hospitalization.
.
# osteoporosis- cont home ca, vit d



medications on admission:
asa 81mg daily
calcium/ vit d 600/400 [**hospital1 **]
mvt daily


discharge medications:
1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
disp:*30 tablet, delayed release (e.c.)(s)* refills:*2*
2. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
3. multivitamin     tablet sig: one (1) tablet po daily (daily).

4. pravastatin 20 mg tablet sig: two (2) tablet po daily
(daily).
disp:*60 tablet(s)* refills:*2*
5. calcium 600 + d(3) 600-400 mg-unit tablet sig: one (1) tablet
po twice a day.


discharge disposition:
home

discharge diagnosis:
primary diagnosis:
stemi
.
secondary diagnosis:
gerd
osteoperosis


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
you were admitted for a cardiac catherization. after the
catherization you had a heart attack and you had additional
stents placed in your coronary arteries. we have started you on
several medications that you must take every day otherwise you
could have another heart attack. please follow up with your
cardiologist.
.
we have started you on the following medications:
1. aspirin 325mg by mouth every day
2. plavix 75mg by mouth every day
3. pravastatin 40mg by mouth every day

followup instructions:
provider: [**first name4 (namepattern1) **] [**last name (namepattern1) **] phone: [**telephone/fax (1) 7960**] date/time: [**2164-8-1**]
1:45pm



completed by:[**2164-7-17**]"
37,"admission date: [**2175-11-5**]        discharge date: [**2175-12-27**]

date of birth:  [**2147-8-13**]        sex:  f

service:  [**last name (un) **]


admission diagnosis:  respiratory distress.

history of present illness:  the patient is a 28-year-old
female with sle/lupus, nephritis, end-stage renal disease
status post cadaveric renal transplant [**2175-9-1**],
complicated by delayed graft function/atn, biopsy done
intraoperatively during reexploration post transplant for
bleeding requiring multiple transfusions. the patient has had
multiple admissions in the past since her transplant for
abdominal pain and dehydration. on [**2175-11-5**], the
patient was admitted for respiratory distress.

the patient was found to have agonal
breathing/unresponsiveness. at that time, fingersticks were
less than 20. the patient was treated with 1.5 amps of d50
but still not adequately awake. the patient was intubated in
the emergency room for airway protection. at that time, her
heart rate was in the 100s. systolic blood pressure was 90-
100.

the patient was transferred to the icu, and labs demonstrated
that the patient had a hematocrit of 14, sodium of 125,
potassium 8.3, chloride 95, bicarb 11, bun and creatinine of
37 and 6.6.

in the icu a line was placed, and a central line was placed.
the patient was transfused with 2 units of packed red blood
cells, 2 units of ffp, 1 unit of platelets and bicarb in the
setting of severe acidosis. the patient remained
hemodynamically stable.

past medical history:
1.  sle diagnosed in [**2166**] complicated by lupus/nephritis,
    anemia, serositis and ascites, currently in remission.
2.  end-stage renal disease on hemodialysis monday, wednesday
    and friday secondary to lupus.
3.  history of vsd status post corrective surgery at age 13.
4.  hypertension.
5.  itp.
6.  mssa endocarditis.
7.  [**year (4 digits) **] cell trait.
8.  status post left oophorectomy related to iud-associated
    infection.
9.  restrictive lung disease noted on pfts from [**2166**]. in [**2173**]
    chest ct was with diffuse ground glass opacities.
10. gerd in [**2172**].
11. history of domestic violence.
12. most recently is status post cadaveric renal on [**8-31**], [**2174**], complicated by delayed graft function.

allergies:  levaquin, cephalosporin, unasyn, vancomycin and
derivative, demerol and meperidine.

medications on admission:  prednisone 5 mg daily, bactrim ss
1 tablet daily, valcyte 450 mg every other day, __________
2.5 mg daily, nifedipine 90 mg sustained release daily,
protonix 40 mg daily, dronabinol 2.5 b.i.d., mirtazapine 15
mg q.h.s., mmf 500 mg b.i.d., nystatin suspension 5 ml
q.i.d., epogen injection 3000 units monday, wednesday and
friday, percocet [**12-11**] 5/325 mg tablets 1 tablet q.4-6 hours
p.r.n., labetalol 400 t.i.d., linezolid 600 q.12 for a total
of 7 days, reglan 5 mg q.i.d., sodium bicarb 650 mg tablets 4
tablets t.i.d., coumadin 5 mg 1 p.o. daily for a left
axillary thrombus, rapamune 6 mg once a day, the patient at
that time was on linezolid because of a gram-negative staph
urinary tract infection, and on coumadin for a non-occlusive
thrombus of left axillary vein that was documented on
[**2175-10-24**].

in the emergency room was intubated and sedation. ct of the
abdomen was performed demonstrating a large right-sided
hematoma displacing the transplanted kidney anteromedially
and inferiorly. the hematoma is larger compared to the cat
scan that was performed on [**2175-6-29**], but appears smaller
compared to the cat scan on [**2175-9-11**].

the transplanted kidney is barely discernable. the uv
catheter is noted in situ. a 3.8 cm heterogenous lesion,
likely arising from the uterus and probably a fibroid was
noted. there was also diffuse thickening of small bowel wall
with a differential of wide and intramural hemorrhage, and
there was massive ascites.

preoperative diagnosis:
1.  anemia.
2.  acute renal failure.
3.  hyperkalemia.
4.  metabolic acidosis.
5.  coagulopathy.
6.  sepsis.

the patient was rushed to the or where surgery was performed
on the morning of [**2175-11-6**], performed by dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **]. exploratory laparotomy and transplant nephrectomy
was performed due to a ruptured kidney.

a french [**doctor last name 406**] drain was brought out through a separate
incision and sutured in place with 3-0 nylon.

the patient remained intubated and was taken to the icu in
stable and satisfactory condition.

postoperatively the patient was febrile. the patient had a
right femoral arterial line and left triple lumen. cultures
were obtained on [**2175-11-7**], because the patient
became febrile which grew out pseudomonas.

the renal consulting team followed the patient closely.

the patient continued with hemodialysis monday, wednesday and
friday. cat scan was obtained postoperatively on [**2175-11-8**], to evaluate the abdomen and hematoma which demonstrated
interval removal of the transplant kidney with extravasation
of right extraperitoneal __________ . at the surgical site
remains an ill-defined collection consisting of residual
hemorrhage and gas and hyperdense perihepatic fluid probably
hemoperitoneum. there was free air present which may be
related to surgery. according to the radiologist, there was
nonspecific cecal thickening, new bibasilar consolidations
and new gallbladder distention.

the patient continued to be intubated. he was placed for tube
feeds, and tube feeds were started for nutrition. the patient
remained intubated. tube feeds were continued. the patient
was continued on antibiotics, linezolid day 16, zosyn day 13.

the patient was also continued on a fentanyl patch for pain
control.

at that time, [**2175-11-20**], she was assist control 40%,
peep of 10, 45 x 25.

infectious disease was consulted for ongoing fever despite
being on multiple antibiotics. the patient had a radial
peroneal abscess that was drained. infectious disease closely
followed the patient and made recommendations without
switching antibiotics.

on [**2175-11-14**], central line change was performed
complicated by a large left apical and basilar hemothorax.
chest tube was placed that evening. another chest x-ray was
performed demonstrating marked decrease of left-sided
pneumothorax, residual small left apical and basilar
pneumothorax.

the patient had another cat scan on [**2175-11-16**], because
of ongoing abdominal pain. the patient required another
catheter for drainage of collection. cat scan demonstrated 1)
interval improvement in bilateral basal consolidations, 2)
there was a collection along the right flank, decreased in
size compared to the prior study with catheter in adequate
position, 3) there was reduction of gallbladder distention,
4) stable small collection to the right of the uterus
consistent with resolving hematoma, 5) stable splenic
infarcts.

the patient hemodynamically stable. the patient did complete
a 7-day course for a possible mucocutaneous hsv. antibiotics
were changed to meropenem. linezolid and gentamicin were
discontinued.

tpn was discontinued. nepro tube feeds were started per
recommendations from nutrition.

the patient was slowly weaning from the vent. tube feeds were
advanced.

on [**2175-11-20**], the patient needed central venous
access, and there was successful placement of an 8.5 french
16 cm long four-lumen catheter via the left common femoral
vein. also the venogram demonstrated occlusion of the left ij
and the left subclavian vein with multiple collaterals, and
also the right ij was shown to be occluded on ultrasound
scan. therefore the left femoral line was in place and ready
to use for central access.

on [**2175-11-24**], the patient had a bronchoscopy to
evaluate and assess airway patency. using an endotracheal
tube, which was flexible, it was documented that her airway
was clear. there were no complications.

the patient continued with the dialysis 3 days a week. renal
continued to follow the patient.

on [**2175-11-30**], the patient had an open tracheostomy
performed by dr. [**last name (stitle) **] because of respiratory failure and
failure to wean off the ventilator status post tracheostomy
tube with a 7 french non-fenestrated tracheostomy tube. the
patient ventilated well, and the patient was transferred back
to the recovery room in stable condition.

on [**2175-12-2**], the patient had another cat scan
because of abdominal pain and persistent fever. the case was
discussed with dr. [**last name (stitle) 816**] who requested drainage of subhepatic
fluid collection.
1.  the size of the subhepatic fluid collection within an
    enhancing wall has decreased slightly since the prior
    study. this was drained with an 8 french pigtail catheter
    which was left in place.
2.  there was a jp drain in the right pericolic fluid
    collection which was in good position. the size of the
    fluid collection was essentially [**last name (stitle) 1506**] from the prior
    study of [**2175-11-23**].
3.  there was a stable appearance of a cystic collection deep
    within the pelvis to the right of the uterus not easily
    amendable to percutaneous drainage.
4.  there was anasarca with ascites.
5.  there was bilateral lower lobe consolidation which was
    [**year (4 digits) 1506**].
6.  there were splenic infarcts, which was [**year (4 digits) 1506**].

we continued to check her labs which included cbc,
electrolytes daily and were replaced as needed.

the patient was evaluated for rehab.

another cat scan was performed on [**12-22**] at 1 a.m.
because of abdominal pain, and was documented:
1.  persistent, although smaller multiloculated fluid
    collection along the right flank, status post removal of
    drainage catheter. the presence of infection cannot be
    excluded.
2.  there was a similar uterine mass.
3.  there was ascites and edema.
4.  improving bilateral lower lobe consolidations.
5.  continued splenic infarcts, not well appreciated on that
    particular study.

the patient continued on antibiotics for pseudomonas coverage
and vre bacteremia related to lines and questionable
abdominal fluid collections.

later that day on [**2175-12-22**], the patient had a ct-
guided abdominal drainage using ct fluoroscopic guidance. [**initials (namepattern4) **]
[**last name (namepattern4) 4300**] needle was advanced to the right flank collection.
approximately 40-50 ml of blood-tinged fluid was aspirated.
postprocedural films demonstrated that the right flank
collection appears in good position. the patient tolerated
the procedure well. there were no immediate complications.
the 8 french catheter remained in place after the ct was
completed.

on [**2175-12-12**], the patient was evaluated for a passy-
muir valve evaluation, and it was observed that she did
tolerate wearing the pmv for 20 minutes with no oxygen
desaturation and was able to speak with a clear voice and
intelligible speech; however, she then began to cough at the
end of the evaluator's exam suggesting either
dryness/irritation or possibility of aspiration secretions.

physical therapy and occupational therapy met with the
patient for evaluation and treatment and definitely felt that
the patient needed to go to rehab. the patient continued with
hemodialysis.

on [**2175-12-21**], the patient had a chest x-ray because of
ongoing fevers, and the radiologist documented the chest x-
ray report as a long-standing interstitial abnormality in the
right lower lobe present since [**5-19**]. this probably
represents irreversible changes of previous edema, pulmonary
hemorrhage, vascular congestion or interstitial lung disease,
not an acute process. top-normal heart size and dilatation of
pulmonary arteries and left atrium are long standing. there
are no findings to suggest further cardiovascular
decompensation or current enterothoracic infection. feeding
tube ends at the pylorus. tracheostomy tube in standard
placement. no pleural effusion.

pigtail catheter was removed on [**2174-12-21**], and
tracheostomy was downsized, and there were no adverse events
over night. she was afebrile with vital signs stable. p.o.
intake 640, tube feeds 710; does not void. the patient had jp
drainage of 35 cc.

infectious disease had recommended to continue tobramycin,
p.o. vancomycin and cipro until her follow-up appointment
with infectious disease on [**2176-1-9**]. at that time,
abdominal/pelvic ct will be obtained to assess fluid
collections to help define further duration of antibiotics.

on [**2175-12-22**], another cat scan was performed to
evaluate the abdominal collections after the drains have been
removed.

on [**2175-12-23**], pain service was consulted requires
multiple narcotics. the pain service had stated to continue
the fentanyl patch, to change her p.o. dilaudid regimen and
to discontinue her iv dilaudid.

currently the patient is on cipro for pseudomonas. the
patient is also on linezolid for enterococcus and history of
vre. the patient continues on vancomycin for prior c-diff.
she is also receiving tobramycin.

she has 2 pending cultures from blood cultures that were
obtained on [**2175-12-24**].

her labs on [**2175-12-26**], revealed the following: wbc
9.4, hematocrit 26.8, platelets 111; ptt 30.5, inr 1.1;
sodium 131, 3.6, 95, 28, bun and creatinine of 20 and 3.5,
glucose 88, calcium 9.6, phos 2.5, magnesium 0.7, albumin
2.6. the patient had a tobramycin level of 1.1 on [**2175-12-26**].

when the patient goes to rehab, the patient will need daily
cbc, chem10 at least once-a-week. the patient will need to
have a cbc with diff and a post dialysis tobramycin level.
those results need to be faxed to infectious disease [**telephone/fax (1) 18624**].

the patient has a follow-up appointment with dr. [**first name (stitle) 2505**] on
[**2176-1-9**], from infectious disease, [**telephone/fax (1) 457**]. this
appointment is for [**2176-1-9**], at 9 a.m. if you have
any questions or problems with the appointment please dr.[**name (ni) 18625**] office immediately. also the facility should make an
appointment with transplant surgery potentially on the same
day; please call [**telephone/fax (1) 673**].

discharge medications:  prednisone 5 mg daily, mucomyst
solution q.4-6 hours as needed, heparin 5000 units subcu
b.i.d., vancomycin 125, which is the oral liquid, q.6 hours,
prevacid 30 mg suspension 1 tablet daily, albuterol aerosol
puff inhalation 1-2 puffs q.6 hours, lopressor 4.5 b.i.d.,
fentanyl patch 100 mcg, please change every 72 hours,
__________  750 q.24 hours, colace 100 mg b.i.d., dilaudid 2
mg tablets 1-3 tablets q.2 hours p.r.n., linezolid 600 mg
q.12 hours, ativan 1 mg iv q.6 hours, tobramycin as needed,
the last dose was 140 mg, but please check level prior to
giving dose. if there are any questions in regards to the
tobramycin, call infectious disease at [**telephone/fax (1) 457**].

the patient is on tube feeds, nepro 3/4 strength, goal rate
of 40 cc/hr. please check residuals q.4 hours and hold tube
feeds for residuals greater than 100 ml. please flush with 50
cc of water q.8 hours. the patient should also receive
calorie counts and have a dietician following the patient.
the patient could be possibly transitioned from tube feeds to
a regular diet.

final diagnosis:  this is a 28-year-old woman with lupus
nephritis status post renal transplant on [**2175-9-1**],
with acute rejection and subsequent graft rupture.

secondary diagnosis:
1.  pseudomonas bacteremia.
2.  peritoneal abscess/necrotizing fascitis.
3.  left ij and left subclavian vein occlusion.
4.  left pneumothorax requiring chest tube placement.
5.
    respiratory failure requiring tracheostomy.
6.  intra-abdominal fluid collection status post drainage.



                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 3432**]

dictated by:[**last name (namepattern1) 4835**]
medquist36
d:  [**2175-12-27**] 12:32:23
t:  [**2175-12-27**] 14:04:32
job#:  [**job number 18626**]
"
38,"admission date:  [**2198-6-19**]              discharge date:   [**2198-7-8**]

date of birth:  [**2120-8-11**]             sex:   m

service: urology

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1232**]
chief complaint:
angiosarcoma of bladder cancer

major surgical or invasive procedure:
radical cystoprostatectomy
ileal loop urinary diversion
regional node dissection
right internal jugular vein central line placement
swan-ganz catheter placement
arterial line placement
nasogastric tube placement

history of present illness:
mr. [**known lastname 19000**] is a 77-year-old male who was
diagnosed with prostate cancer in [**2189-11-8**] by abnormal dre.

he reports a psa of that time of 14. he received external beam
radiation therapy at [**hospital6 **]. he reports that his
psa post radiation was 0.3. he was followed periodically by psa
after radiation. his psa rise to about 11 in [**2193**]. he started
casodex and lupron [**4-8**]. he reports he was getting lupron every

other month. his lowest psa on hormonal treatment was 0.4 in
[**2197-2-6**]. his psa started to climb 1004 and reached 2.2 in 05/

05. he has been followed by dr. [**last name (stitle) 4749**] in [**hospital1 **].

the patient noted painless hematuria and clots beginning of
[**month (only) 958**]
he had a tur at [**hospital 1281**] hospital by dr. [**last name (stitle) **] where a bladder
tumor was noted. he has been seen by dr. [**last name (stitle) **] in evaluation
for a possible cystectomy and dr. [**last name (stitle) **] for medical oncologic

opinion of the angiosarcoma.
he reports he multiple negative ct scans and bone scans in the
past. most recently he had a bone scan in [**4-12**], which showed
increased tracer activity in l5-s1 region, likely representing
degenerative changes. ct chest, abdomen, and pelvis [**4-12**], shows

a infrarenal aortic aneurysm, measuring 4.2 x 4.8 cm, asymmetric

inferior bladder wall thickening, and multiple small bilateral
pulmonary nodules, the largest measuring 5 mm in the right
middle
lobe.
he presents for cystoprostatectomy.

past medical history:
prostate carcinoma
heartburn
asthma
appendectomy
no tuberculosis noted
copd: fev1 58%



social history:
mr. [**known lastname 19000**] is retired. he spent seven and a
half years in the russian army, then he went to college and was
an electrical engineer in a fairly high position. he lives in
[**location **]. he immigrated to the us about ten years ago. he has two
daughters and two grandsons who live in the area. he quit
smoking about 11 years ago. he smoked nonfiltered cigarettes for

a total of 100 pack years. he drinks vodka and bourbon once or
twice a week.


family history:
no family history of cancers. he has five
brothers, four of whom have died of heart attacks. his older
brother lives in [**name (ni) 6607**]. his mother died of a cva. his father
died at age 33 in [**2125**] from typhoid.


physical exam:
gen:  aaox3 nad
cv: s1 s2 rrr
chest: cta b/l
abd: pos bs soft nt/nd midline scar, uretostomy
extrem: no c/c/e

pertinent results:
[**2198-7-5**] 07:20am blood wbc-5.3 rbc-4.35* hgb-12.6* hct-39.1*
mcv-90 mch-29.0 mchc-32.2 rdw-15.6* plt ct-297
[**2198-7-4**] 07:00am blood wbc-4.0 rbc-4.21*# hgb-12.4*# hct-37.3*#
mcv-89 mch-29.4 mchc-33.1 rdw-15.1 plt ct-270
[**2198-7-3**] 07:25am blood wbc-3.8* rbc-3.24* hgb-9.8* hct-28.6*
mcv-88 mch-30.2 mchc-34.2 rdw-14.2 plt ct-211
[**2198-7-2**] 08:00am blood wbc-4.2 rbc-3.22* hgb-9.8* hct-29.0*
mcv-90 mch-30.3 mchc-33.6 rdw-14.2 plt ct-197
[**2198-7-1**] 03:23am blood wbc-3.3* rbc-3.15* hgb-9.4* hct-29.0*
mcv-92 mch-29.8 mchc-32.3 rdw-14.7 plt ct-170
[**2198-6-19**] 05:39pm blood wbc-6.8 rbc-3.27*# hgb-9.8*# hct-29.8*#
mcv-91 mch-29.8 mchc-32.8 rdw-14.1 plt ct-125*
[**2198-6-20**] 04:15am blood wbc-4.9 rbc-2.92* hgb-8.8* hct-26.1*
mcv-89 mch-30.3 mchc-33.9 rdw-14.1 plt ct-104*
[**2198-6-20**] 11:00am blood hct-31.6*
[**2198-6-20**] 03:57pm blood hct-31.3*
[**2198-6-21**] 03:45am blood wbc-7.4# rbc-3.47* hgb-10.7* hct-31.1*
mcv-90 mch-30.9 mchc-34.4 rdw-13.9 plt ct-104*
[**2198-6-21**] 08:29am blood wbc-6.7 rbc-3.48* hgb-10.8* hct-31.1*
mcv-89 mch-31.0 mchc-34.8 rdw-13.7 plt ct-105*
[**2198-6-21**] 04:21pm blood wbc-5.4 rbc-3.29* hgb-10.1* hct-29.4*
mcv-90 mch-30.8 mchc-34.4 rdw-13.9 plt ct-105*
[**2198-7-5**] 07:20am blood plt ct-297
[**2198-7-4**] 07:00am blood plt ct-270
[**2198-7-3**] 07:25am blood plt ct-211
[**2198-7-2**] 08:00am blood plt ct-197
[**2198-7-1**] 03:23am blood plt ct-170
[**2198-6-19**] 05:39pm blood pt-14.6* ptt-32.9 inr(pt)-1.4
[**2198-6-19**] 05:39pm blood plt ct-125*
[**2198-6-20**] 04:15am blood plt ct-104*
[**2198-6-21**] 03:45am blood plt ct-104*
[**2198-6-21**] 08:29am blood plt ct-105*
[**2198-7-6**] 09:00am blood glucose-97 urean-17 creat-1.3* na-142
k-3.7 cl-103 hco3-33* angap-10
[**2198-7-5**] 07:20am blood glucose-104 urean-14 creat-1.2 na-141
k-4.0 cl-102 hco3-32 angap-11
[**2198-7-4**] 07:00am blood glucose-105 urean-12 creat-1.0 na-144
k-3.6 cl-106 hco3-32 angap-10
[**2198-7-3**] 07:25am blood glucose-95 urean-14 creat-1.0 na-145
k-3.7 cl-108 hco3-29 angap-12
[**2198-6-19**] 05:39pm blood glucose-165* urean-17 creat-1.1 na-140
k-4.9 cl-112* hco3-23 angap-10
[**2198-6-20**] 04:15am blood glucose-133* urean-21* creat-1.6* na-135
k-4.4 cl-110* hco3-23 angap-6
[**2198-6-20**] 02:25pm blood glucose-124* urean-25* creat-2.8*# na-137
k-4.6 cl-110* hco3-21* angap-11
[**2198-6-20**] 08:00pm blood urean-28* creat-3.2* na-137 k-4.6 cl-111*
hco3-19* angap-12
[**2198-7-4**] 07:00am blood ck(cpk)-19*
[**2198-6-21**] 04:21pm blood alt-2 ast-24 alkphos-86 amylase-83
totbili-0.4
[**2198-6-21**] 03:45am blood alt-4 ast-28 ld(ldh)-208 ck(cpk)-619*
alkphos-59 totbili-0.5
[**2198-6-20**] 04:15am blood ck(cpk)-808*
[**2198-6-20**] 02:00am blood ck(cpk)-755*
[**2198-6-19**] 05:39pm blood ck(cpk)-160
[**2198-7-4**] 07:00am blood ck-mb-3 ctropnt-0.02*
[**2198-6-20**] 04:15am blood ck-mb-5 ctropnt-<0.01
[**2198-6-20**] 02:00am blood ck-mb-6
[**2198-6-19**] 05:39pm blood ck-mb-3 ctropnt-<0.01
[**2198-7-6**] 09:00am blood calcium-8.7 phos-3.4 mg-2.0
[**2198-7-5**] 07:20am blood phos-3.4 mg-1.9
[**2198-7-4**] 07:00am blood calcium-8.7 phos-3.3 mg-1.8
[**2198-7-3**] 07:25am blood calcium-8.4 phos-2.4* mg-1.7
[**2198-7-2**] 08:00am blood calcium-8.4 phos-2.0* mg-1.6
[**2198-6-19**] 05:39pm blood calcium-8.0* phos-4.9* mg-1.5*
[**2198-6-20**] 04:15am blood calcium-7.4* phos-2.9# mg-2.1
[**2198-6-20**] 02:25pm blood mg-2.1
[**2198-6-21**] 03:45am blood albumin-2.7* calcium-7.5* phos-5.3*#
mg-2.1
[**2198-6-21**] 08:29am blood calcium-7.4* phos-6.0* mg-2.2
[**2198-6-30**] 06:29pm blood type-art po2-122* pco2-35 ph-7.47*
calhco3-26 base xs-2
[**2198-6-30**] 03:38am blood type-art po2-75* pco2-43 ph-7.41
calhco3-28 base xs-1
[**2198-6-28**] 04:03am blood ph-7.42 comment-green top
[**2198-6-19**] 08:35am blood type-art po2-529* pco2-48* ph-7.39
calhco3-30 base xs-3
[**2198-6-19**] 10:19am blood type-art po2-212* pco2-45 ph-7.39
calhco3-28 base xs-2
[**2198-6-19**] 11:30am blood type-art po2-240* pco2-45 ph-7.38
calhco3-28 base xs-1
[**2198-6-19**] 12:30pm blood type-art rates-/10 tidal v-650 fio2-57
po2-239* pco2-41 ph-7.38 calhco3-25 base xs-0 intubat-intubated
vent-controlled
[**2198-6-19**] 02:11pm blood type-art po2-252* pco2-40 ph-7.41
calhco3-26 base xs-1
[**2198-6-19**] 03:54pm blood type-art ph-7.41
[**2198-6-30**] 06:29pm blood lactate-1.5
[**2198-6-30**] 03:38am blood glucose-108*
[**2198-6-27**] 05:12pm blood lactate-0.9
[**2198-6-27**] 03:31am blood glucose-152*
[**2198-6-25**] 03:18am blood glucose-86 lactate-1.2
[**2198-6-19**] 08:35am blood glucose-126* lactate-1.8 na-138 k-4.2
cl-104
[**2198-6-19**] 10:19am blood glucose-149* lactate-1.8 na-140 k-4.6
cl-105
[**2198-6-19**] 11:30am blood glucose-147* lactate-1.8 na-139 k-4.1
cl-109
[**2198-6-19**] 12:30pm blood glucose-153* lactate-2.4* na-137 k-4.6
cl-109
[**2198-6-19**] 02:11pm blood glucose-154* lactate-2.0
[**2198-6-30**] 03:38am blood o2 sat-96
[**2198-6-26**] 04:11pm blood o2 sat-90
[**2198-6-25**] 03:18am blood o2 sat-98
[**2198-6-22**] 11:27am blood o2 sat-97
[**2198-6-30**] 06:29pm blood freeca-1.20
[**2198-6-30**] 03:38am blood freeca-1.11*
[**2198-6-28**] 04:03am blood freeca-1.10*
[**2198-6-27**] 03:31am blood freeca-1.15

cxr - [**2198-7-5**]
indications: desaturation.

ap and lateral chest radiographs: comparison is made to [**2198-7-1**] and a
chest ct scan from [**2198-4-27**]. cardiac size is at the upper
limits of
normal. two rounded nodules are seen, one in each upper lobe.
the one in the
right measures 9 mm and the one in the left measures 13 mm.
these appear
different than on multiple prior studies. the patient has known
nodules on ct
scan. there are no consolidations. there is mild blunting of the
right cp
angle, likely reflecting a small effusion. overall, there is
improved
aeration of the left lower lobe.

impression: bilateral upper lobe nodules, more conspicuous than
on prior
studies. further evaluation with chest ct scanning is
recommended.

cxr - [**2198-7-1**]

there has been interval removal of the right ij line. there is
improved
aeration of both lower lobes. both cp angles are off the film.
there is no
focal infiltrate.

cxr - [**2198-6-22**]
findings: in comparison with the previous examination of the
same date, the
pulmonary artery catheter is again seen, now terminating within
the right
pulmonary artery and entering via a right internal jugular
approach. an
endotracheal tube terminates approximately 8.5 cm from the
carina. nasogastric
tube extends below the diaphragm and likely terminates in the
upper stomach.
there is interval improvement in pulmonary edema. probable small
bilateral
pleural effusions are incompletely evaluated due to exclusion of
the
costophrenic angles bilaterally. stable bibasilar atelectasis.

impression:

1. cardiomegaly and improving congestive heart failure.

2. bibasilar atelectasis and probable small bilateral pleural
effusions.


brief hospital course:
mr. [**known lastname 19000**] [**last name (titles) 1834**] a cystoprostatectomy on [**2198-6-19**] (please see
dictated operative report for details) without adverse events.
it was noted by surgeons that urine output was low throughout
the procedure. in the or he received 6,000cc of crystaloid, 2
units of packed red cells, 1000cc of hespan, and 750cc of 5%
albumin. estimated blood loss was 2,500cc.  given the large
fluid requirement and his history of copd, patient remained
intubated overnight.  he remained hemodynamically stable post
operatively. his urine output was variable with outputs 28-145cc
per hour and a total of 813 by midnight on operative day.  on
post-operative day 1 by 0600, his urine output progressively
decreased to a point where he was making < 5 cc per hour.  he
was given both normal saline and 2 units of prbcs with no kidney
response (24 hour total of 304 cc) and he remained in aneuric
failure despite receiving >5000cc of fluid over 24 hours.   he
was transferred to the intensive care unit from the
post-anesthesia care unit. his bun/cre also began to rise.
nephrology consult was obtained and the worry was that the
patient was in aneuric renal failure vs. outflow obstruction.
ct studies were obtained on [**6-21**] and revealed: 1. no evidence
for hydronephrosis or hydroureter. no evidence for urinoma. 2.
small amount of intraabdominal ascites as well as inflammatory
stranding along the pararenal fascia and within the right lower
quadrant at the site of the ureteroileal loop anastomosis. small
amount of intraabdominal free air. anasarca. these changes are
most likely secondary to recent postoperative state. 3. small
bilateral pleural effusions with bilateral lung base compressive
atelectasis. urinalysis was consistent with acute tubular
nephritis with aneuria, and creatinine continued to rise. he
remained intubated for ventilartory support.  he had minimal
response to lasix challanges. swan-ganz catheter was inserted
over existing right ij to monitor fluid status and cardiac
function. his creatinine and bun peaked at 6.4/49 respectively
on post operative day 2. he developed progressive non-anion gap
acidosis and bicarbonate infusion was started to control
acidemia.  at that point renal function began to return and
patient began to autodiurese with urine outputs in 3,000-4,000cc
range per 24 hours. he spiked fevers to 101.6 on post operative
day 6. blood, urine, sputum cultures were obtained and sputum
culture showed pseudomonas aureginosa presence. he was begun on
zosyn on [**2198-6-21**] and defervesced over the next 3 days. his bun
and creatinine progressively normalized, as did the acidemia. he
ramained intubated for ventilatory support.  with significan
autodiuresis, patient's sodium began to rise and free water
repletion was begun.  electrolytes were repleted as needed
throughout the stay.  propofol sedation was weaned and his
mental function slowly returned to [**location 213**].  he was extubated on
post-operative day 8. he continued to autodiurese. his mental
function slowly improved and he was transferred to the floor on
post-operative day 13.  after transfer to floor pulmonary was
consulted.  he was started on advair and standing
alb/ipratropium inhaler.  he was continued on zosyn.  he was
also diuresed with lasix which helped clear up his lungs.  his
pulmoary exam improved.  he was on 1:1 sitter which was stopped
and then started again and then stopped on [**7-5**].  he got
startled and slid back against the wall on [**7-4**] prompting the
sitter being restarted.  he made adequate urine output on the
floor and was seen and evaluated by pt who helped him ambulate.
his is/os were good on the floor and he tolerated his pos.  he
was screened for rehab and is in good condtion for discharge.


medications on admission:
advair
combivent
casodex 50 mg
protonix,
lupron every other month, last given [**2198-5-13**]


discharge medications:
1. albuterol sulfate 0.083 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for sob, wheezing.
disp:*30 inhalation* refills:*0*
2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every
4 to 6 hours) as needed.
disp:*30 tablet(s)* refills:*0*
3. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for wheezing, copd.
disp:*10 inhalation* refills:*0*
4. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times
a day).
disp:*60 tablet(s)* refills:*0*
5. fluticasone-salmeterol 500-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
disp:*60 disk with device(s)* refills:*0*
6. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
disp:*30 injection* refills:*0*
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:*0*
8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: one
(1) puff inhalation qid (4 times a day).
disp:*30 inhalation* refills:*2*
9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
disp:*60 capsule(s)* refills:*0*
10. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3
times a day).
disp:*135 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital 3915**] [**hospital **] rehab center

discharge diagnosis:
angiosarcoma of bladder


discharge condition:
good

discharge instructions:
discharge to rehab facility
need intructions and care for uroestomy
can shower
if have fever >101.4, intractable nausea, vomiting, severe pain
or trouble with your ostomy, please return.

followup instructions:
follow up with cardiology
follow up with pulmonology
follow up with dr. [**last name (stitle) **] (urology) - ([**telephone/fax (1) 4276**]



"
39,"admission date:  [**2192-8-19**]              discharge date:   [**2192-9-4**]

date of birth:  [**2111-4-12**]             sex:   f

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1042**]
chief complaint:
coffee-ground emesis

major surgical or invasive procedure:
upper endoscopy


history of present illness:
hpi: the patient is an 81 year old female who presented from a
nursing home with coffee ground emesis on [**2192-8-19**]. the patient
was unable to provide a history due to dementia but the micu
admitting team was able to speak to her nursing home who
provided the following history. per her nurse she had several
episodes of dark, coffee-ground emesis on the day prior to
admission. she did not complain of abdominal pain. per report
from her nursing home she also fell two days prior to admission
and hit her forehead (no further history on her fall available).
per the patient's daughter at baseline, pt is minimally verbal,
able to answer simple questions and interject into conversation
but does not speak spontaneously and has significant word
finding difficulties. she adds that the pt has been less active
in the few days preceeding admission.
.
in ed her vitals were bp 132/50, hr 76, o2 sat 95% on ra. she
was found to have a hematocrit of 37. she received 1l of ns and
iv protonix. an ng lavage per report was not performed because
there was no evidence of active vomiting. ct of the head
revealed no evidence of acute bleed.
.
while in the micu her vital signs have been stable. her
hematocrit on admission to the er was 37 on [**8-19**] at 12 am. this
decreased to 29.8 at 6 am, 27.6 at 12 pm and 30.8 at 12 am on
[**8-20**]. at no time did she require transfusion. bilateral lower
extremity ultrasounds were performed given assymetric lower
extremity edema which were negative for clots. she was started
on high dose iv ppi for her presumed gi bleed. she underwent ct
of the abdomen which showed a large hiatal hernia with a
thoracic stomach and no evidence of pancreatitis despite
incidentally noted elevated pancreatic enzymes. she was
evaluated by gastroenterology who plan for her to under upper
endoscopy tomorrow am.
.


past medical history:
# [**first name8 (namepattern2) **] [**male first name (un) 923**] aortic valve, not currently anticoagulated at
rehab/nursing home
# atrial fibrillation
# hiatal hernia with esophagitis
# hypoxic brain injury
# dementia
# breast ca s/p lumpectomy
# osteoporosis
# chf, ef unknown
# cad s/p cabg


social history:
 has been living at [**hospital 19453**] nursing home & rehab for past
month.


family history:
noncontributory

physical exam:
vitals: 95.5 133/56 72 19 99% 3l nc
gen: lying in bed, oriented to person, ""hospital,"" and ""saturday
in [**month (only) 205**].""
heent: ecchymosis over l lower eyelid, perrl, eomi, op clear
neck: jugular veins difficult to assess [**2-24**] body habitus
cv: mechanical valve sounds
chest: cta ant and lateral fields
abd: soft, nontender, nabs
ext: no c/c/e
skin: no rashes


pertinent results:
admission labs [**2192-8-19**]:
hematology:
cbc: wbc-13.0*# rbc-4.38 hgb-12.5 hct-37.2 mcv-85 mch-28.4
mchc-33.5 rdw-21.9* plt count-421#
differential: neuts-80.7* lymphs-14.7* monos-3.4 eos-0.9
basos-0.2
pt-11.6 ptt-21.6* inr(pt)-1.0
chemistries:
glucose-146* urean-30* creat-0.9 na-145 k-3.9 cl-99 hco3-37*
angap-13
calcium-8.9 phos-3.5 mg-2.1
alt-27 ast-37 alkphos-174* amylase-326* totbili-0.4 lipase-276*
albumin-4.1
.
others [**2192-8-21**]:
alt-17 ast-23 ld(ldh)-279* alkphos-149* amylase-62 totbili-1.0
lipase-22 ggt-25
triglyc-70 hdl-51 chol/hd-3.9 ldlcalc-133*
b12: 631 folate: 9.0
tsh: 0.66
.
discharge laboratories:
[**2192-8-31**] cbc: wbc: 9.4 hgb: 10.6* hct: 31.6* plts: 400
[**2192-9-3**] [**name (ni) 2591**]  pt: 21.2* ptt: 28.2 inr: 2.1*
.
imaging:
.
ct head [**2192-8-19**]:
despite repetition, some of the posterior fossa scans are
degraded by patient motion. within this limitation, there is no
significant interval change seen compared to the prior
examination. specifically, there has been no interval
development of an intracranial hemorrhage or overt area of acute
brain ischemia. however, if the latter diagnostic consideration
is a possibility, an mri scan would be a more sensitive means
for detecting an area of acute infarction. the multiple areas of
chronic small-vessel infarctions previously described are
re-demonstrated. no other new extracranial abnormalities are
discerned, either.
.
ct abd [**2192-8-19**]:
1. intrathoracic stomach which may represent gastric volvulus.
if the patient is not symptomatic these findings may be related
to chronic volvulus.
2. no ct evidence of pancreatitis
.
bilateral le us [**2192-8-19**]:
grayscale and doppler examination of bilateral common femoral,
superficial femoral, and popliteal veins were performed. normal
compressibility, augmentation, waveforms, and doppler flow is
demonstrated. there is no evidence of intraluminal clot.
.
upper endoscopy [**2192-8-21**]:
findings: normal esophagus, large hiatal hernia with [**location (un) 3825**]
lesions, normal duodenum.
.
upper gi with small bowel follow through [**2192-8-21**]:
1. intrathoracic stomach with the pyloric at the level of the
diaphragmatic hiatus. no evidence of gastric outlet obstruction
or volvulus.
2. small amount of barium aspiration noted in the central
airways. followup chest x- ray is recommended if there is
concern for development of pneumonia.
.
echocardiogram [**2192-8-22**]:
conclusions: the left atrium is moderately dilated. no atrial
septal defect is seen by 2d or color doppler. 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 ascending aorta is moderately
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 mitral valve leaflets are mildly
thickened. there is no mitral valve prolapse. trivial mitral
regurgitation is seen. the tricuspid valve leaflets are mildly
thickened. there is no pericardial effusion.
.
ct head [**2192-8-24**]:
1.  no significant interval change to brain parenchyma without
acute
hemorrhage identified.
2.  slight decrease to predominantly left supraorbital subgaleal
hematoma.

brief hospital course:
mrs. [**known lastname 24831**] is an 81 year old female with a history of cad,
atrial fibrillation, aortic valve replacement and dementia who
presents with evidence of an upper gastrointestinal bleed.
.
# upper gi bleed: on presentation the patient had experienced
two episodes of coffee ground emesis at her nursing home.  she
has a history of esophagitis but otherwise no history of
gastrointestinal disorders or bleeding events.  in the emergency
room two large bore ivs were placed and she received iv fluids.
her hematocrit on admission was 37.2.  this fell over the course
of the following day decreased to 27.1 but the patient did not
require transfusion.  she was hemodynamically stable and
asymptomatic throughout.  she was started on high dose
intravenous ppi therapy.  a ct scan of the abdomen was performed
in the emergency room which revealed the presence of a large
hiatal hernia with a complete intrathoracic stomach.  the
patient underwent upper endoscopy on [**2192-8-21**] which revealed no
obvious bleeding sources but confirmed the presence of the large
hiatal hernia with the presence of [**location (un) 3825**] lesions.  given that
her hematocrit had stabilized and there was no obvious bleeding
source on endoscopy no further workup was initiated.  she was
discharged on an oral proton pump inhibitor.  no further
episodes of bleeding were observed throughout this
hospitalization.
.
# hiatal hernia: the patient was noted to have a large hiatal
hernia on ct scan.  the presence of an intrathoracic stomach was
confirmed on upper endoscopy.  an upper gi with small bowel
follow through was obtained to further clarify her anatomy.
this again showed the hiatal hernia, but showed no evidence of
volvulus or gastric outlet obstruction.  the possibility of
surgical intervention to prevent strangulation was discussed
with the patient's daughter.  [**name (ni) 227**] the patient's age and
comorbities and relatively low lifetime risk of adverse events
secondary to her hernia, surgical correction was not pursued
further.  she should continue to take a proton pump inhibitor to
protect against future bleeding events.
.
# dementia: the patient has a history of traumatic brain injury
as well as senile dementia.  on admission she was taking
aricept, seroquel and namenda.  while in house she was observed
to have reversal of her sleep/wake cycles with frequent episodes
of calling out at night.  psychiatry was consulted to assist
with her medication regimen.  her aricept and standing seroquel
were discontinued.  she was started on haldol 0.25 mg po tid
with good effect. behavioral interventions particularly
effective included allowing patient to sit in public areas where
she was able to interact with other people.
.
# mechanical aortic valve: the patient has a st. [**male first name (un) 1525**]
mechanical aortic valve.  she was not on anticoagulation on
admission.  her primary care physician was [**name (ni) 653**] who
confirmed that anticoagulation was appropriate.  she was started
on a heparin drip for anticoagulation which was quickly switched
to lovenox.  she was also started on coumadin.  her lovenox was
discontinued when her inr was within therapeutic range.  over
the remainder of her hospitalization her coumadin was titrated
to a goal inr between 2.5 to 3.5 for patients with a mechanical
valve and atrial fibrillation.  she was discharged on coumadin
1.5 mg t,th,[**last name (lf) **],[**first name3 (lf) **] and 2 mg m,w,f.  she will need to have her inr
monitored every other day at her nursing home until her inr is
stable.
.
# atrial fibrillation: currently well-rate controlled with
metoprolol. she was started on anticoaglation with coumadin as
described above.
.
# chf: patient has a past medical history of chf but the details
of this diagnosis are unclear.  as an outpatient she takes
toprol xl and lasix.  on admission her antihypertensive
medications were held in the setting of acute bleeding but were
restarted once serial hematocrits were stable.  an
echocardiogram was performed during this admission which
revealed mild symmetric lvh, no regional wall motion
abnormalities, lvef of > 55%, and a well-seated aortic valve
prosthesis with normal disc motion and transvalvular gradients.
she was started on lisinopril 5 mg daily during this admission
and this can further managed in the outpatient setting.
.
# cad - the patient has an unclear cardiac history but on ct
scan she has evidence of cabg and takes a beta blocker as an
outpatient.  a lipid profile was obtained to further assess her
cardiac risk.  her ldl was elevated at 133 and given her history
of cad she was started on simvastatin 10 mg daily.  she was also
started on lisinopril 5 mg daily.  she was continued on her beta
blocker.  she was not started on an aspirin on this admission
given her presentation with a gi bleed but this can be
considered as an outpatient.
.
# htn: the patient has a history of hypertension treated with
metoprolol as an outpatient.  on admission her antihypertensive
medications were held in the setting of acute bleeding but were
promptly restarted.  given that her blood pressures continued to
be elevated in the 140s on her outpatient regimen she was
started on lisinopril 5 mg daily during this admission with good
blood pressure control.
.
# paget's disease: patient was incidentally noted to have
evidence of paget's disease in the right hemipelvis and l1
vertebral body on ct.  she also has a mildly elevated alkaline
phosphatase and normal ggt consistent with this disorder.  this
issue may be followed as an outpatient.
.
# urinary tract infection: patient was noted to have klebsiella
uti during this admission.  she was asymptomatic but we opted to
treat with a three day course of ciprofloxacin given her waxing
and [**doctor last name 688**] mental status.
.
# osteoporosis: patient has a history of osteoporosis.  she
takes vitamin d and calcium as an outpatient and these were
continued during this admission.
.
# anemia: patient has a history of iron deficiency anemia.
baseline hematocrit is unknown.  further workup was not pursued
during this admission given her acute bleeding episode.  she was
continued on her home iron supplementation.
.
# prophylaxis: she was treated with subcutaneous heparin for dvt
prophylaxis.
.
# code status: dnr/dni

medications on admission:
namenda 10mg [**hospital1 **]
seroquel 12.5mg [**hospital1 **]
trazodone 50mg prn
aricept 10mg daily
calcium with d 600/200 [**hospital1 **]
iron 325mg daily
vit c 500mg daily
mvi
lasix 40mg daily
kcl 20meq [**hospital1 **]
toprol xl 25mg


discharge medications:
1. namenda 10 mg tablet [**hospital1 **]: one (1) tablet po twice a day.
2. ferrous sulfate 325 (65) mg tablet [**hospital1 **]: one (1) tablet po
daily (daily).
3. ascorbic acid 500 mg tablet [**hospital1 **]: one (1) tablet po daily
(daily).
4. acetaminophen 325 mg tablet [**hospital1 **]: 1-2 tablets po q6h (every 6
hours) as needed.
5. furosemide 40 mg tablet [**hospital1 **]: one (1) tablet po daily (daily).

6. simvastatin 10 mg tablet [**hospital1 **]: one (1) tablet po daily
(daily).
7. lisinopril 5 mg tablet [**hospital1 **]: one (1) tablet po daily (daily).

8. melatonin 3 mg tablet [**hospital1 **]: one (1) tablet po at bedtime.
9. docusate sodium 50 mg/5 ml liquid [**hospital1 **]: one (1)  po bid (2
times a day).
10. warfarin 1 mg tablet [**hospital1 **]: 1.5 tablets po hs (at bedtime):
please take tuesday, thursday, saturday and sunday.
11. warfarin 1 mg tablet [**hospital1 **]: two (2) tablet po at bedtime:
please take monday, wednesday and friday.
12. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1)
tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily).
13. haloperidol 0.5 mg tablet [**last name (stitle) **]: 0.5 tablet po tid (3 times a
day).
14. haloperidol 0.5 mg tablet [**last name (stitle) **]: 0.5 tablet po every eight (8)
hours as needed for aggitation .
15. calcium 600 with vitamin d3  oral
16. toprol xl 25 mg tablet sustained release 24 hr [**last name (stitle) **]: one (1)
tablet sustained release 24 hr po once a day.


discharge disposition:
extended care

facility:
armenian nursing & rehabilitation center - [**location (un) 538**]

discharge diagnosis:
primary:
upper gi bleed
dementia
urinary tract infection
.
secondary
atrial fibrillation
mechanical aortic valve
hypertension
chf
cad


discharge condition:
stable


discharge instructions:
you were seen and evaluated because you were vomiting blood.
you were given intravenous fluids and medication to decrease the
acid in your stomach.  you underwent upper endoscopy which did
not identify a clear source of bleeding.  you had a ct scan of
your head which showed no evidence of bleeding in the brain  you
had a ct of your chest which showed that your stomach is located
above your diaphragm.  you also had an upper gi study. you were
found to have a urinary tract infection which was treated with
antibiotics.  you were started on coumadin for your mechanical
heart valve.
.
please take all your medications as prescribed.  the following
changes were made to your medications.
1. your seroquel was discontinued
2 your aricept was discontinued
3 your trazadone was discontinued
4. you were started on haldol 0.25 mg by mouth three times a day
5. you were started on lisinopril 5 mg daily
6. you were started on lansoprazole 30 mg daily
7.  you were started on coumadin for your mechanical aortic
valve.  you will have to have your inr checked daily until your
levels have stabilized.
8.  you were started on simvastatin for your cholesterol
9. you were started on melatonin
.
you should been seen by your new primary doctor at your new
facility within one week
.
please seek immediate medical attention if you experience any
chest pain, shortness of breath, vomiting blood, blood in your
stool or darkness of your stool, fevers, numbness, inability to
move your arms or legs, or any other concerning symptoms.

followup instructions:
you should seen by your new primary care physician at your new
nursing home within one week.



"
40,"admission date:  [**2164-10-7**]       discharge date:  [**2164-10-26**]

date of birth:   [**2118-1-6**]       sex:  f

service:  [**hospital unit name 196**]

chief complaint:  shortness of breath.

history of the present illness:  mrs. [**known lastname **] is a
46-year-old woman with known 3b coronary artery disease,
congestive heart failure with an ejection fraction of 15% and
brittle diabetes.  she was in her usual state of health on 2
pm of [**2164-10-6**], when she was found on the floor of her home
after she attempted transfer from her wheelchair to her
couch.  she did not have any loss of consciousness, no head
trauma.  she did complain of shortness of breath and chest
pain.  the chest pain was described as a heaviness and
radiated to her throat.  it was associated with shortness of
breath, as well as nausea and vomiting times one.  she was
brought to [**hospital6 33**], where ekg was unchanged and
cks were 127, mb 11, troponin t 0.13.  she continued to have
refractory chest pain to the point that she received 10 mg
total morphine sulfate.  she became somnolent.  she was given
narcan to arouse her.  she was also noted to have sodium 113
at the outside hospital.  she was subsequently sent to [**hospital1 1444**] for further management of her
heart failure and chest pain.  upon arrival, she again was
somnolent.  she was given 2 mg narcan with improvement in the
mental status.  heparin drip was continued.  nitroglycerin
drip was started for chest pain and hypertension.

past medical history:
1.  coronary artery disease status post non st elevation mi
on 11/[**2163**].
2.  congestive heart failure, ef of 25% to 30%; 1+ mr.
3.  insulin dependent diabetes mellitus for 36 years,
complicated by retinopathy, neuropathy, gastropathy.  the
last a1c was 13 on [**10-16**].
4.  asthma, no pfts, questionable history of intubation.
5.  osteoporosis with history of multiple rib fractures lower
extremity since [**2163-11-17**], chronically casted.
6.  chronic skin infection, including dermatitis
herpetiformis, as well as glutin sensitivity.
7.  iron-deficiency anemia.
8.  congestive hepatoplasty, diagnosed by mri on [**10-16**].
9.  chronic hyponatremia.
10. glaucoma.

allergies:  the patient is allergic to amoxicillin.

family history:  noncontributory.

social history:  the patient denied tobacco, alcohol.  the
patient lives at homeless services, has support of her
mother.  [**name (ni) **] history of drug abuse.

physical examination:  examination revealed the following:
vital signs:  97.6, pulse 70, blood pressure 134/93,
respirations 21, saturating at 96% on two liter nasal
cannula.  general:  this is a young, chronically
ill-appearing female, somnolent, no acute distress.  heent:
normocephalic, atraumatic.  pupils:  surgical on right, poor
vision bilaterally.  sclerae were anicteric.  extraocular
muscles are intact.  oropharynx:  moist mucosal membranes.
no lesions, no thrush.  neck:  no carotid bruits, supple.
chest:  decreased breath sounds bilaterally over the lung
bases.  crackles 50% of the lung fields.  heart:  regular
rate and rhythm, 2/6 systolic ejection murmur left lower
sternal border.  no radiations, no rubs, or gallops
appreciated.  abdomen:  distended, no fluid wave, positive
bowel sounds, soft, nontender.  extremities:  3+ edema up to
the thighs.  right lower extremity has multiple excoriations.
no evidence of cellulitis.  left lower extremity in cast.
neurological:  the patient was alert, oriented, somnolent,
and at times moves all four extremities.  chest:  x-ray on
admission demonstrated diffuse interstitial markings, curly b
lines, bilateral pleural effusions.  heart:  heart size,
upper limits of normal, moderate pulmonary edema.

hospital course:

cardiovascular:  mrs. [**known lastname **] was admitted to the coronary
care unit for further management of her chest pain, shortness
of breath.  cardiac enzymes at that time demonstrated ck of
114, mb 10, index 8.8, troponin i of 0.8.  it was unclear
whether the enzymes represented a mild ischemic event versus
a congestive heart failure exacerbation with troponin leak.
the enzymes rapidly normalized on the 23rd.  diuresis was
initiated in the unit with good response.  the patient was
quickly stabilized and transferred to the floor for further
management of her congestive heart failure.  echocardiogram
was performed on [**10-8**], when demonstrated extensive regional
left ventricular systolic function, consistent with
multivessel coronary artery disease, or other diffuse
process, possible mural apical thrombus, mild mitral
regurgitation, compared with prior study on [**2163-11-14**],
overall systolic function is more depressed, mild mural
thrombus is now suggested.  mrs. [**known lastname **] was restarted on
oral anticoagulation with coumadin at this time.  the
coumadin had previously been held in anticipation of eye
surgery.

she underwent diuresis on the floor averaging approximately
2  liters to 3 liters negative per day during the first week
of admission.  she was maintained on natrecor, iv lasix 120
mg along with zaroxolyn 5 mg t.i.d.  during the
hospitalization the weight changed from admission weight of
69 kilograms to weight on the day of discharge of 45.9
kilograms representing greater than 50 pound diuresis.
height if 5 foot 1 inch.

mrs. [**known lastname **] initially had an increase in the creatinine,
when she arrived to the floor from baseline creatinine of
approximately 1.0 to 1.7 on [**10-11**].  after the initiation of
natrecor the creatinine again returned to [**location 213**] and
stabilized.  most recent creatinine was 1.2.

medical regimen was optimized with the use of afterload
reductors, hydralazine, during aggressive diuresis and now
currently maintained on ace inhibitor.

electrophysiology:  mrs. [**known lastname **] was maintained on telemetry
during the hospitalization stay with no arrhythmias, no
adverse events.  she was well beta blocked in the 60s.

renal:  mrs. [**known lastname **] has a chronic hyponatremia, etiology
uncertain.  during the hospitalization she was admitted with
a sodium of 114, which then improved to the low 120s with
initial diuresis.  however, with continued diuresis, the
sodium again fell to the 114 range.  she underwent repletion
with hypertonic saline.  the renal department was consulted
and recommended discontinuing her ssri medication at it may
be the culprit in combination with her congestive heart
failure and possible hypovolemia for low sodium.  the prozac
dose was decreased to 40 mg q.d.  she will continue to need
to taper this medication and outpatient psychiatry is being
arranged.

gastrointestinal:  mrs. [**known lastname **] complain of chronic ibs and
gastroparesis.  she was visited by her primary
gastroenterologist, dr. [**first name (stitle) 679**] while in the house, who
recommended starting velnorm.  this was delayed until
outpatient as the medication is newly developed and
unavailable through our pharmacy.  we recommended future
followup for gastroparesis with dr. [**first name (stitle) 679**].

orthopedic:  the orthopedic department was consulted to
evaluate the patient's left lower extremity.  repeat films
were taken and a new cast was placed.  the patient is
regularly followed by dr. [**first name (stitle) **] in the department of
orthopedics.  he will continue to follow her with the next
appointment in early [**month (only) 1096**].  fractures were felt to be
healing well.  she was able to ambulate with the department
of physical therapy despite her cast.

endocrine:  mrs. [**known lastname **] has extremely brittle diabetes
mellitus.  endocrinologists from the [**last name (un) **] center were
consulted and visited her daily to optimize the insulin
regimen.  she is currently maintained on an atypical regimen
as nph initially q.i.d., now currently b.i.d., as well as a
humalog sliding scale insulin.  she will continue to need
close followup for management of her glucose values.
dr.  [**first name (stitle) 1661**] at the [**last name (un) **] center has become familiar with
her case.  she often has critically high values alternating
with critical lows.  she was not symptomatic during any of
these events, other than some lethargy and hypoglycemic
events.  she will need to continue close followup with [**last name (un) **]
and fingersticks q.i.d. with the addition of a 2 am
fingerstick to assist in her monitoring.  she will also take
levothyroxine for hypothyroidism.  she was recently increased
to 137 mcg q.d.  she will need repeat check for tsh in four
weeks, approximately mid [**month (only) **].

infectious disease:  mrs. [**known lastname **] was diagnosed with an
otitis externa by the department of dermatology prior to the
hospital admission.  she was maintained on levofloxacin for a
total of 14 days.  she completed this course in house.  she
was continued on loprox topical cream for her otitis.  she
complained of painful blisters in her ears, likely secondary
to her dermatitis herpetiformis.  these did improve
throughout the hospitalization stay and she will need to
continue to followup with the department of dermatology if
her pain persists, as well as for dermatitis.  she was also
maintained on nystatin cream for [**initials (namepattern4) **] [**last name (namepattern4) 564**] vaginitis.

second iv issue:  mrs. [**known lastname **] developed a urinary tract
infection with coagulase negative staphylococcus, while using
the foley catheter.  she completed a 10-day course of
macrobid and demonstrated clearing urinalysis after removal
of the foley catheter.

genitourinary:  upon admission to the [**hospital unit name 196**] service,
mrs.  [**known lastname **] complained of severe discomfort with foley
catheter.  she complained of urinary retention and fullness,
when the catheter was removed.  she had a post-void residual
of 700 cc at that time.  foley was replaced and remained
there for seven to ten days during her aggressive diuresis,
after which times the foley was removed and she was urinating
well of her own [**location (un) **].  abdominal ultrasound was performed,
which demonstrated no bladder dilatation while the foley
catheter was in place.  no abnormalities were noted.  it was
recommended that she followup with dr. [**last name (stitle) 8872**] at [**company 191**].
phone #:  [**telephone/fax (1) 25523**] if she continues to have problems.

hematology:  mrs. [**known lastname **] coumadin was restarted for possible
mural thrombus.  goal inr 2 to 3.  she is currently
maintained on a 2 mg q.h.s. dose and will need followup
approximately q. week.  the hematocrit remained stable
throughout this hospital admission.

the department of ophthalmology was consulted as the patient
has progressively poor vision in her right eye.  treatment
was initiated for glaucoma with acetazolamide as well as
multiple eye drops.  the acetazolamide was discontinued in
light of her complicated medical regimen.  she underwent
ultrasound examination on [**10-26**], which demonstrated total
retinal detachment on the right with a poor surgical
prognosis, neovascular glaucoma, presence of cataracts.
further evaluation will be performed once the patient is more
established in her outpatient setting.  the feeling at this
point is that she would likely not benefit from surgery.

neurological:  mrs. [**known lastname **] had episodes of increased
somnolence, difficulty awakening, especially in the morning
hours.  these episodes were related to her use of darvocet
for chronic neuropathy pain.  the darvocet was discontinued
with improvement in mental status.  she may need assistance
with better pain control in the future, however, at this
time, she has tolerated treatment with just neurontin and
tylenol p.r.n.

dermatitis herpetiformis:  mrs. [**known lastname **] was maintained on her
recommended lotions and sulfapyridine as well as maintained
on a gluten-free diet, which she should continue.

fluids, electrolytes, and nutrition:  electrolytes were
repleted p.r.n. with aggressive diuresis.  the patient's
fluid was restricted with free-water restriction to 500 cc a
day and total fluid restriction one liter per day.  the
patient had difficulty maintaining this with the multiple
medications, however, efforts to consolidate dosage were
helpful.  she generally was able to maintain fluid intake
just over one liter per day.

nutrition:  diabetic gluten-free sodium restricted diet.

disposition:  the patient is discharge to acute
rehabilitation.

condition on discharge:  stable.

discharge medications:
1.  afrin 81 mg po q.d.
2.  digoxin 0.125 mg po q.d.
3.  zestril 5 mg po q.d.
4.  toprol xl 25 mg q.d.
5.  lasix 120 mg po q.a.m.
6.  lasix 80 mg po q.p.m.
7.  prilosec 20 mg po q.d.
8.  synthroid 137 mcg po q.d.
9.  [**doctor first name **] 60 mg b.i.d.
10. coumadin 2 mg po q.h.s.
11. spironolactone 50 mg po q.d.
12. nph 10 unit q.a.m. with breakfast, as well as eight units
q.h.s.
13. sliding scale with humalog insulin.
14. senna 2 tablets po b.i.d.p.r.n.
15. colace 100 mg po b.i.d.p.r.n.
16. bisacodyl supplements p.r.n.
17. simethicone 180 mg po q.h.s.p.r.n.
18. prednisolone acetate 1% ophthalmologic solution, one drop
od q.i.d.
19. atropine sulfate one drop od b.i.d.
20. dorzolamide 2%, one drop od b.i.d.
21. peridex 15 mg po b.i.d.p.r.n.
22. phenazopyridine hcl 100 mg po t.i.d.
23. lantoprost 0.005% ophthalmologic solution, one drop ou
q.h.s.
24. ....................dose to be determined, likely 40 mg
po q.d.
25. ventolin two puffs q.i.d.p.r.n.
26. serevent two puffs q.a.m., q.p.m.
27. flovent two puffs q.a.m., q.p.m.
28. flonase 2 puffs q.h.s.
29. fosamax 70 mg po q.week.
30. doxepin 30 mg po q.h.s.
31. gabapentin 600 mg po q.6h.
32. bactroban ointment p.r.n.
33. clobetasol cream b.i.d.p.r.n.
24. tretinoin cream 0.25% b.i.d.
25. phenergan 12.5 mg q.i.d.p.r.n.
26. feso4 supplement t.i.d.
27. aranesp 40 mcg subcutaneous injection q.week.

follow-up care:  the patient is to follow up with the
following:

#1.  department of ophthalmology with g. shuruk in three
weeks at the [**last name (un) **] eye clinic.  telephone #:  [**telephone/fax (1) 25524**].

#2.  department of orthopedics with dr. [**first name (stitle) **] at [**hospital1 346**] in early [**month (only) 1096**].

#3.  department of endocrinology followup with dr. [**first name (stitle) 1661**] at
the [**last name (un) **] center.

#4.  primary care physician, [**last name (namepattern4) **]. [**first name (stitle) **] at [**hospital1 346**] who is familiar and very involved
with the patient's care.

#5.  department of neurology:  followup p.r.n. with dr.
[**last name (stitle) 8872**].  telephone #:  [**telephone/fax (1) **].

#6.  department of gastroenterology:  followup with dr. [**last name (stitle) 25316**],
p.r.n.

#7.  department of dermatology followup with regular
dermatologist p.r.n.




                            [**first name11 (name pattern1) **] [**initials (namepattern4) **] [**last name (namepattern4) **], m.d.  [**md number(1) 4786**]

dictated by:[**last name (namepattern1) 7485**]
medquist36

d:  [**2164-10-26**]  14:03
t:  [**2164-10-26**]  14:34
job#:  [**job number 25525**]
"
41,"admission date:  [**2113-9-23**]              discharge date:   [**2113-9-28**]


service: med

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 2972**]
chief complaint:
nausea/vomiting, s/p fall

major surgical or invasive procedure:
none


history of present illness:
89 yo f with alzheimer's and recent admit for gi bleed from
gastritis and metaplastic pyloric mass presented with an episode
of nausea / vomiting / and a fall from her bed. she is a poor
historian, but records from [**location (un) **] indicate that she had
vomited w/o blood x 1 around 2 pm on [**2113-9-23**], and possibly
fell/slid from bed. pt denies f/c/abd pain/diarrhea/melena /
brbpr. in ed, she had episode of vomiting with sbp 60's,
bradycardia to 30's --> given atropine.she was transferred to
the micu for further mgmt.


past medical history:
alzheimer's dementia
htn
ocd
h/o recent gib w/ egd revealing
high grade duodenal dysplasia and intestinal metaplasia ([**8-9**])
egd [**9-9**] with ulcerating pyloric mass increased in size.


social history:
she lives at [**hospital3 **] facility). has a
remote history of tobacco use, quit 40 years ago. no etoh.

family history:
nc

physical exam:
o: v: t96.4 bp 114/84 p74 r20 94% 2l
gen: nad
heent: op clear, ng tube in place
resp: lungs coarse bilaterally
cv: distant, rrr
abd: soft ntnd +bs
ext: no edema
neuro: a+ox1 (to person), oriented to season and general place


pertinent results:
[**2113-9-23**] 03:45pm blood wbc-7.7 rbc-2.07*# hgb-6.4*# hct-20.5*#
mcv-99*# mch-31.1 mchc-31.4 rdw-18.9* plt ct-371#

[**2113-9-24**] 01:16am blood wbc-12.4*# rbc-3.01*# hgb-9.5*#
hct-28.7*# mcv-95 mch-31.4 mchc-33.0 rdw-18.7* plt ct-318
[**2113-9-24**] 05:59am blood hct-29.0*
[**2113-9-24**] 02:54pm blood hct-31.7*
[**2113-9-24**] 09:05pm blood hct-35.9*
[**2113-9-25**] 05:35am blood wbc-14.7* rbc-3.63* hgb-11.2* hct-34.1*
mcv-94 mch-30.8 mchc-32.9 rdw-19.5* plt ct-264
[**2113-9-25**] 03:15pm blood hct-35.2*
[**2113-9-26**] 06:00am blood hct-33.8*
[**2113-9-27**] 05:30am blood hct-33.3*
[**2113-9-24**] 01:16am blood ck-mb-86* mb indx-18.5* ctropnt-1.62*
[**2113-9-24**] 02:54pm blood ck-mb-135* mb indx-16.2* ctropnt-3.06*
[**2113-9-24**] 09:05pm blood ck-mb-97* mb indx-13.3*

[**9-23**] ct head - negative
[**9-23**] cxr - unremarkable


brief hospital course:
1. anemia - on admission her hct was 20.3 so she received total
of 3 units prbcs with an appropriate hct bump to around 33-35.
she was given 2 l ns in ed. this was felt to be secondary to
bleeding from the pre-pyloric mass. gi was consulted and felt
that she would benefit from stent placement only if she was
nauseated/vomiting, but that it would not control the bleeding,
so she was tried on food and tolerated all foods well. her ppi
was continued twice a day. it was discussed with her family that
a conservative/palliative approach will be pursued, with
symptomatic control with ppi twice a day, biweekly hct checks,
and likely no readmission if she has a massive gi bleed. this
will be conveyed to her [**hospital3 **] facility, where she is
to return.

2. cardiac ischemia: her troponins/ck were elevated during
admission, likely secondary to ischemia from low hematocrit. as
pt has history of bleeding, anticoagulation with heparing was
contraindicated anyway. a betal blocker was added to her regimen
instead of her calcium channel blocker. she was monitored on
telemetry without any adverse events. as she is dnr/dni, no
further enzymes will be drawn.

3. htn: a beta blocker was substituted for her calcium channnel
blocker for its cardioprotective effects. her bp was stable.

4. s/p fall: she was noted to have had a fall at the outside
hospital, but her head ct was negative for bleed and her mental
statyus

5. nausea/vomiting: she tolerated clears then solid food in the
hospital without aspiration or vomiting. she did not need
antiemetics.

6. code status: dnr/dni - this was discussed with the family and
palliative care. also no invasive procedures (i.e. cath, egd for
massive gi bleed) should be done but will consider egd/stent as
outpatient if gastric outlet obstruction develops. the family
will clarify her status further, with possible cmo, as an
outpatient, and may fill out a do not hospitalize plan.


medications on admission:
home meds:pantoprazole 40 mg po bid, b-12 1000 mcg po qd,
ferrous sulfate 5 g po tid, folic acid 0.4 mg po bid, diltiazem
(tiazac) 240

discharge medications:
1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2
times a day).
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 q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*2*
3. fluoxetine hcl 10 mg capsule sig: one (1) capsule po once a
day.
disp:*30 capsule(s)* refills:*2*
4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po
once a day.
disp:*30 tablet(s)* refills:*2*
5. b complex-c     tablet sustained release sig: one (1) tablet
sustained release po once a day.
6. multi-vit 55 plus     tablet sig: one (1) tablet po once a
day.
7. outpatient lab work
please draw hct every monday and thursday and send results to
dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]. [**0-0-**]
8. colace 100 mg capsule sig: one (1) capsule po twice a day.
disp:*60 capsule(s)* refills:*2*
9. senna 8.6 mg tablet sig: one (1) tablet po twice a day as
needed for constipation.
disp:*30 tablet(s)* refills:*0*


discharge disposition:
home with service

facility:
homecare  solutions

discharge diagnosis:
pyloric mass with subacute bleeding
dementia
cardiac ischemia


discharge condition:
pt was eating and drinking well. she was ambulating, and had no
complaints of pain.

discharge instructions:
please administer her current medications, and give colace and
senna if constipated.

she may resume a normal diet.

please have the nurse or laboratory draw her blood monday [**10-2**], and each thursday and monday after that, with results sent
to dr. [**last name (stitle) **].

if she has vomiting, nausea, bleeding or dark stools, please
contact dr. [**last name (stitle) **]. please do not hospitalize without contacting
her daughter first.

followup instructions:
follow up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] early next week for check of
your blood count ([**0-0-**]).

follow up with [**first name4 (namepattern1) **] [**last name (namepattern1) 3815**] (gi) as needed, ([**telephone/fax (1) 8892**].



"
42,"admission date:  [**2104-3-29**]              discharge date:   [**2104-5-2**]

date of birth:  [**2043-11-1**]             sex:   f

service: medicine

allergies:
codeine / vicodin / percocet / compazine / percodan / tigan /
latex / betadine viscous gauze / protonix / surgical lubricant

attending:[**first name3 (lf) 943**]
chief complaint:
""severe all over body pain""


major surgical or invasive procedure:
- esophagogastroduodenoscopy


history of present illness:
60-year-old female with history of etoh/nash cirrhosis
complicated by ascites and encephalopathy (no known varices or
history of sbp) who presents with ""severe all over body pain"".
.
the patient was recently admitted for hypotension and
hyponatremia where she was found to have esbl uti and treated
with tobramycin/tetracycline. she was discharged to a nursing
home on [**2104-3-25**]. at the nursing home, the patient states that she
has not been taking her lactulose and has not had bowel
movements. she is confused and states she has ""all over body
pain"" although she is unable to describe it and unsure of if it
is different or more severe than her baseline chronic pain. she
presents to [**hospital1 18**] for further evaluation.
.
upon presentation to the ew, intial vitals were: t 98.2, hr 86,
bp 130/80, rr 18, sao2 97% ra. labs show inr 1.6, hct 27 (near
recent baseline), lfts okay. she is confused and has asterixis
on exam. she denies rectal. cxr with question of focal
infiltrate. kub with dilated loops of small bowel likely
secondary to ileus (although cannot rule out obstruction).
ultrasound with difficult anatomy and not enough ascites to
safely do diagnostic paracentesis at bedside. recommend
ultrasound guided paracentesis. she received lactulose and was
admitted for hepatic encephalopathy treatment.
.
currently, patient confused. yelling at nurses and very slow
with movement. she notes chills, nausea, right upper quadrant
discomfort and diffuse pain. she is unsure if this is different
than baseline. she is unsure of her last bowel movement and is
unsure if she is taking lactulose. she denies or does not know
about other ros.

past medical history:
1. cirrhosis: thought to be secondary to etoh use and fatty
liver disease
2. h/o pancreatitis
3. etoh abuse
4. cholelithiasis
5. obesity
6. hypothyroidism
7. venous insuffuciency
8. chronic lower extremity edema
9. spinal stenosis
10. reflex sympathetic dystrophy
11. hypokalemia
12. mitral regurgitation
13. neuropathy
14. bilateral hand weakness
15. osteoporosis
16. macrocytic anemia
17. thrombocytopenia
18. uterine fibroids
19. chronic renal insufficiency
20. ""tummy tuck""
21. chronic pain: on narcotics


social history:
lives with her roomate. is a former constable and volunteer
police officer. drinks 3-4 beers/day x 12 yrs. no h/o withdrawl
szs. no tobacco or illicit drug use. estranged from family. no
hcp, though patient believes that father or [**name2 (ni) 8317**] [**name (ni) **] could
be hcp.


family history:
aunt with cirrhosis. mother with alcoholism.

physical exam:
vs: t 98.2, bp 104/66, hr 86, rr 16, sao2 94% ra
general: yelling at nurses - ""no - i want to do it my own way"",
no apparent distress
heent: nc/at, perrl, eomi, sclerae anicteric, mmm, op clear
neck: supple
lungs: limited lung volumes, bibasilar crackles, no cough,
wheezes.
heart: rr, nl rate, i/vi murmur
abdomen: obese, soft, diffuse tenderness no rebound or guarding,
decreased bowel sounds
extremities: warm, le edema 2+
skin: stasis dermatitis bilateral lower extremities, multiple
ecchymotic lesions, rash right forearm
neuro - awake, a&ox2 (name and hospital, wrong day, month,
unsure of year) unwilling to participate in neuro examination,
very upset when asked to participate, emotionally labile. +
asterixis.

pertinent results:
labs on admission:
[**2104-3-29**] 06:54pm   comments-green top
[**2104-3-29**] 06:54pm   glucose-89 lactate-1.4 na+-131* k+-3.5
cl--97* tco2-26
[**2104-3-29**] 06:50pm   urea n-10 creat-1.0
[**2104-3-29**] 06:50pm   estgfr-using this
[**2104-3-29**] 06:50pm   alt(sgpt)-15 ast(sgot)-22 ld(ldh)-227 alk
phos-61 tot bili-1.9*
[**2104-3-29**] 06:50pm   lipase-14
[**2104-3-29**] 06:50pm   calcium-9.3 phosphate-3.9# magnesium-1.5*
[**2104-3-29**] 06:50pm   wbc-5.7 rbc-2.43* hgb-9.1* hct-27.0* mcv-111*
mch-37.7* mchc-33.9 rdw-16.1*
[**2104-3-29**] 06:50pm   neuts-62.6 lymphs-23.1 monos-8.5 eos-4.9*
basos-0.9
[**2104-3-29**] 06:50pm   plt count-148*
[**2104-3-29**] 06:50pm   pt-17.8* ptt-37.0* inr(pt)-1.6*

labs on discharge:
131  95  5
------------<98
3.1  31  0.8

microbiology:
[**2104-3-30**] 10:57 am urine      source: cvs.

                            **final report [**2104-3-31**]**

   urine culture (final [**2104-3-31**]):
      yeast.    >100,000 organisms/ml..

[**2104-4-3**] 3:23 pm urine      source: cvs.

                            **final report [**2104-4-6**]**

urine culture (final [**2104-4-6**]):
      enterococcus sp..    >100,000 organisms/ml..
      yeast.    >100,000 organisms/ml..

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             enterococcus sp.
                             |
ampicillin------------  =>32 r
linezolid-------------     1 s
nitrofurantoin--------    64 i
tetracycline----------  =>16 r
vancomycin------------  =>32 r

[**2104-4-17**] 11:03 am sputum      source: endotracheal.

                            **final report [**2104-4-22**]**

   gram stain (final [**2104-4-17**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2104-4-22**]):
      commensal respiratory flora absent.
      escherichia coli.    rare growth.
         warning! this isolate is an extended-spectrum
beta-lactamase
         (esbl) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. consider
infectious
         disease consultation for serious infections caused by
         esbl-producing species.
      yeast.    rare growth.

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             escherichia coli
                             |
amikacin--------------   <=2 s
ampicillin------------  =>32 r
ampicillin/sulbactam--  =>32 r
cefazolin-------------  =>64 r
cefepime--------------       r
ceftazidime-----------       r
ceftriaxone-----------       r
ciprofloxacin---------   =>4 r
gentamicin------------  =>16 r
meropenem-------------<=0.25 s
tobramycin------------     8 i
trimethoprim/sulfa----  =>16 r

[**2104-4-29**] 9:39 am urine     no growth.

imaging:
- chest (pa & lat)	study date of [**2104-3-29**] 7:11 pm
impression: markedly limited study. question increased density
at the medial right lung base. this could represent
superimposition of normal structures crowded by significant
volume loss, however focal infiltrates cannot be entirely
excluded.

- portable abdomen	study date of [**2104-3-30**] 9:07 am
impression: two frontal views of the supine abdomen show
disproportionate
dilatation of the stomach and proximal small bowel with respect
to relatively mild gaseous dilatation of the colon, probably the
transverse. appearance is similar to [**3-29**]; small-bowel
obstruction must still be considered. no nasogastric tube is
seen despite severe gaseous distention of the stomach.
right lung base is elevated, probably a combination of
subpulmonic pleural
effusion and upward displacement of the diaphragm.

- ct abd & pelvis with contrast	study date of [**2104-3-30**] 2:56 pm
impression:
1. proximal small bowel dilatation measuring up to 3.6 cm with a
point of transition in the right lower quadrant. imaging
findings are consistent with partial versus complete obstruction
likely on the basis of adhesions.
2. findings of hepatic cirrhosis as on prior exams.
3. anterior abdominal wall hernia containing mesenteric fat and
fluid.

- lung scan	study date of [**2104-3-31**]
impression: underventilated triple match v/q defect with low
probability of pe.

- unilat up ext veins us	study date of [**2104-4-3**] 9:53 am
impression: no evidence of deep vein thrombosis in the right
arm.

- ct abd & pelvis with contrast	study date of [**2104-4-5**] 2:58 pm
impression:
1. stable mild dilatation of the proximal small bowel loops,
maximally measuring 3.6 cm. distal loops appear less distended,
with possible transition point in the right lower quadrant,
likely representing mild/partial small-bowel obstruction.
2. cirrhosis with moderate amount of abdominal and pelvic
ascites.

- ct head w/o contrast	study date of [**2104-4-16**] 6:30 pm
impression:
1. no acute intracranial hemorrhage or mass effect. if there is
continued
concern for parenchymal abnormalities, consider mr head if not
contra-indicated.
2. mild diffuse volume loss increased from [**2096**] ct head study.

- portable abdomen	study date of [**2104-4-20**] 9:38 pm
impression:
in comparison to [**2104-4-17**] exam, there is mild improvement of
ileus without
complete resolution.

- chest (portable ap)	study date of [**2104-4-25**] 8:38 am
findings: in comparison with the study of [**4-23**], the degree of
pulmonary
vascular congestion may have slightly improved. extensive
bilateral
atelectatic changes are again seen with blunting of the
costophrenic angles
consistent with pleural fluid. area of increased opacification
in the right
mid zone may merely represent atelectasis, though in the
appropriate clinical setting the possibility of pneumonia would
have to be considered.

brief hospital course:
summary statement:

ms. [**known lastname 28445**] is a 60 year old female with a provisional diagnosis
of etoh cirrhosis who presented from rehab after a brief
hospitalization for an mdr e.coli uti, new diagnosis of
cirrhosis, and hyponatremia with chronic pain who was found to
have an narcotic ileus who required tpn and then was transferred
to the micu for concern for prolonged epistaxis from presumably
ngt trauma who has remained encephalopathic with decompensated
cirrhosis, persistent ileus from administration from narcotics,
volume overload and hypoxia secondary to pulmonary edema and
atelectasis

prior to transfer to the micu:

1) narcotic ilues: prior to admission she presented with diffuse
abdominal pain, and dilated small loops of bowl on kub.
subsequent abdominal ct scans reveal potential transistion
points and partial small bowel obstruction.  she also developed
non-bloody bilious emesis necessitating ngt placement and small
bowel decompression.  surgery was consulted and a small bowel
follow through revealed and an ileus that was secondary to
prolonged narcotic use for a presumed diagnosis of rsd.  her
narcotics were then stopped, but her ileus persisted which
necessitated starting tpn, and subsequently her ileus resolved
after  methalynaloxone was administered.  her pain from rsd was
subsequently controlled with non-opioid analgesia including
tramadol and lyrica.  radiographs of the abdomin showed passing
of contrast from the small bowel to the colon and her nutrition
was transitioned from tpn to po.  she was tolerating po prior to
her transfer to the micu for epistaxis

2) decompensated cirrhosis:  she presented with peripherial
edema ascities without evidence of encephalopathy.  however, she
became mildly encephalopathic (grade i) with mild asterixis and
disorientation (date) as her ileus persisted.  she was given
lactulose enemas which helped resolve her confusion.  there was
also concern that she may have sbp, although she was never
febrile, and a a diagnostic paracentesis was negative.
subsequently however, she underwent a therapeutic paracentesis
to help remove ascites (3l removed) to improve her respiratory
mechanics in addition to her ileus.  she remained mildly
encephalopathic until her transfer to the micu.

2) volume overload:  she developed volume overload secondary to
decompensated cirrhosis and portal hypertension, ascities, and
the administration tpn in addition to iv medications and
antibiotics.  she was given albumin and prbc to maintain her map
to help diuresis with aldactone and lasix.  due to her uti, and
concern for delerium, a foley was note placed to monitor uop.
her weights were followed to monitor her fluid balance.

3) nutrition: due to her inability to tolerate po and narcotic
ileus.  she was started on tpn for several days.  she also
required additional potassium repletion due to diuresis for
volume overload.

4) hyponatremia: she developed hypervolemic hyponatremia due to
decompensated cirrhosis.  her hyponatremia resolved after the
administration of diurectics and free water restriction.

5) enterococcus/yeast uti.  upon admission she was noted to have
inflammation on her ua in addition to persistent yeast in her
urine and vre.  she was treated empirically for seven days for a
complicated uti with linezolid and fluconazole.  subsequent
urine cultures were negative for persisent yeast or vre.

6) mdr e.coli uti: upon admission she was completing a course of
tobramycin for an esbl uti, please see previous discharge
summary for sensitivities.

7) anemia: the patient remained anemic on presentation and
required multiple prbc transfusions for volume due to
hypotension secondary to decreased intravascular volume.  prior
to her transfer to the micu she did not have evidence of active
bleeding.

micu course: patient transferred to micu given concern for
hematemesis and upper gi bleed.  was electively intubated for
egd on [**4-16**].  egd did not reveal presence of varices, but did
show barrett's and gastropathy.  patient continued on famotidine
for gi ppx.  there was no recurrence of hematemesis, and hct
remained stable.  patient did develop hypotension while
intubated, likely multifactorial secondary to her underlying
cirrhosis and to sedating medications.  was briefly on pressors,
but quickly weaned off once extubated.  was successfully
extubated [**2104-4-17**].  patient developed recurrent ileus while in
icu; ngt kept to continuous low wall suction and patient kept
npo.  course notable for persistent ams, and patient was given
lactulose enemas while npo.  no evidence of infection, as
patient afebrile without leukocytosis.  diagnostic para [**4-16**]
negative for sbp.

post micu course

# encephalopathy: the patient's encephalopathy continued after
she was transferred from the micu to the floor. she was aao x 1
with asterixis. she was treated heavily with lactulose po/pr,
and began to put out an appropriate amount of stool, but without
resolution of her encephalopathy. an infectious work-up with
blood, urine, and chest x-ray was negative. opioid medications,
which were given to her in the icu, were avoided on the floor.
the patient's encephalopathy cleared on [**2104-4-24**], when she was
aaox3, and was following commands, but with occasional
asterixis. she no longer required restraints, and had not been
using the olanzapine which was written for her prn for
agitation. her encephalopathy was felt likely secondary to
lingering opioid medication, and not to hepatic encephalopathy
given her appropriate output of stool.

# epistaxis: upon transfer back from the icu, the patient did
not have any signs of epistaxis, and did not require any
transfusion.

# ileus: the patient had an ileus that was noted on abdominal
x-ray upon return from the icu, which was felt likely secondary
to opioid medication. the patient was made npo, and started on
metoclopromide. a few days later the patient's gi motility
started to return, and her diet was gradually advanced, and her
medications were returned to po. opioid medication was again
thought to play the largest role in the patient's ileus.
metoclopromide was discontinued on patient's discharge.

# tachypnea: the patient was noted on the floor for tachypnea
during her stay, with a normal abg and normal o2 sats. her
tachypnea was felt to be secondary to abdominal ascities with
ateletasis and an element of volume overload. she was treated on
the floor with iv lasix, and ultimately her o2 requirements were
removed. the patient was started on a dose of 40 mg lasix po bid
and her home dose of spironolactone (50 mg daily). she was
discharged on her home dose of 40 mg lasix daily and a new dose
of 100 mg spironolactone daily without tachypnea.

# decompensated cirrhosis: underlying etoh cirrhosis. no history
of varices or sbp; egd from [**4-16**] confirmed patient does not have
varices, and diagnostic para [**4-16**] not suggestive of sbp. the
patient was continued on lactulose and rifaximin.

# hypernatremia/hyponatremia: the patient transiently became
hypernatemic with na of 154 after diuresis, which resolved with
free water administration. on discharge she was hyponatremic
without end organ signs likely secondary to diuresis.

# nutrition: given resolving ileus and multiple bm, the patient
was discharged on regular diet low salt/heart healthy diet

# pain: the patient's chronic leg and back pain had previously
been treated with opiod medication, but her hospital course was
complicated by several adverse events secondary to opioid
medication (ileus, encephalopathy). her morphine doses were
discontinued, and the patient was started in house on standing
tylenol for pain control.

# history of restless legs: the patient previously had been on
mirapex 1mg qhs for restless legs.  this was stopped while in
the hospital, but may be restarted as needed.

medications on admission:
1. alendronate 70 mg po qweekly
2. morphine 30 mg po q12h
3. morphine 15 mg po q6h prn
4. omeprazole 20 mg po daily
5. potassium chloride 20 meq po bid
6. mirapex 1 mg po qhs
7. trazodone 300 mg po qhs
8. hydroxyzine hcl 25 mg po q6h prn
9. lactulose 30ml po tid
10. phenazopyridine 100 mg po tid prn
11. triamcinolone acetonide 0.1 % cream topical [**hospital1 **]
12. lidocaine 5 %(700 mg/patch) adhesive patch daily
13. zofran 8 mg po qid prn
14. calcium citrate + d 630-400 mg-unit po bid
15. vitamin d-3 1,000 unit po daily
16. cyanocobalamin (vitamin b-12) 1,000 mcg po daily
17. docusate sodium 100 mg po bid
18. centrum silver po daily
19. furosemide 40 mg po daily
20. spironolactone 50 mg po daily
21. rifaximin 550 mg po bid
22. tetracycline 500 mg po qid last day [**2104-3-31**]
23. azithromycin 250mg daily (started at rehab)
24. albuterol nebulizer (started at rehab)

discharge medications:
1. alendronate 70 mg tablet sig: one (1) tablet po once a week.

2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
3. potassium chloride 10 meq capsule, extended release sig: two
(2) capsule, extended release po twice a day.
4. trazodone 300 mg tablet sig: one (1) tablet po at bedtime as
needed for insomnia.
5. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po every six
(6) hours as needed for itching.
6. lactulose 10 gram/15 ml solution sig: thirty (30) ml po three
times a day.
7. phenazopyridine 100 mg tablet sig: one (1) tablet po three
times a day as needed for pain.
8. triamcinolone acetonide 0.1 % cream sig: one (1) application
to affected areas topical twice a day.
9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) patch topical once a day.
10. zofran 8 mg tablet sig: one (1) tablet po four times a day
as needed for nausea.
11. calcium 600 with vitamin d3 600 mg(1,500mg) -400 unit
capsule sig: one (1) capsule po twice a day.
12. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet,
chewable po once a day.
13. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1)
tablet po once a day.
14. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day.
15. centrum silver     tablet sig: one (1) tablet po once a day.

16. furosemide 40 mg tablet sig: one (1) tablet po once a day.
17. rifaximin 550 mg tablet sig: one (1) tablet po twice a day.

18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1) puff inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
19. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler
sig: one (1) puff inhalation every four (4) hours as needed for
shortness of breath or wheezing.
disp:*1 inhaler* refills:*3*
20. acetaminophen 500 mg capsule sig: one (1) capsule po every
six (6) hours.
disp:*120 capsule(s)* refills:*0*
21. artificial tears(glycerin-peg) 1-0.3 % drops sig: one (1)
drop to both eyes ophthalmic prn as needed for dry eye.
disp:*1 tube* refills:*0*
22. spironolactone 100 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
primary diagnosis:
- [**female first name (un) 564**] and vre cystitis
- opioid-induced ileus
- hepatic encephalopathy
secondary diagnosis:
- etoh cirrhosis


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:
ms. [**known lastname 28445**], it was a pleasure taking care of you in the
hospital. you were admitted to the hospital with diffuse body
pain. you were found to have an infection in your bladder, and
we treated you with the appropriate antibiotics. however, your
hospital course was complicated by a slow moving gi tract that
likely happened because of the high dose of narcotics which you
normally take. we confirmed that you did not have an obstruction
in your abdomen, and gave you some medications to help your gut
move along. during that time when you were not eating, we were
giving your nutrition through your veins. also during your
hospital stay, you had started vomiting some blood; we took you
to the icu were we put a breathing tube down your throat and
also looked at your stomach lining, where we did not see any
bleeding. we believe that your vomiting of blood may have been
blood which dripped into your stomach from your nose.

unfortunately, when you were intubated, we needed to give you
more doses of narcotics, which caused your gi tract to slow down
again. your gut motility improved, but you still remained a
little bit confused, which improved once the narcotics had
worked their way out of your system.

when you leave the hospital:
- stop morphine 30 mg every 12 hours
- stop morphine 15 mg every 6 hours as needed for pain
- stop tetracycline 500 mg four times a day
- stop azithromycin 250 mg every day
- stop mirapex 1mg before bedtime
- start ipratropium bromide inhaler 1 puff inhalation every four
(4) hours as needed for shortness of breath or wheezing
- start acetaminophen 500 mg every 6 hours
- start artificial tears(glycerin-peg)  1-0.3 % drops: use one
(1) drop to both eyes as needed for dry eyes
- increase your dose of spironolactone to 100 mg daily
(previously you had been taking 50 mg daily)

we did not make any other changes to your medications, so please
continue to take them as you normally have been.

followup instructions:
when you leave the hospital, please have your rehab facility
make the following appointments for you:

- make an appointment to see your primary care doctor, dr. [**first name (stitle) 1022**],
one week after your discharge from rehab by calling [**telephone/fax (1) 250**]

department: liver center
when: wednesday [**2104-5-7**] at 10:00 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 7128**], md [**telephone/fax (1) 2422**]
building: lm [**hospital unit name **] [**location (un) 858**]
campus: west     best parking: [**hospital ward name **] garage



"
43,"admission date:  [**2170-6-12**]              discharge date:   [**2170-6-15**]

date of birth:  [**2105-8-24**]             sex:   m

service: medicine

allergies:
penicillins

attending:[**first name3 (lf) 2901**]
chief complaint:
chest pain

major surgical or invasive procedure:
left heart catheterization


history of present illness:
mr. [**known lastname 5066**] is a 54 y/o m with a history of cad s/p bms to
lad in [**2158**], htn, dm2 who presented with sudden onset chest
pain/indigestion approximately 1 hour prior to presentation to
the ed. patient reports burning chest pain that felt like
indigestion radiating to his left arm and up his neck. he was
watching television during the onset of his symptoms. he took
his home omeprazole with no relief. he called ems and who noted
ste in anterolateral leads. he was brought to the ambulance and
had an episode of v-fib, which responded to one shock. he
reverted to nsr after and was loaded with 150mg of amiodarone.
he was also given a aspirin 81mg.
.
when he arrived to the ed initial vitals were  pulse: 106 rr:
25, bp: 130/76, o2sat: 95%, o2flow: ra. a code stemi was called
and he was taken to the cath lab which revealed significant lad
disease primarily in-stent restenosis of his previous bms and a
more distal occlusion that was felt to be the culprit lesion. in
the ed he was given aspirin 325mg, plavix 600mg, and started on
a heparin and amiodarone drip. ekg showed ste in v1-v4 and
pathological q waves in ii, iii and avf.
.
on arrival to the floor, patient the patient was comfortable and
in no acute distress. he did note having continued indigestion
however he states that the sensation was different than what he
was experiencing previously. 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:
1. cardiac risk factors: + diabetes, + dyslipidemia, +
hypertension
2. cardiac history:
-cabg: n/a
-percutaneous coronary interventions: bms to lad [**2158**]
-pacing/icd: n/a
3. other past medical history:
ulcerative colitis
pud
osa not on cpap
asthma


social history:
he is a retired navy consultant.
-tobacco history: denies
-etoh: denies
-illicit drugs: denies

family history:
he states that his mother has angina but had never had an
intervention. his sister has struggled with arthritis and
multiple cancers.
no family history of early mi, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

physical exam:
admission exam:
general: comfortbale and 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.
cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3
or s4.
lungs: ctab, no crackles, wheezes or rhonchi.
abdomen: soft, ntnd. no hsm or tenderness.
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:
98-99.5 74-98 109-162/57-82 rr 18 93-98% ra
gen: comfortable, nad, nt/nd
heent: sclera anicteric, perrla. conjunctive pink without
cyanosis or pallor. no xanthelasma.
neck: supple, jvp of 7
cardiac: normal s1, s2. no murmurs, rubs, or gallops, difficult
due to adiposity.
lungs: good air entry bilaterally, no rales, rhonchi, or
wheezes.
abdomen: soft, non-tender, non-distended, normal bowel sounds.
no organomegaly.
extremities: edema present to one hands-breadth below knee
skin: no stasis ulcers, dermatitis, scars. abundant skin lesions
on back.
pulses: right and left dps and pts 2+

pertinent results:
[**2170-6-15**] 06:57am blood wbc-7.5 rbc-3.39* hgb-9.9* hct-30.4*
mcv-90 mch-29.2 mchc-32.6 rdw-14.8 plt ct-244
[**2170-6-12**] 03:30am blood wbc-12.4* rbc-4.10* hgb-11.9* hct-36.6*
mcv-89 mch-29.0 mchc-32.4 rdw-15.1 plt ct-225
[**2170-6-15**] 06:57am blood plt ct-244
[**2170-6-15**] 06:57am blood pt-14.3* ptt-73.5* inr(pt)-1.3*
[**2170-6-12**] 03:30am blood pt-12.2 ptt-150* inr(pt)-1.1
[**2170-6-12**] 03:30am blood plt ct-225
[**2170-6-12**] 03:30am blood fibrino-426*
[**2170-6-15**] 06:57am blood glucose-166* urean-10 creat-0.7 na-142
k-4.1 cl-105 hco3-28 angap-13
[**2170-6-12**] 09:08am blood glucose-221* urean-18 creat-0.8 na-139
k-3.5 cl-99 hco3-28 angap-16
[**2170-6-13**] 02:45am blood alt-28 ast-59* ld(ldh)-472* alkphos-79
totbili-0.2
[**2170-6-14**] 06:59am blood alt-22 ast-29
[**2170-6-14**] 09:24pm blood ck(cpk)-172
[**2170-6-14**] 09:24pm blood ck-mb-3 ctropnt-1.32*
[**2170-6-12**] 09:08am blood ck-mb-53*
[**2170-6-12**] 03:30am blood ck-mb-11* mb indx-2.9 ctropnt-0.90*
[**2170-6-15**] 06:57am blood calcium-8.3* phos-2.0* mg-2.2
[**2170-6-12**] 09:08am blood calcium-7.6* phos-2.0* mg-1.1*
[**2170-6-12**] 03:30am blood %hba1c-7.1* eag-157*
[**2170-6-12**] 03:30am blood triglyc-102 hdl-35 chol/hd-2.8 ldlcalc-44
[**2170-6-12**] 03:30am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2170-6-12**] 03:46am blood glucose-246* lactate-4.2* na-140 k-2.9*
cl-99 calhco3-27
[**2170-6-12**] 03:46am blood hgb-11.6* calchct-35 o2 sat-94 cohgb-2
methgb-0
[**2170-6-12**] 03:21pm blood freeca-1.03*
[**2170-6-13**] 02:09pm blood aldosterone-pnd
[**2170-6-13**] 02:09pm blood renin-pnd
indications for catheterization:
coronary artery disease, canadian heart class iv,  unstable.
prior ptca
[**2158-12-4**].

procedure:
percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

hemodynamics results body surface area:  2.58 m2
  hemoglobin: 11.9 gms %
  entry
**pressures
aorta {s/d/m} 112/74/86
**cardiac output
heart rate {beats/min} 103
rhythm sinus




**ptca results
  lad

ptca comments:
primary pci was delayed because of severe torutosity in the
right upper
extremity and inability to seat the guide appropriately. we
initially
gained access via the right radial artery. however, because of
severe
tortuosity in the right axilla and because of a short ascending
aorta,
we were unable to engage the left main coronary artery. because
of this,
we then gained access in the right femoral artery. a 6f sheath
was
inserted. initial angiography revealed a 70% stenosis in the
proximal
lad, a 70% stenosis in the proximal portion of the prior mid lad
stents
and a 95% stenosis in the mid to distal edge of the prior mid
lad
stents. we planned to treat all of these lesions with ptca and
stenting.
bivalirudin was administered for anticoagulation, and a
therapeutic act
was confirmed. a 6f xblad 3.5 guide provided adequate support. a

prowater wire crossed the lesions with mdoerate difficulty.  we
then
predilated the distal lesion with a 2.25 x 12 mm sprinter legend
rx
balloon at 10 atm three times. this led to a short dissection
and no
reflow in the distal lad. we therefore attempted to rapidly
deliver a
2.25 x 18 mm resolute rx stent, but we were not able to deliver
due to
tortuosity. we therefore elected to change for a stiffer wire. a
2.25 x
15 mm sprinter balloon was advanced to the distal lad, and the
prowater
wire was removed. a choice pt extra support wire was advanced to
the
distal lad, and the distal lad was again predilated with the
2.25 x 15
mm sprinter balloon at 12 atm. we were then able to deliver a
2.25 x 14
mm resolute stent to the distal lesion and deployed it at 13
atm. we
then delivered a 2.75 x 22 mm resolute to the more proximal
portion of
the prior stents and deployed it at 16 atm. the proximal portion
of
the new stents was postdilated with a 3.0 x 15 mm nc quantum
apex mr
balloon at 16 atm. the mid portion of the newly deployed stents
was
postdilated with a 2.75 x 12 mm nc quantum apex balloon at 18
atm. we
then direct stented the more proximal lad lesion with a 3.5 x 15
mm
resolute stent at 16 atm. final angiography revealed no residual

stenosis, no evidence of dissection and timi 3 flow. right
femoral
angigoraphy revealed an arteriotomy site appropriate for
closure, and a
6f perclose was deployed with adequate hemostasis.


technical factors:
total time (lidocaine to test complete) = 1 hour 54 minutes.
arterial time = 1 hour 53 minutes.
fluoro time = 35 minutes.
effective equivalent dose index (mgy) = 6634 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 440 ml

premedications:
          midazolam 0.5 mg iv
          fentanyl 25 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          diltiazem (ia) 500mcg
          nitroglycerine (ia) 200mcg
           potassium 40meq
          amiodarone (iv) 1mg/min
          bivalrudin 100mg ivb f/b 238mg/hr
          fentanyl 100mcg
          midazolam 1.5mg
          nicardipine 1000mcg
cardiac cath supplies used:
          - [**doctor last name **], prowater 300cm
          - [**company **], magic torque 260cm
          - [**company **], choice pt extra support 300cm
          2.25mm [**company **], sprinter 12mm
          2.25mm [**company **], sprinter 15mm
          - [**company **], nc apex 15/3.0
          - [**company **], nc apex 12/2.75
          6fr cordis, xblad 3.5
          6fr [**doctor last name **], perclose proglide
          - [**company **], resolute 15/3.5
          - [**company **], resolute 15/3.5
          - allegiance, custom sterile pack
          - merit, left heart kit
          6fr terumo, glidesheath
          - [**doctor last name **], priority pack 20/30
          - terumo, tr band large


comments:
1. selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel cad. the lmca had no
angiographically-apparent disease. the lad had 70% proximal
stenosis
prior to the old mid-lad stent. there was also 95% stenosis at
the
distal end of the old mid-lad stent. the lcx had 80% stenosis in
the om1
branch. the dominant rca had no angiographically apparent
disease.
2. limited resting hemodynamics revealed normal systemic
arterial
pressures with a measured central aortic pressure of 112/67/84.
3. left ventriculography was deferred.
4. successful ptca and stenting of the mid to distal lad with
overlapping 2.25 x 14 mm (distal) and 2.75 x 22 mm resolute dess

postdilated to 2.75 mm in the mid portion and 3.0 mm proximally
(see
ptca comments).
5. successful direct stenting of the more proximal lad with a
3.5 x 15
mm resolute des (see ptca comments).
6. successful rfa perclose (see ptca comments).

final diagnosis:
1. two vessel cad with lad stenosis (culprit).
2. successful pci of the mid to distal lad with overlapping 2.25
x 14 mm
(distal) and 2.75 x 22 mm (proximal) resolute dess postdilated
to 2.75
mm in the overlapping segment and 3.0 mm in the proximal
segment.
3. successful pci of the proximal lad with a 3.5 x 15 mm
resolute des.
4. successful rfa perclose.
.
i, dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **],
was physically present during the entire procedure and in
compliance with the cms regulations.
.
[**hospital1 18**] attending of record: [**last name (lf) **],[**first name3 (lf) **] e.
referring physician: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].
fellow: [**last name (lf) **],[**first name3 (lf) **]
[**last name (lf) **],[**first name3 (lf) **] b.
invasive attending staff: [**last name (lf) **],[**first name3 (lf) **] e.
electronically signed by: [**last name (lf) **],[**first name3 (lf) **] on fri [**2170-6-15**] 10:23
am
[**medical record number 28546**] m  64  [**2105-8-24**]
.
cardiovascular report ecg study date of [**2170-6-12**]  3:14:42 am
.
sinus tachycardia. left axis deviation. acute anterolateral wall
myocardial infarction. possible inferior wall myocardial
infarction. compared to the previous tracing of [**2159-6-21**] the
acute infarction is new.
.
echo [**2170-6-12**]
conclusions
the left atrium is mildly dilated. left ventricular wall
thicknesses and cavity size are normal. there is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior wall, septum and apex. the remaining segments contract
normally (lvef = 25%). no masses or thrombi are seen in the left
ventricle. right ventricular chamber size is normal with focal
hypokinesis of the apical free wall. the aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. no
aortic regurgitation is seen. the mitral valve leaflets are
mildly thickened. trivial mitral regurgitation is seen. 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.
.
impression: extensive regional left ventricular systolic
dysfunction, c/w proximal lad disease. no lv thrombus seen.
.
compared with the report of the resting portion of the prior
stress study (images unavailable for review) of [**2162-11-16**],
regional lv wall motion abnormalities are new.
.
findings were discussed with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] at 1120 hours
on the day of the study.
  electronically signed by [**first name8 (namepattern2) **] [**last name (namepattern1) 171**], md, interpreting
physician [**last name (namepattern4) **] [**2170-6-12**] 11:22
.
.
ekg study date of [**2170-6-12**]  7:54:28 pm
.
sinus rhythm. left axis deviation. there are q waves in the
anterior leads
with st segment elevation and terminal t wave inversion
extending into the
anterolateral leads. there are tiny r waves in the inferior
leads consistent
with probable infarction. there are additional non-specific st-t
wave changes.
compared to the previous tracing of the same day st segment
elevation in the
anterior leads has increased. clinical correlation is suggested.

tracing #3



brief hospital course:
active issues:
# stemi with reduced ef:
mr. [**known lastname 5066**] presented to the ed one hour after the onset of
sudden, severe, burning chest pain that radiated up his neck and
to his left arm. he perceived the chest pain to be indigestion
and took an antacid to no relief. he called ems, who documented
st elevation inthe anterolateral leads. during transport, mr.
[**known lastname 5066**] had an episode of ventricular fibrillation, which
responded to one shock. he reverted to normal sinus rhythm and
was administered amiodarone and aspirin.

in the ed, ecg demonstrated ste in v1-v4 and pathological q
waves in ii, iii and avf. mr. [**known lastname 5066**] was taken straight for
cardiac catheterization, which revealed significant lad disease
- primarily in-stent restenosis of his in situ bare metal stent
and a more distal 95% stenosis. three drug-eluting stents were
placed in the proximal and distal lad with good angiographic
results.

post-stemi echocardiography demonstrated an ejection fraction of
25%, which is a marked deterioration from previous studies
(ef=60%). moreover, there was newly diagnosed apical, anterior,
and septal akinesis. based on these findings, the team decided
that mr. [**known lastname 5066**] would benefit from the initiation of
coumadin therapy for thrombus prevention.

during mr. [**known lastname 28547**] stay, an electrophysiology consult
advised us to schedule mr. [**known lastname 5066**] for electrophysiology
follow-up as an outpatient in 40 days' time to assess his need
for an icd. they felt that he would not benefit from
anti-arrhythmic therapy or an external defibrillating device in
the interim.

recovery, first in the ccu and subsequently on the cardiology
[**hospital1 **], was speedy. mr. [**known lastname 5066**] required some potassium
supplementation, and several changes were made to his
medications. during his hospitalization, mr. [**known lastname 5066**] [**last name (titles) 28548**]d nifedipine 30mg once daily, irbesartan 150mg once
daily, metoprolol tartrate 100mg twice daily, and
hydrochlorothiazide 25mg once daily, and was commenced on
coumadin 3mg once daily, clopidogrel 75mg once daily, losartan
25mg once daily, metoprolol succinate 200mg once daily,
eplerenone 25mg once daily. his other medications remain
unchanged.

#inactive issues
1. ulcerative colitis: appears to be doing well with no recent
flares. continue dicyclomine as needed and sulfazaline 1000mg
tid

2. diabetes mellitus: the patient was switched from his oral
medications to insulin while in house with good results.

#transitional issues
1. mr. [**known lastname 5066**] has commenced coumadin prophylaxis. he
received his first dose (5mg) on [**2170-6-13**], and was discharged on
3mg once daily. his inr is to be checked by a visiting nurse on
[**2170-6-16**], and he is scheduled to attend your clinic on [**2170-6-19**].
he has been instructed to take 3mg once daily at 4pm until he
attends your clinic or is linked in with your coumadin service.
we defer any dose adjustments that he may require to you. i have
already contact[**name (ni) **] a nurse in your office with this information.

(2) given the fact that mr. [**known lastname 5066**] required potassium
supplementation a few times during his hospital stay, we
recommend that his serum electrolytes be checked in the short
term, possibly alongside his inr. we commenced him on
eplerenone, which may help in avoiding hypokalemia.

(3) outpatient appointments have been arranged with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] (cardiac services [**2170-6-18**]) and dr. [**last name (stitle) **] [**name (stitle) 1911**]
(cardiac services, electrophysiology [**2170-7-26**]).

(4) mr. [**known lastname 5066**] has expressed interest in cardiac rehab
services in [**location (un) 745**]. i informed him that he should contact the
center of his choice, which would correspond with your office to
arrange for an official referral. he also expressed concern at
having missed a recent appointment with a dietician, which he
would like to have rescheduled through your office.


medications on admission:
1. omeprazole 20 mg oral capsule, delayed release(e.c.) take 1
capsule 30 min before first meal of day
2. sitagliptin (januvia) 100 mg oral tablet take one tablet
daily
3. metformin 750 mg oral tablet extended release 24 hr take 1
tablet three times a day
4. sitagliptin (januvia) 100 mg oral tablet 1 tab po qd
5. fluticasone (flonase) 50 mcg/actuation nasal spray,
suspension 1 spray in each nostril twice a day
6. glipizide 10 mg oral tablet extended rel 24 hr take 1 tablet
twice daily
7. sulfasalazine 500 mg oral tablet 2 tablets (1000mg) three
times daily
8. atorvastatin 80 mg oral tablet take one tablet daily
9. irbesartan (avapro) 150 mg oral tablet take 1 tablet daily
10. loratadine 10 mg oral tablet 1 tablet daily as needed.
11. epinephrine (epipen) 0.3 mg/0.3 ml intramuscular pen
injector use as needed and seek medical advice
12. hydrochlorothiazide 25 mg oral tablet 1 tablet daily
13. nifedipine er 30 mg 24 hr tab 30 mg oral tr24 take 1 tablet
daily
14. dicyclomine 20 mg tab take 1 tablet by mouth 4 times a day
as needed
15. one touch ultra test strips (blood sugar diagnostic) use as
directed 2 times daily
16. lancets use [**hospital1 **] prn
17. metoprolol 100 mg tab (metoprolol tartrate) 1 tablet twice
daily
18. baby aspirin oral (aspirin) none entered

discharge medications:
1. omeprazole 20 mg po daily
2. losartan potassium 25 mg po daily
please hold for sbp<100
please start [**2170-6-15**]
rx *losartan 25 mg 1 tablet(s) by mouth daily disp #*30 tablet
refills:*3
3. nitroglycerin sl 0.3 mg sl prn chest pain
rx *nitrostat 0.3 mg 1 tablet sublingually every 15 minutes as
needed for chest pain not to exceed three pills disp #*30 tablet
refills:*3
4. eplerenone 25 mg po daily
rx *eplerenone 25 mg 1 tablet(s) by mouth daily disp #*30 tablet
refills:*3
5. metoprolol succinate xl 200 mg po daily
start in am on [**6-15**]
rx *metoprolol succinate 200 mg 1 tablet(s) by mouth daily disp
#*30 tablet refills:*3
6. clopidogrel 75 mg po daily
rx *clopidogrel 75 mg 1 tablet(s) by mouth daily disp #*30
tablet refills:*3
7. atorvastatin 80 mg po daily
please stop this drug if you develop muscle weakness or pain or
if your urine gets very dark.
8. aspirin 81 mg po daily
9. sulfasalazine_ 1000 mg po tid
10. januvia *nf* (sitagliptin) 100 mg oral daily
11. metformin xr (glucophage xr) 750 mg po tid
do not crush
12. fluticasone *nf* 50 mcg/actuation nu [**hospital1 **]
1 spray each nostril twice daily
13. glipizide xl 10 mg po bid
14. loratadine *nf* 10 mg oral qday:prn asthma
15. epipen *nf* (epinephrine) 0.3 mg/0.3 ml injection once:prn
anaphylaxis
use as needed and seek medical advice immediately
16. dicyclomine 20 mg po tid:prn bowel irritation
please do not take this medication until you see your physician,
[**last name (namepattern4) **]. [**last name (stitle) 28549**], on [**6-19**].
17. one touch ultra test *nf* (blood sugar diagnostic)
miscellaneous [**hospital1 **]
use as directed two times daily
18. lancets *nf*    miscellaneous [**hospital1 **]
use as directed twice daily
19. warfarin 3 mg po daily16
rx *warfarin 1 mg 3 tablet(s) by mouth daily disp #*30 tablet
refills:*3
20. outpatient lab work
please draw blood for an inr on [**2170-6-16**] and fax the result to
dr. [**last name (stitle) 28549**] at [**telephone/fax (1) 6808**]
21. outpatient lab work
please draw blood on [**2170-6-22**] and send it for serum sodium,
potassium, chloride, bicarbonate/co2, bun, creatinine, calcium,
magnesium, and phosphate. please fax the results to dr. [**last name (stitle) 28549**]
at [**telephone/fax (1) 6808**]


discharge disposition:
home with service

facility:
[**company 1519**]

discharge diagnosis:
primary diagnosis: anterolateral st segment myocardial
infarction (heart attack to the front wall of your heart)
secondary diagnosis: apical akinesis of the left ventricle


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
dear mr. [**known lastname 5066**],

it was a pleasure taking care of you while you were hospitalized
at the [**hospital1 **]. as you know, you were admitted to
the hospital because of your chest pain. on the way, the
emergency medical technicians had to shock you because of an
irregular heart rhythm, which reverted to normal subsequently.
when you got to the hospital, we confirmed that you indeed had a
heart attack and performed a procedure called a left heart
catheterization where a wire was threaded into the arteries that
supply your heart. we found that the area where you already had
a stent placed in [**2158**] was narrowed and there was a very severe
narrowing farther along the artery. the newly diagnosed
narrowing was fixed with a drug-eluting stent. this should help
prevent the re-narrowing that occurred at the site of the bare
metal stent you received in [**2158**].

please keep in mind two important points:
1. you must take plavix for at least 6 months to one year based
on the placement of your drug-eluting stent. you must not miss
any doses because if you do, you will run the risk of having a
sudden and severe blockage of the new stent that could give you
another severe heart attack.

2. because of the location of your heart attack, part of your
heart is not moving properly. this can cause blood to be
stagnant inside of the heart and clot, which can lead to strokes
or other adverse events. as a result, you will need to start a
blood thinner called coumadin for at least a few months. if your
heart regains some of its lost function, you may be able to stop
blood thinners, but this is a discussion that needs to be
undertaken in several months in conjunction with your
cardiologist. until you see dr. [**last name (stitle) 28549**], you should take 3mg of
coumadin by mouth each afternoon at 4pm.

you were brought to the cardiac care unit after your procedure
where you did well. you were transferred to the non-intensive
care cardiology floor shortly thereafter where your course
continued to be unremarkable.

you have several follow-up appointments listed below. please
keep all of them; each is extremely important. also, please
discuss cardiac rehabilitation with your cardiologist and
primary care provider next [**name9 (pre) 766**] and tuesday, respectively.

start:
coumadin 3mg by mouth once daily (on [**8-16**], and [**6-17**]). you
will have blood tests drawn on the 14th and 15th that will
dictate your dose on [**6-18**] and thereafter. you must go to [**hospital1 2292**] in [**location (un) **], [**university/college **], or [**location (un) 38**] to have these labs
drawn. they will be submitted electronically to dr.[**name (ni) 28550**]
office, where he and his team can decide the appropriate
coumadin dose.
plavix 75mg by mouth once daily
losartan 25mg by mouth once daily
metoprolol succinate (xl) 200mg by mouth once daily
eplerenone 25mg by mouth once daily

stop:
nifedipine er 30 daily
irbesartan 150 daily
metoprolol tartrate 100mg twice daily
hydrochlorothiazide 25mg daily


followup instructions:
department: cardiac services
when: monday [**2170-6-18**] at 4:20 pm
with: [**first name11 (name pattern1) **] [**last name (namepattern4) 1523**], md [**telephone/fax (1) 62**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

name: [**last name (lf) **],[**first name3 (lf) **] j
location: [**location (un) 2274**]-[**location **]
address: 291 independence dr, [**location **],[**numeric identifier 1700**]
phone: [**telephone/fax (1) 28551**]
appt:  [**6-19**] at 2:20pm

department: cardiac services
when: friday [**2170-7-13**] at 10:00 am
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

department: cardiac services
when: thursday [**2170-7-26**] at 1 pm
with: [**name6 (md) 1918**] [**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


                             [**first name11 (name pattern1) **] [**last name (namepattern1) 2908**] md, [**md number(3) 2909**]

"
44,"admission date:  [**2180-6-3**]              discharge date:   [**2180-6-12**]

date of birth:  [**2134-3-21**]             sex:   f

service: medicine

allergies:
vancomycin

attending:[**first name3 (lf) 759**]
chief complaint:
fever, sputum production, shortness of breath, stomach pain

major surgical or invasive procedure:
none

history of present illness:
mrs. [**known lastname **] is a 46-year-old with a history of intracranial
hemorrhage secondary to avm s/p evacuation in [**2179-8-27**],
complicated by hydrocephalus requiring vp shunt, brought in from
[**hospital3 2558**] nursing home. she has a tracheostomy and peg. she
has undergone rehabilitation at [**hospital3 **] [**hospital1 8**] and
[**location (un) 1036**] [**location (un) 620**]. during her time at [**location (un) 1036**], she was
hospitalized at [**hospital1 18**] [**location (un) 620**] and found to have a mucous plug
with sputum culture positive for mrsa, as well as e. faecalis
urinary tract infection (sensitive to linezolid, vancomycin, and
furantoin) treated with nitrofurantoin x 6 days. she was
transferred from [**location (un) 1036**] to [**hospital3 2558**] on [**2180-5-30**]. per a
[**hospital3 2558**] employee who spoke with the patient's respiratory
therapist, the patient was noted to have increasingly voluminous
secretions requiring increasingly frequent sunctioning (every
four hours -> every two hours -> every hour -> every 30
minutes). she was febrile to 101.2 with a heart rate in the
120s.
.
in the [**hospital1 18**] ed, vs were hr 126, bp 90/68, rr 26, o2 99% on ?
o2. she was thought to have suprapubic tenderness on exam. chest
x-ray revealed no acute intrathoracic process. urinalysis was
leukocyte- and nitrite-positive with many bacteria. sputum
gram-stain and culture, blood culture, and urine culture went
sent. she received cefepime 2g iv x 1 and linezolid 600mg iv x 1
for possible healthcare-associated pneumonia and urinary tract
infection, plus acetaminophen and fluids.
.
on the floor she is noted to be hypotensive to 82/palp and is
triggered in the setting of losing her iv access. she is
admitted to the micu for closer monitoring. in the micu she
denies complaints.
.
 in the micu pt received fluid boluses (6.5l total) to treat
hypotension, but did not receive pressors. linezolid and
cefepime were continued [**12-29**] vanc allergy. cxr revealed
questionable pneumonia with retrocardiac opacity vs atelectasis,
and current abx should treat for any hap as well. on hospital
day 3, pt's hypotension stabilized, with sbps in the 100s. at
time of txfr, sputum culture taken is growing gnr, which will
need to be followed. urine cx revealed e. coli sensitive to
cefepime. pt's lactate trended down with condition improvement.
pt was transferred to the floor.
.
on the floor, pt remained stable, with sbps in the 100s.
midodrine was added to pt's regimen, with resumption of normal
blood pressures in the 110s to 120s. pt remained afebrile on the
floor, with no adverse events. cefepime and linezolid were
continued. pt was restarted on her normal cycled tube feeding
regimen from continuous feeds, which she tolerated well.
.
review of systems:
(+) per hpi; she has had ongoing hyperthermia thought to a
""central fever""/reset thermostat, though she was afebrile on
discharge from [**location (un) 1036**] (t 98.0); husband also notes that she
has complained of intermittent headache recently; she is
constipated at baseline
(-) denies sinus tenderness, rhinorrhea or congestion. denied
chest pain or tightness, palpitations. denied arthralgias or
myalgias

past medical history:
intracranial hemorrhage in [**2179-8-27**]
s/p vp shunt
enterococcus faecalis uti ([**2-4**])
mucous plug ([**2-4**])
mrsa colonized
situational depression

social history:
cared for by husband, who is her guardian. currently [**name2 (ni) 546**] at
[**hospital3 2558**] ([**location (un) **]), a nursing facility, but has spent
the last ~9 months at [**hospital3 **] [**hospital1 8**] and [**location (un) 1036**]
[**location (un) 620**]. [**university/college **] grad [**first name8 (namepattern2) **] [**doctor first name **] note.


family history:
non-contributory

physical exam:
on admission:
vs: t 97.3, bp 95/60, hr 79, rr 24, spo2 100% on 50%
ga: somnolent and uncommunicative
heent: perrl. eyes with strabismus. oropharynx exam limited but
there are visible secretions. no lad. trach with visible
secretions.
cards: faint s1 and s2, no mrg, pulses full but faint
pulm: diffusely rhonchorous breath sounds with scattered
background wheezes
abd: soft, deep palpation did not elicit grimace
extremities: wwp
skin: warm with no rashes, peg site clean and non-draining
neuro/psych: strabisus as above. cn iv-xii, ue/le strength,
coordination, reflexes, and gait not assessed.

on discharge:
vs: t 98.8, bp 116/75, hr 82, rr 24, spo2 99% on 35% humidified
through trach mask
ga: alert and responsive.
heent: eyes with strabismus, left anisocoria. oropharynx without
lesions. no lad. trach clean and well-cushined with no leaking
secretions.
cards: normal s1 and s2, no mrg, pulses 2+
pulm: good air entry b/l throughout. transmitted upper airway
sounds from trach heard throughout.
abd: soft, non-tender, non-distended.
extremities: wwp 2+ pt/dp pulses
skin: warm with no rashes, peg site clean and non-draining
neuro/psych: strabisus as above, left anisocoria unchanged
during course on floors.


pertinent results:
admission labs:

discharge labs:

studies:
cxr [**2180-6-3**]:
impression: no acute intrathoracic process.

ct abd/pelvis:
impression:
mild amount of subcutaneous air in the anterior abdominal wall
inferiorly is likely related to injections.
trace pelvic free fluid, could be physiologic (if patient
pre-menopausal), or could relate to vp shunt.

micro:
blood cx [**2180-6-3**]: pending
urine cx [**2180-6-3**]: pending
sputum cx [**2180-6-3**]:
[**2180-6-3**] 11:45 am sputum

   gram stain (final [**2180-6-3**]):
      >25 pmns and <10 epithelial cells/100x field.
      3+  (5-10 per 1000x field):   gram negative diplococci.
      2+   (1-5 per 1000x field):   gram negative rod(s).
      1+    (<1 per 1000x field):   gram positive cocci.
                                    in pairs and in short
chains.
      1+    (<1 per 1000x field):   gram positive rod(s).

   respiratory culture (preliminary):

[**2180-6-8**] 06:15am blood wbc-8.8 rbc-3.24* hgb-10.0* hct-30.7*
mcv-95 mch-30.9 mchc-32.6 rdw-14.9 plt ct-378
[**2180-6-7**] 05:55am blood wbc-7.5 rbc-3.19* hgb-9.8* hct-30.3*
mcv-95 mch-30.8 mchc-32.4 rdw-14.6 plt ct-333
[**2180-6-6**] 06:14am blood hct-30.9*
[**2180-6-6**] 04:02am blood wbc-7.4 rbc-2.68* hgb-8.2* hct-24.9*
mcv-93 mch-30.8 mchc-33.1 rdw-14.5 plt ct-322
[**2180-6-5**] 05:46am blood wbc-8.0 rbc-3.20* hgb-9.9* hct-29.8*
mcv-93 mch-30.8 mchc-33.1 rdw-14.4 plt ct-264
[**2180-6-4**] 04:25am blood wbc-7.1# rbc-2.98*# hgb-9.2*# hct-28.0*#
mcv-94 mch-30.9 mchc-32.9 rdw-14.4 plt ct-280
[**2180-6-3**] 11:12am blood wbc-16.8* rbc-4.34 hgb-13.3 hct-39.0
mcv-90 mch-30.6 mchc-34.0 rdw-14.5 plt ct-421
[**2180-6-3**] 11:12am blood neuts-82.2* lymphs-10.4* monos-5.8
eos-0.7 baso-0.8
[**2180-6-8**] 06:15am blood plt ct-378
[**2180-6-5**] 05:46am blood pt-11.1 ptt-26.3 inr(pt)-0.9
[**2180-6-8**] 06:15am blood glucose-117* urean-6 creat-0.4 na-137
k-4.0 cl-98 hco3-32 angap-11
[**2180-6-7**] 05:55am blood glucose-103* urean-4* creat-0.3* na-138
k-3.9 cl-101 hco3-30 angap-11
[**2180-6-6**] 04:02am blood glucose-87 urean-6 creat-0.4 na-141 k-3.8
cl-107 hco3-27 angap-11
[**2180-6-5**] 05:46am blood glucose-139* urean-6 creat-0.4 na-136
k-4.0 cl-105 hco3-24 angap-11
[**2180-6-4**] 04:25am blood glucose-117* urean-11 creat-0.4 na-137
k-3.9 cl-108 hco3-22 angap-11
[**2180-6-3**] 11:12am blood glucose-128* urean-19 creat-0.7 na-132*
k-5.1 cl-95* hco3-20* angap-22*
[**2180-6-7**] 05:55am blood alt-74* ast-50* alkphos-78 totbili-0.1
[**2180-6-5**] 05:46am blood alt-33 ast-22 ld(ldh)-242 alkphos-69
totbili-0.1
[**2180-6-3**] 11:12am blood alt-53* ast-38 ld(ldh)-309* alkphos-98
amylase-47 totbili-0.2
[**2180-6-7**] 05:55am blood lipase-24
[**2180-6-5**] 05:46am blood lipase-29
[**2180-6-3**] 11:12am blood lipase-42
[**2180-6-8**] 06:15am blood calcium-9.0 phos-3.2 mg-2.4
[**2180-6-7**] 05:55am blood albumin-3.2* calcium-8.7 phos-3.6 mg-2.4
[**2180-6-6**] 04:02am blood calcium-8.5 phos-3.4 mg-2.3
[**2180-6-5**] 05:46am blood calcium-8.4 phos-2.8 mg-2.2 iron-20*
[**2180-6-4**] 04:25am blood calcium-7.9* phos-3.1 mg-2.2
[**2180-6-3**] 11:12am blood albumin-4.3 calcium-9.5 phos-3.1 mg-2.8*
[**2180-6-5**] 05:46am blood caltibc-218* ferritn-290* trf-168*
[**2180-6-4**] 04:56am blood type-[**last name (un) **] po2-76* pco2-43 ph-7.37
caltco2-26 base xs-0
[**2180-6-4**] 04:56am blood lactate-1.2
[**2180-6-3**] 11:21am blood lactate-2.3*

brief hospital course:
pt is a 46 yo f w pmh of avm intracerebral bleed c/b cerebral
edema in [**2178**] requiring a trach and peg who presents with
increased respiratory secretions, increased lethargy,
hypotension and fever concerning for severe sepsis. she was
transferred to the micu for hypotension and closer monitoring.
she was treated with linezolid and cefepime. cultures were sent
and showed e coli in the urine sensitive to cefepime.

# severe sepsis: patient's vitals in the ed were temp 102, hr
126, rr 26, with a wbc count of [**numeric identifier 2686**]. patient met all 4
criteria for sirs. patient also has a ua concerning for uti. pt
also has a trach aspirate growing moraxella from an osh and a
sputum culture pending here; however, clear lungs, lack of
increased sputum or o2 requirement here, lack of infiltrate
makes hap unlikely. ct abdomen unrevealing. pt was bolused with
ivf's and hypotension resolved. she would become intermittently
hypotensive 1-2x/day throughout her micu course thought to be
secondary to autonomic dysfunction secondary to her stroke.
sepsis was thought to be resolved, and the hypotension would
quickly recover on its own or with small fluid bolus. she was
started on linezolid given history of vanc allergy & vre
positive per report, in addition to cefepime to cover for gnr's
on [**2180-6-3**] for day 1. c. diff was ordered; however, pt was not
stooling while in the micu. kub was sent and revealed
constipation. she remained hemodynamically stable with no
pressor requirement while in the micu. cultures were sent and
showed e coli in the urine sensitive to cefepime.
outpatient issues:
-- continue cefepime next 4 days to complete 14d course,
midodrine

# abdominal pain: unclear origin but most likely [**12-29**] uti,
possible pyelonephritis. lfts showed only mildly elevated alt.
ct abd unrevealing. abdomen remained soft. vp peritonitis
considered, but only minimal ascites on imaging in addition to
benign abdomen on exam. kub revealed constipation and she
improved with suppositories and laxatives. once on floor s/p
micu stay, pt no longer complained of abdominal pain.

# anion gap acidosis: likely [**12-29**] lacate. lactate downtrended and
acidosis resolved.

# anemia: normocytic, previous baseline ~ 30-32. likely dry on
admission, and hct fell to 28, likely dilutional in setting of
volume resuscitation. patients hematocrit monitored daily. hcts
remained stable.
 .
# hypotension. per report patient with baseline sbps in
90s-100s. in micu patient received a total of 6.5l in 500cc
boluses to maintain pressures. with treatment of infection sbps
stabilized to 100s. decision made to start patient on standing
midodrine to treat possible component of autonimic dysfunction
secondary to known intracranial pathology.

# s/p intracerebral bleed: baseline neuro status according to
husband. on trach and peg. has [**2-29**] r sided strength, left sided
weakness. no acute issues.

# depression: wellbutrin held on linezolid due to initial
concern for serotonin syndrome. patient continued on ambien.


medications on admission:
-jevity tube feeds @ 85 cc/hr via ng tube at 8pm off at 6am
-azocranberry 150 mg ng [**hospital1 **]
-lactulose 15 ml ng [**hospital1 **]
-ritalin 2.5 mg ng daily
-clonidine 0.1 mg ng [**hospital1 **]
-vitamin b complex 1 tab ng daily
-lovanox 40 mg subq daily
-zantac 150 mg/10 ml syrup ng daily
-senna 2 tabs ng daily
-wellbutrin 100 mg ng daily
-ambien 5 mg ng qhs
-tylenol 650 mg ng q4h prn:pain, fever
-simethicone 80 mg ng qid prn:gas pain
-acetylcysteine [mucomyst] 600 mg neb [**hospital1 **]

discharge medications:
1. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2
times a day): [**month (only) 116**] decrease by half if pt has more than 2 bowel
movements per day.
2. b complex vitamins capsule sig: one (1) cap po daily (daily).

3. ranitidine hcl 15 mg/ml syrup sig: one [**age over 90 1230**]y (150) mg
po daily (daily).
4. senna 8.6 mg tablet sig: two (2) tablet po daily (daily).
5. acetaminophen 500 mg tablet sig: one (1) tablet po q4h (every
4 hours) as needed for pain.
6. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
7. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
8. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid
(4 times a day) as needed for thrush.
9. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1)
tablet, sublingual sublingual qid (4 times a day).
10. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2
times a day).
11. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po
daily (daily) as needed for constipation.
12. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a
day). disp:*180 tablet(s)* refills:*2*
13. cefepime 2 gram recon soln sig: one (1) recon soln injection
q12h (every 12 hours): for the next four days through [**2180-6-16**].
14. lovenox 40 mg/0.4 ml syringe sig: one (1) subcutaneous once
a day.
15. bisacodyl 5 mg tablet sig: 1-2 tablets po once a day as
needed: for constipation. tablet(s)
16. mucomyst neb sig: 600mg twice a day: give acetylcysteine
600mg neb [**hospital1 **].


discharge disposition:
extended care

facility:
[**hospital3 2558**] - [**location (un) **]

discharge diagnosis:
urosepsis

discharge condition:
level of consciousness: alert and interactive, though
neurologically limited.
activity status: bedbound.
mental status: confused - sometimes.


discharge instructions:
dear ms. [**known lastname **]: it was a pleasure participating in your care at
[**hospital1 69**]. you were treated here for
urosepsis, which is a severe infection of the bladder. you need
4 more days of antibiotics through your veins. you were also
treated for a likely infection of your lungs, you already
completed antibiotics for that. you should continue your
medications as you had previously, and take the antibiotics as
prescribed in the medicine list.
.
changes to your medication:
start: to treat infection, please take your cefepime twice per
day for the next 4 days.
start: please continue your bowel regimen (laxatives) as
prescribed on the medication sheet to avoid constipation and
belly pain.
start: to treat low blood pressure please take the midodrine as
prescribed on your medication sheet.

stop: ritalin 2.5mg daily, you did not seem to need this. you
are now getting midodrine.
stop: clonidine, your blood pressures were low during this
admission.
hold: wellbutrin 100mg daily. you can discuss with your rehab
doctor when you resume this medication.
to avoid future urinary tract infections, you should have your
diapers changed very regularly. your institution may want to
straight-cath collect urine every 4 hours if diaper changes are
not frequent enough.

followup instructions:
please follow up with the doctors at rehab this week.



completed by:[**2180-6-12**]"
45,"admission date:  [**2108-6-26**]              discharge date:   [**2108-7-2**]

date of birth:  [**2049-2-6**]             sex:   f

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2108-6-26**]: laparascopic sleeve gastrectomy


history of present illness:
[**known firstname **] has class iii extreme morbid obesity with weight of
364.3 pounds as of [**2108-5-29**] (her initial screen weight on [**2108-5-22**]
was 368 pounds), height of 65 inches and bmi 60.6.  her previous
weight loss efforts have included hmr for one year in [**2104**]
losing 20 pounds, off-label prescription weight loss medication
combination of fenfluramine/phentermine (""fen/phen"") in [**2092**] for
one year losing 70 pounds and [**street address(1) 41635**] visits on/off over
the past 5 years with very little weight loss.  she has exercise
for two years at curves for women losing 50 pounds and one year
of [**location (un) 86**] sports club in [**2106**] to [**2107**] losing 20 pounds. in all
of her efforts whatever weight she loss she was unable to
maintain from no more than one year.  she denied taking
over-the-counter ephedra-containing appetite suppressant/herbal
supplements.  her weight at age 21 was 150 pounds with her
lowest adult weight 125 pounds and her highest weight being 377
pounds earlier this year (2/[**2108**]).  she weighed 192 pounds at
age 33, 200 pounds at age 38, 286 pounds at age 46 and 325
pounds at the age of 50.  she stated she developed a significant
[**last name 4977**] problem at the age of 35 and has been struggling with
weight since birth of her second child and quit  smoking in
[**2081**].  factors contributing to her excess weight include large
portions, genetics, too many carbohydrates and emotional eating.
 for exercise she does water aerobics 60 minutes 5 days per week
since [**month (only) 359**] and lap swimming 90 minutes 5 days per week.  she
denied history of eating disorders and does have depression but
has not been followed by a therapist nor has she been
hospitalized for mental health issues and she is on psychotropic
medication (sertraline).


past medical history:
past medical history:  notable for fatty liver, rotator cuff
tendinitis, right shoulder, obstructive sleep apnea, type 2
diabetes with a1c of 6%, dyslipidemia, gastroesophageal reflux,
osteoarthritis of the knees, aortic valve regurgitation, past
depression.

past surgical history:  c-section x 2, carpal tunnel, right hand

social history:
she smoked one to two packs a day for 25 years quit [**2091**], no
recreational drugs, has occasional alcohol, drinks caffeinated
beverages.  she is a retired teacher, is divorced and has two
adult children

family history:
her family history is noted for father deceased age 58 with
heart disease, hyperlipidemia and obesity; mother living with
hyperlipidemia; sister deceased at 36 years of age secondary to
bulimia; maternal and paternal grandparents with heart
disorders.

physical exam:
vs: t 98, hr 86, bp 149/65, rr 18, o2 97%ra

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd: soft, appropriate peri-incisional tenderness, no rebound
tenderness/guarding
wounds: abd lap sites with steri-strips cdi, no periwound
erythema, + periwound ecchymosis
ext: no edema

pertinent results:
labs:
[**2108-6-27**] 07:40am blood hct-36.2
[**2108-6-26**] 04:21pm blood hct-38.4
[**2108-6-28**] 09:38am blood type-art po2-70* pco2-47* ph-7.40
caltco2-30 base xs-2
[**2108-6-30**] 06:40am blood wbc-5.6 rbc-4.21 hgb-11.3* hct-36.6
mcv-87 mch-26.7* mchc-30.7* rdw-15.2 plt ct-184 neuts-81.0*
lymphs-12.6* monos-3.6 eos-2.7 baso-0.1

imaging:
[**2108-6-27**]:
ugi sgl contrast w/ kub:
impression:  no evidence of obstruction or leak.


brief hospital course:
the patient presented to pre-op on [**2108-6-26**]. pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparascopic sleeve gastrectomy. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout
hospitalization; pain was initially managed with a pca and then
transitioned to oral roxicet once tolerating a stage 2 diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient was triggered on pod2 for desaturations
with an increased oxygen requirement.  the patient was
subsequently transferred to the tsicu on pod2 where she was
weaned to 3l nasal cannula; vancomycin was initiated as empiric
therapy.  she was subsequently transferred back to the general
surgical [**hospital1 **] on pod3 and weaned completely from o2 on pod5.
good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization. the pt was
maintained on cpap overnight for known sleep apnea.
gi/gu/fen: the patient was initially kept npo.  on pod1, an
upper gi study, which was negative for a leak, therefore, the
diet was advanced sequentially to a bariatric stage 2 diet,
which was well tolerated. however, on pod2, during period of
acute oxygen desaturation, the pt was made npo.  a methylene
blue dye test was performed without change in character of drain
output which remained serosanguinous throughout the admission.
the patient's diet was resumed and she was able to tolerate a
stage 3 diet without incident. patient's intake and output were
closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none; empiric treatment with
vancomycin was administered from pod2 through pod5 as described
above.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
metformin 500 mg [**hospital1 **]
omeprazole 20 mg daily
sertraline 50 mg daily
simvastatin 20 mg daily
vitamin d3 5000 units daily
multivitamin with minerals 1 tablet daily

discharge medications:
1. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*
2. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day
for 1 months.
disp:*600 ml* refills:*0*
3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**6-21**] ml
po every four (4) hours as needed for pain.
disp:*250 ml* refills:*0*
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day.
disp:*250 ml* refills:*0*
5. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable/crushable; no gummy.
6. metformin 500 mg tablet sig: 0.5 tablet po twice a day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule;
sprinkle contents onto applesauce, swallow whole.
8. sertraline 50 mg tablet sig: one (1) tablet po once a day.
9. simvastatin 20 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
morbid obesity


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except:
1.  please decrease your metformin to 250 mg twice daily.
please continue to monitor blood sugars and report elevated or
low readings to your prescribing provider.

crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:15 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:30 am
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2108-7-2**]"
46,"admission date:  [**2118-10-14**]              discharge date:   [**2118-10-25**]

date of birth:  [**2068-6-1**]             sex:   m

service: [**hospital unit name 196**]

allergies:
vancomycin

attending:[**first name3 (lf) 4765**]
chief complaint:
dizziness

major surgical or invasive procedure:
cardiac catheterization with stent placement
intubation
urinary tract infection


history of present illness:
50yo man with h/o cad s/p imi and rca stent in [**2-13**], also with
h/o hypercholesterol, [**date range **], etoh, who p/t an osh hospital with
nstemi (st depressions in ii, iii, avf), bradycardic and
nauseated. he was transferred to [**hospital1 18**] emergently for cardiac
cath.

past medical history:
cad s/p imi and rca stent in [**2-13**]
hypercholesterol
[**date range **]
etoh

social history:
lives with his wife and daughter in [**name (ni) 28117**], ma, though wife
has avoided him recently because of his etoh use and depression.

etoh: significant increase in use x 6mths since his mother died
[**name2 (ni) **]: none
drugs: none

family history:
cad, with mi <55 in several relatives

physical exam:
vitals: t100.3, hr 100(paced), rr24 (vent), o2 sat 100% on 50%
fio2
gen: middle-aged man lying in bed, sleeping, awoken to voice
skin: warm and dry; no perspiration, no groin hematoma, no flank
hematoma; right groin with no bleeding
heent: normal size pupils, perrl, mmm, no oral bleeding, poor
dentition with missing teeth
cv: normal s1 s2, no g/r/m
lungs: bibasilar rales, no w/r, no egoph, no tact frem
abd: +bowel sounds, soft, nt/nd, no hsm, no masses palpated
ext: 2+ dp pulses b/l, feet warm and well perfused; no le edema
neuro: a+ox3

pertinent results:
[**2118-10-14**] 10:00pm blood wbc-16.4*# rbc-3.20* hgb-11.4* hct-33.0*
mcv-103*# mch-35.4* mchc-34.5 rdw-11.6 plt ct-221
[**2118-10-15**] 12:30am blood wbc-25.8*# rbc-3.83* hgb-13.3* hct-37.6*
mcv-98 mch-34.7* mchc-35.4* rdw-12.0 plt ct-362#
[**2118-10-23**] 12:15pm blood wbc-13.6* rbc-4.08* hgb-13.3* hct-38.2*
mcv-94 mch-32.5* mchc-34.8 rdw-13.8 plt ct-442*
[**2118-10-25**] 11:24am blood wbc-14.8* rbc-4.01* hgb-13.1* hct-37.1*
mcv-93 mch-32.7* mchc-35.3* rdw-14.0 plt ct-616*
[**2118-10-18**] 11:09pm blood neuts-77.8* lymphs-10.3* monos-5.2
eos-6.2* baso-0.5
[**2118-10-14**] 10:00pm blood pt-18.2* ptt-150.0* inr(pt)-2.1
[**2118-10-14**] 10:00pm blood plt ct-221
[**2118-10-15**] 12:30am blood pt-15.8* ptt-138.5* inr(pt)-1.6
[**2118-10-15**] 12:30am blood plt ct-362#
[**2118-10-22**] 06:01am blood plt ct-319
[**2118-10-23**] 12:15pm blood pt-13.9* ptt-25.4 inr(pt)-1.2
[**2118-10-23**] 12:15pm blood plt ct-442*
[**2118-10-25**] 11:24am blood plt ct-616*
[**2118-10-17**] 12:08pm blood fibrino-567* d-dimer-1370*
[**2118-10-17**] 12:08pm blood fdp-0-10
[**2118-10-14**] 10:00pm blood glucose-406* urean-8 creat-0.7 na-133
k-3.5 cl-104 hco3-13* angap-20
[**2118-10-15**] 12:30am blood glucose-229* urean-8 creat-0.9 na-135
k-4.1 cl-106 hco3-14* angap-19
[**2118-10-22**] 06:01am blood glucose-96 urean-11 creat-0.7 na-141
k-3.7 cl-101 hco3-31* angap-13
[**2118-10-23**] 12:15pm blood glucose-83 urean-11 creat-0.8 na-145
k-3.6 cl-107 hco3-24 angap-18
[**2118-10-24**] 06:45am blood glucose-95 urean-18 creat-0.8 na-145
k-4.7 cl-109* hco3-28 angap-13
[**2118-10-14**] 10:00pm blood ck(cpk)-69
[**2118-10-15**] 12:30am blood ck(cpk)-512*
[**2118-10-15**] 03:56am blood alt-33 ast-150* ld(ldh)-506* alkphos-82
totbili-0.6
[**2118-10-15**] 04:17am blood alt-25 ast-53* ld(ldh)-259* ck(cpk)-1355*
alkphos-85 totbili-0.6
[**2118-10-15**] 04:55pm blood ck(cpk)-6653*
[**2118-10-16**] 12:10am blood ck(cpk)-6893*
[**2118-10-16**] 07:27am blood alt-35 ast-144* ld(ldh)-428*
ck(cpk)-6313* alkphos-73 totbili-0.6
[**2118-10-19**] 04:24am blood ck(cpk)-3207*
[**2118-10-22**] 06:01am blood alt-50* ast-48* ck(cpk)-581* alkphos-167*
totbili-0.5
[**2118-10-23**] 12:15pm blood ggt-227*
[**2118-10-14**] 10:00pm blood ck-mb-5
[**2118-10-15**] 12:30am blood ck-mb-19* mb indx-3.7 ctropnt-0.28*
[**2118-10-15**] 04:17am blood ck-mb-44* mb indx-3.2 ctropnt-1.19*
[**2118-10-15**] 04:55pm blood ck-mb-45* mb indx-0.7 ctropnt-1.17*
[**2118-10-14**] 10:00pm blood calcium-3.5* phos-2.5* mg-1.7
[**2118-10-15**] 12:30am blood calcium-6.1* phos-1.8* mg-1.9
[**2118-10-15**] 03:56am blood calcium-8.1* phos-3.3 mg-1.9
[**2118-10-15**] 04:17am blood albumin-3.3* calcium-8.1* phos-1.9*
mg-2.5
[**2118-10-23**] 12:15pm blood calcium-8.7 phos-3.8 mg-2.3
[**2118-10-24**] 06:45am blood calcium-8.8 phos-3.7 mg-2.3
[**2118-10-17**] 04:35pm blood hapto-53
[**2118-10-15**] 08:35am blood %hba1c-5.0
[**2118-10-17**] 12:08pm blood triglyc-99
[**2118-10-16**] 07:27am blood tsh-0.090*
[**2118-10-16**] 07:27am blood free t4-1.0
[**2118-10-16**] 07:27am blood cortsol-29.8*
[**2118-10-14**] 10:13pm blood type-art tidal v-700 peep-5 o2-100
po2-304* pco2-41 ph-7.19* calhco3-16* base xs--11 aado2-390 req
o2-67 -assist/con intubat-intubated
[**2118-10-15**] 12:51am blood type-art temp-34.4 tidal v-600 o2-100
po2-191* pco2-31* ph-7.25* calhco3-14* base xs--12 aado2-509 req
o2-83 intubat-intubated vent-imv
[**2118-10-15**] 04:19am blood type-art po2-280* pco2-34* ph-7.46*
calhco3-25 base xs-1
[**2118-10-15**] 06:51am blood type-art o2-80 po2-291* pco2-30* ph-7.48*
calhco3-23 base xs-0 aado2-264 req o2-50 intubat-intubated
[**2118-10-15**] 01:45pm blood type-art temp-39.3 rates-22/ tidal v-650
peep-5 o2-50 po2-168* pco2-37 ph-7.46* calhco3-27 base xs-3
intubat-intubated
[**2118-10-17**] 04:13pm blood type-art temp-36.8 rates-/24 tidal v-430
peep-5 o2-40 po2-132* pco2-43 ph-7.45 calhco3-31* base xs-5
intubat-intubated vent-spontaneou
[**2118-10-20**] 06:03am blood type-art po2-142* pco2-44 ph-7.45
calhco3-32* base xs-6
[**2118-10-20**] 01:05pm blood type-art temp-36.8 po2-104 pco2-39
ph-7.46* calhco3-29 base xs-3
[**2118-10-15**] 12:51am blood lactate-7.3*
[**2118-10-15**] 12:51am blood freeca-0.83*
[**2118-10-19**] 09:19pm blood freeca-1.13

brief hospital course:
upon arrival to the cath lab the pt was slurring his speech,
nauseated and smelled of etoh. while his disorientation
prohibited the pt from making an informed decision about the
cath, the concern for acute mi and the apparent life threatening
nature of the event compelled the cardiac team to proceed with
the cath.

during the cath, the pt was found to be in bradycardic afib with
[**last name (lf) 46360**], [**first name3 (lf) **] two attempts at cardioversion were attempted without
success.  the pt was intubated at this time for airway
protection in the setting of repetitive vomitting. an attempt
was made to cross a lesion in the patient's om1 branch with a
graphix wire, at which time the patient went into vfib. over the
next 30-40 minutes, the pt received cpr intermittently, iv
lidocaine, amiodarone bolus x 300mg and iv drip, iv epinephrine,
defribrillation at 360j x 20 attempts. because of severe
bradycardia after cardioversion, a temporary pacing cath was
placed, with initial rate set at 100bpm. after stabilized in
this manner, the om1 branch was stented open. an attempt
thereafter to decrease his pacer rate to 60bpm resulted in
recurrent vfib. a second pacer wire was placed to reposition,
and then first pacer wire removed. finally, an iabp was placed
with sbp around 130mmhg thereafter, and the patient was
transferred to the ccu for further care.

1. cardio
a. coronaries: as above, pt had stent placed to his om1 branch
in the cath lab, with good post-cath flow and no evid of
dissection. pt was cont on asa, plavix, lipitor. also given
aggrastat x 2d post cath. was on heparin for iabp, which was
stopped after the iabp was removed.
b. pump: pt was transferred to the unit on pressors and iabp on
am on [**2118-10-15**]. iabp was d/c on pm of [**2118-10-16**].  dopamine was
titrated off over the course of several days as his blood
pressure tolerated.  tte revealed lvef 40%; hk of the inferior
free wall. started on metoprolol and captopril, switched over to
lisinopril prior to d/c.
c. rhythm: as noted, pt had recurrent vfib in cath lab, then had
5 episodes of vfib overnight while in the ccu during his first
night, all reverted to paced rhythm at 100bpm once shocked with
pacing pads at 360j x once.  pt was felt to be moving and
dislodging the pacing wires, leading to his vfib, so his
sedation was increased and thereafter he did not have any
further vfib. was initially on an amio drip and a lido drip from
cath lab. lido was weaned off on [**10-16**], with amio weaned off [**10-17**].
pt had his pm turned off, with normal sinus at 70bpm but
occassional drops to 35bpm with no [**month/day (4) 46360**].  pacer was d/c'd after
several days with no adverse events, no requirement for external
pacing. ep felt that pt's arrythmias were [**3-14**] acute ischemia now
resolved and that he would not benefit from an aicd.

2. pulm: pt extubated from cath lab, extubated on [**10-21**]; pt was
given a course of flagyl and levaquin x 10d for possible asp
pna.

3. renal: lytes were repleted qd

4. id: pt had rll atelectasis vs pna on initial cxr, was started
on abx; blood cultures with 1/2 anaerobic bottles growing gpc in
pairs/chains; started on abx on [**10-16**] -- was on vanc for 3d, zosyn
for 7d, ceftriaxone, ceftaz and flagyl; continued flagyl and
levaquin x 10d for possible asp pna.

5. gi: pt had sanguinous heme+ ogt drainage initially, gi
consult was sought. gi advised to follow hct, protonix [**hospital1 **] and
conservative management given the patient's anticoagulated
state. pt's ogt drainage resolved spontaneously after several
days.

6. heme: pt had platelet and hct drop initially, both of unclear
etiologies, which resolved; hit ab test was negative, plt drop
may have been related to prbc transfusions; hemolysis and dic
w/u negative, no source of bleeding other than initial ugib
found. pt received a total of 6 units over the course of this
hospitalization. hct was trending up and greater than 30 upon
discharge.

7. neuro/psych: pt was thought to be likely to have anoxic brain
injury vs. etoh dementia initially, though this did not seem to
be the case. he had no gross neuro deficits, was briefly on a
ciwa scale but did not show signs of etoh withdrawal. psych
evaluated, recommended outpatient f/u for patient's depression
and etoh use, which was set up for the pt prior to his d/c.

medications on admission:
asa
plavix
enalapril
lopressor
lipitor
ativan
paxil

discharge medications:
1. metoprolol succinate 50 mg tablet sustained release 24hr sig:
one (1) tablet sustained release 24hr po qd (once a day).
disp:*30 tablet sustained release 24hr(s)* refills:*2*
2. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every
24 hours) for 7 days.
disp:*7 tablet(s)* refills:*0*
3. multivitamin     capsule sig: one (1) cap po qd (once a day).
disp:*30 cap(s)* refills:*2*
4. lisinopril 5 mg tablet sig: 0.5 tablet po qd (once a day).
disp:*15 tablet(s)* refills:*2*
5. thiamine hcl 100 mg tablet sig: one (1) tablet po qd (once a
day).
disp:*30 tablet(s)* refills:*2*
6. folic acid 1 mg tablet sig: one (1) tablet po qd (once a
day).
disp:*30 tablet(s)* refills:*2*
7. atorvastatin calcium 80 mg tablet sig: one (1) tablet po once
a day.
disp:*30 tablet(s)* refills:*2*
8. aspirin, buffered 325 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
9. pantoprazole sodium 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*
10. docusate sodium 100 mg capsule sig: one (1) capsule po once
a day as needed for constipation.
disp:*30 capsule(s)* refills:*0*
11. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*


discharge disposition:
home

discharge diagnosis:
myocardial infarction (nstemi)
ventricular fibrillation
urinary tract infection


discharge condition:
stable

discharge instructions:
please take all medications as prescribed and attend all
appointments made for you. you will also need to schedule an
appointment with your primary care doctor, dr. [**last name (stitle) 27542**], by
calling ([**telephone/fax (1) 29515**] and with your cardiologist, dr. [**last name (stitle) 11493**], by
calling ([**telephone/fax (1) 29810**]. you should ask for appointments within
the next two weeks if at all possible.  you should mention to
the secretaries that you have just been discharged from the
hospital after having a myocardial infarction (heart attack)
that was complicated by ventricular fibrillation (a dangerous
disorganized electrical activity in the heart).  you should
mention that your doctor in the hospital wanted you to be seen
as soon as possible as an outpatient to follow up on the
medications that you were started on during your admission.

you have been set up for an appointment at [**hospital1 **], [**last name (namepattern1) 46361**] in [**hospital1 1559**], [**numeric identifier 46362**] this thursday, [**10-27**] at 1pm for
assistance in avoiding the health problems associated with
alcohol use.  while this is voluntary, we feel that it is very
important to your well being and the best way you can stay
healthy in the weeks and months ahead.  drinking for you is
particularly risky given your heart condition, and may have been
a factor in your recent heart attack.

you were admitted to this hospital on [**2118-10-14**] with a myocardial
infarction and are being discharged on [**2118-10-25**] having been
treated for this health problem as well as several complications
that have arrisen during the course of your hospitalization.
while you do not require physical therapy at this time, it is
important that you return to work only once you feel comfortable
to do so.  this may take up to a week depending on how quickly
your body recovers.

if you have any symptoms of chest pain, shortness of breath, or
any other complaints that concern you please return the er for
evaluation.

followup instructions:
please make appointments to see your primary care doctor as well
as your cardiologist:
dr. [**last name (stitle) 27542**] ([**telephone/fax (1) 29515**]
dr. [**last name (stitle) 11493**] ([**telephone/fax (1) 29810**]



"
47,"admission date:  [**2179-2-8**]     discharge date:  [**2179-2-12**]

date of birth:   [**2125-1-21**]     sex:  f

service:  ccu

history of present illness:  the patient is a 54 year old
white female with a history of hypertension,
hypercholesterolemia, and smoking history, who was
transferred to [**hospital1 69**] with
acute anterior myocardial infarction, status post failed
thrombolysis at outside hospital.

the patient reports onset of symptoms on the morning of
admission of acute midback pain with eventual radiation to
the chest, seven out of ten, with radiation to her left upper
extremity with associated shortness of breath, nausea and
diaphoresis.

she called ems within five minutes and was brought to [**hospital3 6454**] emergency department where she was found to have
anterior st elevations in v1 through v4.  she was given
morphine 2 mg intravenously times two, sublingual
nitroglycerin and nitroglycerin drip, heparin and reteplase
times two.

per records, she arrived at the [**hospital3 1280**] emergency
department at 10:40 a.m.  symptom onset was approximated to
be at 10:00 a.m.  she received her first dose of reteplase at
10:53 a.m. and her second dose at 11:23 a.m.  her symptoms
did not improved and her st elevation persisted and she was
transferred to [**hospital1 69**] for
emergent catheterization.

she arrived at the catheterization laboratory at 1:30 p.m.
at cardiac catheterization, she was found to have a tortuous
coronary circulation with a totally occluded distal left
anterior descending which was stented with timi two flow post
and complicated by grade b dissection distally.  she was
given intracoronary vasodilators and no further intervention
was pursued.  her left circumflex, right coronary artery and
left main coronary artery were without significant disease.

a left ventriculogram was performed and notable for
anteroapical and inferoapical akinesis with an ejection
fraction of 40%.

right heart cardiac catheterization revealed pulmonary
capillary wedge pressure of 18 and right atrial pressure of
13.  postprocedure, she was given full dose integrilin for 18
hours.

upon arrival to the ccu, she had the chief complaint of
nausea but denied shortness of breath or chest pain.

past medical history:
1.  hypertension.
2.  hypercholesterolemia.
3.  osteoporosis.
4.  history of atypical colitis, steroid dependent since
[**9-4**].  history of diagnosis of collagenous colitis in the past.
6.  status post tubal ligation.

medications on admission:
1.  zestril 2.5 mg p.o. once daily.
2.  prednisone 20 mg p.o. once daily.
3.  asacol 1600 mg p.o. three times a day.
4.  rowasa enemas pr once daily.
5.  fosamax 10 mg p.o. once daily.
6.  prempro p.o. once daily.
7.  serax p.r.n.
8.  zomig p.r.n.

allergies:  no known drug allergies.

family history:  no history of early coronary artery disease
or myocardial infarction.

social history:  the patient lives in [**location 38080**] with
husband.  she has two children.  she has smoked one pack per
day since college.  she has one to two cocktails per night.
recently laid off.

physical examination:  on examination, temperature is
afebrile, blood pressure 135/74, heart rate 90, respiratory
rate 16, oxygen saturation 98% on two liters.  in general,
the patient is somnolent in no apparent distress.  head,
eyes, ears, nose and throat - the pupils are equal, round,
and reactive to light and accommodation.  extraocular
movements are intact.  mucous membranes are mildly dry.  the
neck is soft, supple, no lymphadenopathy, jugular venous
distention, thyromegaly or masses.  cardiac examination -
regular rate and rhythm, no murmurs, s4 gallop.  the lungs
are clear to auscultation bilaterally.  the abdomen is soft,
nondistended, nontender, no organomegaly or masses,
normoactive bowel sounds.  extremities - right groin with
small hematoma.  extremities without edema, warm and with
good distal pulses.  neurologically, the patient is alert and
oriented times three, grossly nonfocal.

laboratory data:  white count 15.8, hematocrit 36.5,
platelets 238,000.  inr 1.1.  sodium 137, potassium 4.7,
blood urea nitrogen 7, creatinine 0.6, glucose 150.  ck peak
1148, ck mb peak 150.

initial electrocardiogram normal sinus rhythm, normal axis,
intervals, 2.[**street address(2) 2811**] elevations in v2 through v4 with
peaked t waves, 1.[**street address(2) 2811**] elevations in i and ii, 0.[**street address(2) 38081**] elevations in v5 and v6.

hospital course:
1.  coronary artery disease - status post acute anterior
myocardial infarction, total occlusion of the distal left
anterior descending, status post left anterior descending
stent, complicated by distal dissection and with timi two
flow post intervention.  the patient was hemodynamically
stable throughout her hospitalization.  her ck peaked at 1148
and then trended down.  she was treated with integrilin for
18 hours postcatheterization and then received aspirin,
plavix, beta blocker and ace inhibitor.  she was also started
on lipitor for a lipid panel with total cholesterol of 249,
and ldl of 143.  she will be discharged on aspirin, plavix to
finish one month course, atenolol, zestril and lipitor.

2.  pump - left ventriculogram during cardiac catheterization
was notable for apical akinesis and ejection fraction of 40%.
she had no signs or symptoms of congestive heart failure
during her hospitalization.  she was started on beta blocker
and ace inhibitor as above.  given her apical akinesis, she
was started on anticoagulation initially with heparin drip
and then with low molecular weight heparin as well as
coumadin.  she will be discharged on lovenox and coumadin, to
have inr followed up as an outpatient.

3.  electrophysiology - the patient with no adverse events on
telemetry during her hospitalization except for rare
premature ventricular contractions.

4.  hematology - the patient with right groin hematoma,
status post cardiac catheterization.  she was also noted on
the following evening to have a bruit over that area.  an
ultrasound revealed 1.7 by 2.0 centimeter pseudoaneurysm
which was treated with thrombin injection with good result.
her anticoagulation was held temporarily during these events
and then restarted without complications.  at the time of
discharge, the patient still has residual ecchymosis over her
right lower extremity as well as a small but stable hematoma.

5.  gastrointestinal - the patient had no gastrointestinal
symptoms during her hospitalization and was continued on her
outpatient regimen of asacol and rowasa enemas.  she received
stress dose steroids pericatheterization and then was
switched to a p.o. prednisone taper starting at 60 mg to be
tapered down to her baseline of 20 mg.

6.  endocrine - the patient has been on prempro as an
outpatient.  this was held in the setting of her acute
myocardial infarction but she will be able to restart this as
an outpatient.

medications on discharge:
1.  enteric coated aspirin 325 mg p.o. once daily.
2.  plavix 75 mg p.o. once daily, to continue one month
course.
3.  coumadin 5 mg p.o. once daily.
4.  lovenox 60 mg subcutaneous times three more doses.
5.  zestril 2.5 mg p.o. once daily.
6.  atenolol 25 mg p.o. once daily.
7.  prednisone taper down to 20 mg once daily.
8.  asacol 1600 mg p.o. three times a day.
9.  rowasa enema once a day.
10. fosamax 10 mg p.o. once daily.
11. prempro p.o. once daily.
12. serax p.r.n.

the patient has been ask to discontinue zomig in the setting
of coronary artery disease.

discharge follow-up:  with primary care physician, [**last name (namepattern4) **]. [**first name (stitle) 9959**]
[**name (stitle) 9960**], telephone [**2179**].




                          [**first name8 (namepattern2) 870**] [**last name (namepattern1) **], m.d.  [**md number(1) 5219**]

dictated by:[**name8 (md) 4925**]

medquist36

d:  [**2179-2-12**]  13:01
t:  [**2179-2-15**]  17:11
job#:  [**job number **]
"
48,"admission date:  [**2154-3-6**]     discharge date:  [**2154-3-10**]

date of birth:   [**2092-4-14**]     sex:  m

service:

history of present illness:  the patient has a long standing
history of hearing loss in the right side.  evaluation of
this hearing loss by his primary care physician led to an
mri, which revealed a right sided 1.6 cm acoustic neuroma.
he was evaluated by dr. [**last name (stitle) 3878**] in [**hospital **] clinic and the choice
of management was reviewed with the patient.  it was decided
that he would undergo a trans-labyrinthine excision of the
acoustic neuroma.

past medical history:  significant for hypertension and
hypercholesterolemia.

past surgical history:  he is status post left herniorrhaphy.

medications:  cardizem cd 360 mg po q.d., lipitor 5 mg po
q.d., hydrochlorothiazide 25 po q.d.

allergies:  no known drug allergies.

hospital course:  the patient was admitted on [**3-6**] and
underwent an uncomplicated right sided trans-labyrinthine
excision of his right acoustic neuroma.  preservation of the
facial nerve was verified with the use of nerve stimulation
at the end of the case.  the patient tolerated the procedure
well and was recovered in the intensive care unit overnight
without any adverse events.

on postop day one the patient was transferred to the floor.
the remainder of his hospital course was uneventful.
initially he had a mild nystagmus, as well as sensation of
dizziness and mild nausea.  after the ensuing couple of days
the patient's symptoms diminished.  the neurosurgery service
continued to follow the patient.  physical therapy was
consulted to assist the patient with ambulation.

on the day of discharge the patient was doing well, remained
afebrile.  he had adequate oral intake and no dizziness.  he
was discharged to home in stable condition with instructions
to contact dr.[**name2 (ni) 37129**] office to make his follow up
appointments.

discharge medications:  percocet one to two tabs po q 3 to 4
hours prn pain.  colace 100 mg po b.i.d., cardizem cd 360 mg
po q.d., lipitor 5 mg po q.d., hydrochlorothiazide 25 mg po
q.d.

discharge diagnosis:
right acoustic neuroma status post trans-labyrinthine
resection.

condition at discharge:  stable.






                          [**first name11 (name pattern1) **] [**last name (namepattern4) **], m.d.  [**md number(1) 37130**]

dictated by:[**last name (namepattern1) 3801**]

medquist36

d:  [**2154-3-9**]  15:42
t:  [**2154-3-13**]  05:56
job#:  [**job number **]
"
49,"admission date:  [**2109-4-21**]       discharge date:  [**2109-5-3**]

date of birth:   [**2046-6-13**]       sex:  f

service:  acove
history of present illness:  the patient is a 62 year-old
female admitted to the acove service on [**2109-4-21**] after transfer
from the medical intensive care unit.  the patient was initially
admitted to an outside hospital on [**4-16**] for a right total hip
replacement.  postoperatively, the patient was anticoagulated
with lovenox and coumadin secondary to thromboembolic concerns
given her history of deep venous thrombosis, pulmonary embolus
and known anticardiolipin antibody positive.  on postop day
number two several adverse events occurred including the patient
spiking a temperature to greater then 101, having an elevated
white blood cell and an inr, which was noted to be
supratherapeutic.  her creatinine also increased from a baseline
of 1.4 to 3.8 and the patient had become anuric and acidotic.  on
postoperative day number three the patient became transiently
hypotensive and an infection workup was instituted.  at that time
she was given stress dose steroids.  further anticoagulation was
held and the renal team was consulted.  subsequently the patient
was transferred to the [**hospital1 69**] on
postoperative day number four for further management.  prior
to transfer she was given bicarbonate and transfused 3 units
of packed red blood cells.

on the 30th the patient was directly admitted to the intensive
care unit.  at that time she was evaluated by the renal service
who felt that her physiology, urine and phena represented acute
atn and as such hemodialysis was not indicated.  the patient also
had antibiotics tapered to levaquin for treatment of an e-coli
urinary tract infection.  on the 27th the patient was noted to
have a hematocrit drop from 28 to 22 and abdominal pelvic ct
demonstrated a right hip thigh hematoma.  as such the patient was
taken to the operating room by orthopedics dr. [**first name8 (namepattern2) **] [**name (stitle) 1022**] for
exploration and evacuation of the expanding hematoma.  the
patient was transfused 5 units of packed red cells at that time.
she was also noted to hve neurological deficits in the right leg.
it is not clear as to the timing of these deficits.

past medical history:  1.  right hip avascular necrosis
diagnosed by mri with subsequent total hip replacement as
described in the history of present illness.  2.  history of
prior deep venous thrombosis and pulmonary embolism last
approximately five years prior to admission.  3.  systemic
lupus erythematosus.  4.  sjogren.  5.  chronic renal
insufficiency.  6.  peripheral vascular disease.  7.
coronary artery disease status post myocardial infarction,
status post percutaneous transluminal coronary angioplasty.
8.  known anticardiolipin antibody positive.  9.  anemia
thought secondary to chronic renal insufficiency.  10.  total
abdominal hysterectomy.  11.  history of benign prostatic
biopsy.

medications on transfer:  1.  synthroid .125.  2.  protonix
40 mg po q day.  3.  prednisone 60 mg po q day.  4.  sodium
bicarb [**2056**] mg t.i.d.  5.  amphojel 30 cc q.d.  6.  zocor 5
mg po q day.  7.  epogen 3000 units one time per week.  8.
colace 100 mg po b.i.d.  9.  percocet prn.  10.  iron sulfate
325 mg po b.i.d.  11. levaquin 250 mg po q.o.d.  12.  lovenox
30 mg subq b.i.d.  13.  regular insulin sliding scale.  14.
lactulose prn.

allergies:  the patient has reported allergies to penicillin,
sulfa, codeine and imuran.

social history:  the patient lives with her husband.  she has
a remote history of both tobacco and ethanol use
unquantitative.

hospital course on the acove service:  given the patient's renal
failure the decision was made in consultation with the renal
service to hold her lovenox and change over to heparin as there
is little data as to the clearance of lovenox in acute renal
failure and as such could not be appropriately dosed.  during the
transition period to heparin, which was done without a bolus the
patient was again noted to have increasing girth of her right
thigh and an 8 point hematocrit drop.  as such repeat ct scan of
the thigh was done, which showed reaccumulation of the hematoma.
the patient was again evaluated by orthopedics in this setting,
however, since there was no progression of her neurologic
deficits and there was no neurovascular compromise of the leg the
decision was made not to intervene at this time.  instead
anticoagulation was held until the patient was stabilized and the
patient was transfused a total of 3 units of packed red blood
cells.  during this time the patient was also evaluated by the
neurology service for her right sided deficits.  on further
evaluation it was determined that the patient that the patient
has a history of spondylolithiasis. however, this could not
account for all of her symptoms.

consultation with both orthopedics and neurology suggests the
possibility of damage of the nerve at time of initial surgery, as
her nerve was noted to be very superficial in the operative
report during the second operation at the [**hospital1 190**] for evacuation.  it also possible that some
compression of the nerve occurred with her initial hematoma.
after the patient was hemodynamically stable her renal function
was noted to return to baseline and her creatinine fell to 1.1.
as such it was felt that it was safe to reinstitute lovenox in
this patient and to slowly load coumadin.  it was verified with
her primary care physician that indeed the patient is
anticardiolipin antibody positive and as such will require
long term anticoagulation with a goal inr of approximately 3.5.
in this setting coumadin was again started.  on both lovenox and
coumadin the patient was hemodynamically stable with no further
evidence of bleeding for greater then 48 hours.  given the
patient's neurologic deficits evaluation by physical therapy
revealed that the patient would benefit from a rehab facility and
the patient was discharged on hip precautions for three months to
rehab.

discharge medications:  1.  synthroid 0.125 mg po q day.  2.
zocor 5 mg po q.d.  3.  iron sulfate 325 mg po b.i.d.  4.
colace 100 mg po b.i.d.  5.  tylenol 500 mg po q 6.  6.
oxycontin 10 mg po q 12.  7.  aspirin 81 mg po q day.  8.
prednisone 5 mg po q day, which is her baseline dose.  9.
metoprolol 75 mg po t.i.d.  10.  captopril 25 mg po t.i.d.
11.  oxycodone 5 mg po q 6 prn.  12.  lovenox 30 mg subq q 12
until therapeutic inr is met.  13.  coumadin 5 mg po q.h.s.
with goal inr of approximately 3.5.  14.  multivitamin one
tab po q day.

the patient is to be on hip precautions for three months
including no hip flexion with internal rotation.  the patient
is to follow up with dr. [**first name8 (namepattern2) **] [**name (stitle) 1022**] of [**location (un) 86**] orthopedics,
[**telephone/fax (1) 36310**].  at this time emg will be deferred as the patient
is to be anticoagulated and as such the risk of the procedure
would out weigh the benefits of the information gained.  the
patient was discharged to rehab in stable condition.

discharge diagnoses:
1.  status post right total hip replacement with subsequent
hematoma and evacuation with reaccumulation.
2.  anticardiolipin antibody positive.
3.  atn now resolved.

secondary diagnoses:
1.  hypothyroidism.
2.  sjogren.
3.  systemic lupus erythematosus.
4.  right avn.






                            [**name6 (md) **] [**name8 (md) **], m.d.  [**md number(1) 4446**]

dictated by:[**last name (namepattern1) 9348**]
medquist36

d:  [**2109-5-3**]  07:28
t:  [**2109-5-3**]  08:25
job#:  [**job number 42109**]
"
50,"admission date:  [**2124-3-19**]              discharge date:   [**2124-4-4**]


service: medicine

allergies:
penicillins

attending:[**first name3 (lf) 30**]
chief complaint:
s/p fall

major surgical or invasive procedure:
orif l hip
ivc filter placed


history of present illness:
ms. [**known lastname 39618**] is an 82 year old female with history of htn,
melanoma, paf, and nph s/p vp shunt admitted after a fall [**2124-3-19**]
with l hip fracture and bilateral subdural hematomas. no loc,
but did feel dizzy prior to fall. she was admitted to the
neurosurgical icu.
.
incidentally, on cspine and follow up ct scan she was found to
have extensive pleuroparenchymal scarring and traction
bronchiectasis with calcification involving r>l apex which
raised the question of tb, though the patient denied any
shortness of breath, cough, or fever, she did report chills at
night and a 35 lb weight over last year. she noted that she has
had ppds placed in the past and believes that one may have been
positive, however she had never received any treatment. id was
consulted.


past medical history:
nph s/p vp shunt
htn
hypercholesterolemia
osteoporosis
h/o amaurosis fugax
paf
melanoma, on face s/p excision
bilateral sdh hematoma
left hip fracture


social history:
lives at home alone in a retirement community. no alcohol,
tobacco or drug use. she is a retired social worker for
psychiatric patients.

family history:
father has a history of tb.

physical exam:
vs t99.8, bp 112-152/50-60, hr 80-90, rr18-22, o2sat 100% on 2l

gen: elderly appearing female in nad, lying still in bed.
heent: constricted but reactive pupils, dry mm. eomi - but did
not comply entirely with exam.
cv: regular rhythm, nl s1 s2, [**1-25**] holosystolic murmur best heard
at apex.
chest: lungs clear to auscultation bilaterally, no w/r/r
abd: soft, nt, nd, +bs, no hsm appreciated
ext: pneumoboots in place, no c/c/e appreciated. no tenderness
to palpation of bilateral hips.
neuro: a&o x 2. lle with good sensation. both le well perfused.
did not assess strength given recent or and mental status.


pertinent results:
[**2124-3-19**] 09:19am   pt-11.3 ptt-23.9 inr(pt)-1.0
[**2124-3-19**] 09:19am   plt smr-normal plt count-156
[**2124-3-19**] 09:19am   hypochrom-1+ anisocyt-normal poikilocy-normal
macrocyt-normal microcyt-normal polychrom-normal
[**2124-3-19**] 09:19am   neuts-87.1* bands-0 lymphs-9.6* monos-2.9
eos-0.3 basos-0.1
[**2124-3-19**] 09:19am   wbc-12.5* rbc-3.62* hgb-12.1 hct-35.8*
mcv-99* mch-33.3* mchc-33.7 rdw-12.8
[**2124-3-19**] 09:19am   ck-mb-notdone ctropnt-0.07*
[**2124-3-19**] 09:19am   ck(cpk)-53
[**2124-3-19**] 09:19am   estgfr-using this
[**2124-3-19**] 09:19am   glucose-133* urea n-21* creat-0.8 sodium-142
potassium-3.4 chloride-104 total co2-29 anion gap-12
[**2124-3-19**] 09:40am urine  blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0
leuk-neg
[**2124-3-19**] 09:40am urine  color-yellow appear-hazy sp [**last name (un) 155**]-1.019
[**2124-3-19**] 04:45pm   ctropnt-0.04*
.

.
[**3-19**] chest ct: impression:
1) biapical pleural parenchymal scarring, r>l. on the right,
there is traction bronchiectasis but no true cavitation. this
finding remains nonspecific, and could relate to a number of
chronic infectious and inflammatory causes ([**initials (namepattern4) **] [**doctor first name **] or other
granulomatous disease); correlation with clinical picture and
any prior chest cts is recommended, as tb is not excluded.
2) diffuse, peripheral peribronchiolar nodules consistent with
small airways inflammation; this is also very nonspecific
finding with a broad differential including infectious and
inflammatory etiologies
.
[**3-19**] hip film: impression: comminuted intertrochanteric fracture
left hip, with varus and anterior apex angulation.
.

[**3-20**] ct head w/o contrast: impression:
1. thin ""balanced"" bilateral subdural hematomas with minimal
mass effect on the subjacent gyri, and no significant shift of
midline structures. these may be acute-on-chronic.
2. questionable small subarachnoid hemorrhagic component in the
left parietal sulci.
3. ventriculoperitoneal shunt catheter in place.

[**3-20**] echo: the left atrium is elongated. no atrial septal defect
is seen by 2d or color  doppler. there is mild symmetric left
ventricular hypertrophy with normal  cavity size and systolic
function (lvef>55%). regional left ventricular wall  motion is
normal. tissue doppler imaging suggests an increased left
ventricular filling pressure (pcwp>18mmhg). there is no
ventricular septal  defect. right ventricular chamber size and
free wall motion are normal. the  aortic valve leaflets (3) are
mildly thickened. 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 (1+) mitral
regurgitation is seen. the left  ventricular inflow pattern
suggests impaired relaxation. the tricuspid valve  leaflets are
mildly thickened. there is mild pulmonary artery systolic
hypertension. there is no pericardial effusion.

[**3-23**] head ct
1. bilateral acute on chronic subdural convexity hematomas,
moderately increased compared to before; displacement of the
cerebral parenchyma on the left side with partial effacement of
the left lateral ventricle.
2. new subfalcine subdural hematoma - mild to moderate.
3. atherosclerotic disease with calcification involving
bilateral ica with 30-40% stenosis of the origin of the left
ica; moderate stenosis of the right vertebral artery origin;
moderate stenosis of left vertebral artery with no
calcification.
4. decreased blood volume in the left temporal lobe, unclear if
this is due to more proximal cervical ica stenosis. no increase
in mtt to suggest acute infarct.
5. no obvious evidence of cerebral infarct on the present study.
.
[**3-24**] ct head- impression:
1. unchanged mild to moderate acute on chronic subdural
hematomas, left more than right, with mass effect on the left
cerebral hemisphere.
2. marginal increase in the subfalcine hematoma.
3. unchanged 1.1 cm left temporal intraparenchymal hematoma.
4. study moderately limited due to motion artifacts
increasing bilateral subdural hematomas per neuro and neurosurg.
awaiting official rads read.
.

[**3-27**] cxr: ap semi-upright portable chest x-ray: the patient is
status post ventriculoperitoneal placement. the cardiac
silhouette, mediastinal and hilar contours are stable. pulmonary
vascular redistribution and prominence has increased slightly
from prior exam. small bilateral pleural effusions are also
increased. there are no new consolidations. no pneumothorax is
identified. there is a 6mm rounded opacity in the soft tissues
of the right arm which was not previously imaged and is likley
related to the skin.


brief hospital course:
82f with h/o nph s/p vp shunt, paroxysmal afib, htn who was
admitted s/p fall with b/l sdh and l hip fracture.  the patient
was initially observed overnight in the neuro-icu; her sdh was
stable overnight.  ortho performed orif of her l hip fracture on
[**3-21**].  she was transferred to medicine [**2124-3-22**].
.
on [**2124-3-23**] the patient was found to have noted to have new
neurological changes with right sided facial droop and new right
sided weakness. noted to have a 10 point hct drop since her
surgery. developed new rapid afib with hr in the 130's, and bp's
in the 120 range. given lopressor 5mg iv x 2 (no change in hr,
[**month (only) **] sbp). then given dilt 10mg iv with drop in hr to 90's but
also drop in sbp to 90's. stat head ct at that time showed
increase size in the sdh. skull films were taken to evaluate her
vp shunt. she was transferred to the micu.
.
in the micu the patient was tranfused 3 units prbc's.  repeat
head ct [**3-24**] showed a stable sdh since [**3-23**].  she had an ivc
filter placed on [**3-25**] for pe prophylaxis. induced sputum was
negative x1 for afb; the patient was unable to provide further
sputum samples. ms [**first name (titles) 4245**] [**last name (titles) 39619**], however, r sided weakness
and facial droop resolved.  a uti was diagnosed on [**3-24**] and
treatment was instituted with ciprofloxacin. sensitivities
returned on [**3-27**] and antibiotics were changed to bactrim as the e
coli infection was resistant to cipro. she was called out to the
floor on [**2124-3-27**].
.
on the floor, the following issues were addressed:
.
#uti- the patient was found to have a uti.  she was initially
treated with cipro, however, culture revealed growth of e coli,
resistant to cipro but sensitive to bactrim. therefore, her
antibiotics were changed to bactrim.  she was treated with
bactrim ds [**hospital1 **] from [**date range (1) 39620**].  a repeat ua was wnl.  her mental
status markedly improved with treatment of her uti.
.
# ms changes/delerium- the patient was delerious through much of
her hospitalization.  this was thought to be toxic metabolic in
the setting of infection, icu setting, sdh and hip fracture.
she required prn haldoperidol and restraints for safety while in
the icu, these measures were discontinued by the time of her
transfer to the floor.  her mental status markedly improved with
treatment of above, and returned to near her baseline per her
family members at the time of discharge, though she still had
some mild waxing and [**doctor last name 688**] (especially in the early mornings).
her home psychiatrist, dr [**first name8 (namepattern2) **] [**last name (namepattern1) **], was contact[**name (ni) **] and
updated throughout her stay.  her remeron dose was decreased per
dr [**last name (stitle) **] suggestion from 7.5 mg qhs to 3.75 mg qhs.

#sdh- presented with small b/l sdh on [**3-19**], found to have
increased sdh on [**3-23**].  treated with dilantin for seizure
prophylaxis x 1 week after enlargement.  eeg revealed no
evidence of seizures.  followed by neurosurgery and neurology
without intervention. stable at discharge.  she will follow up
with her outpatient neurologist, dr [**last name (stitle) 4887**] ([**hospital1 112**]) after discharge.

.
# [**name (ni) 39621**] pt with history of paf.  she initially had an episode of
afib with rvr in the setting of hct drop from 30 to 20 ([**3-23**]),
but this resolved after resuscitation with blood products.
received total of 3 u prbcs. from [**3-27**] until [**3-31**] the patient had
several episodes of sustained rvr to the 140s (without symptoms,
change in bp or ekg changes).  diltiazem was started and
titrated up; a beta blocker was also added with good control.
tsh was normal. she was not anticoagulated given her recent sdh.
 we did not do a cta to assess for pe as underlying etiology of
recurrent afib as it would not change management (no
anticoagulation in setting of sdh).  at the time of discharge
her rate was well controlled in the 80's x >24hours, with 1-2
brief and self limited episodes of rates of 120.  in general,
the frequency of rvr, duration of episodes and amplitude of hr
were markedly improved.  given the limitations of her bp we were
not able to further uptitrate her nodal agents. the patient was
asymptomatic, hd stable throughout these bursts of tachycardia
without any adverse events such as ekg changes, hypotension or
cp.  given the size of her la, it is unlikely she would stay in
sinus rhythm; she is not currently a candidate for
anticoagulation.  she will follow up with her pcp for possible
further uptitration of her betablocker after discharge.
.
# hip fx: an orif was performed on [**2124-3-21**].  ortho followed the
patient throughout her stay.  an ivc filter was placed for dvt
ppx as the patient was not a candidate for anticoagulation given
her sdh.  physical therapy was started. she will require
extensive pt at discharge.  staples were removed [**4-4**].  she will
follow up with ortho in [**2-20**] weeks.
.
# pleuroparenchymal scarring/traction bronchiectasis at
bilateral apices: pt was aasymptomatic throughout her course.
there is a question of tb infection in the past. ppd negative
this admission. unlikely but possible etiologies include tb,
mac, fungal infection or malignancy. an attempt was made to rule
her out for tb, but given lack of cough and sputum production,
we could not obtain adequate specimens.  she did have one
induced sputum which was negative for afb.  as the patient has
no cough, no hymoptysis, no night sweats and a repeat cxr showed
only mild volume overload, tb precautions were discontinued and
the workup was halted based on low clinical suspicion of active
disease.  an outpatient workup may be considered if respiratory
symptoms develop.
.
# hypercholesterolemia, hypertension, osteoporosis: the patient
was continued on lipitor, hctz, and calcium/vitamin d.
alendronate was restarted at discharge.
.
# code status:dnr/dni


medications on admission:
aggrenox
prilosec
hctz
atenolol
lovastatin
fosamax
remeron
rhinocort
ativan prn


discharge medications:
1. rhinocort aqua 32 mcg/actuation spray, non-aerosol sig: one
(1) spray nasal once a day.
2. cholecalciferol (vitamin d3) 400 unit tablet sig: 2.5 tablets
po daily (daily).
3. atorvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
4. lovastatin 40 mg tablet sig: one (1) tablet po once a day.
5. calcium carbonate 500 mg tablet, chewable sig: one (1)
tablet, chewable po bid (2 times a day).
6. hexavitamin     tablet sig: one (1) cap po daily (daily).
7. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1)
tablet po bid (2 times a day) as needed for uti for 5 days: last
day: [**4-7**].
8. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily
(daily).
9. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h
(every 4 to 6 hours) as needed.
10. diltiazem hcl 240 mg capsule, sustained release sig: two (2)
capsule, sustained release po daily (daily).
11. mirtazapine 15 mg tablet sig: 0.25 tablet po hs (at
bedtime).
12. alendronate 70 mg tablet sig: one (1) tablet po once a week.

13. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: generic okay.
14. metoprolol succinate 50 mg tablet sustained release 24 hr
sig: one (1) tablet sustained release 24 hr po daily (daily).
15. acetaminophen 325 mg tablet sig: two (2) tablet po q6h
(every 6 hours).
16. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg
po twice a day.


discharge disposition:
extended care

facility:
[**location (un) **] - [**location (un) 620**]

discharge diagnosis:
primary:
1. left peritrochanteric hip fracture.
2. bilateral acute on chronic subdural hematoma.
3. aphasia, dysarthria, right facial droop - seizure vs. mass
effect (resolved w/o intervention).
4. e. coli urinary tract infection.
5. atrial fibrillation with rapid ventricular response.
6. diastolic heart failure.
7. malnutrition.
8. blood loss anemia.

secondary:
1. biapical pleural parenchymal scarring.
2. traction bronchiectasis.
3. nph s/p right occipital vps - [**first name4 (namepattern1) **] [**last name (namepattern1) 4887**], md [**hospital1 112**] [**2122**].
4. osteoporosis.
5. hypertension.
6. hypercholesterolemia
7. osteoporosis
8. melanoma




discharge condition:
afebrile and hd stable. rate controlled. pain controlled.


discharge instructions:
during this admission you have been treated for a l hip
fracture, subdural hematomas (bleeding around your brain), a
urinary tract infection and atrial fibrillation.
.
please continue to take all medications as prescribed.
.
please seek immediate medical care if you develop increasnig
pain, confusion, weakness, difficulty speaking, numbness, or any
other concerning symptoms.

followup instructions:
follow up with your pcp within one week of leaving rehab.  call
[**telephone/fax (1) 18377**] for an appointment.  you should discuss whether you
will eventually start anticoagulation for your afib at this
visit.
.
follow up with dr [**last name (stitle) 1005**] (orthopedics) in 3 weeks.  call
([**telephone/fax (1) 2007**] to make this appointment.
.
follow up with your neurologist, dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 4887**], 2-4 weeks.
call for an appointment.



"
51,"admission date:  [**2126-12-29**]              discharge date:   [**2127-1-9**]

date of birth:  [**2056-7-5**]             sex:   m

service: surgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 3223**]
chief complaint:
s/p mva

major surgical or invasive procedure:
exploratory laparotomy with 1 foot small bowel resection
orif of r tibia, r olecranon


history of present illness:
pt is a 70 year old male unrestrained driver, lost control of
vehicle and hit pole travelling at approx 45 mph.  possible loc,
chest struck steering wheel.  c/o facial laceration, right elbow
pain, l hand laceration, diffuse chest pain, r knee swelling.

past medical history:
unknown congenitcal spine abnormality


social history:
noncontributory

family history:
noncontributory

physical exam:
pt [**name (ni) 9830**]3
perrla
heent: midface stable, large through& through lip laceration
chest: crepitus on palpation of l chest with palpable bony
instability. cta
card: rrr
abd: soft, diffusely tender, stable pelvis, rectal neg
ext: lue diffusely tender, decreased rom
l hand lacerated, no visible tendons or deep structures
bilateral knee abrasions


pertinent results:
[**2126-12-29**] 03:00pm   wbc-12.8* rbc-5.13 hgb-15.5 hct-45.1 mcv-88
mch-30.2 mchc-34.4 rdw-13.9
[**2126-12-29**] 03:00pm   asa-neg ethanol-neg acetmnphn-neg
bnzodzpn-neg barbitrt-neg tricyclic-neg
[**2126-12-29**] 03:00pm   amylase-65
[**2126-12-29**] 03:15pm urine  bnzodzpn-neg barbitrt-neg opiates-neg
cocaine-neg amphetmn-neg mthdone-neg
[**2126-12-29**] 05:52pm   hgb-11.1* calchct-33
[**2126-12-29**] 05:52pm   type-art po2-125* pco2-32* ph-7.43 total
co2-22 base xs--1

studies on presentation:

head ct: impression: no mass effect, hemorrhage, or skull
fractures.

c-spine ct: impression: no fractures or dislocations.

ct tls spine:
impression: bilateral spondylolysis l5/s1 without
spondylolisthesis. no evidence of fracture.

ct chest/abd/pelvis:
impression
1. left pneumo- and hemothorax.
2. left-sided pulmonary contusions.
3. multiple left-sided rib fractures and sternal fracture.
4. left-sided subcutaneous emphysema and air around the
pectoralis muscles.
5. small amount of mesenteric stranding likely representing
mesenteric injury and hemorrhage.

ct facial cuts:
impression: nasal fracture. no definite acute fracture. sinus
disease.

xr bilateral ue: findings: two views of the right forearm and a
single view of the left hand show an avulsion fracture of the
olecranon process. there is distraction of approximately 2 cm
between fracture fragments. there is no evidence of dislocation.
no radio- opague foreign bodies are seen. extensive soft tissue
swelling is seen in the right elbow. a minimally displaced
fracture of the sahft of the proximal phalanx of the left thumb
is also seen.

r tib/fib xr:
findings: an oblique minimally displaced right tibial plateau
fracture traverses the knee joint from the lateral tibial
plateau to the metaphysis medially. there is minimal step-off at
the articular surface. no other fractures are seen. associated
lipohemarthrosis is seen.


brief hospital course:
the pt presented to the trauma bay on [**2126-12-29**] by ems. vitals on
presentation were normal and stable.  physical exam and results
of studies obtained on admission are as above.  when the l
hemopneumothorax was noted on cxr, a l chest tube was placed.
orhtopedics was consulted for the tibial plateau and elbow fx.
plastics was consulted for the hand fx.  omfs was consulted for
the nasal fx.  the pt was admitted to the trauma sicu.  plastics
placed the l hand in thumb spica splint and planned on following
up with the pt in clinic.  orthopedics placed the r arm in a
posterior splint and the r knee in an immobilizer with a plan
for operative fixation of injuries the following day.  omfs
repaired the pt's lip laceration and upon review of the facial
ct stated there was no nasal fracture.

while waiting in the emergency department for a trauma sicu bed
to become available, the pt was noted to become tachycardic and
hypotensive to the 80s with a hct drop of 14 points 4 hours
after arrival.  a repeat abdominal ct was obtained showing
evolution of the mesenteric hematoma noted on the initial scan.
the pt was then brought to the or for an emergent exploratory
laparotomy during which a branch of the sma was noted to be
lacerated and was clamped.  a one-foot section of non-viable
small bowel was resected.  post operatively, the pt was
transferred to the trauma sicu still intubated.

the pt did well on the night of [**12-29**] and on [**12-30**] was taken to the
or by othopedics for orif of the right elbow and right tibial
plateau fx.  the pt remained stable until [**1-3**] when he was
extubated.  from [**1-3**] to [**1-5**] the pt was noted to have severl
bloody stools, likely from oozing from his small bowel
anastomosis.  his hct trended downward over this period to 25.
he was given 2 units prbcs on [**1-4**] which increased his hct to
31.5 on [**1-5**].  he was transferred to the floor in the evening of
[**1-5**].  hct remained stable throughout his stay on the floor and
the pt had no adverse events until discharge.

medications on admission:
none

discharge medications:
1. insulin regular human 100 unit/ml solution sig: one (1)
injection asdir (as directed): see sliding scale.
2. acetaminophen 650 mg suppository sig: one (1) suppository
rectal q6h (every 6 hours) as needed.
3. albuterol sulfate 0.083 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed.
4. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
q6h (every 6 hours).
5. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls
po q4-6h (every 4 to 6 hours) as needed.
6. hydralazine hcl 10 mg tablet sig: one (1) tablet po q6h
(every 6 hours).
7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q4-6h (every 4 to 6 hours) as needed.
8. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po bid (2
times a day).
9. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) syringe
subcutaneous q12h (every 12 hours).


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - acute rehab

discharge diagnosis:
r olecranon fx
l hemopneumothorax
l [**1-27**] rib fx with flail chest
mesenteric vessel injury
l 1st metacarpal fx


discharge condition:
improved

discharge instructions:
please take all medications as directed.

return to the er if you develop:
chest pain, shortness of breath, severe nausea or vomiting, high
fever, weakness

followup instructions:
please arrange to follow up with dr. [**last name (stitle) 1005**] from orthopedics
in 2 weeks.  his number is ([**telephone/fax (1) 8746**].  you will need to
arrange to have a pin placed in your elbow.

please follow up with dr. [**last name (stitle) **] from gerontology, your new pcp.
 [**name10 (nameis) **] expects to see you on thursday, [**2-13**] at 3:30 pm.
her address is [**last name (namepattern1) **], [**location (un) 86**], [**location (un) 453**]. please call
ahead to confirm your appointment.


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

"
52,"admission date:  [**2154-12-2**]              discharge date:   [**2155-1-1**]

date of birth:  [**2097-7-11**]             sex:   m

service: surgery

allergies:
lisinopril

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2154-12-2**]:
1. takedown fundoplication from previous mark iv thoracotomy.
2. paraesophageal hernia repair.
3. roux-en-y gastric bypass, open.
4. open cholecystectomy.
5. [**last name (un) **] gastrostomy tube.

[**2154-12-10**]:
1.  central line placement

[**2154-12-10**]:
1. exploratory laparotomy and irrigation of abdominal cavity.
2. placement of drains x3.
3. placement of chest tube, right

[**2154-12-13**]:
1 right-sided pigtail catheter placement


history of present illness:
[**known firstname **] has class iii morbid obesity with weight as of [**2154-4-1**]
304.4 pounds.  his initial screen weight on [**2154-3-20**] was 302.7
pounds and more recent weight recorded through his primary care
office was 293.5 pounds.  his height is 70 inches and his bmi is
42.2. his previous weight loss efforts have included 6 months of
optifast in [**2142**] losing 60 pounds that he maintained for 6
months, 12 weeks [**first name8 (namepattern2) 1446**] [**last name (namepattern1) **] in [**2141**] losing 20 pounds, 26 weeks
of weight watchers in [**2140**] losing 30 pounds and he lost about 25
pounds with 16 weeks of nutrisystem in [**2129**] that he maintained
for about 10 years.  he has not taken prescription weight loss
medications or used over-the-counter ephedra-containing appetite
suppressants/herbal supplements.  his weight at age 21 and was
172 pounds with his lowest adult weight 160 pounds and his
highest weight was 304.4 pounds on [**2154-4-1**].  he weight 281.6
pound in [**10/2147**], 293.4 pounds in [**3-/2149**] and 261 pounds one year
ago.  he states he has been struggling with weight since the age
of 40 and cites as factors contributing to his excess weight
large portions, inconsistent meal pattern, too many saturated
fats, emotional and stressful eating as well as lack of exercise
regimen.  her activity he does walk one hour one to two times
per week.  he denied history of eating disorders and has no
diagnosis of depression however has had anxiety/mood issues that
are weight related, has not seen a therapist nor has he been
hospitalized for mental health issues and he is currently on no
psychotropic medications.


past medical history:
pmh: morbid obesity, fatty liver, sleep apnea, diabetes type ii,
hypertension, severe esophagitis and reflux, mild congestive
heart failure

psh: [**last name (un) 13989**] mark iv in [**2130**], pilonidal cyst, appendectomy in
[**2142**], laminectomy, and abdominoplasty

social history:
he denied tobacco or recreational drug usage, has one to two
glasses of wine twice per week, drinks both caffeinated and
carbonated beverages.  he works as
coo at [**state 350**] biologics and has a very hectic schedule
traveling mostly domestically, lives with his spouse age 48 who
is a professor of business, he has no children

family history:
his family history is noted for father deceased age 73 secondary
to congestive heart failure, copd and thyroid disorder; mother
living in her mid 80s with heart disease s/p cabg x 4, valve
replacement, hypertension, diabetes and overweight; has two
brothers and two sisters living with younger sister borderline
hypertension and one brother with hypertension and a younger
brother with diabetes.

physical exam:
vs: t97.7 hr 95 bp 121/76 rr 20 02 95% ra

constitutional: nad
neuro: alert and oriented to person, place and time
cardiac: rrr, nl s1,s2
lungs: cta bilaterally
abdomen: soft, non-tender to palpation, no rebound
tenderness/guarding
wounds: abd midline incision, open to air, intact, no periwound
erythema, no drainage; jp insertion site without erythema or
drainage; g-tube insertion
ext: no edema


pertinent results:
[**2154-12-2**] ecg: normal sinus rhythm with a-v conduction delay and
left bundle-branch block with secondary st-t wave abnormalities.
compared to the previous tracing of [**2152-10-27**] no diagnostic
interval change

[**2154-12-3**] ecg: sinus rhythm. atrio-ventricular conduction delay.
left atrial abnormality.  left bundle-branch block. compared to
the previous tracing of [**2154-12-2**] the findings are similar

[**2154-12-3**] cxr: impression: ap chest compared to [**7-27**]:
lung volumes are lower and there is a mild-to-moderate degree of
subsegmental atelectasis at both lung bases. upper lungs are
clear. moderate cardiomegaly is stable and there is no good
evidence of pulmonary edema. small left pleural effusion may be
present. no pneumothorax. nasogastric tube passes below the
diaphragm and out of view. likely an epidural catheter
projecting over the midline but course indeterminate \

[**2154-12-4**]:
cta chest w&w/o c&recons, non-; ct abd & pelvis with contrast:
impression:
1. pulmonary embolism in the right superior lobar segmental
artery.
2. bilateral pleural effusions, greater on the right than the
left.
3. small right lower lobe consolidation, likely atelectasis,
although in the proper clinical setting could represent
aspiration or pneumonia.
4. post-surgical air within the mediastinum.
5. small amount of fluid in the lesser sac, likely
postoperative.
6. normal postoperative appearance of roux-en-y without evidence
of leaks or adjacent fluid collections.

[**2154-12-6**]:
unilat up ext veins us right: impression: superficial
thrombophlebitis of the right cephalic vein

[**2154-12-6**]:
bilat lower ext veins: impression: no evidence of lower
extremity dvt

[**2154-12-9**]:
echo: suboptimal image quality. borderline left ventricular
cavity enlargement with extensive systolic dysfunction c/w
multivessel cad or other diffuse process. pulmonary artery
hypertension. compared with the prior study (images reviewed) of
[**2154-4-23**], left ventricular dysfunction is more pronounced c/w
interim ischemia.

[**2154-12-9**]:
ecg: sinus tachycardia with first degree a-v delay. frequent
ventricular premature beats. intraventricular conduction delay
of the left bundle-branch block type. compared to the previous
tracing of [**2154-12-3**] the rate is faster and ventricular ectopy is
new.

[**2154-12-9**]:
chest (portable ap): there is no evidence of pneumothorax on the
current radiograph. bibasilar areas of atelectasis are unchanged
associated with small amount of pleural effusion. infectious
process in the lung bases, in particularly on the right, cannot
be excluded

[**2154-12-9**]:
chest port. line placement: the right internal jugular line tip
is at the level of superior svc. within the limitations of this
extremely lordotic and limited radiograph, no evidence of
complications demonstrated. left upper mediastinal drain is
partially imaged.

[**2154-12-9**]:
ct chest w/contrast; ct abdomen w/contrast: impression:
1. a large collection from the distal esophagus into the upper
mid abdomen
that contains gas bubbles and debris within it, compatible with
an abscess, which is most probably secondary to a leak.
2. enlarging lesser sac fluid collection as described.
3. small fluid collection just anterior to the first part of the
duodenum.
4. small right pneumothorax.
5. right pleural effusion with secondary atelectasis.

[**2154-12-9**]: bas/ugi air/sbft: impression: leak at the
gastrojejunal anastomosis

[**2154-12-11**]: echo: impression:severe global left ventricular
systolic dysfunction with potential regionality

[**2154-12-12**]: echo: impression: mild to moderate global left
ventricular systoilc dysfunction. mild mitral regurgitaiton.
mild pulmonary hypertension. compared with the prior study
(images reviewed) of [**2154-12-11**], biventricular systolic function
has improved.

[**2154-12-13**]: chest port. line placement
new left ij catheter tip is at the confluence of the
brachiocephalic veins.  there is no evident pneumothorax. new
right basal pleural catheter is in place. right pleural effusion
has decreased. there are no other interval changes.

[**2154-12-14**]: ct chest w/contrast; ct abd & pelvis with contrast:
impression: 1. several fluid loculations in the right hemithorax
with complete collapse of the right lower lobe.
2. fluid in the mid abdomen adjacent to the gastroesophageal
junction has
decreased in size since recent washout.
3. poorly defined fluid collection posterior to the stomach has
slightly
increased in size and is not in continuity with any of the
surgical drains.

[**2154-12-16**]: ecg: sinus rhythm. p-r interval prolongation. consider
left atrial abnormality. intraventricular conduction delay of
left bundle-branch block type. since the previous tracing the
rate is somewhat slower. left atrial abnormality pattern is more
recognizable

[**2154-12-18**]: cxr:
findings: orogastric tube ends approximately just below the
level of the
preliminary reportcarina. left internal jugular line terminates
at the mid svc. right chest preliminary reporttube ending at mid
thorax and right basal pigtail catheter present, unchanged
preliminary reportin position. low lung volumes and
mild-to-moderate right pleural effusion preliminary
reportassociated with right lower lung atelectasis is similar.
no pneumothorax.  preliminary reportheart size, mediastinal and
hilar contours are unchanged. no consolidation or preliminary
reportpleural effusion on the left side.

[**2154-12-22**]: chest (portable ap)
impression: ap chest compared to [**12-22**], 4:39 a.m.:
moderate right pleural effusion is smaller. i see only one right
pleural
drain, pigtail catheter unchanged in position at the base of the
right
hemithorax. previous pulmonary edema and mediastinal vascular
engorgement
have also improved. heart size is normal. left lung is clear. no

pneumothorax. left jugular line ends in the upper svc.
nasogastric tube ends just inferior to the level of the left
main bronchus in the upper esophagus

[**2154-12-22**]: chest port. line placement:
a left subclavian picc line is present -- the tip lies at the
svc/ra junction. no pneumothorax is detected. an additional tube
which appears to terminate in the mid mediastinum apparently
represents an enteric tube with tip near the left mainstem
bronchus and sideport near the thoracic inlet. the picc line and
enteric tube findings were discussed by radiology resident, dr.
[**last name (stitle) **] with the iv nurse, [**first name8 (namepattern2) **] [**doctor last name 7830**], at 9:30 a.m. on
[**2154-12-23**].
there is lordotic positioning. the cardiomediastinal silhouette
is probably unchanged. again seen is opacity at the right lung
base likely representing a combination of pleural fluid and
right base collapse and/or consolidation.  there is a small left
effusion, with some patchy retrocardiac density, also probably
unchanged. tube overlying the right lung base on [**2154-12-22**] film
is not visualized on the current film. no pneumothorax is
detected.

[**2154-12-30**]: ugi sgl contrast w/ kub:
impression: no evidence of anastomotic leak or obstruction at
the
gastrojejunostomy.


brief hospital course:
the patient presented to pre-op on [**2154-12-2**]. pt was
evaluated by anaesthesia and taken to the operating room where
he underwent a takedown fundoplication from previous mark iv
thoracotomy, paraesophageal hernia repair, roux-en-y gastric
bypass, open, open cholecystectomy and [**last name (un) **] gastrostomy tube
placement. there were no adverse events in the operating room;
please see the operative note for details.

patient was extubated and taken to the pacu. it should be noted
that patient required an insulin drip intra-operatively to
control persistently high blood glucose levels, which was
continued in the pacu and eventually replaced on post-operative
day 1 with an insulin sliding scale while on the floor at the
direction of [**last name (un) **] who was consulted for diabetes management.
also while in the pacu, the patient was experiencing mild chest
pain. cardiology was consulted and the patient received
nitroglycerin, pr aspirin and metoprolol. no ekg changes were
observed. once stable, the patient was transferred to the
inpatient surgery [**hospital1 **] for further observation.

on pod 1, the patient's oxygen saturation levels dropped to
below 85% after maintaing sats in the 90s on 3l nc, the patient
triggered on the floor and required 5l of continuous oxygen via
face mask to maintain >90% oxygen saturation. the patient denied
shortness of breath, chest pain, palpitations, headache at this
point. a stat cxr was ordered and revealed mild-to-moderate
degree of subsegmental atelectasis at both lung bases with no
evidence of pneumothorax. ekg was unchanged from previous study.
with the lack of any clinical symptoms, volume overload was
suspected as the most likely culprit for the dropping o2 sats.
the patient was continued on 5l face mask overnight. on pod 2,
he was given a dose of lasix and a ct scan was ordered.
following the lasix dose, the patient was weaned from the
facemask to 3l nc, however, the chest ct revealed a right
segmental pulmonary embolism.  subsequently, a heparin gtt was
initiated to maintain ptt 60-80 and eventually transitioned to
therapeutic lovenox.  the patient continued to deny sob or cp
and was weaned from supplemental oxygen and maintained on room
air.

he remained stable on the floor until he reported severe
abdominal pain, chest pain, fever and tachycardia following an
episode of coughing on pod7.  he was subsequently transferred to
the sicu where he was noted to be febrile, tachycardic,
tachypneic and diaphoretic with a stable bp.  also, given
bandemia empiric broad spectrum intravenous antibiotics were
intiated.  a central line was also placed at this time.  an abd/
chest ct and ugi series was suggestive of a large collection
from the distal esophagus into the upper mid abdomen containing
gas bubbles and debris, compatible with an abscess, likely
secondary to leak; also a small right sided pneumothorax was
noted.  given the findings, the patient returned to the
operating room where he underwent an exploratory laparotomy and
irrigation of abdominal cavity, placement of drains x3 and
placement of a right-sided chest tube.  post-operatively, the
patient remained intubated and was transferred back into the
sicu.

neuro: the patient was initially alert and oriented
post-operatively; pain was initially managed with an epidural.
on pod 2, due to findings of a right-sided pulmonary embolism
requiring anticoagulation via heparing gtt, the epidural was
d/c'd and pca was started for pain control.  on pod4, the pain
regimen was transitioned to oral roxicet.  however, on pod7, the
patient was transferred to the sicu and was taken to the
operating room.  post-operatively he remained intubated and
sedated with fentanyl and versed until pod 15/9.  following
extubation, pain was controlled with prn iv hydromorphone and
transitioned to an oral regimen of liquid oxycodone.

cv: vital signs were routinely monitored. the chest pain the
patient experienced immediately post-operatively subsided by pod
1 and did not recur until the patient required transfer to the
icu on pod7 as described above.  an ekg remained unchanged
showing left bundle branch block, a troponin x 1 was negative
and an echo revealed ef 20-25% likely related to demand ischemia
per report. cardiology re-evaluated the patient and felt was
mildly fluid overloaded but that his decompensation was related
to possible anastomotic leak and was not ischemic in nature.
recommendations included gentle diuresis once clinically stable
and daily electrolyte monitoring.  a repeat echo cardiogram was
performed on pod [**8-24**] and [**9-24**] with progressively improved
systolic function (ef 35-40%).  intravenous lasix was resumed on
pod [**10-26**] with goal of negative 1liter daily until shortly before
leaving the icu on pod 20/13. he remained hemodynamically stable
while on the floor and remained on telemetry for monitoring.

pulmonary: on pod2, following an acute desaturation, a right
segmental pe was identified on cta as described above.  he
remained stable from a pulmonary standpoint with a heparing gtt
for anticoagulation until pod7.  on pod7, the patient returned
to the operating room (as described above) and remained
intubated post-operatively.  a chest tube was placed
intra-operatively due to findings of a small pneumothorax
following central line placement. on pod [**10-26**], the patient
underwent thoracentesis with pigtail catheter placement by
interventional pulmonary with drainage of 100 cc purulent fluid.
 an abdominal ct obtained the following day indicated several
fluid loculations in the right hemithorax with complete collapse
of the right lower lobe. on pod 13/6, the patient underwent
bronchoscopy with evidence of mucus plug or excessive
secretions. he was gradually weaned from the ventilator and
extubated on pod 16/9; he was maintained on cpap overnight for
known osa for the remainder of the hospitalization.  the chest
tube output gradually decreased and was removed on pod 14/7.
the pigtail catheter output also decreased gradually and was
removed on pod 20/13. he was on room air and was noted to have
no desaturation on ambulation on pod 21/14. as he was able to
ambulate more and no longer experienced epsiodes of desaturation
and was ambulating on room air without difficulty by pod 25/18.

gi/gu/fen: the patient was initially kept npo, however, his diet
was gradually advanced beginning on pod1 following a negative
abd ct scan and subsequent removal of the ngt.  his diet was
progressively advanced to a stage 3 diet, which was well
tolerated until the episode of coughing with severe abdominal
pain (described above) occured on pod7.  at this time he was
made npo.  a repeat abd ct and ugi series were performed and
indicative of a large collection from the distal esophagus into
the upper mid abdomen most likely from an anastamotic leak at
the ge anastamosis; as described above, the patient was
subsequently taken back to the operating room for an abdominal
washout and placement of 2 additional jp drains.  as the
patient's diet was unable to be advanced, tpn was initiated on
pod [**11-26**]. after ugi study and subsequent methylene blue test
showed no evidence of leak he was started on trophic tube feeds
at 10cc/hr on pod 19/12.  this was advanced slowly and
eventually reached goal rate on pod 26/19. tpn was weaned as the
tf rate increased and eventually disconitnued on pod 24/17.
following a repeat methylene blue dye test (pod 22/15) in
conjuction with minimal drain output, the ngt and jp #2 were
removed on pod 23/16 followed by jp#1 on pod 24/17 as drain
input did not increase.  on pod 28/21, a repeat ugi series
suggested no leak, therefore, the diet was advanced to stage 1,
which was well tolerated.  on pod 29/22, following removal of jp
#3 and a negative repeat methylene blue dye test, the diet was
advanced to stage 3 and tube feedings were discontinued.  the
patient tolerated the diet advancement well.  he will remain on
this diet until outpatient follow-up with dr. [**last name (stitle) **].

id: patient was noted to have low grade fevers in the immediate
post op course and was found to have positive blood cultures,
growing g+ cocci in pairs and clusters on pod [**7-23**] and was
started on vanc/zosyn/fluc. id was consulted and transitioned
him to vanc/[**last name (un) **]/fluc on pod [**8-24**]. his wbc peaked at 12.6 on pod
[**9-24**]. there was concern for hap but his mini bal and sputum were
negative. repeat blood cultures afterwards had no growth. he had
pleural fluid sampled on pod [**9-24**] that grew veillonella species
on placment of a right sided pigtail that returned 100cc of
purulent drainage on insertion. the following day his ct scan
showed that he had a loculated enhancing pleural effusion. he
underwent a bronch on pod [**10-26**] and was weaned to extubation on
pod 13/6. his antibiotics were narrowed to unasyn on pod 17/10
and remained afebrile and without a leukocytosis afterwards.
unasyn was discontinued on pod 29/22 following a negative ugi
series.  the patient subsequently remained afebrile without
leukocytosis.  he was started on nystatin swuch and spit for
presumed thrush on pod 20/13. after the ngt was removed he had
no further issues with pain in his throat.

heme: he required one unit transfusions on pod [**7-23**], pod [**11-26**],
and pod 14/7. otherwise his hematocrit remained stable.

endo: immediately post-operatively, he maintained on an insulin
gtt as described above.  post-operatively, blood sugars were
controlled with a regular insulin sliding scale.  once on a
stage 3 diet, the patient did not require insulin coverage.

prophylaxis: he was maintained on subcutaneous heparin until he
was found to have a pulmonary embolism as mentioned above, at
which point he was transitioned to a heparin drip, with goal ptt
of 60-80. he was maintained on this until 23/16 when he was
tranistioned to lovenox. hematology recommended 1 mg/kg
therapeutic dosing with anticoagulation for 6 months.  a factor
xa was therapeutic at the time of discharge.  the patient will
follow-up with hematology in [**3-3**].  additionally, wore pneumatic
boots throughout this hospitalization.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received extensive discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
acyclovir 400 mg daily prn
albuterol ih prn
amlodipine 10 mg daily
chlorthalidone 25 mg daily
fluticasone 50 mcg 2 sprays [**hospital1 **]
losartan 100 mg daily
metformin 1000 mg [**hospital1 **]
metoprolol succinate 50 mg daily
pantoprazole 40 mg daily
potassium kcl 10 meq daily
sildenafil 100 mg daily prn
simvastatin 20 mg daily
vitamin d3 1000 units daily
mvi w/ minerals 1 tablet daily


discharge medications:
1. enoxaparin 120 mg/0.8 ml syringe [**hospital1 **]: one (1) syringe
subcutaneous [**hospital1 **] (2 times a day).
disp:*60 syringe* refills:*2*
2. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1)
tablet,rapid dissolve, dr [**last name (stitle) **] once a day.
disp:*30 tablet,rapid dissolve, dr(s)* refills:*0*
3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler [**last name (stitle) **]:
1-2 puffs inhalation every six (6) hours as needed for shortness
of breath or wheezing.
4. insulin regular human 100 unit/ml solution [**last name (stitle) **]: 2-10 units
injection four times a day as needed for refer to sliding scale:
sliding scale:101-150-0 units; 151-200-0 units; 201-250-2
units;251-300-4 units;301-350-6 units;351-400-8 units; >400-10
units.
disp:*1 vial* refills:*2*
5. oxycodone 5 mg/5 ml solution [**last name (stitle) **]: [**5-1**] ml po every 4-6 hours
as needed for pain: administer via g-tube; flush w/ 30 ml water
before and after administration.
disp:*300 ml* refills:*0*
6. docusate sodium 50 mg/5 ml liquid [**month/year (2) **]: ten (10) ml po bid (2
times a day) as needed for constipation: administer via g-tube;
flush w/ 30 ml water before and after administration.
disp:*300 ml* refills:*0*
7. lorazepam 0.5 mg tablet [**month/year (2) **]: one (1) tablet po every twelve
(12) hours as needed for anxiety: sublingual; do not combine
with oxycodone.
disp:*10 tablet(s)* refills:*0*
8. insulin syringe-needle u-100 1 ml 25 x 1  syringe [**month/year (2) **]: one
(1) syringe miscellaneous four times a day as needed for refer
to sliding scale.
disp:*1 box* refills:*2*
9. multivitamin with minerals     tablet [**month/year (2) **]: one (1) tablet po
once a day: chewable only; no gummy.


discharge disposition:
home with service

facility:
[**hospital3 **] [**doctor last name **]

discharge diagnosis:
1. sepsis.
2. pneumothorax.
3. gastrointestinal leak.
4. recurrent hiatal hernia with obstruction.
5. cholelithiasis.
6. obesity.
7. fatty liver.
8. type 2 diabetes.
9. severe reflux esophagitis.
10. sleep apnea.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
100.7, chills, chest pain, shortness of breath, severe abdominal
pain, pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stage 3 diet; do not self-advance

medication instructions:
you will be starting some new medications:
1.  lovenox: 120 mcg subcutaneous injection, twice daily
2.  lorazepam sublingual: 0.5 mg twice daily as needed for
anxiety.  do not take with oxycodone.
3.  prevacid sublingual: 30 mg tablet daily.  this medication is
being prescribed in place of pantoprazole (protonix) as
pantoprazole cannot be crushed.
4.  regular insulin sliding scale: please check your blood
sugars four times daily and adhere to the provided sliding scale
to determine dosage of insulin.  your will not require insulin
if your blood sugar is less than 200 mg/dl.
1.  you are being discharged on medications to treat the pain
(liquid oxycodone) from your operation. this medications will
make you drowsy and impair your ability to drive a motor vehicle
or operate machinery safely. you must refrain from such
activities while taking these medications. also, do not combine
with lorazepam (ativan).
2. you should begin taking a complete multivitamin with
minerals, crushed and administered via your g-tube. no gummy
vitamins.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-6**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: orthopedics
when: tuesday [**2155-1-7**] at 9:40 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: orthopedics
when: tuesday [**2155-1-7**] at 10:00 am
with: hand clinic [**telephone/fax (1) 3009**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 551**]
campus: east     best parking: [**hospital ward name 23**] garage

department: [**last name (un) **] diabetes center
when: tuesday [**2155-1-7**] at 0830 am
with: [**first name8 (namepattern2) **] [**doctor last name **], n.p. [**telephone/fax (1) 2384**]

department: bariatric surgery
when: wednesday [**2155-1-15**] at 4:00 pm
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2155-1-15**] at 4:30 pm
with: [**first name4 (namepattern1) **] [**last name (namepattern1) **], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: [**hospital3 249**]
when: friday [**2155-1-31**] at 10:20 am
with: [**first name11 (name pattern1) 569**] [**last name (namepattern4) 12637**], m.d. [**telephone/fax (1) 250**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 895**]
campus: east     best parking: [**hospital ward name 23**] garage

department: hematology/oncology
when: friday [**2155-2-28**] at 10:30 am
with: [**first name4 (namepattern1) 569**] [**last name (namepattern1) **], 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: friday [**2155-2-28**] at 10:30 am
with: [**first name8 (namepattern2) 25**] [**last name (namepattern1) **], md [**telephone/fax (1) 22**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2155-1-1**]"
53,"unit no:  [**numeric identifier 44622**]
admission date: [**2113-4-17**]
discharge date: [**2113-4-24**]
date of birth:  [**2091-7-11**]
sex:  m
service:


history of present illness:  the patient is a 21-year-old
male with a history of end-stage renal disease (on
hemodialysis) secondary to reflux nephropathy, and focal
segmental glomerulosclerosis who presented with fevers to 102
and a facial rash.

initially, he had a temperature of 100.6 at [**location (un) 4265**]
hemodialysis unit on [**2113-3-27**].  there, he received
vancomycin which was complicated by red man syndrome.  this
consisted of a fever and rash from the forehead down to his
waistline.  he was given benadryl and tylenol and sent home.

he received hemodialysis on [**2113-4-12**] uneventfully.  at
hemodialysis on [**2113-4-14**] he had a temperature to 102.7.
blood cultures were taken from his hemodialysis line.  he was
given 1 gram of kefzol and referred to the emergency
department.

in the emergency department, a chest x-ray showed no
pneumonia.  laboratories with a white blood cell count of
5.4.  urinalysis had small leukocyte esterase, but no
nitrites.  therefore, he was started empirically on
ciprofloxacin 500 mg twice per day times seven days for a
possible urinary tract infection.  urine culture ultimately
returned negative.  he began taking ciprofloxacin in the
morning of [**2113-4-15**].  he woke up on [**2113-4-16**] with
""dots"" all over and pruritus.  he took his last dose of
ciprofloxacin on [**2113-4-16**] in the evening.  his rash was
not relieved with benadryl or tylenol, so he came to the
emergency department for further evaluation.

in the emergency department - on [**2113-4-17**] - he was
noted to have a temperature of 98.8, his blood pressure was
128/64, his pulse was 98, his respiratory rate was 16, and
his oxygen saturation was 100 percent on room air.  in the
emergency department, he was pan-cultured and given one dose
of vancomycin intravenously and ceftriaxone intravenously.
laboratories at that time showed a potassium of 6.3 with
questionable peaked t waves on his electrocardiogram.
therefore, he also received calcium gluconate 1 gram, 10
units of regular insulin, 1 ampule of dextrose, 1 ampule of
bicarbonate, and kayexalate 60 grams.  before leaving to the
emergency department, he spiked a temperature to 103.6.
therefore, tylenol was given.

of note,  he had a recent admission in [**month (only) 956**] after two
generalized tonic-clonic seizures.  at that time he was
started on dilantin.  also during that admission, he
completed a 3-day course of ciprofloxacin for a urine culture
that grew out acinetobacter.

during this admission, review of systems was significant for
fevers, sore throat, and generalized malaise.  he denied any
rigors, night sweats, or weight loss.  he denied chest pain,
shortness of breath, palpitations, orthopnea, or paroxysmal
nocturnal dyspnea.  there was no cough, wheezing, or
hemoptysis.  there was no dysuria, abdominal pain, or
suprapubic tenderness.  no nausea, vomiting, diarrhea, or
constipation.  no recent travel.  no recent medication
changes.  no outdoor activities or camping.  no recent
vaccinations.  no pets or tic exposures.  no recent sexual
contacts other than his longtime girlfriend with whom he is
in a monogamous relationship.

past medical history:  end-stage renal disease (on
hemodialysis) secondary reflux, nephropathy, and focal
segmental glomerulosclerosis.  he is dialyzed on monday,
wednesday, and friday.  he started hemodialysis on [**2113-3-1**].  reflux nephropathy resulted in recurrent ascending
escherichia coli infections.  he is status post placement of
a right subclavian perm-a-cath on [**2113-3-15**] and an
arteriovenous fistula was placed on [**2113-3-17**].

spina bifida; status post repair as an infant - complicated
by bowel and bladder incontinence, with a history of straight
catheterization three times daily - complicated by numbness
in the soles of the feet and backs of both thighs as well as
left foot weakness and hyperreflexive bilateral lower
extremities.

newly diagnosed seizure disorder on [**2113-3-14**] for two
generalized tonic-clonic seizures - started on dilantin on
[**2113-3-26**].  seizures characterized by initial head
deviation toward to the right followed by generalized tonic-
clonic movements.  his first seizure on [**2113-3-14**] was
felt to be secondary to hypercalcemia in the setting of a
calcium level of 6.  his second seizure took place on
[**2113-3-26**] and was felt to be idiopathic.  at that
time, he was loaded on dilatation 300 mg three times per day.
he erroneously continued on dilantin 300 mg three times per
day until a follow-up appointment on [**2113-4-6**].  at that
time, he was switched to a regimen of 300 mg in the morning
and 200 mg in the evening.

hypoparathyroidism.

history of multiple urinary tract infections; last diagnosed
in [**2113-2-26**] and treated with ciprofloxacin.

anemia of chronic disease.

allergies:  the patient reports no known drug allergies.

medications prior to admission:
1. dilantin 300 mg by mouth in the morning alternating with
   200 mg by mouth in the evening.
2. lisinopril 10 mg by mouth once per day.
3. epogen subcutaneously every week.
4. sodium bicarbonate tablets four tablets by mouth twice per
   day.
5. oxybutynin 5 mg by mouth twice per day.
6. tums 500 mg by mouth three times per day.
7. calcitriol at each hemodialysis session.
8. nephrocaps once per day.


social history:  the patient is a sophomore at [**university/college 5130**]
[**location (un) **].  he lives in a dormitory.  he is originally from
[**location (un) 17004**], [**state 531**].  he denies any tobacco or illicit drug use,
but he reports occasional social alcohol intake.  he is in a
monogamous sexual relationship with a longstanding
girlfriend.

family history:  the patient reports no family history of
seizures or kidney disease.

physical examination on presentation:  generally, this was
well-developed, well-nourished, thin, young male.  he was
uncomfortable and ill-appearing, but nontoxic.  vital signs
revealed his temperature was 99.8, his blood pressure was
128/64, his heart rate was 98, his respiratory rate was 16,
and his oxygen saturation was 100 percent on room air.  head
and neck examination was remarkable for normocephalic and
atraumatic.  the pupils were equal, round, and reactive to
light.  the mucous membranes were moist.  the posterior
oropharynx was erythematous, but there were no lesions
exudates.  the neck was supple with no masses or
lymphadenopathy.  the chest wall had hemodialysis catheter
site bandaged with no evidence of edema, fluctuance or
purulent discharge.  the lungs were clear to auscultation
bilaterally.  there were no rhonchi, rales, or wheezes.
cardiovascular examination revealed a regular rate and rhythm
with normal first and second heart sounds auscultated.  there
were no murmurs, rubs, or gallops.  the abdomen was soft,
nontender, and nondistended.  there were positive normal
active bowel sounds.  there was no hepatosplenomegaly.
examination of the back revealed no spinal or costovertebral
angle tenderness.  the extremities were warm and well
perfused.  there was no clubbing, cyanosis, or edema.  the
left forearm arteriovenous fistula had some serous drainage;
but no erythema, edema, or fluctuance.  a bruit was
auscultated over the arteriovenous fistula.  his skin
demonstrated erythematous, raised, maculopapular rash
diffusely, but concentrated mostly on the face, abdomen,
extremities, palms, and soles.  the lesions were
approximately 1 cm in diameter.  on the face, the eyelids
were spared.  otherwise, the rash was confluent, pruritic,
blanching, nonconfluent on the body with a questionable
appearance of wheels.  there were no bullae formation.  no
target lesions.  the skin examination was also remarkable for
a tuft of hair on his back and a scar overlying his previous
spina bifida surgery site.  neurologically, he was alert and
oriented times three with no tremor or asterixis.

pertinent laboratory values on presentation:  a complete
blood count on admission revealed his white blood cell count
was 5.1 (with 61 percent neutrophils, 26 percent lymphocytes,
5 percent monocytes, 7.2 percent eosinophils - 2.9 percent on
[**2113-3-26**] - and 0.5 percent basophils), his
hematocrit was 41.6, and his platelets were 194.  chemistries
showed his sodium was 138, potassium was 6.3, chloride was
95, bicarbonate was 27, blood urea nitrogen was 58,
creatinine was 13.5, and his blood glucose was 87.  his
calcium was 10.6, his phosphorous was 4.4, and his magnesium
was 2.5.  coagulation profile revealed his prothrombin time
was 12.7, his partial thromboplastin time was 26.4, and his
inr was 1.1.  hemolysis studies on [**2113-4-18**] showed a
haptoglobin of 87, his fibrinogen was 253, and his d-dimer
was elevated at 2274.  an additional workup for his rash and
fever revealed a throat swab with culture negative for beta
streptococcal infection.  stool culture was negative.  mono
spot was negative.  aso titer from [**4-19**] demonstrated a
positive aso screen with a titer positive to 200 to 400.
rapid plasma reagin nonreactive.  [**doctor last name 3271**]-[**doctor last name **] virus titer
showed the patient to be igg positive and igm negative.
urine culture from [**2113-4-14**] was also negative for
growth.

brief summary of hospital course:  fever issues:  a concern
over line source of fevers in the emergency department, the
patient received a vancomycin.  he was started on ceftriaxone
for gram-negative coverage given his history of multiple
urinary tract infections and a history of straight
catheterization use.  prior to antibiotic initiation, he was
pan-cultured.  on the night of admission, he spiked a
temperature to 103.7 which decreased to 101.5 with tylenol.

on the morning of [**2113-4-18**] he went to hemodialysis and
there spiked a temperature to 105.  he was cultured from his
hemodialysis line and sent back to the general medicine
floor.  as the fever started after hemodialysis sessions and
appeared to worsen with accessing his hemodialysis line, the
interventional radiology service was contact[**name (ni) **] for removal of
the patient's tunnel catheter.  initially, the interventional
radiology service did not feel the catheter needed to be
removed.  thereafter, the patient himself refused removal.
later on the day of [**2113-4-18**] he was dialyzed via his
arteriovenous fistula with no adverse events.

he was seen in consultation by the infectious disease service
who recommended holding vancomycin, ciprofloxacin, and
dilantin.  an exhaustive workup; including pan cultures,
liver function tests, mono spot, cytomegalovirus, [**doctor last name 3271**]-
[**doctor last name **] virus, mycoplasma, and titers, rapid plasma reagin, aso,
throat swab, antineutrophil cytoplasmic antibody, rheumatoid
factor, and sedimentation rate was initiated out of concern
for drug fevers, viral infection, line infection, vasculitis,
toxic shock syndrome, primary human immunodeficiency virus
infection.

the patient was covered initially with aztreonam after he
spiked a fever to 107.3 in the setting of a normal blood
pressure of 140/90 and a heart rate of 120.  in addition to
aztreonam during this temperature spike he also received 1
gram of tylenol and benadryl.  he was moved from the floor to
the medical intensive care unit for further monitoring.

out of continued concern for a line infection in spite of
negative culture data, the patient's tunneled port-a-cath was
removed on [**2113-4-19**].  he continued to have dialysis and
was dialyzed on [**2113-4-20**] through his arteriovenous
fistula.  about one hour into that hemodialysis session, he
had rigors.  there was some question of whether his fevers
and rigors could be secondary to a membrane issue.

as all of the patient's culture data was negative, and his
fevers subsided status post discontinuation of vancomycin and
dilantin, it was felt that his fevers were most likely
secondary to an acute drug reaction.  it is therefore
recommended that he avoid exposure to vancomycin and dilantin
in the future.

rash issues:  it was unclear whether the patient's rash was
drug related versus infectious in etiology.  the onset
occurred after therapy with ciprofloxacin and had an
urticaria appearance and peripheral eosinophilia which was
suggestive of a drug related process.  however, in light of
the high fevers ________ was maintained for infectious
sources as well.

an exhaustive workup (as outlined above) was undertaken in
order to help delineate the source of the patient's fevers.
an infectious workup was negative.  for symptoms, he was
continued on benadryl and an h2 blocker to decrease histamine
release.  he was not initially treated with steroids out of
concern for infection.

on [**2113-4-18**] he was noted to have cracking and peeling
as well as a edema of his lips and a question ulcerative
lesion in his oropharynx and conjunctivae.  this was
concerning for [**doctor last name **]-[**location (un) **] syndrome.  he was seen in
consultation by the dermatology, infectious disease, and
ophthalmology services.  ophthalmology saw only mild
conjunctivitis on their examination and recommended
artificial tears and lacri-lube.  per dermatology, the likely
culprits for the patient's rash included vancomycin and
dilantin.  however, there was really no way to delineate
which of these two agents were the cause of this.  with
conservative and symptomatic therapy, the patient's rash
improved.

end-stage renal disease issues:  on the day of his admission,
the patient had discontinuation of his tunneled port-a-cath.
he started hemodialysis via an arteriovenous fistula.  he
tolerated this well with the exception of intermittent fever
spikes.  he was continued on nephrocaps, calcium acetate,
epogen, and calcitriol per the renal team.

seizure disorder issues:  in light of the suspicion of
dilantin as an etiologic [**doctor last name 360**] for the patient's fevers and
rash, dilantin was discontinued.  he was monitored closely in
the setting of fevers due to the fact that fevers can
decrease seizure threshold.  he was started on gabapentin
after consultation with the neurology service.  outpatient
neurology followup was arranged as well.

code status issues:  the patient was a full code.

condition on discharge:  good - afebrile times 36 hours and
hemodynamically stable.  dilantin and vancomycin levels were
trending down.  skin rash was improving.  all culture data
was negative for acute infection.

discharge status:  the patient was discharged to home.

discharge diagnoses:  drug fever and reaction secondary to
vancomycin or dilantin.

end-stage renal disease (on hemodialysis).

history of recurrent urinary tract infections.

history of a seizure disorder.

history of spina bifida; status post surgical repair.

bowel and bladder incontinence.

anemia of chronic disease.

medications on discharge:
1. gabapentin 300 mg by mouth at hour of sleep.
2. lisinopril 20 mg by mouth once per day.
3. epogen injections subcutaneously at hemodialysis.
4. oxybutynin 5 mg by mouth twice per day.
5. calcium acetate 670 mg two tablets by mouth three times
   per day (with meals).
6. nephrocaps one capsule by mouth every day.
7. artificial tears 1 drop each eye q.2h.
8. lacri-lube one application each eye at hour of sleep.
9. benadryl 25 mg one capsule by mouth q.4-6h. as needed (for
   itching).
10.      calcitriol.


follow-up plans:  the patient was instructed to call his
primary care physician or visit [**name initial (pre) **] local emergency room if he
experienced recurrent fevers, shaking chills, headaches,
chest pain, confusion, recurrent skin rash, or any other
worrisome symptoms.  he was instructed if he feels fevers and
rash, the most likely reaction was medications; however, we
could not ascertain whether the reaction was due to dilantin
or vancomycin.  we strongly suggested that he absolutely
avoid both of these agents in the future.  he was instructed
to discontinue his dilantin and sodium bicarbonate.

additionally, he had follow-up appointments with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] in the neurology department on [**2113-6-6**].  he was
instructed to call both dr. [**last name (stitle) 44623**] and dr. [**last name (stitle) **] from the
renal division for follow-up appointments after discharge.


                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 20314**]

dictated by:[**last name (namepattern1) 14378**]
medquist36
d:  [**2113-7-6**] 16:30:22
t:  [**2113-7-6**] 22:13:09
job#:  [**job number 44624**]

cc:[**last name (namepattern1) 44625**]



"
54,"admission date:  [**2130-10-16**]       discharge date:  [**2130-10-24**]


service:  ccu

history of present illness:  this is an 83-year-old white
male with history of coronary artery disease status post
coronary artery bypass graft times three vessels in [**2121**], end
stage renal disease on hemodialysis three times a week,
diabetes mellitus and hypertension transferred from [**hospital 1474**]
hospital for cardiac catheterization.

the patient initially presented to [**hospital 1474**] hospital with
complaints of increased dyspnea on exertion, weakness and
dizziness.  in the emergency department their he was found to
have new ekg changes, new t wave depressions in v2 through v3
and more depressed t wave depressions in v4 through v6 and
atrial fibrillation.  the patient was ruled out for mi by
serial enzymes, although he did have an initial ck mb index
of 3.2 and had an echocardiogram which showed lv enlargement
with akinesis of the inferior and posterior walls.  also with
hypokinesis of other lv walls and ejection fraction of 30%,
mitral tricuspid regurgitation with a pulmonary artery
systolic pressure of 45 mg of mercury, mild mr with
significant left atrial enlargement.  patient then had a
persantine mibi which showed a small lateral wall ischemia
and small inferior wall infarct.

decision was then made to transfer to [**hospital1 190**] for cardiac catheterization.  cardiac
catheterization showed a pulmonary capillary wedge pressure
of 22 mg of mercury, right atrial pressure of 25 mg of
mercury, pa pressure of 46/17, right ventricular pressure
48/9.  a totally occluded lad with positive collateral flow,
70% stenosis of the left circumflex.  the svg to om graft was
totally occluded.  svg to dm graft was patent and lima to lad
graft was patent.  overall severe three vessel disease.  two
out three grafts had moderately decreased left ventricular
ejection fraction of 40%, moderate mitral regurgitation and
moderately diffuse hypokinesis.

during the procedure, the patient became hypertensive with a
210/110 and intravenous prior to nitroglycerin was started.
patient also had flash pulmonary edema after a
................. load of about 500 cc and was electively
intubated for increased shortness of breath and agitation.
the patient was then transferred to the ccu for nipride wean
and extubation.

medications on transfer:
1.  tylenol p.r.n.
2.  ambien p.r.n.
3.  metoprolol 25 mg p.o. b.i.d.
4.  captopril 6.25 mg p.o. t.i.d.
5.  ec-asa 325 mg p.o. q.d.
6.  coumadin 5 mg h.s. then 2 mg h.s.
7.  nitroglycerin drip 0.052.2 mcg per kilogram per minute.
8.  nephrocaps one cap p.o. q.d.
9.  regular insulin sliding scale.
10. glipizide xl 10 mg p.o. q.d.
11. propofol drip.

past medical history:
1.  coronary artery disease status post coronary artery
bypass graft for three vessels in [**2121**].
2.  end stage renal disease on hemodialysis on tuesday,
thursday and saturday.
3.  hypertension.
4.  diabetes mellitus.
5.  anemia.
6.  prostate ca.
7.  new onset atrial fibrillation.

social history:  not obtainable.

family history:  not obtainable.

initial ekg showed atrial fibrillation at 65 beats per
minute, normal axis, qrs mildly elongated, left ventricular
hypertrophy by voltage, t wave inversions in v2 through v5,
st depressions in i and l, unchanged from outside hospital
ekgs.

physical examination:  vital signs with a temperature of 97.6
f, blood pressure 106/45, heart rate 68.  pulmonary artery
pressure 37/11.  in general elderly, sedated, intubated male
lying still in bed.  head, eyes, ears, nose and throat:
normocephalic, atraumatic.  pupils are 2 mm bilaterally,
equal, round, reactive to light.  endotracheal tube in place.
neck:  no jugular venous distention.  cardiovascular:  iv/vi
systolic murmur loudest at the apex radiating to the axilla
into the back, irregular.  pulmonary:  loud bronchial sounds
bilaterally.  abdomen:  soft, nondistended with normal
abdominal bowel sounds, no hepatosplenomegaly.  positive
abdominal bruit.  extremities:  warm, no edema, no hematoma
at right groin.  neuro:  patient sedated.  withdraws from
touching of feet.

initial laboratory results:  white blood cell count of 5.7,
hematocrit 32.7, platelets 134.  differential was 72.4%
neutrophils, 18.2% lymphocytes, 8.2% monocytes, 1.0%
eosinophils, 0.2% basophil.  inr was 1.3. potassium 5.5,
calcium 8.3, magnesium 2.7, phosphorus was 9.7.

abg done was 7.45, 73 and 345 on 100% oxygen.

initial assessment:  this is an 83-year-old male with history
of coronary artery disease, diabetes mellitus, end stage
renal disease on hemodialysis transferred from outside
hospital for cardiac catheterization secondary to abnormal p
mibi with dyspnea and hypertension in cath lab.  started on
nipride and nitroglycerin drips, intubated and electively
transferred to ccu for extubation and drip weaning.

hospital course:
1.  cardiac:  patient is being kept on the nitroglycerin drip
throughout the entire course when he was on the ventilator
and it was discontinued once he had been weaned.  the patient
was started on imdur 50 mg p.o. q.d. for approximately six
hours prior to stopping the nitroglycerin drip with no ill
effects.

patient was noted to have a moderately decreased left
ventricular ejection fraction of 30 to 40%.  the patient was
started on an ace inhibitor and was gradually titrated up,
however two days into ace inhibitor therapy with captopril,
the patient developed an erythematous rash which was
pruritic.  at this point, it was assumed that the rash was
secondary to the sulfur group of the captopril and patient
was switched to lisinopril 40 p.o. q.d. with eventual
clearing of rash and no other ill effects.

the patient was switched over from nitroglycerin drip to
imdur with no ill effects.  patient remained moderately
hypertensive throughout the hospital course with blood
pressures up to 160 mg of mercury systolic were tolerated as
this patient is on hemodialysis.

2.  rhythm:  patient was noted to have new onset atrial
fibrillation.  patient was maintained on telemetry and had
frequent episodes of nonsustained ventricular tachycardia as
well as ventricular tachycardia throughout the first two days
of hospitalization with gradual clearing of these.  the
patient was tried on a beta blocker and pr prolongation was
noted.  at this point, the beta blocker was discontinued and
patient had a pacemaker placed so that he would be able to
tolerate amiodarone therapy.

patient had a dual chamber rate responsive pacemaker placed
and was started on amiodarone loading 400 mg p.o. b.i.d.  at
pacemaker placement, the patient received a dose of
vancomycin.  the patient tolerated the pacemaker placement
and was kept on telemetry for 24 hours after pacemaker was
placed with no adverse events noted.

the patient was also restarted on coumadin for
anticoagulation after pacemaker placement.  the decision of
how long to continue coumadin will be left up to the pcp.
[**name10 (nameis) **] patient's amiodarone loading should be 400 mg p.o. b.i.d.
times one week then 400 mg p.o. q.d. times one week and then
200 mg p.o. q.d.  the patient should be seen at [**hospital **]
clinic in one week.

3.  coronaries:  patient with status post coronary artery
bypass graft in [**2121**], lima to lad, svg to lpda, and svg to om
which is totally occluded, 70% stenotic lesion in mid
circumflex.  patient was started on lipitor 10 mg p.o. q.d.
and was kept on aspirin throughout hospital course.  the
patient should continue to take these two drugs indefinitely.


4.  pulmonary:  patient had an initial weaning trial
approximately 12 hours after admission to the ccu.  the
patient became tachypneic as he was initially weaned from the
ventilator and it was decided to rest him for another day.
the patient was switched over to pressure support and
successfully weaned on hospital day #2.  the patient
initially required oxygen, but soon was able to tolerate room
air with o2 saturations of 95% and above.  there were no
further pulmonary issues in the hospital course.

5.  renal:  patient was continued on hemodialysis throughout
hospital course and initially started on amphojel and phos-lo
as patient had increased phosphorus on presentation.
eventually, amphojel was able to be discontinued after four
hospital days as per renal's recommendation.  patient to
continue hemodialysis as an outpatient on tuesdays, thursdays
and sundays.

6.  endocrine:  the patient was noted to become hypoglycemic
with blood sugars as low as 48.  patient had his glipizide
discontinued and had some hypoglycemia for one day after
discontinuation and subsequently high blood sugars of 160s to
200s while continuing regular insulin sliding scale.  it was
decided to reinitiate glipizide at a lower dose of 2.5 mg
q.d. and further watch for hypoglycemia as an outpatient.

7.  dermatologic:  patient developed an erythematous
maculopapular and some areas ................ pruritic rash
over the trunk and upper thighs and back on day #2 of
captopril.  a dermatology consult was called and a skin
biopsy was performed.  the patient was switched from
captopril to lisinopril.  skin biopsy confirmed a lymphocytic
infiltrate with rare eosinophils, focal rbc extravasation
consistent with systemic hypersensitivity reaction, no
leukocytoclastic vasculitis was seen.

the patient's rash eventually cleared, although not
completely after lisinopril was initiated.  the patient was
given sarna lotion, [**doctor first name **] and benadryl p.r.n. for itching
with moderate effect.

8.  prophylaxis:  patient received aspirin, lipitor, coumadin
and protonix for gi prophylaxis during hospital course.

discharge diagnosis:
1.  new onset atrial fibrillation status post dual chamber
pacemaker placement, initiation of amiodarone therapy.
2.  coronary artery disease.
3.  end stage renal disease on hemodialysis tuesday, thursday
and saturday.
4.  hypertension.
5.  diabetes mellitus type 2.
6.  anemia.
7.  prostate ca.

discharge medications:
1.  warfarin 2 mg p.o. q.h.s.
2.  amiodarone 400 mg p.o. b.i.d. times seven days started
[**2130-10-23**] then 400 mg p.o. q.d. times seven days then
200 mg p.o. q.d.
3.  lisinopril 40 mg p.o. q.d.
4.  imdur 60 mg p.o. q.d.
5.  lipitor 10 mg p.o. q.h.s.
6.  enteric coated aspirin 325 mg p.o. q.d.
7.  benadryl 25 mg p.o. q. six hours p.r.n.
8.  docusate 100 mg p.o. b.i.d.
9.  [**doctor first name **] 60 mg p.o. b.i.d.
10. sarna tp p.r.n.
11. phos-lo three caps p.o. t.i.d.
12. [**doctor last name **] two tabs p.o. b.i.d. p.r.n.

condition on discharge:  good.

discharge status:  to short term rehab.  patient to follow up
with own cardiologist to arrange pulmonary function test as
patient is now being started on amiodarone and also to follow
up tsh and lfts.




                            [**first name11 (name pattern1) **] [**last name (namepattern4) 1008**], m.d.  [**md number(1) 1009**]

dictated by:[**name8 (md) 45172**]
medquist36

d:  [**2130-10-24**]  16:26
t:  [**2130-10-24**]  14:35
job#:  [**job number 45173**]
"
55,"admission date:  [**2176-10-29**]              discharge date:   [**2176-11-5**]

date of birth:  [**2136-3-10**]             sex:   f

service: surgery

allergies:
nsaids

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
1. laparoscopic repair of paraesophageal hernia.
2. placement of laparoscopic adjustable band and port device.


history of present illness:
[**known firstname 45779**] has class iii morbid obesity with weight of 276.2
pounds as of [**2176-9-10**] (her initial screen weight on [**2176-8-8**] was
280 pounds), height of 64 inches and bmi of 47.4.  her previous
weight loss efforts have included weight watchers, the salad
diet, the south beach diet, the [**doctor last name 1729**] diet, over-the-counter
ephedra-containing ma [**doctor last name **], slim-fast, prescription weight loss
medication and pancreatic lipase inhibitor orlistat (xenical),
and [**first name8 (namepattern2) 1446**] [**last name (namepattern1) **].  her weight and age 21 was 140-145 pounds with
her lowest adult weight 130 pounds at age 20 and her highest
weight 281.7 pounds on [**2176-8-19**].  she weighed 140-145 pounds 10
years ago and 165 pounds 5 years ago.  she states she developed
significant [**last name 4977**] problem in childhood and cites as factors
contributing to her excess weight genetics, large portions,
grazing, late night eating, too many carbohydrates in saturated
fats, stress, compulsive eating and emotional eating as well as
lack of exercise regimen.  her current activity includes
swimming 30 minutes 2-3 times per week and walking 10-15 minutes
twice per week.  she denied anorexia, bulimia, diuretic or
laxative abuse but stated she does have binge eating without
purging.  she has significant psychological history of
depression/bipolar disorder/anxiety and suicide attempts
admitted to [**hospital 1191**] hospital in [**location (un) 10059**] x 2 in [**2171**] for drug
overdose and lithium toxicity with auditory hallucinations,
followed by psychiatrist and a therapist and is currently on
psychotropic medications (paroxetine, abilify and lorazepam).


past medical history:
pmh: copd, fatty liver, htn, hl, hypothyroidism,gerd, bipolar
disorder, iron deficiency anemia, renal insufficiency,
nephrogenic diabetes insipidus

psh:  wisdom teeth, breast implants, precervical cancer surgery


social history:
she smoked one pack per day of cigarettes for 25 years quit
[**2176-7-29**], no
recreational drugs, no alcohol and does drink both carbonated
and caffeinated beverages. two daughters age 20 and age 21 who
had been in dss group homes and in [**doctor last name **] homes.  she is
divorced and is on disability, used to work in cosmetic sales,
lives alone but does have supportive friends.


family history:
her family history is noted for both parents living father with
history of stroke, mother with heart disease, hyperlipidemia,
asthma, thyroid disorder; sister living with heart disease and
thyroid disorder; multiple family members with mental illness

physical exam:
vs: t 98 hr 80 bp 120/78 rr 20 o2 99%ra

constitutional: nad
neuro: alert and oriented to person, place and time; affect flat
cardiac: rrr, nl s1,s2, no mrg
lungs: cta b
abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
wounds: abdominal lap sites with steri-strips, no periwound
erythema/ induration, mild periwound ecchymosis
ext: 2+ dp pulses

pertinent results:
labs:
[**2176-11-5**] 10:09am blood wbc-8.4 rbc-3.77* hgb-9.7* hct-30.8*
mcv-82 mch-25.7* mchc-31.5 rdw-16.0* plt ct-207
[**2176-11-5**] 06:27am blood glucose-90 urean-24* creat-1.5* na-146*
k-3.7 cl-108 hco3-26 angap-16
[**2176-11-5**] 10:09am blood glucose-124* urean-22* creat-1.5* na-143
k-4.1 cl-106 hco3-27 angap-14
[**2176-11-5**] 10:09am blood calcium-9.7 phos-3.3 mg-2.2
[**2176-11-4**] 02:05am blood glucose-100 urean-21* creat-1.4* na-143
k-4.0 cl-107 hco3-23 angap-17
[**2176-11-4**] 04:05pm blood na-139 k-3.9 cl-103
[**2176-11-4**] 08:39pm blood na-141 k-3.7 cl-105
[**2176-11-3**] 04:04am blood glucose-102* urean-19 creat-1.6* na-149*
k-3.9 cl-112* hco3-26 angap-15
[**2176-11-2**] 12:31am blood glucose-102* urean-15 creat-1.7* na-155*
k-4.1 cl-119* hco3-23 angap-17
[**2176-11-2**] 04:44am blood na-158* k-4.0 cl-121*
[**2176-11-2**] 12:31am blood glucose-102* urean-15 creat-1.7* na-155*
k-4.1 cl-119* hco3-23 angap-17
[**2176-11-2**] 04:44am blood na-158* k-4.0 cl-121*
[**2176-11-2**] 07:58am blood glucose-147* urean-17 creat-1.8* na-159*
k-4.4 cl-122* hco3-28 angap-13
[**2176-11-2**] 12:28pm blood glucose-95 urean-19 creat-1.8* na-154*
k-4.5 cl-117* hco3-26 angap-16
[**2176-11-2**] 04:15pm blood glucose-101* urean-18 creat-1.6* na-149*
k-4.0 cl-113* hco3-25 angap-15
[**2176-11-2**] 08:25pm blood glucose-105* urean-19 creat-1.6* na-150*
k-4.2 cl-114* hco3-26 angap-14
[**2176-11-1**] 09:27am blood na-159* cl-122*
[**2176-11-1**] 09:48am blood glucose-139* urean-15 creat-2.0* na-159*
k-3.9 cl-123* hco3-26 angap-14
[**2176-11-1**] 12:05pm blood na-156* k-3.5 cl-120*
[**2176-11-1**] 02:10pm blood na-154* k-3.9 cl-120*
[**2176-11-1**] 10:10pm blood na-152* k-3.5 cl-116*
[**2176-11-1**] 01:25am blood glucose-128* urean-15 creat-2.1* na-168*
k-3.9 cl-131* hco3-26 angap-15
[**2176-10-31**] 08:50am blood glucose-136* urean-15 creat-1.9* na-167*
k-3.7 cl-129* hco3-27 angap-15
[**2176-10-31**] 10:50am blood glucose-100 urean-15 creat-1.9* na-167*
k-4.5 cl-132* hco3-23 angap-17
[**2176-10-31**] 04:02pm blood na-164* k-3.6 cl-128*
[**2176-10-31**] 08:50am blood calcium-10.7* phos-2.5*# mg-2.6
[**2176-10-31**] 10:50am blood osmolal-346*
[**2176-11-4**] 02:05am blood osmolal-304
[**2176-10-31**] 10:50am blood tsh-0.71
[**2176-10-31**] 10:50am blood t4-13.1*
[**2176-10-31**] 05:31pm blood na-163*
[**2176-10-31**] 08:36pm blood na-159*
[**2176-10-31**] 11:32pm blood na-163*
[**2176-11-1**] 04:50am blood na-163*
[**2176-11-1**] 04:12pm blood na-154*
[**2176-11-1**] 06:40pm blood na-154*
[**2176-11-1**] 08:48pm blood na-153*
[**2176-11-3**] 12:29am blood na-148*
[**2176-11-3**] 09:08am blood na-145
[**2176-11-3**] 12:32pm blood na-146*
[**2176-11-3**] 04:38pm blood na-143 k-4.4
[**2176-11-3**] 08:36pm blood na-144
[**2176-11-4**] 06:33am blood na-144
[**2176-11-4**] 11:58am blood na-144

imaging:
[**2176-10-30**]: ugi sgl contrast w/ kub:
impression: appropriate lap band position, patent stoma, no
evidence of leak.

[**2176-10-31**] ecg:
sinus tachycardia. low precordial lead voltage. st-t wave
changes in the
anterolateral leads which raise the question of active
anterolateral ischemic process. followup and clinical
correlation are suggested. no previous tracing available for
comparison

[**2176-11-1**]: chest (portable ap):
impression: no pneumothorax, hematoma, or other sequela of
procedural
complication identified. bibasilar atelectasis.

[**2176-11-1**]:
chest port. line placement:
impression: new right picc terminating within the right atrium,
4.5-5.0 cm
beyond the cavoatrial junction.


brief hospital course:
the patient presented to pre-op on [**2175-10-30**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic adjustable gastric band placement. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient became intermittently agitated beginning on
pod1, pulling at her ngt, iv lines and threatening to leave
against medical advice and complaining of thirst.  psychiatry
was consulted, however, the patient declined visitation; the
patient's home psychiatric medication regimen was resumed at
this time.  overnight on pod2, the pt became progressively
disoriented, again attempting to leave against medical advice
and lacked insight into all aspects of her hospitalization and
expected post-operative recovery.  psychiatry was re-consulted
as the patient appeared to lack any capacity for decision
making.  at this time, electrolytes had been checked and the
serum sodium was noted to be 167 making a metabolic cause for
the patient's disorientation more likely; upon reviewing the
sodium level, psychiatry felt her mental status changes were
more likely the result hypernatremia induced delerium related to
diabetes insipidus.  after normalization of serum sodium levels,
the patient remained alert and oriented x 3 without any further
issues regarding agitation or insight into her care.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.  of note, the
patient's innopran xl was changed to regular release propranolol
as all medications must be crushed.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially on bariatric stage 1 diet, which
was well tolerated despite patient consuming more liquid than
ordered.  an upper gi study was performed on pod 1 which
revealed appropriate band position without evidence of
obstruction.  her diet was further advanced to stage 2 and then
3 due to the patient's extreme thirst and dietary
non-compliance; the patient tolerated this level of intake well.
 additionally, on pod2, the patient was noted to be
hypernatremic with a serum sodium level of 167.  renal was
consulted and felt this was due to diabetes insipidus related to
prior lithium use; [**name8 (md) **] rn at the patient's pcp's office confirmed
this was a known diagnosis.  the patient was identified as
having a free water deficit of approximately 10 liters; lr was
discontinued, d5w initiated, fluid intake liberalized and the
patient was transferred to the tsicu for q 3-4 hour serum sodium
monitoring.  while in the tsicu, the patient's hypernatremia
gradually resolved over the course of 4 days with resolution of
her delerium; she was transferred back to the general surgical
[**hospital1 **] on pod6.  her serum sodium remained between 141-146; renal
felt it was safe for discharge to home with liberal fluid
intake, a stage 3 diet and a repeat serum sodium level within 1
week.  both the patient's pcp and nephrologist were contact[**name (ni) **]
and follow-up appointments were made for the patient.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a
liberalized stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled.  the patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan including
follow-up with her pcp tomorrow and her nephrologist on [**11-25**], [**2175**].


medications on admission:
aripiprazole 15 mg daily
paroxetine 10 mg daily
perphenazine 32 mg q hs
propranolol xl 160 mg daily
levothyroxine 88 mcg daily
zolpidem 10 mg daily
omeprazole 40 mg [**hospital1 **]
lorazepam 1 mg qid
diphenhydramine 25 mg daily

discharge medications:
1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
disp:*250 ml* refills:*0*
2. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls
po q4h (every 4 hours) as needed for pain.
disp:*100 ml(s)* refills:*0*
3. aripiprazole 15 mg tablet sig: one (1) tablet po once a day:
please crush.
4. paroxetine hcl 10 mg tablet sig: one (1) tablet po once a
day: please crush.
5. perphenazine 8 mg tablet sig: four (4) tablet po qhs (once a
day (at bedtime)).
6. propranolol 40 mg tablet sig: two (2) tablet po bid (2 times
a day).
disp:*120 tablet(s)* refills:*0*
7. levothyroxine 88 mcg tablet sig: one (1) tablet po daily
(daily).
8. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime):
please crush.
9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day: open capsule,
sprinkle contents onto applesauce, swallow whole.  do not chew
beads.
10. lorazepam 1 mg tablet sig: one (1) tablet po four times a
day: please crush.


discharge disposition:
home

discharge diagnosis:
1. gastroesophageal reflux with paraesophageal hernia.
2. obesity.
3. fatty liver.
4. diabetes insipidus
5. hypernatremia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, nausea or vomiting,
difficulty drinking fluids, severe abdominal bloating, inability
to eat or drink, foul smelling or colorful drainage from your
incisions, redness or swelling around your incisions, confusion,
headache, weakness, increased thirst or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.  please drink fluids freely and contact dr. [**last name (stitle) 15645**] office
or report to the emergency department immediately if you are
unable to tolerate liquids.

medication instructions:
resume your home medications except for the following changes:
1.  please stop innopran xl (propranolol) as this medication
cannot be crushed.  a new prescription for propranolol (regular
release) has been provided to you as you may crush this
medication.  please notify your primary care provider of this
change.
2.  please stop amiloride per our nephrologist.
crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-12**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.



completed by:[**2176-11-5**]"
56,"admission date:  [**2197-4-26**]       discharge date:  [**2197-5-6**]

date of birth:   [**2130-3-5**]       sex:  m

service:  card-[**last name (un) **]

history of present illness:   this is a 67 year old male who
presented to his primary care provider with [**name initial (pre) **] chief complaint
of progressive dyspnea on exertion over the past 18 months.
the patient's wife reported that the patient has become
progressively more and more dyspneic upon walking up a flight
of stairs and has episodes every day that resolve with rest.
the patient denied ever experiencing any chest pain in
association with these episodes.  the patient subsequently
underwent a stress test in [**2197-3-28**], which was stopped
after six minutes and 34 seconds of the [**doctor first name **] protocol
secondary to shortness of breath.  the patient did not
experience any chest pain during this test.

the patient's ekg at this time demonstrated [**street address(2) 49111**] depressions in leads ii, iii, avf and v5 through
6 during the last stage of exercise.  in the recovery room,
the patient developed [**street address(2) 49112**] depressions
in leads i, ii, iii, avf and v1 through v6, with t wave
inversions which persisted until 12 minutes after exercise.

imaging studies demonstrated moderate reversible anterior and
septal wall defects.  the patient's ejection fraction was
estimated to be 43%.  the patient was subsequently referred
to [**hospital1 69**] for an outpatient
cardiac catheterization to evaluate heart function.

the catheterization took place on [**2197-4-26**], and
demonstrated 80% distal stenosis of the left main coronary
artery and 80% occlusion of the left anterior descending.
ejection fraction was noted to be 49%.  the patient was
subsequently admitted to the [**hospital unit name 196**] service under the direction
of dr. [**first name (stitle) **] k. w. ho, on [**2197-4-26**] for further
evaluation and management.

past medical history:
1.  hypertension.
2.  hypercholesterolemia.
3.  penile cancer status post resection.
4.  crohn's disease status post resection.
5.  chronic cough.

home medications:
1.  aspirin.
2.  pravachol.
3.  b12.
4.  atenolol.

allergies:   no known drug allergies.

social history:   the patient lives with his wife and works
as a cashier.  the patient has a remote history of smoking
cigarettes which he quit approximately 15 years ago.  he
drinks one to two alcoholic drinks per week.  no intravenous
drug use history.

hospital course:   the patient was admitted to the [**hospital unit name 196**]
service on [**2197-4-26**], under the direction of dr. [**last name (stitle) **].  a
cardiothoracic surgery consultation was obtained upon
admission; following an extensive discussion with the patient
and his family regarding the relative risks and benefits of
surgery, the patient agreed to undergo coronary artery bypass
graft on [**2197-4-27**].

on [**2197-4-27**], the patient underwent a coronary artery
bypass graft times three.  anastomoses included left internal
mammary artery to left anterior descending; saphenous vein
graft to diagonal; and saphenous vein graft to obtuse
marginal.  the patient tolerated the procedure well and had a
bypass time of 79 minutes and a cross clamp time o4 44
minutes.  the patient's pericardium was left open;
intraoperative lines placed included a right radial and right
internal jugular line; both ventricular and atrial wires were
placed; mediastinal and left pleural tubes were placed.

the patient was subsequently transferred from the operating
room to the cardiac surgery recovery unit, intubated, for
further evaluation and management.  on transfer, the
patient's mean arterial pressure was 80; his central venous
pressure was 6; his pad was 13 and his [**doctor first name 1052**] was 17.  the
patient was atrially paced at a rate of 88 beats per minute.

active drips on transfer included neo-synephrine and
propofol.  following arrival in the csru, the patient was
successfully weaned and extubated.  his postoperative
hematocrit was noted to be 36.1.  in the csru, the patient
progressed well clinically.  he was advanced successfully to
oral medications without adverse events and was successfully
weaned from pressor drips.  the patient's chest tubes were
successfully removed without complication as were his pacer
wires, after which point he was cleared for transfer to the
floor on postoperative day number four.

the patient was subsequently admitted to the cardiothoracic
service under the direction of dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 70**].
postoperatively, the patient's clinical course was
uneventful.  the patient was evaluated by physical therapy
who deemed him an appropriate candidate for eventual
discharge to home following completion of the acute medical
care.

the patient was noted to develop atrial fibrillation
refractory to medical therapy, after which point he was begun
on a coumadin anti-coagulation pathway.  as the patient was
progressively dosed with coumadin for a therapeutic inr of
over 2.0, the patient was noted to be successfully
transitioned to a full regular diet and his pain was
controlled adequately with oral pain medications.  the
patient was noted to be independently ambulatory and was
noted to be independently productive of adequate amounts of
urine for the duration of his stay.

by postoperative day number eight, the patient was noted to
be afebrile and stable.  his incisions were noted to be
healing well with steri-strips intact and no evidence of
cellulitis or purulent drainage.  the patient was noted to be
fully tolerant of a regular diet and his pain was well
controlled.

following a final inr [**location (un) 1131**] of 2.3, the patient was cleared
for discharge to home on postoperative day number 9, [**2197-5-6**], with instructions for follow-up.

condition on discharge:   the patient is to be discharged
home with instructions for follow-up.

discharge status:   stable.

discharge medications:
1.  colace 100 mg p.o. twice a day.
2.  amiodarone 400 mg p.o. q. day times 14 days, followed by
200 mg p.o. q. day times four weeks.
3.  vicodin one to two tablets p.o. q. four to six hours
p.r.n.
4.  pravastatin 80 mg p.o. q. day.
5.  coumadin 5 mg p.o. q. day times four days, with the
patient's dose to be titrated thereafter by his primary care
physician, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **].

discharge instructions:
1.  the patient is to maintain his incisions clean and dry at
all times.
2.  the patient may shower but should pat-dry incisions
afterwards; no bathing or swimming until further notice.
3.  the patient is to resume a cardiac diet.
4.  the patient has been instructed to limit physical
activities; no heavy exertion.
5.  no driving while taking prescription pain medications.
6.  the patient is to have his coumadin dosage schedule
managed by his primary care provider, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **]; the
patient is to receive biweekly blood draws on mondays and
thursdays beginning [**2197-5-8**], and is to call dr. [**last name (stitle) **]
with his results following each blood draw for subsequent
modification of his coumadin dosing schedule for a target inr
of 2.0.
7.  the patient is to have additional primary care physician
[**name9 (pre) 702**] as needed.
8.  the patient is to follow-up with dr. [**first name4 (namepattern1) 919**] [**last name (namepattern1) 911**] in
cardiology within three to four weeks.
9.  the patient is to follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 70**] six
weeks following discharge.

the patient is to call to schedule all appointments.



                            [**first name11 (name pattern1) **] [**initials (namepattern4) **] [**last name (namepattern4) **], m.d.  [**md number(1) 75**]

dictated by:[**last name (namepattern1) 1053**]
medquist36

d:  [**2197-5-6**]  15:39
t:  [**2197-5-6**]  16:08
job#:  [**job number 49113**]
"
57,"admission date:  [**2125-2-9**]              discharge date:   [**2125-2-18**]

date of birth:  [**2058-2-22**]             sex:   f

service: medicine

allergies:
ace inhibitors

attending:[**first name3 (lf) 69838**]
chief complaint:
hematuria

major surgical or invasive procedure:
trans-urethral resection of bladder


history of present illness:
66 y.o. female with cad s/p mi and bm stent, chf, s/p mechanical
avr on coumadin and recently discovered bladder tumor who was
transferred from [**hospital 8125**] hospital with hematuria. patient developed
hematuria on [**1-17**], which prompted her to go to the
hospital. at that time, she was felt to have a uti and was
treated wtih tetracyclin. additionally a ct abdomen showed a
bladder tumor, that as of yet has not been biopsied. after
completing antibiotics, the hematuria cleared and the patient
was doing well, being followed by dr. [**last name (stitle) 770**] for eventual plans
to biopsy the tumor. on [**2-7**], patient noticed blood in her
urine, but says it was minimal. she spoke to her urologist who
reassured her but told her to continue to monitor the symptoms.
on the following day, she developed clots and by the day of
admission, [**2-9**], felt as though she was ""hemorrhaging"". prior to
this, she was asymptomatic, but on the day of presentation,
reports feeling dizzy without chest pain or palpitations. she
additionally denies f/c, n/v but does endorse some mild back
pain and dysuria.
.
patient initially presented to [**hospital 8125**] hospital with her
complaints, but was then transferred to [**hospital1 18**] because her
urologist was here. in the ed, labs revealed an inr of 4.3 and a
strongly positive ua and wbc of 21 with 84% neutrophils, no
bands. she was afebrile and hemodynamically stable. urology was
consulted and placed a 22 french foley and hand irrigated many
clots from the bladder, after which the urine remained pink.
patient's cardiologist, dr. [**last name (stitle) **], saw the patient in the ed and
recommended holding her asa and coumadin for now. patient was
given ceftriaxone empirically for the uti and was then admitted
to the medicine team for continued management of her hematuria.



past medical history:
bladder tumor
chf (ef 40-45% in 10/'[**23**])
cad s/p mi and stents to lcx [**8-5**]
carotid stenosis
hypertension
hypercholesterolemia
s/p hysterectomy


social history:
former smoker, but stopped in [**2124-7-29**]. denies alcohol
or illicit drug use. patient lives in [**hospital3 **] and works in real
estate.

family history:
non-contributory

physical exam:
physical exam:
t: 96.9, bp: 110/60, p: 83, rr: 18, o2 sats: 94% ra
gen: awake, alert, nad
heent: nc/at; perrla, eomi; op clear, nonerythematous
neck: supple, no lad, no jvd
cv: s1, s2 nl, no m/r/g appreciated, though valvular click was
ausculated
resp: ctab
abd: soft, tender to palpation in suprapubic area, nd, + bs
back: no flank tenderness
gu: normal female genitalia with foley in place, draining frank
blood
ext: no c/c/e
neuro: grossly intact


pertinent results:
=================
  admission labs
=================

wbc-21.3*# rbc-3.53* hgb-8.9*# hct-28.0* mcv-79*# mch-25.2*#
mchc-31.7 rdw-14.6 plt ct-458*
neuts-84.2* lymphs-10.8* monos-3.9 eos-1.0 baso-0.1
pt-39.4* ptt-37.2* inr(pt)-4.3*
glucose-114* urean-17 creat-0.7 na-136 k-4.6 cl-97 hco3-28
angap-16

===============
  radiology
===============

chest (pa & lat)  [**2125-2-10**] 3:07 pm
median sternotomy wire and mitral valve annuloplasty again
noted. the lungs are grossly clear. cardiac contour within
normal limits. aortic arch is calcified. aorta is ectatic.
impression:
1. no active disease in the chest.
2. ectatic aorta.

ct pelvis w&w/o c   [**2125-2-11**] 11:15 am
findings: there is a large intraluminal filling defect within
the urinary bladder, predominantly on the right, slightly
adherent to the wall, measuring 6 x 5.5 x 5.3 cm. this filling
defect is heterogeneous in appearance and has irregular margins.
it is also directly related to the right ureterovesical
junction. there is a foley catheter within the urinary bladder
as well as foci of air. there is no evidence of significant
retroperitoneal lymphadenopathy. there is no evidence of
hydronephrosis. multiple small foci of hypodensity within the
right renal parenchyma, most likely representing small cysts.
the bilateral adrenal glands are unremarkable. the spleen, the
liver and the pancreas are unremarkable. there is evidence of
cholelithiasis. there is no evidence of free fluid or free air.
the bowel appears unremarkable. there is a thoracoabdominal
aortic aneurysm, measuring 4.4 cm in maximum diameter at the
inlet to the abdomen, after which it tapers to 2.5 cm at the
level of the sma.
bilateral lung bases are unremarkable.
there are no suspicious bony lesions.
impression:
1. large filling defect within the urinary bladder, which is
heterogeneous, measuring 6 cm in maximal diameter. differential
diagnosis includes a bladder tumor versus a blood clot given
that the patient has been on coumadin

================
 microbiology
================

urine culture (final [**2125-2-14**]):    no growth.

=================
 discharge labs
=================

wbc-13.3* rbc-3.60* hgb-9.5* hct-29.8* mcv-83 mch-26.2*
mchc-31.8 rdw-16.4* plt ct-420
pt-17.9* ptt-125.2* inr(pt)-1.6*
glucose-102 urean-10 creat-0.8 na-139 k-4.3 cl-99 hco3-29
angap-15
calcium-8.8 phos-3.2 mg-2.0

brief hospital course:
66 y.o. female with known bladder tumor and mechanical mitral
valve, presenting with gross hematuria, now with stable hct, s/p
transurethral tumor resection
.
# hematuria / bladder tumor: although culprit for hematuria was
a known tumor, intervention was not possible upon admission
secondary to anticoagulation. patient has mechanical valve at
the mitral position, for which she is anticoagulated with
coumadin. patient required a single transfusion of 2 units of
pbrc after warfarin was stopped. continuous bladder irrigation
was initiated and inr was allowed to drift down without reversal
due to increased risk of adverse events in setting of mechanical
valve.
patient was started on heparin drip when inr reached 2.5 and
urology performed trans-urethral bladder tumor resection once
inr reached 1.5.
tissue sent to pathology, this however is pending at the time of
discharge. patient will follow up with dr [**last name (stitle) 770**] for further
management.

# mechanical mitral valve: as above, patient with ([**hospital3 **])
valve in place. after procedure was performed patient was
re-startedd on heparin drip and transitioned to lovenox. she was
discharged on a lovenox to coumadin drip and asked to have inr
checked at her primary care provider, [**name10 (nameis) **] request of her
cardiologist. patient given script for [**name10 (nameis) **] work. defer further
management to primary care physician.

# uti: history of vre uti in the past. this admission, patient
had infection with streptococcus species. she will complete 10
day course of [**last name (lf) **], [**first name3 (lf) **] require two more doses as outpatient.
.
# cad: patient is s/p mi with bare metal stent [**8-5**]. we
re-started aspirin at time of discharge, and continued beta
blocker and statin during entire admission.
.
# chronic systolic heart failure: ef 40-45% on [**9-4**], following
mvr. patient remained well compensated during this admission and
no changes in medication regimen were made.
.
# carotid artery stenosis: per ultrasound ([**2124-9-6**]) 80-99%
right ica stenosis, with no significant left ica stenosis. no
neurological symptoms during this presentation.
.
# fen: patient tolerated a cardiac/heart-healthy diet
.
# code: patient remained full code during this admission.


medications on admission:
lipitor 20 mg po qd
lasix 80 mg po bid
potassium
coumadin 5mg mwf, 2.5mg tuthsasu
asa 81 mg po qd
toprol xl 50 mg po qd
digoxin 125 mcg
advair


discharge medications:
1. atorvastatin 20 mg tablet sig: one (1) tablet po daily
(daily).
2. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a
day).
3. metoprolol succinate 50 mg tablet sustained release 24 hr
sig: one (1) tablet sustained release 24 hr po daily (daily).
4. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily).

5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
6. lovenox 80 mg/0.8 ml syringe sig: one (1) syringe (80 mg)
subcutaneous twice a day: until your doctor asks you to stop.
[**hospital1 **]:*28 syryinges* refills:*0*
7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
8. warfarin 5 mg tablet sig: one (1) tablet po at bedtime:
please note, dose will be modified by your primary care
physician.
[**name initial (nameis) **]:*30 tablet(s)* refills:*0*
9. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h
(every 12 hours) for 2 days.
[**name initial (nameis) **]:*4 tablet(s)* refills:*0*
10. percocet 5-325 mg tablet sig: one (1) tablet po every six
(6) hours as needed for pain for 7 days.
[**name initial (nameis) **]:*28 tablet(s)* refills:*0*
11. outpatient [**name initial (nameis) **] work
please have cbc and pt/ptt/inr drawn on [**2-21**]


discharge disposition:
home

discharge diagnosis:
primay:
mechanical mitral valve
hematuria
bladder tumor


discharge condition:
hemodynamically stable, afebrile


discharge instructions:
you were admitted to the hospital because you were having
bleeding from your bladder and required a different type of
anticoagulation that would allow for a surgery to find the cause
of your bleeding. you underwent the procedure and tolerated it
well. the results of the tissue analysis will not availabe for a
few days, your primary care doctor will need to follow this up.

you will need to follow up with your primary care doctor and
take all medications as prescribed. you will also need to give
yourself lovenox injections twice daily until your inr (level of
coumadin) is at a good range.

if you experience any chest pain, nausea, vomiting, diarrhea, or
any other symptom that concerns you, please seek medical
attention immediatly.

followup instructions:
please make schedule a follow up appointment with your primary
care physician [**name initial (pre) 176**] 1 week. you will need to have your
coumadin level checked in his office on [**2-21**].

[**last name (lf) **],[**first name3 (lf) **] h [**telephone/fax (1) 57926**]


                             [**first name4 (namepattern1) **] [**last name (namepattern1) **] md [**md number(2) 69841**]

"
58,"admission date:  [**2103-6-23**]              discharge date:   [**2103-7-8**]

date of birth:  [**2035-8-7**]             sex:   m

service: medicine

allergies:
azilect

attending:[**first name3 (lf) 2763**]
chief complaint:
hypoxia

major surgical or invasive procedure:
intubation, trach, peg

history of present illness:
67yom with parkinson's disease, bipolar disorder, htn,
dyslipidemia, right vertebral artery aneurysm who presents for
hypoxia.
.
per ed report and per the patient's sister's report (who spoke
directly to the nurses who were taking care of the patient
today), the patient was in his usual state of health at [**hospital 100**]
rehab and had just eaten breakfast and was waiting to be wheeled
to his room for his routine nap. the nurse turned away to finish
feeding another patient and turned back to see the patient with
emesis coming out of his nose and mouth. the patient was
unresponsive during this episode and was rapidly suctioned.
however, he was hypoxic and ems was called who found the patient
to be hypoxic en route to the ed and bag masked and ventilated
for initial apnea, per report. he was lethargic en route and
transferred to the [**hospital1 18**] ed for further evaluation. there was no
reports of fevers or symptoms preceeding the event, but the
sister states that the patient does not typically complain of
symptoms even when he feels unwell. the patient's sister reports
the patient has never had difficulties with swallowing or
eating, and has never had an aspiration episode in the past.
.
in the ed, initial vs: 99.6 (rectal) 67 132/94 91% nrb
the patient was reportedly not responsive to commands and had
coarse rales diffusely. he was given vanc/levofloxacin/flagyl in
the ed and intubated for hypoxia. ekg showed sinus rhythm at
62bpm without evidence of acute ischemia. cxr was obtained which
showed possible rml infiltrate. cta chest was obtained to r/o pe
which instead showed evidence of aspiration pneumonia. ct head
showed enlargement of the patient's known right vertebral artery
aneurysm, and neurology and neurosurgery were consulted out of
concern that the intracranial aneurysm could be contributing to
his symptoms. neurosurgery recommended mri head/neck and
neurology planned to have the stroke consult see him in the am
pending mri/mra results. he was transferred to the micu for
further management. transfer vitals were: 84 109/68 19 100% tv
500 peep 8 rr 20 fio2 100
.
on arrival to the micu, the patient was minimally responsive to
pain off sedation after having received paralytics. he went to
for the mri/mra during which time his respiratory rate increased
and sedation was initiated with propofol boluses, then a low
dose gtt. he became fully responsive to commands and his
respiratory rate and blood pressures increased on cmv/ac.


past medical history:
- htn
- hyperlipidemia
- bipolar disorder
- parkinson's disease (pet in [**2094**] consistant with diagnosis)
- gastropathy
- unruptured right vertebral artery aneurysm (cta from an
outside facility was reviewed; right vertebral artery aneurysm,
longest dimension 9-10 mm located intradurally in the region of
the right vertebral artery. he could not becertain whether the
aneurysm involved the pica origin, but most likely it seemed to
be separate from it.)
- depression
- degenerative arthritis/multilevel spondylosis
- knee oa, s/p tka


social history:
- tobacco: denies
- etoh: denies
- illicit drugs: denies
non-ambulatory at baseline. lives at nursing home, [**hospital 100**] rehab
since [**2099**]. retired ph.d. psychologist.


family history:
father with ""ataxia"" and prostate cancer. mother with breast
cancer.  pt denies family cardiac history.

physical exam:
vs: 100.1 80 130/75 100% on cmv fio2 100% tv 6000 peep 5
gen: intubated, not following commands, no acute distress
heent: perrl, sclera anicteric, mmm
cv: soft heart sounds, rrr, normal s1/s2, no m/r/g
resp: equal bs b/l, rhonchi and coarse crackles at rlb, no
wheezes
abd: soft, nt/nd, +bs, no masses or hepatosplenomegaly
ext: wwp, no c/c/e, 2+ dp pulses b/l
skin: no rashes/no jaundice/no splinters
neuro: corneal reflexes b/l, rare spontaneous non-purposeful
movements of right finger.


pertinent results:
[**2103-6-23**] 10:55am blood wbc-10.6 rbc-4.82 hgb-14.5 hct-40.5
mcv-84 mch-30.2 mchc-35.9* rdw-13.5 plt ct-213
[**2103-6-23**] 10:40pm blood neuts-39* bands-39* lymphs-5* monos-2
eos-1 baso-0 atyps-3* metas-11* myelos-0
[**2103-6-23**] 10:55am blood pt-13.0 ptt-22.9 inr(pt)-1.1
[**2103-6-23**] 10:55am blood fibrino-334
[**2103-6-23**] 10:55am blood glucose-119* urean-24* creat-1.1 na-140
k-5.7* cl-104 hco3-20* angap-22*
[**2103-6-23**] 10:40pm blood alt-12 ast-15 ck(cpk)-111 alkphos-38*
totbili-0.5
[**2103-6-23**] 10:55am blood lipase-37
[**2103-6-23**] 10:55am blood ctropnt-<0.01
[**2103-6-23**] 10:40pm blood ck-mb-4 ctropnt-<0.01
[**2103-6-24**] 04:14am blood ck-mb-4 ctropnt-<0.01
[**2103-6-23**] 10:55am blood calcium-8.5 phos-4.8* mg-2.5
[**2103-6-23**] 10:55am blood triglyc-136
[**2103-6-28**] 06:20am blood vanco-13.6
[**2103-6-23**] 10:55am blood asa-neg ethanol-neg acetmnp-6*
bnzodzp-neg barbitr-neg tricycl-neg
[**2103-6-23**] 12:12pm blood type-art rates-16/ tidal v-500 peep-8
fio2-100 po2-436* pco2-56* ph-7.27* caltco2-27 base xs--1
aado2-233 req o2-46 -assist/con intubat-intubated
[**2103-6-23**] 11:41am blood lactate-2.9*
[**2103-6-23**] 11:48pm blood lactate-2.3*
[**2103-6-24**] 04:34am blood lactate-2.7*
[**2103-6-24**] 03:23pm blood lactate-1.6
[**2103-7-4**] 04:49pm blood lactate-1.4
[**2103-6-24**] 03:23pm blood freeca-1.14

reports:

cxr ap [**2103-6-23**]
impression:
1. standard position of endotracheal tube.
2. nasogastric tube extends below level of diaphragm, but
inferior aspect not well seen. consider repeat if desire to
confirm that it terminates in the stomach.
3. low lung volumes with mild bibasilar atelectasis.

ct head [**2103-6-23**]
1. interval increased size of a right-sided vertebral artery
aneurysm with
increased mass effect upon the brainstem. cta should be
considered for
further evaluation.
2. parenchymal atrophy and small vessel ischemic disease. no
other acute
findings.

cta chest [**2103-6-23**]
1. bibasilar, and perihilar opacities with peribronchial
thickening may
reflect aspiration pneumonia. hilar lymph nodes may be reactive.

2. no pulmonary embolism.
3. ng tube tip at the ge junction and should be further advanced
to achieve gastric positioning.

mra head/neck [**2103-6-23**]
impression: right vertebral artery aneurysm at the v3 segment,
apparently
partially thrombosed, the carotid bifurcations and the left
vertebral artery are grossly normal.

cta head w and w/o contrast [**2103-7-7**] (prelim read!) - (final
report dictation confirms preliminary findings.)
1. right vertebral artery aneurysm measuring smaller on cta than
routine head ct - likely secondary to differences in technique.
difficult to measure on non-contrast images due to artifact.
continues to demonstrate compression on the brainstem.
reconstructions pending at this time.
2. no evidence for other aneurysm, vascular malformation or
proximal large
arterial occlusion.
3. new fluid in mastoid air cells bilaterally, may be secondary
to recent
intubation and supine positioning. clinical correlation
recommended.

micro
[**2103-7-6**] sputum gram stain-final; respiratory
culture-preliminary inpatient
[**2103-7-4**] blood culture blood culture, routine-pending
inpatient
[**2103-7-4**] blood culture blood culture, routine-pending
inpatient
[**2103-7-4**] urine urine culture-final inpatient
[**2103-7-3**] stool clostridium difficile toxin a & b
test-final inpatient - negative
[**2103-7-2**] rapid respiratory viral screen & culture
respiratory viral culture-final; respiratory viral antigen
screen-final inpatient
[**2103-7-2**] bronchial washings gram stain-final;
respiratory culture-final {stenotrophomonas (xanthomonas)
maltophilia, gram negative rod #2, yeast}; immunoflourescent
test for pneumocystis jirovecii
(carinii)-final; fungal culture-preliminary {yeast} inpatient
+
   gram stain (final [**2103-7-2**]):
      2+   (1-5 per 1000x field):   polymorphonuclear
leukocytes.
      no microorganisms seen.
      smear reviewed; results confirmed.

   respiratory culture (final [**2103-7-4**]):
      commensal respiratory flora absent.
      due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      stenotrophomonas (xanthomonas) maltophilia.
         10,000-100,000 organisms/ml..
         identification and sensitivities performed on culture #
324-8468n
         ([**2103-6-27**]).
      gram negative rod #2.    rare growth.
      yeast.    10,000-100,000 organisms/ml..

[**2103-7-2**] stool clostridium difficile toxin a & b
test-final inpatient - negative
[**2103-7-1**] urine urine culture-final inpatient
[**2103-6-30**] blood culture blood culture, routine-final
inpatient
[**2103-6-30**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification} inpatient

   gram stain (final [**2103-6-30**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2103-7-3**]):
      commensal respiratory flora absent.
      stenotrophomonas (xanthomonas) maltophilia.    sparse
growth.
         identification and sensitivities performed on culture #
324-8468n
         ([**2103-6-27**]).
      [**female first name (un) **] albicans, presumptive identification.    sparse
growth.
         identification performed on culture # 324-8468n
([**2103-6-27**]).

[**2103-6-29**] blood culture blood culture, routine-final
inpatient
[**2103-6-28**] blood culture blood culture, routine-final
inpatient
[**2103-6-28**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification} inpatient
[**2103-6-28**] urine urine culture-final inpatient
[**2103-6-28**] blood culture blood culture, routine-final
inpatient
[**2103-6-27**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification, serratia species}
inpatient
[**2103-6-26**] blood culture blood culture, routine-final
inpatient
[**2103-6-24**] sputum gram stain-final; respiratory
culture-final {yeast} inpatient
[**2103-6-24**] blood culture blood culture, routine-final
inpatient
[**2103-6-23**] sputum gram stain-final; respiratory
culture-final inpatient
[**2103-6-23**] mrsa screen mrsa screen-final inpatient
[**2103-6-23**] urine urine culture-final emergency [**hospital1 **]
[**2103-6-23**] blood culture blood culture, routine-final
emergency [**hospital1 **]
[**2103-6-23**] blood culture blood culture, routine-final
emergency [**hospital1 **]

discharge labs:
na 143
k 4.3
cl 108
bun 26
bun 9
cr 0.5
gluc 94
ca 8.5
mg 2
phos 3.7

wbc 5.5
hct 31 (stable)
plt 243

brief hospital course:
67yom with parkinsonism & cognitive impairment with known r
vertebral aneurysm (prior eval by [**doctor last name **] in [**2099**]). pt admitted
after syncopal episode after which he was unresponive, apneic.

#. hypoxic respiratory distress: per report, the patient's
episode of coughing while eating, hypoxia, and subsequent loss
of consciousness is consistent with aspiration pneumonia. he was
intubated for his hypoxemic respiratory failure. his chest
imaging, and purulent sputum from endotracheal tube all confirm
this diagnosis. patient was treated with an 8 day course of
vanc/cefepime/flagyl from [**2103-6-23**] until [**2103-7-1**] for
health-care-associated pneumonia. given that he had
stenotrophamonas growing in his sputum sensitive to bactrim, he
was started on bactrim 40 ml po/ng qid d1=[**6-29**] for a long 2-week
course, last dose to be given on [**2103-7-13**]. given his baseline
parkinson's disease, likely icu myopathy, and generalized
weakness, the patient was unable to be weaned from the
ventilator successfully. he was extubated on [**2103-7-2**] but had to
be emergently reextubated the same day for acute respiratory
failure. a trach and peg was placed on [**2103-7-6**] without
complication and he was successfully weaned off of the
ventilator on [**2103-7-8**], currently satting in the mid-high 90s on
50% fio2 trach mask. he would benefit from continued antibiotics
and pulmonary rehabilitation/chest pt. blood and repeat sputum
cultures remained negative.

#. loss of consciousness: given the limited history, it is
unclear whether the patient had loss of consciousness following
or preceeding the emesis and aspiration event. cardiac enzymes
negative x2. neurologic work up revealed slightly larger known
vertebral artery aneurysm (more on this below) thought not to be
related to his current presentation per neurology and
neurosurgery consultation. this was thought to be related to his
hypoxic respiratory failure per above. the patient remained
sedated throughout the admission and on day of discharge.

#. vertebral artery aneurysm: patient with known right vertebral
artery aneurysm, currently 14x12mm as compated to 11x9mm in
[**2101-8-6**]. neurosurgery was consulted and did not recommend
acute treatment of the aneurysm, but recommended mri brain, mra
head and neck. neurology stroke consult was also recommended
given the as stroke is a possibility given this limited history
and exam. repeat cta head/neck revealed a slightly smaller
aneurysm. these findings were discussed with neurosurgery on day
of discharge and a follow up appointment with neurosurgery
should be arranged [**telephone/fax (1) 1669**] within 4-8 weeks.

#. fever: patient persisted to have multiple low grade fevers
for several days all thoughout his icu course (tmax in 24 hours
100.5 last evening [**2103-7-7**]) and 100 this morning [**2103-7-8**]. a large
number of blood, urine, stool, and sputum cultures were drawn
and only positive for stenotrophomonas (xanthomonas) maltophilia
per above and negative for c diff x 2 over the course of [**7-15**]
days. yeast grew in the sputum as well that was thought to be
nonpathologic. the patient developed an acne-like rash on his
backside thought to be secondary to diaphoresis, however,
drug-hypersensitivity secondary to bactrim was considered but
felt to be unlikely. eosinophil count remained normal on day of
discharge. his picc line was also pulled as a potential source
of infection on day of discharge. his fever was therefore
thought to be secondary to stenotrophomonas infection of the
lungs. monitoring of the rash by [**hospital 100**] rehab staff would be
appropriate as well.

#. elevated lactate: patient with lactate of 2.9 on initial
presentation, likely secondary to volume depletion and
hypovolemia. this cleared after ivf.

#. parkinson's disease: continued home sinemet 25/100mg 0.5 tab
at 5pm, 8pm, 1.5 tabs at 8am, 12pm, 2pm

#. bipolar disorder: stable. continued home seroquel 50mg [**hospital1 **],
hold seroquel 25mg q6h prn given patient is intubated, continued
neurontin 100mg daily, continued valproic acid 250mg tid with no
adverse events.

#. hypertension: bp stable, no evidence of shock or hypotension.
held lisinopril , metoprolol 25mg [**hospital1 **], held klonipin 0.5mg tid
as patient sedated and intubated, can be restarted at rehab.

#. dyslipidemia: continued simvastatin 20mg qhs

#. depression: continued cymbalta 40mg [**hospital1 **] per home regimen

#. prophylaxis: patient continued on heparin subcutaneous 5,000
units tid. ppi and chlorhexadine were discontinued upon
discharge as he became vent independent today.
lidoderm patch for chronic pain was continued.
senna/colace/miralax. ppi.

#. contact: sister [**name (ni) **] - [**name (ni) **] [**name (ni) **] [**telephone/fax (1) 74952**] (home),
[**telephone/fax (1) 74953**] (cell). sister [**name (ni) 382**], poa) - [**name (ni) **] [**last name (namepattern1) **]
[**telephone/fax (1) 74954**] (home), [**telephone/fax (1) 74955**] (cell).

#. code status: after extensive family meetings, patient was
deemed dnr but not dni. ambulance services refused to accept dnr
order, despite md signature, demanded hcp signature,
unfortunately, she was not available for signature, therefore
she remained full code for transport. he would return to dnr
status upon arrival to [**hospital 100**] rehab.


medications on admission:
- lisinopril 40mg qhs
- lopressor 25mg [**hospital1 **]
- simvastatin 20mg qhs
- seroquel 25mg q6h prn
- seroquel 50mg [**hospital1 **]
- sinemet 25/100mg 0.5 tab at 5pm, 8pm, 1.5 tabs at 8am, 12pm,
2pm
- valproic acid 250mg tid
- lidoderm patch
- tylenol 1gm q8h prn pain
- vitamin d 1000 units daily
- klonipin 0.5mg tid
- cymbalta 40mg [**hospital1 **]
- neurontin 100mg daily
- nitro tp 0.2mcg/day
- miralax 17g [**hospital1 **]
- dulcolax 5mg qday prn
.


discharge medications:
1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid
(2 times a day).
2. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
3. quetiapine 25 mg tablet sig: two (2) tablet po bid (2 times a
day).
4. quetiapine 25 mg tablet sig: one (1) tablet po q6h (every 6
hours) as needed for agitation.
5. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po
tid (3 times a day).
6. carbidopa-levodopa 25-100 mg tablet sig: 0.5 tablet po q 5pm,
8pm ().
7. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: five
(5) ml (250 mg) po q8h (every 8 hours).
8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) adhesive patch, medicated topical daily (daily).
9. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain, fever.
10. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1)
tablet po daily (daily).
11. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times
a day).
12. duloxetine 20 mg capsule, delayed release(e.c.) sig: two (2)
capsule, delayed release(e.c.) po bid (2 times a day).
13. gabapentin 250 mg/5 ml solution sig: 100 mg (2 ml)  po daily
(daily).
14. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day): ok to hold if pt is able to
ambulate tid.
15. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: [**1-7**]
drops ophthalmic prn (as needed) as needed for dry, red eyes.
16. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension sig:
forty (40) ml po qid (4 times a day) for 5 days: take through
[**7-13**].
17. erythromycin 5 mg/gram (0.5 %) ointment sig: one (1)
ophthalmic [**hospital1 **] (2 times a day) for 2 days.
18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1)  inhalation q6h (every 6 hours) as
needed for wheezing, shortness of breath.
19. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
qid (4 times a day) as needed for wheezing, shortness of breath.

20. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
21. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2)
tablet, delayed release (e.c.) po daily (daily) as needed for
constipation.
22. docusate sodium 50 mg/5 ml liquid sig: one (1)  po bid (2
times a day).
23. polyethylene glycol 3350 17 gram/dose powder sig: one (1)
po daily (daily) as needed for constipation.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - macu

discharge diagnosis:
primary: aspiration pneumonia, respiratory failure, altered
mental status
.
secondary: conjunctivitis, parkinson's, bipolar, loss of
conciousness, verterbral artery anuerysm


discharge condition:
mental status: confused - always.
level of consciousness: lethargic but arousable.
activity status: bedbound.


discharge instructions:
you were admitted to the hospital for hypoxic respiratory
distress thought to be due to aspiration pneumonia.  you were
treated with antibiotics and you improved, however you were
unable to be weaned from the ventilator, therefore a
tracheostomy was performed and a peg tube was placed for
nutrition.  additionally while in the hospital you were treated
for conjunctivitis and followed for your vertebral artery
anuerysm which was stable.  your home psychiatric and
parkinson's medications were continued.
.
the following changes were made to your medications:
-start bactrim, continue taking through [**7-13**]
-stop lisinopril and nitroglycerin pathc, this can be restarted
if you are hypertensive, however it was discontinued during the
admission because your pressures were well controlled
-start sc heparin for dvt prophylaxis
-start erythromycin eye ointment and moisturizing eye drops
-start albuterol and ipratroprium nebs as needed for shortness
of breath
-start senna and docusate for constipation

followup instructions:
please follow up with your rehab physician.  [**name10 (nameis) 357**] schedule
follow up with neurosurgery in [**4-13**] weeks by calling:
[**telephone/fax (1) 1669**].


                             [**name6 (md) **] [**name8 (md) **] md [**md number(2) 2764**]

completed by:[**2103-7-8**]"
59,"admission date:  [**2187-12-18**]     discharge date:  [**2187-12-24**]


service:  ccu

history of present illness:  patient is an 83-year-old female
with a history of coronary artery disease status post mi and
cabg in [**2186**], hypertension, hyperlipidemia, who was
transferred from an outside hospital after she was found to
have markedly elevated cardiac enzymes consistent with a
non-st segment elevation mi.  ekg showed st depressions in
the lateral leads.

according to the patient, she was in her usual state of
health until two days prior to admission at which time she
had onset of severe diaphoresis.  there were no chest pains,
but she does report palpitations and increasing dyspnea on
exertion.  she also notes that she has had increasing
orthopnea over the last several weeks.  patient denies
nausea, vomiting, or worsening lower extremity edema.  she
notes that she has been fatigued also lately.

past medical history:
1. coronary artery disease status post myocardial infarction
in [**2186**] and subsequent cabg x4 at [**hospital6 **] in
[**2186**].
2. hypertension.
3. hyperlipidemia.
4. status post left carotid endarterectomy in [**2187-7-17**].
5. history of paroxysmal atrial fibrillation.
6. history of a pancreatic cyst and left renal cyst.

allergies:  no known drug allergies.

medications on admission:
1. aspirin 81 mg p.o. q.d.
2. lisinopril 10 mg p.o. q.d.
3. lopressor 50 mg p.o. b.i.d.
4. lipitor 20 mg p.o. q.d.
5. multivitamin q.d.
6. celebrex.
7. potassium chloride.
8. lasix 40 mg p.o. q.d.

social history:  the patient has a 20 pack year smoking
history, but she quit after her cabg.  the patient recently
resumed smoking half a pack per day for the past month.  the
patient denies alcohol use.  she lives alone.  she is widowed
with two children.

physical exam on admission:  afebrile with a blood pressure
of 145/50 and a heart rate of 79.  she was satting 99% on 3
liters of o2 by nasal cannula.  physical exam is notable for
a flat jugular venous pressure.  her heart is regular, rate,
and rhythm with a 3/6 systolic murmur heard at the left
sternal border radiating to the apex and the axilla.  there
are crackles at the left lung base, but is otherwise clear to
auscultation.  abdominal exam is benign.  there is no lower
extremity edema.  she is alert and oriented times three.

laboratories:  are notable for a white count of 11.5 and a
hematocrit of 34.0.  her creatinine is 1.5.  cardiac enzymes
are elevated.

ekg shows sinus rhythm at a rate of 72 with a q wave in lead
iii and downsloping st depressions in leads i, avl, and v4
through v6.  she has a t-wave inversion in lead ii.  these
findings are new since her previous ekg performed in [**2184-1-17**].

ct performed at the outside hospital shows no evidence of
aortic dissection.

hospital course:
1. cardiovascular:  the patient was transferred from an
outside hospital with a non-st segment elevation mi.  she
ruled in by elevated cardiac enzymes.  she was initially
admitted to the [**hospital unit name 196**] service.  the patient had not received
lasix for three days prior to admission and again her lasix
dose was held on the day of admission.

the patient was taken to cardiac catheterization and in the
holding area she was found to be hypertensive with a blood
pressure of 200/100.  in addition due to her elevated
creatinine of 1.5 on admission, the patient had been started
on iv fluid for prehydration prior to cardiac
catheterization.  in the holding area, the patient was found
to be in flash pulmonary edema.

an ekg was obtained, which showed no changes from the
previous ekg performed prior to the event.  the patient was
started on a nitroglycerin and nitroprusside drip with good
resolution of her symptoms as her blood pressure decreased.
she was also given lasix 200 mg iv to which she diuresed
well.  the patient was transferred to the ccu for further
monitoring.

the patient was eventually able to be weaned off her face
mask down to 3 liters nasal cannula.  she was monitored
overnight in the ccu with good blood pressure control as she
was transitioned from nitroglycerin and nitroprusside drip to
metoprolol and captopril p.o.  the patient was taken to
cardiac catheterization the following day.  the patient was
found to have severe three vessel disease in the native
coronary arteries.  vein graft angio revealed a patent svg to
om graft supplying the distal left circumflex.  she was noted
to have severe diastolic dysfunction as well as right renal
artery stenosis.  the patient underwent successful stenting
of the distal lmca/proximal ra with a cypher stent.

the patient was placed on integrilin and plavix and sent back
to the ccu for further monitoring.  the patient had no
further episodes of shortness of breath or chest pain.  pt
consult was obtained prior to discharge, and she was found to
have very good functional status.  the patient will be
discharged on aspirin, plavix, lipitor, atenolol, and
lisinopril.  an echocardiogram was performed prior to
discharge.  she was noted to have an ejection fraction of
greater than 55%.  there was mild symmetric left ventricular
hypertrophy with normal cavity size.  regional left
ventricular wall motion was normal.  there was mild aortic
valve stenosis as well as moderate mitral regurgitation.  the
left atrium was mildly dilated.  there was also mild
pulmonary artery systolic hypertension.

2. gastrointestinal:  the day following cardiac
catheterization, the patient was found to have a bloody bowel
movement.  in the early morning hours of [**12-21**], she
passed dark maroon colored stools and also possibly melena. a
gi consult was obtained and there was a prolapsed internal
hemorrhoid that was mildly excoriated, but not thrombosed
found on physical exam.  her hematocrit dropped from a
precath level of 35.2 down to 27.1 on the morning of the
bleed.  the patient was resuscitated with iv fluids as well
as 2 units of packed red blood cells.

an upper endoscopy was performed, which showed a small hiatal
hernia, schatzki's ring, blood in the stomach, but an
otherwise normal egd.  gi consult felt that her stools were
most likely due to a lower gi bleed.  they recommended
following her hematocrit.  there was no indication for urgent
colonoscopy.  patient's hematocrit was followed throughout
the remainder of the hospitalization and it remained stable.
she had another brownish bowel movement with streaks of blood
prior to discharge.  the patient stated, however, that this
is her normal bowel movement and she normally has streaks of
blood due to her internal hemorrhoids.  gi recommended
following up for a colonoscopy in [**4-22**] months following
discharge.  the patient remained hemodynamically stable
during the gi bleed event on [**12-21**] and throughout the
remainder of her hospitalization.

3. pulmonary:  on the morning of cardiac catheterization, the
patient was found to have to be in flash pulmonary edema.
cardiac enzymes and ekgs were followed, but there was no
evidence to suggest a re-infarction as the cause of her flash
pulmonary edema.  the cause of the pulmonary edema was most
likely severe diastolic dysfunction with an elevated blood
pressure of 200/100 as well as the holding of her lasix dose
for the four days prior to cardiac catheterization.  the
patient was initially hypoxic to 80% on room air.  patient
was placed on face mask and given a lasix dose of 200 mg iv
with good diuresis.  her o2 saturations quickly improved to
the high 90s on face mask and she was eventually able to be
weaned off down to nasal cannula.  the patient had no further
episodes of pulmonary edema, and she was restarted on a dose
of lasix of 20 mg p.o. q.d. prior to hospital discharge.
patient was found to have good ambulating o2 saturations also
prior to discharge.

condition on discharge:  stable, ambulating without
assistance, breathing on room air, chest pain free with no
evidence of orthostasis.

discharge status:  patient is discharged to home without any
services.

discharge diagnoses:
1. non-st segment elevation myocardial infarction status post
stent of the distal left main coronary artery/proximal ri.
2. diastolic dysfunction.
3. flash pulmonary edema.
4. anticoagulation related adverse events leading to blood
loss.
5. lower gastrointestinal bleed.
6. internal hemorrhoids.

discharge medications:
1. aspirin 325 mg p.o. q.d.
2. atorvastatin 40 mg p.o. q.d.
3. plavix 75 mg p.o. q.d. x3 months.
4. lisinopril 20 mg p.o. q.d.
5. pantoprazole 40 mg p.o. q.d.
6. lasix 20 mg p.o. q.d.
7. multivitamin p.o. q.d.
8. atenolol 37.5 mg p.o. q.d.

followup:
1. patient is asked to followup with her primary care
physician, [**last name (namepattern4) **]. [**first name (stitle) **] [**name (stitle) 30747**] on wednesday, [**12-26**] at
3:15 p.m.
2. patient is asked to followup with her cardiologist, dr.
[**last name (stitle) 3497**] on [**1-25**] at 9:20 a.m.
3. patient has a previously scheduled follow-up appointment
with her general surgeon, who performed her left carotid
endarterectomy.  he has also been following her for her
pancreatic cyst.
4. patient should follow up with a gastroenterologist to
obtain a colonoscopy in [**4-22**] months.  a letter has been
written by the gi consult service to her primary care
physician, [**last name (namepattern4) **]. [**first name (stitle) **] [**name (stitle) 30747**] detailing the events surrounding
her gi bleed as well as need for colonoscopy.  gi consult
asked dr. [**last name (stitle) 30747**] in a letter to arrange a follow-up
appointment with a gastroenterologist.



                          [**first name11 (name pattern1) **] [**last name (namepattern4) **], m.d.12.222

dictated by:[**name8 (md) 4993**]

medquist36

d:  [**2187-12-24**]  12:47
t:  [**2187-12-26**]  05:32
job#:  [**job number 54449**]
"
60,"admission date:  [**2131-8-2**]              discharge date:   [**2131-8-21**]

date of birth:  [**2067-11-7**]             sex:   m

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 2297**]
chief complaint:
reason for admission: seizures


major surgical or invasive procedure:
none.

history of present illness:
mr. [**known lastname 916**] is a 63yo male with pmh significant for seizures,
atrial fibrillation, and s/p cabg who is being transferred from
osh for management of seizures. per patient's wife, on tuesday
the patient complained of seeing spots in his eyes. on wednesday
night/early morning the patient complained of seeing spots
again. at approximately 4am mr. [**known lastname 916**] attempted to go the
bathroom but fell on the floor at which time his wife woke up
and found her husband seizing. she called 911 and the patient
was brought to [**hospital 1562**] hospital. initial vitals in ed were t
100.4 bp 182/66 ar 128 rr 14 o2 sat 96% ra. in the ed he had
another generalized tonic clonic seizure. he was given keppra
via the ngt. he was intubated for airway protection. per osh
records, the intubation was difficult and required help of
anesthesiologist. ct scan of head and c spine were unrevealing.

.
he was then transferred to the icu for closer management. in the
icu the patient spiked a temperature to 102 and he was given
rocephin and clindamycin for suspected aspiration pneumonia. on
[**8-2**] at 3am patient went into 15-30 minutes of status
epilepticus. he was loaded with dilantin 500mg iv x1. and placed
on benzos. ventilation settings at this time were: simv tv 600
rr 10 fio2 60% ps 15 peep 5. he was then transferred to [**hospital1 18**]
for further management.
.
per patient's wife, he was diagnosed with seizures 1 year ago
when he had a seizure at home and presented to [**hospital1 2025**]. found to
have cva which was thought to be cause of seizure. he was
started on keppra. he has not had a seizure since then but has
complained of seeing spots occasionally. she is followed closely
by her neurologist and saw him 1 month ago.
.
no recent fevers, chills, chest pain, sob, dizziness, or
dysuria. per wife, the patient has good and bad days but had
been feeling well prior to this admission.


past medical history:
1)cad s/p cabg 9 years ago
2)seizure disorder-last seizure 1 year ago
3)atrial fibrillation on anticoagulation
4)ulcerative colitis


social history:
patient lives with wife in [**hospital3 **]. currently retired. no
history of tobacco, alcohol, or ivda.

family history:
nothing relevant, per wife

physical exam:
vitals t 102.4 bp 159/114 ar 103 rr 14
vent settings: ac fi02 1.0 tv 600 rr 14 peep 5
gen: patient sedated, responsive to sternal rub
heent: ett in place
heart: irregularly, irregular. +systolic murmur
lungs: course breath sounds anteriorly
abdomen: obese, soft, nt/nd, decreased bss
extremities: no edema, 2+ dp/pt pulses bilaterally


pertinent results:
[**2131-8-2**] 05:30pm   pt-24.6* ptt-43.6* inr(pt)-2.5*
[**2131-8-2**] 05:30pm   plt count-259
[**2131-8-2**] 05:30pm   wbc-5.7 rbc-3.38* hgb-12.9* hct-37.5*
mcv-111* mch-38.3* mchc-34.6 rdw-16.1*
[**2131-8-2**] 05:30pm   tsh-0.39
[**2131-8-2**] 05:30pm   albumin-3.1* calcium-8.1* phosphate-3.1
magnesium-2.4
[**2131-8-2**] 05:30pm   ck-mb-6 ctropnt-0.10*
[**2131-8-2**] 05:30pm   lipase-12
[**2131-8-2**] 05:30pm   alt(sgpt)-25 ast(sgot)-27 ld(ldh)-312*
ck(cpk)-187* alk phos-47 amylase-174* tot bili-1.5
[**2131-8-2**] 05:30pm   glucose-124* urea n-14 creat-1.2 sodium-143
potassium-3.9 chloride-111* total co2-21* anion gap-15
[**2131-8-2**] 06:11pm urine  uric acid-few
[**2131-8-2**] 06:11pm urine  rbc-[**5-13**]* wbc-[**2-5**] bacteria-few
yeast-none epi-0-2
[**2131-8-2**] 06:11pm urine  blood-lg nitrite-neg protein-tr
glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0
leuk-neg
[**2131-8-2**] 06:11pm urine  color-amber appear-clear sp [**last name (un) 155**]-1.028
[**2131-8-2**] 09:51pm   phenytoin-4.5*
[**2131-8-2**] 09:51pm   digoxin-0.9
[**2131-8-2**] 10:51pm   type-art temp-38.2 rates-14/0 tidal vol-600
peep-5 o2-60 po2-133* pco2-43 ph-7.36 total co2-25 base xs--1
-assist/con intubated-intubated
[**2131-8-3**] 03:22am blood wbc-5.0 rbc-3.24* hgb-12.3* hct-34.8*
mcv-107* mch-38.0* mchc-35.4* rdw-17.3* plt ct-223
[**2131-8-4**] 03:14am blood wbc-4.5 rbc-2.98* hgb-11.3* hct-32.0*
mcv-107* mch-38.1* mchc-35.4* rdw-16.8* plt ct-209
[**2131-8-3**] 03:22am blood glucose-115* urean-12 creat-1.2 na-143
k-4.0 cl-113* hco3-21* angap-13
[**2131-8-3**] 03:44pm blood glucose-119* urean-10 creat-1.0 na-143
k-3.7 cl-111* hco3-21* angap-15
[**2131-8-4**] 03:14am blood glucose-119* urean-8 creat-0.9 na-143
k-3.6 cl-110* hco3-21* angap-16
[**2131-8-5**] 03:01am blood glucose-92 urean-5* creat-0.8 na-146*
k-3.2* cl-111* hco3-25 angap-13
[**2131-8-5**] 03:01am blood lipase-75*
[**2131-8-3**] 03:22am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-pos barbitr-neg tricycl-neg

[**hospital 93**] medical condition:
63 year old man with sob, hypoxia
reason for this examination:
r/o dvt
shortness of breath and hypoxia. question dvt.

grayscale and doppler son[**name (ni) 1417**] were performed of the ij,
subclavian and axillary veins on the left and of the ij on the
right. there was diminished compressibility in the left cephalic
vein compatible with acute thrombosis. there was normal
compressibility, flow, and augmentation in the other vessels.

impression: superficial venous thrombus noted in the cephalic
vein. no dvt.

[**hospital 93**] medical condition:
63 year old man with sob, hypoxia
reason for this examination:
r/o dvts
indication: rule out dvt.

[**doctor last name **] scale and doppler son[**name (ni) 1417**] of bilateral common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins was performed. there is normal compressibility, color
flow, and augmentation.

impression: no evidence of right or left leg dvt.

the study and the report were reviewed by the staff radiologist.
dr. [**first name4 (namepattern1) 19115**] [**last name (namepattern1) **]
dr. [**first name11 (name pattern1) 8711**] [**initial (namepattern1) **] [**last name (namepattern4) **]
approved: fri [**2131-8-17**] 8:37 am

brief hospital course:
hd#1 ([**2131-8-2**]):  patient arrived in the [**hospital1 18**] micu-6 the
afternoon of [**2131-8-2**] intubated, sedated and in stable condition
with ngt in place.  on arrival active patient medications
included keppra 1000 mg [**hospital1 **] and sedation with fentanyl 50 mcg/hr
and midazolam 4 mg/hr.  all other home medications were intially
held.  given suspicion for meningitis in the setting of seizure
+ fevers patient was given one dose of ceftriaxone 2 gm iv with
infectious disease consent required for further treatment.
also, a history suspicious for patient was sent for urgent mra
of head & neck and mr of head which showed:  1)no enhancing
lesions.  chronic infarct in left parieto-occipital lesion, and
2)50% narrowing of right proximal ica.  left ica origin
atheroma.""  patient was initially seen on unit by neurology who
recommended continuation of keppra, eeg to evaluate for seizure
activity, echo for new murmur + fever, lp when inr < 1.5, and an
increase in versed drip with consideration of dilantin load if
patient seized again.  suctioning from ett showed brownish-grey
aspirate and ua that day showed no organisms.  patient remained
febrile throughout first day in micu.
.
hd#2 ([**2131-8-3**]):  patient received tylenol for fever overnight
and had echo and eeg in the morning.  echo showed no signs of
valvular vegetations and eeg showed no signs of an epileptiform
focus.  in the setting of seizure + fevers meningitis remained
at the top of our differential diagnosis and an lp was arranged.
 prior to admission patient had taken coumadin for his atrial
fibrillation and on transfer to micu initial inr was 2.5,
patient was initially given 3 units of ffp with following
inr=1.7.  transfusion of two more units of ffp resulted in no
change in inr so plan for lp was aborted.  during the day
patient became very anxious, became tachycardic to the 140s,
began demonstrating tremor in his lower extremities bilaterally
and started pulling against his restraints.  his fentanyl was
incresaed to 75 mg/hr and versed was increased to 5.0 mcg/hr.
he was also bolused with dilantin 1000 mg iv once since patient
was also displaying tremor in le bilaterally while sedated.
patient remained tachycardic to the 120s-130s depsite the
increase in sedation and diltiazem 60 mg po qid was started with
diltiazem 5 mg iv for immediate control.  to empirically cover
aspiration pneumonia vancomycin & flagyl were started and id
approval for ceftriaxone therapy (to cover pneumococcus) was
obtained.  ampicillin was also started to cover listeria
monocytogenes and acyclovir was started due to concern for hsv
encephalitis after blood drawn for hsv pcr.  temperature spiked
to 101 at 18:00 with repeat panculture including mini-bal which
showed 1+ pmns and oropharyngeal flora.  ett was advanced 1 cm
after cxr showed approx 5 cm above the carina.  patient remained
npo.
.
hd#3 ([**2131-8-4**]):  patient remained febrile and began having
episodes of loose stools.  patient with long history of
ulcerative colitis, but stool sample sent for c.diff toxin which
was negative.  restarted on 6-mercaptopurine for uc.  lp was
re-attempted prior to which patient received an additional 5
units of ffp with following inr=1.3.  following lp tube feedings
were intiated and changed later in the day to include fiber with
a goal of 90 cc/hr.  urine output was noted to be poor, patient
putting out approximately 15 cc/hr.  two fluid boluses of 500 cc
were given with no effect.
.
hd#4 ([**2131-8-5**]):  patient remained febrile, with attempts to wean
sedation aborted due to increased patient anxiety/agitation.  in
light of negative blood/csf/urine cultures acyclovir, ampicillin
and ceftriaxone were discontinued.  mr. [**known lastname 916**] continued to take
vancomycin for [**8-4**] sputum culture that grew 2+ g(+) cocci in
pairs and clusters and flagyl for empiric tx of c.diff diarrhea
despite negative stool toxin screens.  ct of chest with contrast
showed:  1)bilateral pleural effusions with associated
atelectasis & consolidation, left>right, 2)2 small pulmonary
nodules in rul ~4 cm in diameter, 3)airspace disease in the lul,
and 4)coronary artery and mitral annulus calcifications.
.
hd#5 ([**2131-8-6**]):  patient continued to be febrile, reaching
temperature of 102 degrees overnight.  also continued to have
loose stools with output of 2l, flagyl discontinued due to
multiple negative c.diff toxin screens.  however, stool was
re-sent for c.diff a&b toxins and banana flakes were added to
tube feeds to bulk-up stools.  plan for gi consult the following
day.  urine output continued to be poor, patient was given
one-time dose of lasix iv 40 mg with transient increase in uop.
patient was placed on trial of pressure support starting @ 13:00
and continuing on throughout the night without adverse events.
sedation was gradually weaned with fentanyl decreased from 75
mcg/hr to 60 mcg/hr and versed at 4.0 mg/hr.  patient continued
to have episodes of anxiety throughout the day for which he was
given lorazepam 1 mg iv for breakthrough relief.  picc line was
place in right arm in the a.m.  zosyn 4.5 mg iv q8h was started
to empirically cover g(-) organisms causing pneumonia
.
hd#6 ([**2131-8-7**]):  no high fever spikes, but patient ran low-grade
fever of 100.5.  per cxr, pna not progressing/worsening.
azithromycin 500 mg po bid added to cover atypical causes of pna
(mycoplasma/chlamydia/etc).  gi consulted for increased, watery
stool output (patient has h/o uc treated with 6-mp, requested
consult to determine any additional management
options/symptomatic relief).  no recommendations per gi, cannot
determine at this time if current stooling is any change from
baseline.  per neurology, keppra dose was increased to 1250 mg
po bid (from 1000 mg).  patient on coumadin as outpatient for
a.fib, held on admission to perform lp.  heparin ggt restarted
for dvt prophylaxis.  given another single dose of lasix 40 mg
iv to removed third-spaced fluid, net -850 cc at end of day with
los fluid net +8.6l.  diltiazem ggt titrated up to 10 u/hr to
maintain hr<100 bpm.  overnight, patient became agitated on
cpap+ps, ac restarted briefly for a few hours and placed back on
pressure support.
.
hd#7 ([**2131-8-8**]):  patient placed back on pressure support with ps
15/peep 8 (increased from [**11-7**]).  arterial line placed in right
arm without complications.  abg showed 7.44/33/102/23.  dosed
again with lasix 40 mg iv to removed fluid that had third spaced
into tissues/pleural space.  continued vanc/zosyn/azithro.
again spiked temperature to 101.5 degrees at mid-day and was
pancultured.  patient also became tachycardic with hr increase
to 130s-140s, diltiazem drip increased to 10 mg/hr.  began
having apneic episodes on pressure support and was placed back
on ac at 20:00.  sedation weaned to versed 3.0 mg/hr and
fentanyl 25 mcg/hr.  lost last piv access, patient only with
arterial line and right picc line.  k 3.2, corrected.  tube
feeds held due to continued high gastric residuals.  during late
afternoon/evening patient was dosed once again with lasix 20 mg
iv with repeat cr 1.8.
.
hd#8 ([**2131-8-9**]):  cr this a.m. 2.0.  urine sent for urine lytes
(na, bun, creatinine), urine eosinophils, microscopic analysis.
likely due to hypovolemia secondary to diuresis.  lasix held
today, monitoring cr for improvement of [**last name (un) **].  throacic
ultrasound performed to look for possible empyema/loculated
plueral effusions and did not reveal any significant fluid
collection that would benefit from throacentesis.  patient
remained on ac vent overnight, risbi in the a.m. 103, mid-day
abg on ac 7/46/36/106.  decided to give patient spontaneous
breathing trial.  patient maintained own ventilation for 30 min
at which time respirations were ~40/min, sao2 92% and patient
having difficulty breathing.  trial was stopped and patient put
back on pressure support with ps 5/peep 0.  id consulted for
further work-up of fuo.  recommended checking borellia and
ehrlichia serologies and inspecting peripheral smear of blood
for parasites (babesiosis) if spiked temp again.  also
recommended changing azithromycin to doxycycline if spiked temp
again.  later in evening patient spiked temp to 102.5 and id
recs were instituted.
.
hd#9 ([**2131-8-10**]):  renal consulted for decline in renal fxn and
proposed atn vs. prerenal azotemia vs. ain, though most likely
non-oliguric atn.  recommended increase in free water intake as
patient was also hypernatremic and renally dosing medications.
renal us showed no evidency of hydronephrosis.  had ct of
head/sinuses which showed no acute sinusitis with mild mucosal
thickening and non-contrast ct of chest & abdomen which showed:
1.  bilateral pleural effusions with associated atelectasis and
consolidation, greater on the left than the right.  this is
stable from prior exam. 2.  stable pulmonary nodules in the
upper lobe. 3.  stable extensive coronary artery and aortic
calcifications. 4.  no discrete focus of infection is identified
although this study is limited by lack of contrast. 5.  anasarca
of the body wall in abdomen and pelvis.
.
hd#10 ([**2131-8-11**]):  stopped diltiazem gtt & started esmolol gtt to
control hr & bp.  sedation weaned and discontinued and patient
extubated, after which patient was tachypneic but abgs looked
good.  id recommended further checking cmv serologies, patient
spiked temp to 101 and blood was cultured again for anaerobic
bacteria and fungus.
.
hd#11 ([**2131-8-12**]):  patient continued tx with iv vancomycin (dosed
by levels) and renally-dosed zosyn.  received 1 gm vanc when
afternoon levels 13.5.  attempted to wean esmolol gtt, could not
maintain adequate control of hr & bp.  stopped drip and gave
metoprolol 25 mg po tid, soon increased to 75 mg po tid with
additional dosing of diltiazem 10 mg iv once to control rate.
patient then started on diltiazem 30 mg po qid in addition to
metoprolol 75 mg po tid to control rate, though patient
continued to be tachycardic and htnive throughout day.
metroprolol increased to 100 mg po tid and diltiazem increased
to 60 mg po qid.  overnight patient remained confused, likely
residual effect of multiple heavy sedatives, and attempted to
climb out of bed and required one-time doses of ativan &
zyprexa.  patient will require one-on-one sitter upon tx to
floor.  patient had tee which showed no vegetations and severely
deformed aortic valve.  d/c'd doxycycline per id recs and had
repeat cxr due to increased airway secretions and concern over
?aspiration while taking a.m. medications.  order placed for
speech & swallow eval, post-poned until tomorrow due to patient
having brief episode of tachypnea and sats down to 92% requiring
non-rebreating mask.  per renal, adjusted dose of keppra
according to gfr, approved by neuro and will be seen by their
service tomorrow.  na noted to be 149 and given 1l d5w over 24
hours.
.
hd#12 ([**2131-8-13**]):  patient not seen by neuro.  patient continued
to be hypernatremic and was given 1l d5w @ 200 cc/hr and another
at 125 cc/hr.  metoprolol was increased to 100 mg po tid and
diltiazem was increased to 60 mg po qid to control heart rate.
per nursing that morning, patient had questionable episode of
aspiration while taking morning medications.  repeat cxr showed
marginal worsening infiltrates in the rml.  later that night
patient dropped sats to 85% and given cpap for 30 minutes with
improvement.  he had several hours of respiratory stability but
eventually re-developed tachypnea (50) and hypoxemia (7.48/36/61
on nrb) followed by an episode of hypotension and was
re-intubated.  the rest of hospital summary will be in
problem-based format:
.
1)hypoxic respiratory failure: patient intubated @ osh in
setting of status epilepticus in order to protect airway.
initially struggling against ventilator requiring increases in
sedation, suctioning of ett showing brownish-[**doctor last name 352**] sputum. now
weaning sedation with vent on cpap+ps as patient tolerates,
decreased sputum production. arterial line placed [**2131-8-8**], d/ced
by pt on [**8-11**]. pt extubated [**8-11**], required supplemental o2 via nc
and hiflow nrb over following days & developed tachypnea and
hypoxia early morning of [**8-15**] requiring re-intubation. [**8-15**] leni
and l ueni show no dvt, ct chest same day showing new bilat ll
consolidation concerning for aspiration, bridging
small-to-moderate pleural effusions and new hydrostatic
pulmonary edema. bnp 30,173 on [**8-15**]. serial cardiac enzymes r/o
mi.
-rested overnight on psv, good sbt this a.m. and extubated
without complications. ngt placed prior to extubation for tube
feedings due to recent h/o aspiration.
-continue suppl. 02, wean as tolerated to maintain sa02 >90%.
chest pt. patient oob with assist to chair.
-thoracic us [**8-16**] showed ~1.6 ml of pleural fluid, ip unable to
tap effusions.
-aspriation pna most likely culprit, cont iv vanc/zosyn renal
dosing. concern for developing lung abscess. currently on day
13/14 of zosyn regimen, will extend until chest can be re-imaged
and abscess confirmed/ruled-out.
-continue lasix gtt with goal of net negative 1l fluid balance
today. if patient auto-diureses may stop gtt and begin scheduled
regimen.
-daily cxr
-pt to evaluate for rehab.
.
2)fevers: patient presents with fevers since he was admitted to
osh. likely cause of new onset seizures. possible sources of
infection include lll infiltrate. no report of productive cough,
dysuria, other symptoms at home. still unclear source. tee done,
blood and urine negative to date, cdiff negative, csf negative.
lack of leukocytosis may be due to uc tx with 6-mp. [**8-4**], [**8-5**],
[**8-6**] c.diff screens negative.
[**8-4**] blood culture showing not growth. [**8-11**] non-contrast ct of
head/chest/abdomen for eval of possible sinusitis and
surveillance of occult focus of infection =>no infectious
source. pt continues to spike temps nightly. [**2131-8-13**] tee shows
not evidence of endocarditis and a severely deformed aortic
valve. -lyme, -hsv, c.diff toxin b negative. relatively afebrile
[**8-12**] through [**8-14**] but spiked temp to 102 degrees am of [**8-15**],
resolved to low-grade temp ~100.5 by [**8-20**]. negative
ehrlichia/coxiella/legionella bal culture.
- tylenol prn for fever
- continue broad coverage of pna. zosyn renally dosed to 2.25 gm
iv q6 hours, back on scheduled vanc 750 mg iv daily, follow vanc
levels
- check routine vanc levels.
- f/u [**8-15**] and [**8-17**] blood cultures as well as [**8-11**] fungal/afb
cultures. c.diff rechecked and negative [**8-17**].
- f/u additional id recs, appreciate input,
.
3)acute kidney injury: cr stable now. likely due to
hypovolemia/prerenal azotemia secondary to lasix diuresis. urine
lytes show no eosinophiluria, fena and feuria indicate intrinsic
renal etiology of [**last name (un) **].
- cr stable, monitor daily
- renal consult, appreciate recs
- dose medications for patient's creatinine
- continue lasix gtt, stop if cr >2.5. [**month (only) 116**] start schuled iv
lasix this pm.
.
4)hypernatremia: increased to 149 [**2131-8-14**] & decreased to 139
with d5w supplementation. morning of [**8-15**] found to be 155 but
patient sedated after reintubation and difficult to assess for
mental status changes. patient with good uop.
-na now wnl
-ngt placed prior to extubation and tube feedings stopped. [**month (only) 116**]
gently re-start tube feedings this pm. d/c free water boluses.
-continue lasix gtt and monitor uop.
-daily chem7.
.
5)atrial fibrillation: patient remains in atrial fibrillation;
confirmed by ekg on admission to osh and [**hospital1 18**]. previously on
coumadin for a.fib.
- on heparin drip at 1400 u/hr. holding coumadin 5 mg po daily.

- [**2131-8-9**] shows severe as with valve diameter of 0.8 cm2. patient
will need aggressive rate control to decrease stress to heart.
- continue metoprolol 100 mg tid, po diltiazem increased at 90
mg po qid.
.
6)seizure disorder (requiring intubation): patient was diagnosed
with seizure disorder 1 year ago in setting of cva. now presents
with recurrent seizures despite being on keppra. differential
for seizures include infection, stroke, metabolic
encephalopathy, drugs, head trauma, tumors, etc. most likely
infection since patient has been febrile. concerned about
meningitis as a possible etiology though ruled out by negative
lp. [**2131-8-3**] mra head/neck and mr of head show no new enhancing
lesions. same day echo for new murmur showed no vegetations and
eeg showed no epileptiform focus.
- infectious etiology continues to be at top of differential,
but pneumonia only foci identified thus far.
- keppra renally-dosed to 750 mg po bid, approved by neuro.
- iv ativan if patient becomes symptomatic for seizures
.
7)ulcerative colitis: patient on mercaptopurine as outpatient.
per wife, patient has history of cramping and loose stools on a
regular basis.
- continue mercaptopurine 75 mg po daily. 400 cc stool op
yesterday.
- per gi consult, no evidence current stool op is change from
baseline.
- banana flakes added to tube feeds if having loose stools.
.
8)cad s/p cabg: no complaint of recent sob or chest pain during
this admission.
- continuing home statin, on oral beta blocker and ccb for rate
& pressure control.
.
9)fen:
- speech & swallow evaluation shows okay to take pre-thickened
nectar feeds, however will initially feed via ngt s/p
extubation.
- repeat speech & swallow study in the am
- restart nutren full-strength tube feedings tonight at 10 cc/hr
with goal of 45 cc/hr, advance as tolerated and checking
residuals q6 hours
.
10)access: right picc line placed [**2131-8-6**]. arterial line placed
[**2131-8-15**] in rue and pivx1 (20g).
.
11)prophylaxis: iv heparin, ppi.
.
12)code: full (verified with wife
.
13)dispo:  c/o to floor bed.
.
final instructions to accepting team:
1)  monitor na
2)  follow mental status for return to baseline.  will likely
need 1:1 sitter due to increased pm agitation, pulling ngt,
well-controlled with iv ativan.
3)  continue iv zosyn (day 14) due to concern for ? lung
abscess.  per id okay to d/c vanc (18 day course total)
4)  follow-up 9/12 & [**8-17**] blood cultures, [**8-11**] fungal/afb culture
5)  wean 02, continue chest pt and
6)  speech & swallow to perform video swallow eval once mental
status improves
7)  screen for rehab
8)  f/u pt/ot consult on day of transfer, oob with assistance.

medications on admission:
digoxin
diltiazem 240mg po daily
lasisx 40mg po daily
isordil
coumadin
omeprazole
purinethol 75mg po daily
keppra 750mg po daily


discharge medications:
keppra 750 mg po bid
diltiazem 90 mg po qid
metoprolol 100 mg po tid
asa 81 mg po daily
lasix 40 mg iv bid
zosyn 2.25 gm iv q6 hours (day 14/16)
protonix 40 mg iv daily
mercaptopurine 75 mg po daily
ativan 1 mg iv prn agitation

discharge disposition:
extended care

facility:
[**hospital3 105**] northeast - [**location (un) 701**]

discharge diagnosis:
recurrent seizures/status epilepticus of unknown etiology
requiring intubation complicated by aspiration pneumonia and
recurrent fevers.

discharge condition:
stable, mental status not returned to baseline.

discharge instructions:
please keep all scheduled medical appointments.  call a
physician or go to the emergency room if experiencing the
following symptoms:  chest pain, shortness of breath, change in
mental status/increased confusion, fever greater than 102
degrees, recurrent seizures or loss of consciousness, onset of
weakness or loss of sensation or any other concerning symptoms.

followup instructions:
please call your neurologist and primary care provider within
two weeks of leaving rehabilitation to set up an appointment.
please also have your primary care provider refer you to a
cardiologist or see your pre-existing cardiologist to evaluate a
valvular abnormality that was noted during your hospital stay.


"
61,"admission date:  [**2119-2-22**]              discharge date:   [**2119-2-25**]

date of birth:  [**2088-12-4**]             sex:   m

service: neurosurgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1835**]
chief complaint:
headache

major surgical or invasive procedure:
[**2119-2-22**]:  suboccipital craniotomy for chiari decompression


history of present illness:
patient is a 30m electively admitted for chiari type i
decompression.

past medical history:
osa
chiari malformation(type i)

social history:
non-contributory

family history:
non-contributory

physical exam:
exam on discharge:
neurologically intact

pertinent results:
[**2119-2-25**] 06:05am blood wbc-8.2 rbc-4.07* hgb-12.4* hct-35.7*
mcv-88 mch-30.4 mchc-34.6 rdw-12.4 plt ct-284
[**2119-2-25**] 06:05am blood plt ct-284
[**2119-2-25**] 06:05am blood glucose-106* urean-13 creat-0.8 na-136
k-4.1 cl-98 hco3-26 angap-16
[**2119-2-25**] 06:05am blood calcium-9.6 phos-4.3 mg-2.1
[**2119-2-25**] 06:05am blood glucose-106* urean-13 creat-0.8 na-136
k-4.1 cl-98 hco3-26 angap-16
[**2119-2-25**] 06:05am blood calcium-9.6 phos-4.3 mg-2.1

brief hospital course:
patient is a 30m electively admitted for suboccipital craniotomy
for chiari type i malformation. operative course was uneventful,
and he was taken to the icu post-operatively for close
neuromonitoring overnight. post-op head ct showed no hemorrhage.
there were no adverse events overnight. he was transfered to the
floor on [**2119-2-23**], his pca was discontinued and given po
medications. he continued with normal expected headaches
throughout his hospitalization. his incision was clean and dry.
on discharge he was voiding, tolerating a regular [**date range **] and had a
normal neurological exam.

medications on admission:
ambien prn, motrin prn, fluocinonide prn

discharge medications:
1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
disp:*60 capsule(s)* refills:*2*
2. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours)
as needed for pain.
disp:*40 tablet(s)* refills:*0*
3. methocarbamol 500 mg tablet sig: 1.5 tablets po qid (4 times
a day).
disp:*180 tablet(s)* refills:*2*
4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
5. glucagon (human recombinant) 1 mg recon soln sig: one (1)
recon soln injection q15min () as needed for hypoglycemia
protocol.


discharge disposition:
home

discharge diagnosis:
chiari type i malformation


discharge condition:
neurologically stable


discharge instructions:
general instructions
wound care
??????	you or a family member should inspect your wound every day and
report any of the following problems to your physician.
??????	keep your incision clean and dry.
??????	you may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
??????	do not apply any lotions, ointments or other products to your
incision.
??????	do not drive until you are seen at the first follow up
appointment.
??????	do not lift objects over 10 pounds until approved by your
physician.
[**name10 (nameis) **]
usually no special [**name10 (nameis) **] is prescribed after a craniotomy. a
normal well balanced [**name10 (nameis) **] is recommended for recovery, and you
should resume any specially prescribed [**name10 (nameis) **] you were eating
before your surgery.
medications:
??????	take all of your medications as ordered.  you do not have to
take pain medication unless it is needed.  it is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
??????	do not use alcohol while taking pain medication.
??????	medications that may be prescribed include:
-narcotic pain medication such as dilaudid (hydromorphone).
	-an over the counter stool softener for constipation (colace or
docusate). if you become constipated, try products such as
dulcolax, milk of magnesia, first, and then magnesium citrate or
fleets enema if needed). often times, pain medication and
anesthesia can cause constipation.
??????	unless directed by your doctor, do not take any
anti-inflammatory medicines such as motrin, aspirin, advil, and
ibuprofen etc, as this can increase your chances of bleeding.
activity:
the first few weeks after you are discharged you may feel tired
or fatigued. this is normal. you should become a little stronger
every day. activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. in general:
??????	follow the activity instructions given to you by your doctor
and therapist.
??????	increase your activity slowly; do not do too much because you
are feeling good.
??????	you may resume sexual activity as your tolerance allows.
??????	if you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
??????	do not drive until you speak with your physician.
??????	do not lift objects over 10 pounds until approved by your
physician.
??????	avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
??????	   do your breathing exercises every two hours.
??????	   use your incentive spirometer 10 times every hour that you
are awake.

when to call your surgeon:
with any surgery there are risks of complications. although your
surgery is over, there is the possibility of some of these
complications developing. these complications include:
infection, blood clots, or neurological changes. call your
physician immediately if you experience:

??????	confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
??????	double, or blurred vision. loss of vision, either partial or
total.
??????	hallucinations
??????	numbness, tingling, or weakness in your extremities or face.
??????	stiff neck, and/or a fever of 101.5f or more.
??????	severe sensitivity to light. (photophobia)
??????	severe headache or change in headache.
??????	seizure
??????	problems controlling your bowels or bladder.
??????	productive cough with yellow or green sputum.
??????	swelling, redness, or tenderness in your calf or thigh.

call 911 or go to the nearest emergency room if you experience:
??????	sudden difficulty in breathing.
??????	new onset of seizure or change in seizure, or seizure from
which you wake up confused.
??????	a seizure that lasts more than 5 minutes.

important instructions regarding emergencies and after-hour
calls
??????	if you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
??????	should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
.

followup instructions:
follow-up appointment instructions

??????please return to the office in [**11-9**] days (from your date of
surgery) for removal of your sutures and a wound check. this
appointment can be made with the nurse practitioner.  please
make this appointment by calling [**telephone/fax (1) 1669**]. if you live quite
a distance from our office, please make arrangements for the
same, with your pcp.
??????please call ([**telephone/fax (1) 88**] to schedule an appointment with dr.
[**last name (stitle) **], to be seen in 2 weeks.
??????you will not need a ct scan of the brain.



completed by:[**2119-10-4**]"
62,"admission date:  [**2154-1-14**]              discharge date:   [**2154-1-20**]

date of birth:  [**2097-6-25**]             sex:   m

service: surgery

allergies:
penicillins / levaquin / dextromethorphan / adhesive tape /
actigall / zithromax

attending:[**first name3 (lf) 1556**]
chief complaint:
s/p gallstone pancreatitis, now resolved, presenting for
scheduled cholecystectomy.

major surgical or invasive procedure:
1. open cholecystectomy with intraoperative cholangiogram.
2. incisional hernia repair with implantation of prosthetic
mesh.


history of present illness:
the patient is a 56-year-old man who is status post open gastric
bypass surgery approximately 9 months previously. he lost
approximately 135 pounds before he
developed gallstone pancreatitis. the pancreatitis had resolved
and therefore cholecystectomy was indicated. he unfortunately
did have an enormous ventral incisional hernia which rendered
laparoscopic approach impractical.  we
therefore elected for open repair with mesh.


past medical history:
hypertension
diabetes, type 2
hyperlipidemia
gastroesophageal reflux
ostructive sleep apnea on cpap
history of kidney stones
osteoarthritis of the hips, knees and thumbs
fatty liver
colonic polyps (benign)
history of iron deficiency anemia


social history:
tobacco: none
etoh: occasional wine
married, lives with wife


family history:
non-contributory

physical exam:
vital signs: t 97.4  hr 76  bp 116/64  rr 14  o2 sat 98% ra
general: alert and oriented, no acute distress
cardiovascular: rrr, no murmurs, rubs or gallops
pulmonary: clear to ascultation bilaterally
abdomen: obese, soft, minimally tender around incision site, non

distended, no guarding or rebound, incision clean, dry and
intact, there are two abdominal jp drains, draining clear
serosanguinous fluid
extremities: 1+ pedal edema bilaterally


pertinent results:
[**2154-1-15**]  hct-36.7
[**2154-1-18**]  hct-29.8

[**1-15**]/ glucose-161 urean-18 creat-1.8 na-134 k-4.9 cl-98 hco3-26
angap-15
[**2154-1-20**] glucose-159 urean-15 creat-1.5 na-137 k-5.0 cl-99
hco3-28 angap-15

[**2154-1-14**] intraoperative cholangiogram
impression: 1. normal common bile duct and intra- and
extra-hepatic ducts,
cystic duct and gallbladder.

cxr [**2154-1-16**]
findings: in comparison with the study of [**1-3**], the patient has
taken a
better inspiration. there is increased opacification at the left
base
consistent with pleural effusion and compressive atelectasis.
calcified
granuloma is again seen in the right mid to upper region
laterally. no
evidence of vascular congestion.


brief hospital course:
the patient presented to pre-op on [**2154-1-14**]. pt was
evaluated by anaesthesia and taken to the operating room for an
open cholecystectomy with intraoperative cholangiogram and
incisional hernia repair with implantation of prosthetic mesh.
there were no adverse events in the operating room; please see
the operative note for details. blood loss was 200 cc. pt was
extubated, taken to the pacu until stable, then transferred to
the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout his
hospitalization; pain was well controlled with dilaudid pca at
first and then oral roxicet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu: he was initially on bariatric stage 1 diet, which was
advanced sequentially to stage 5, and well tolerated.
fen: the patient's intake and output were closely monitored. on
pod #1 it was noted that the patient had a low urine output and
he was aggresively resscitated with multiple fluid boluses. this
was accompanied by an acute rise in cr from a baseline of 0.6 to
1.9 at this peak on pod 2. nephrology was consulted and
suggested his arf developed in the setting of mild hypotension
and an ace-i inhibitor (patient was taking lisinopril at home).
they recommended continued fluid ressucitation and avoidance of
metformin, lisonopril and nsaids or other nephrotoxins. during
the next few days his urine output markedly improved and
normalized, while his cr came down to 1.5 and will continue to
improve.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 5
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.



medications on admission:
lisinopril 10 mg daily
metformin 1000 mg [**hospital1 **]
pioglitazone 15 mg daily
sertraline 50 mg daily
vitamin supplements


discharge medications:
1. pioglitazone 15 mg tablet sig: one (1) tablet po daily
(daily).
2. sertraline 25 mg tablet sig: two (2) tablet po daily (daily).

3. multivitamin     tablet sig: one (1) tablet po daily (daily).

4. cyanocobalamin (vitamin b-12) 100 mcg tablet sig: one (1)
tablet po daily (daily).
5. ferrous sulfate 300  mg (60 mg iron) tablet sig: one (1)
tablet po daily (daily).
6. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2)
tablet po daily (daily).
7. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one
(1) tablet, chewable po daily (daily).
8. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls
po q4h (every 4 hours) as needed for pain.
disp:*500 ml(s)* refills:*0*


discharge disposition:
home with service

facility:
community vna, [**location (un) 8545**]

discharge diagnosis:
1. acute gallstone pancreatitis with cholelithiasis.
2. incisional hernia.
3. acute renal failure, most likely mild atn


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage 5 diet until your follow up appointment. do
not self advance diet, do not drink out of a straw or chew gum.

medication instructions:
resume your home medications, crush all pills. do not resume
taking lisinopril and metformin until further notice.
you will be starting some new medications:
1. you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
3. you should continue taking a chewable complete multivitamin
with minerals. no gummy vitamins.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-23**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
please record the output from each one of your drains separately
twice daily. bring the record with you to your next appointment
with dr. [**last name (stitle) **].

followup instructions:
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 9325**], md phone:[**telephone/fax (1) 305**]
date/time:[**2154-1-24**] 4:00



completed by:[**2154-1-20**]"
63,"admission date:  [**2101-5-17**]              discharge date:   [**2101-5-22**]

date of birth:  [**2072-12-18**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2101-5-17**]
1. open cholecystectomy.
2. open roux-en-y gastric bypass.


history of present illness:
[**known firstname 87221**] has class iii extreme morbid obesity with bmi of 60.7.
previous weight loss efforts have included weight watchers,
slim-fast, prescription [**street address(1) 87222**]/pcp [**name initial (pre) 51433**]. she has
been struggling with weight her entire life and  cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
she denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse.  has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. she was once on psychotropic
medication (citalopram), but is no longer.


past medical history:
htn, migraine, osa(recommended cpap), fatty liver,
cholelithiasis


social history:
denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. works as a day care teacher and she is
single living with her mother age 62 and she has no children.

family history:
father deceased age 72 with cancer, diabetes and hyperlipidemia.
mother living age 62 with heart disease, hyperlipidemia, dm, oa
and obesity.  sister in her 40s also with obesity and underwent
roux-en-y gastric bypass.

physical exam:
admission physical exam:
bp 129/79, pulse 73, respirations 18 and o2 saturation 100% on
room air.
gen: casually dressed, pleasant and in no distress.
skin: warm, dry with no rashes.
heent: sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
chest: ctab, symmetric, good air movement
cv: distant but present s1 and s2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
abd: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. no spinal tenderness or flank pain.
ext: lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good.  there was no joint swelling or inflammation
of the joints.
neuro: there were no gross neurological deficits and gait was
normal.

pertinent results:
post-operative: [**2101-5-17**] 03:27pm
hct-45.7

discharge labs: [**2101-5-21**] 03:06am
wbc-7.2  hgb-11.4*  hct-34.1*  plt-210
na-136 k-3.6 cl-101 hco3-28 urean-8 creat-0.7 glucose-109*
calcium-8.3* phos-3.0 mg-2.0

[**2101-5-19**] - cta chest
no large central pe. evaluation of segmental and subsegmental
branches is limited.

[**2101-5-19**] - ct abdomen
the patient is status post recent gastric bypass surgery. no
contrast is noted in the peritoneal cavity. the liver, spleen,
both adrenals, both kidneys, pancreas are unremarkable. the
patient is status post cholecystectomy. a drain is noted in the
right upper quadrant appropriately. the small bowel loops are
mildly prominent, likely representing ileus. the large bowel is
unremarkable. no free fluid or air noted. no evidence of leak.

[**2101-5-19**] - ugi
approximately 20 cc of optiray contrast was administered orally
which passed freely into the gastric pouch and proximal loops of
bowel without evidence of a leak. subsequently, thin barium was
orally administered, which demonstrated no further evidence of a
leak.


brief hospital course:
ms [**known firstname 87221**] was evaluated by anaesthesia and taken to the
operating room for open cholecystectomy and roux-en-y gastric
bypass. there were no adverse events in the operating room;
please see dr[**name (ni) 78793**] operative note for details. she was
extubated in the or, taken to the pacu until stable, then
transferred to the [**hospital1 **] for observation. she remained on the
surgical [**hospital1 **] for 2 days then was transferred to the icu given
her persistent tachycardia and concern for anastamotic leak. she
was transferred back to the floor 2 days later and was
discharged on pod 5.

neuro: she was alert and oriented throughout her
hospitalization. her pain was initially managed with an epidural
which was removed on post-operative day 4. she was transitioned
to low dose oral roxicet but this appeared to make her
somnolent, so she was provided liquid acetaminophen as
monotherapy for pain relief.

cv: she was persistently hypertensive and tachycardic beginning
immediately post-operatively. this was felt to be due primarily
to fluid deficit, given her post-op hemoconcentration (hct 45).
she was refractory to hydralazine and metoprolol iv. she
responded partially to fluid boluses, but not until starting a
labetolol drip in the icu were we able to control her heartrate
and blood pressure. after weaning her off the drip, her
hemodynamics sustained in a normal range using only her home
dose of chlorthalidone. serial ekgs were performed for
intermittent dull epigastric pain; these showed no changes from
prior.

pulmonary: she was administered cpap during some of her nights
while admitted. she did not tolerate this well, and preferred to
sleep without it. she had mild oxygen demand pod [**3-17**] and given
persisent tachycardia, she was evaluated by cta chest to
rule-out pulmonary embolus. the study was negative albeit
limited by body habitus. good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.

gi/gu/fen: she was initially kept npo until an upper gi study,
methylene blue test, and ct abdomen were performed on
post-operative day 2. all were negative for leak, therefore, her
diet was advanced to a bariatric stage i. she tolerated this for
over 24 hours before being advanced to stage ii. after a day of
stage ii, she was put on stage iii which was well tolerated. her
intake and output were closely monitored.
the jp bulb was removed on post op day 5 immediately prior to
discharge.

id: her fever curves and wbc count were closely watched for
signs of infection. perioperative antibiotics were
adminitstered; none other were warranted.

heme: her blood counts were closely watched for signs of
bleeding, of which there were none. her hematocrit returned back
down to baseline following resuscitation.

prophylaxis: she received subcutaneous heparin and venodyne
boots were used during this stay; she was encouraged to ambulate
as early as possible. she was ambulating independently by pod 4.


at the time of discharge, she was doing well, afebrile with
stable vital signs. she was tolerating a stage 3 diet,
ambulating, voiding without assistance, and pain was well
controlled. she received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.

medications on admission:
chlorthalidone 25'

discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: 20-30 ml po q6h
(every 6 hours) as needed for pain / fever: maximum 120ml per
day.
disp:*1000 ml* refills:*0*
2. colace 60 mg/15 ml syrup sig: two (2) tsp po twice a day:
hold for loose stool.
disp:*600 ml* refills:*0*
3. pediatric multivitamin-iron     tablet, chewable sig: one (1)
tablet, chewable po once a day.
4. zantac 15 mg/ml syrup sig: ten (10) ml po twice a day.
disp:*600 ml* refills:*0*
5. chlorthalidone 25 mg tablet sig: one (1) tablet po once a
day: please crush and mix with liquid.


discharge disposition:
home

discharge diagnosis:
1. obesity, body mass index of 64, weight of 394 pounds.
2. obstructive sleep apnea.
3. fatty liver.
4. gallstones.
5. borderline type 2 diabetes.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
[**hospital 1560**] clinic, surgical subspecialties, [**hospital ward name 23**] building
[**hospital1 **] [**last name (titles) 516**]
[**2101-6-1**] 11:00   dr. [**last name (stitle) **],md  [**telephone/fax (1) 305**]
[**2101-6-1**] 11:30   [**first name8 (namepattern2) **] [**doctor last name **],rd,ldn  [**telephone/fax (1) 305**]



"
64,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
65,"admission date:  [**2106-11-2**]              discharge date:   [**2106-12-3**]

date of birth:  [**2036-10-2**]             sex:   f

service: obstetrics/gynecology

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 7141**]
chief complaint:
pelvic mass

major surgical or invasive procedure:
exploratory laparotomy, total abdominal hysterectomy, bilateral
salpingo-oophorectomy, tumor debulking, omentectomy, extended
right colectomy, right pelvic peritoneal implant excision,
partial wedge gastrectomy, ileal descending colostomy, and rigid
proctosigmoidoscopy

history of present illness:
the patient is a 70-year-old g2, p2 sent by dr. [**first name8 (namepattern2) **] [**name (stitle) 468**] for
consultation regarding a possible diagnosis of ovarian cancer.
the patient presented with a several month history of increasing
abdominal distention, diffuse abdominal discomfort, and
exacerbation of heartburn symptoms. she was evaluated with an
upper endoscopy on [**2106-8-27**], at which time a submucosal mass in
the stomach was noted. no biopsy was obtained. she then had a ct
angiography of the abdomen and a ct of the pelvis on [**2106-10-8**].
this revealed the surface of the liver to be studded with
multiple discrete enhancing nodules. there were also nodules in
the region of the fissure for the ligamentum venosum and
ligamentum teres. the pancreas was normal. there was
disseminated peritoneal carcinomatosis, with large omental cakes
seen along the right flank.  there was a small amount of
perihepatic ascites. discrete nodules were identified studding
the surface the liver as previously described, as well as the
surface of the spleen and stomach. there was no significant
retroperitoneal adenopathy. in the pelvis, there was some
suggestion of uterine and bilateral adnexal masses. given the
nonspecific nature of these findings, a ct guided omental biopsy
was performed on [**2106-10-13**]. this revealed high-grade papillary
carcinoma, consistent with ovarian origin. the patient states
that she has had increasing abdominal girth and has difficulty
fitting into her clothes. she has had about a 12 pound
unintentional weight loss. she has some shortness of breath,
which she attributes to the increasing abdominal distention. she
has diffuse but low-grade abdominal discomfort.


past medical history:
gerd and hypothyroidism.
past surgical history:  rotator cuff repair and cholecystectomy.
ob history:  vaginal delivery x2.
gyn history:  last pap smear and mammogram were both recently
normal.


social history:
the patient does not smoke or drink.

family history:
significant for mother with stomach cancer, a brother with
pancreatic cancer, cousin with [**name2 (ni) 499**] cancer and aunts with
stomach cancer.


physical exam:
general:  well developed and moderately overweight.
heent:  sclerae anicteric.
lymphatics:  lymph node survey was negative.
lungs:  clear to auscultation.
heart:  regular without murmurs.
breasts:  without masses.
abdomen:  soft and moderately distended.  there was no
appreciable ascites.  there was a palpable mass extending along
the entire right side of the abdomen.  this was quite firm.
extremities:  without edema.
pelvic:  the vulva and vagina were normal.  the cervix was
normal.  bimanual and rectovaginal examination was limited by
body habitus.  no definite pelvic masses were appreciated.
there was no definite cul-de-sac nodularity and the rectal was
intrinsically normal.


pertinent results:
[**11-22**] ct abd/pelvis:
impression:
1. small-bowel obstruction with candidate transition point in
llq
2. large left pleural effusion with associated compressive
atelectasis.
3. overall, slight improvement in carcinomatosis and malignant
ascites.


brief hospital course:
on [**2106-11-2**], the patient underwent exploratory laparotomy, total
abdominal hysterectomy, bilateral salpingo-oophorectomy, tumor
debulking, omentectomy, extended right colectomy, right pelvic
peritoneal implant excision, partial wedge gastrectomy, ileal
descending colostomy, and rigid proctosigmoidoscopy, requiring 4
units of packed red blood cells intraoperatively.
post-operatively, she remained intubated and was transferred to
the sicu, with transfer to regular post-operative floor on
pod#2.
.
the patient's post-operative course was complicated by low
hematocrit, post-operative fever w/ clostridium perfringens on
blood culture, an intrahepatic ivc thrombus, bilateral upper
lobe opacities and bibasilar effusions l>r with dyspnea/hypoxia
and o2 requirement, lower extremity fungal infection, and small
bowel obstruction.
.
1) heme:
the pt's low hematocrit stabilized after 2 additional
transfusions of 2 units prbc's each, and was thought to be
dilutional gvien a fluid excess of 12l.  hcts subsequently
remained stable at ~27, and she had no evidence of bleeding. on
pod #6, the patient underwent a ct of the abdomen for evaluation
of fever, and an intrahepatic ivc thrombus was discovered
incidentally.  per surgery recommendation the patient was
started on heparin for anticoagulation, however this was
discontinued when the pt had another hct drop.  vascular surgery
recommended no further anticoagulation, and given the location
of the thrombus, filter placement was also not technically
feasible. on repeat ct scan [**11-22**], the thrombus was not
visualized.
.
2) id: the pt had post-operative fevers, for which blood
cultures were obtained.  1 of 2 bottles from [**11-4**] was positive
for c. perfringens. infectious disease was consulted and she was
started on vancomycin empirically, with ampicillin-sulbactam
added after identification and sensitivities. other cultures
from [**11-5**], 13, 14, 15 all showed no growth, therefore the c.
perfringens was thought to be a contaminant.  on pod#4, the pt
continued to require 4 l of oxygen by nc. she underwent a cta of
the chest which showed no pulmonary emboli but did show
bilateral upper lobe opacities concerning for pneumonia. she was
started on levofloxacin, and repeat chest x-ray showed that her
pneumonia improved after 4 days of levofloxacin, and this was
discontinued. given continued temperatures, cts of the abdomen
were obtained [**11-8**], [**11-12**] which showed increasing
carcinomatosis and multiple pelvic pockets of free fluid, some
loculated, which were thought to be malignant ascites; none
amenable to percutaneous drainage.  the pt remained afebrile on
vanco/zosyn from [**11-11**], with decreasing wbc, and v/z were
discontinued on [**11-23**].  the patient was also noted to have a
bilateral lower extremity and groin rash on [**11-23**]; id consult
was obtained, and it was felt that this was the result of a
fungal infection, and iv fluconazole was started.  the rash
improved on fluconazole, and the patient was switched to po
fluconazole on [**12-2**], to continue for a 6 week total course.
.
3) pulm:
in addition to the presumed pneumonia as above, the pt continued
to have subjective dyspnea and o2 requirement.  repeat cta [**11-12**]
was again negative for pe.  cxr's and cts showed bibasilar
effusions, l>r.  an interventional pulm consult was obtained for
possible thoracentesis, but per bedside u/s, the left effusion
was found to be subpulmonic and quite small, and therefore not
likely to account for pt's symptoms; given the location,
thoracentesis would also be at higher risk for adverse events
i.e. ptx, bleeding, per ip.  the patient's hypoxia and shortness
of breath resolved spontaneously, and for the last week of
admission she was 96-100% on ra.
.
3) fen/gi:
given nausea and poor po intake, the pt was started on tpn, with
diet slowly advanced.  however, on ct scan [**11-22**], the patient
was noted to have a small bowel obstruction, associated with
some nausea and vomiting.  she was made npo until passing flatus
and subjective resolution of nausea, and was advanced to clears
[**11-29**], then regular [**12-1**].  as she was tolerating regular po
without nausea, her tpn was d/c'd [**12-2**].
.
4) endocrine:
the patient's levoxyl was briefly increased to 200 mcg qd, but
this was decreased to 150 mcg [**11-17**].  she was covered for
somewhat elevated fsg's with an insulin sliding scale.
.
5) oncology:
per discussion with tumor board, medical oncology was consulted
for administration of chemotherapy while in-house.  it was
decided to administer first dose of carboplatin alone, given
greater potential toxicity with taxol.  on [**11-23**] the patient
received her 1st carboplatin dose and tolerated this adequately
with only some nausea.  she is to follow up with a medical
oncologist at [**hospital3 3583**] for further chemotherapy cycles.
.
the patient was discharged home on [**2106-12-3**], pod#30.


medications on admission:
levothyroxine alternating 0.112mg and 0.15mg daily, tricor 145mg
half tab daily, omeprazole 20mg daily

discharge medications:
1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q4-6h (every 4 to 6 hours) as needed.
disp:*60 tablet(s)* refills:*0*
2. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6
hours) as needed.
disp:*60 tablet(s)* refills:*0*
3. fluconazole 100 mg tablet sig: one (1) tablet po q24h (every
24 hours) for 5 weeks.
disp:*35 tablet(s)* refills:*0*


discharge disposition:
home with service

facility:
community vna

discharge diagnosis:
ovarian cancer
small bowel obstruction
lower extremity fungal infection


discharge condition:
good


discharge instructions:
no heavy lifting or strenuous exercise.  no driving while on
narcotics.  call for worsening pain, nausea/vomiting, fever
>101, other concerns.

followup instructions:
provider: [**name10 (nameis) **],[**first name3 (lf) **] b.  [**telephone/fax (1) 5777**]  call to schedule
appointment for next week



completed by:[**2106-12-3**]"
66,"admission date:  [**2189-1-2**]              discharge date:   [**2189-1-21**]

date of birth:  [**2116-1-21**]             sex:   f

service: cardiothoracic

allergies:
iodine; iodine containing / lipitor / codeine

attending:[**first name3 (lf) 165**]
chief complaint:
transfer from an outside hospital for non st elevation
myocardial infarction, congestive heart failure exacerbation

major surgical or invasive procedure:
cardiac catheterization without pci
coronary artery bypass grafts x 4
(lima-lad,svg-dg1,svg-om,svg-rca)& mitral valve repair (28mm
[**company 1543**] annuloplasty ring)- [**1-14**]
left heart catheterization, coronary angiography- [**1-4**]


history of present illness:
this is a 72-year-old female with a past medical history
significant for hypertension, diabetes, smoking, cad s/p mi x3
most recently in [**10-25**] complicated by cardiogenic shock, s/p rca
stenting x2 and lcx stenting x2, chf with ef of 40%, mr,
pulmonary hypertension, and pvd s/p lower extremity stenting
transfered from an osh for nstemi and chf exacerbation.

in brief, she was discharged from [**hospital1 18**] on [**2188-11-11**] after a
prolonged hospitalization notable for a nstemi with stenting of
the lcx and hemodynamic compromise requiring a iabp. she did
well after discharge with improvement of her sob and mobility.
she and her husband went on vacation during which time she
developed doe, the cp mostly a night with no correlation to
activity. her cp responded consistently to 1 to 2 ntg. she began
to notice orthopnea and pnd as well as ankle edema. she had
nausea and sob associated with her cp but not sweats or
dizziness. on [**2189-1-1**] she had a bacon and cheese omelet for
breakfast and clam chowder and [**location (un) 20935**] steak with french fries
for lunch. that afternoon she began to have persistent cp and
sob with associated nausea not relieved by ntg x3q5 minutes. ems
was called and she was admitted to [**hospital 67742**] medical center in
[**location (un) **], n.h. where she was found to be atrial fibrillation and
pulmonary edema with and an admission probnp of 5814.4. a
central line was placed and emergent cardioversion was
performed. she initially was hypotensive but stablized post
cardioversion. ekg revealed st depression in the lateral leads.
her tni trended 1.17, 3.03, 8.9 consistent with an nstemi. she
was maintained on a heparin drip with aggressive diuresis. proir
to transfer she had been on and off nitroglycerin drip. she has
chest pressure whenever it was shut off but she was hypertensive
when the nitro is increased. by report from the osh she was
wheezing on admission. her blood sugar on admission to the osh
was 515 and she was briefly on an insulin drip with improvement
of her sugars. there is also a question of whether she missed a
dose of her beta-block dose prior to her admission. she was
transferred to [**hospital1 18**] for further management.
.

she developed 7/10 chest pain with no ecg changes. she was
continued on heparin drip and ntg drip was restarted with
resolution of her cp.

she had recurrent chest pain w/ ekg chnages and was taken for an
emergent coronary srtery bypass graft and mv repair om [**2188-1-14**].

past medical history:
coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis


social history:
heavy smoker up to 2 ppd for 50 years, quit in [**10-25**]. denies
etoh or ivdu. pt is a retired x-ray technician. she lives with
her husband and two grandchildren in [**name (ni) 67740**], she is the
caregiver for her sister with [**name (ni) 309**] body dementia and her husband
as well as her two grandchildren.

family history:
no family history of cad or premature death, dm, htn, hld.
mother with pd. sister with [**name (ni) 309**] body dementia. sister with lung
ca.

physical exam:
admission:
gen: obese elderly lady in nad. oriented x3. mood, affect
appropriate.
heent: ncat. sclera anicteric. perrl, eomi. dry mm. no pallor or
cyanosis of the oral mucosa. no xanthalesma. no cervical or
axillary lad. neck supple with jvp of 10 cm. no carotid bruits
cv: pmi difficult to assess. rr, normal s1, s2. no m/r/g. no
thrills, lifts. no s3 or s4.
pulm: no chest wall deformities, scoliosis or kyphosis. resp
were unlabored, no accessory muscle use. poor air movement.
diffuse mile crackles greater in the bases with scattered
wheezes.
abd: bs+, soft, ntnd. no hsm or tenderness. gas on percussion.
limbs: no c/c/e. no stasis dermatitis, ulcers, scars, or
xanthomas.
pulses:
right: carotid 2+ radial 2+ dp 1+
left: carotid 2+ radial 2+ dp 2+


pertinent results:
[**2189-1-18**] 03:52am blood wbc-17.3* rbc-3.53* hgb-10.8*# hct-30.9*
mcv-87 mch-30.6 mchc-35.0 rdw-14.3 plt ct-191
[**2189-1-19**] 04:28am blood wbc-14.4*
[**2189-1-19**] 04:28am blood glucose-57* urean-28* creat-1.2* k-3.8

[**hospital1 18**] echocardiography report

[**known lastname **], [**known firstname **]       [**hospital1 18**] [**numeric identifier 67743**] (complete)
done [**2189-1-14**] at 10:54:24 am      final
referring physician     [**name9 (pre) **] information
[**name9 (pre) **], [**first name3 (lf) **]
division of cardiothoracic [**doctor first name **]
[**first name (titles) **] [**last name (titles) **]
[**hospital unit name 4081**]
[**location (un) 86**], [**numeric identifier 718**]  status: inpatient dob: [**2116-1-21**]
age (years): 72 f  hgt (in): 65
bp (mm hg): 123/67  wgt (lb): 230
hr (bpm): 67  bsa (m2): 2.10 m2
indication: intraoperative tee for cabg procedure and mitral
valve repair. chest pain. congestive heart failure. left
ventricular function. mitral valve disease. myocardial
infarction. preoperative assessment. right ventricular function.

icd-9 codes: 428.0, 786.05, 786.51, 440.0, 424.0
test information
date/time: [**2189-1-14**] at 10:54    interpret md: [**name6 (md) 1509**] [**name8 (md) 1510**],
md
test type: tee (complete) son[**name (ni) 930**]: [**last name (namepattern5) 9958**], md
doppler: full doppler and color doppler test location:
anesthesia west or cardiac
contrast: none tech quality: adequate
tape #: 2009aw2-: machine: [**doctor last name 11422**] 3d
echocardiographic measurements
results  measurements  normal range
left atrium - long axis dimension:  *5.0 cm  <= 4.0 cm
left ventricle - septal wall thickness:  1.0 cm  0.6 - 1.1 cm
left ventricle - inferolateral thickness:  1.0 cm  0.6 - 1.1 cm

left ventricle - diastolic dimension:  *6.0 cm  <= 5.6 cm
left ventricle - ejection fraction:  35%  >= 55%
aorta - annulus:  2.0 cm  <= 3.0 cm
aorta - sinus level:  2.7 cm  <= 3.6 cm
aorta - sinotubular ridge:  2.5 cm  <= 3.0 cm
aorta - ascending:  3.3 cm  <= 3.4 cm
aorta - arch:  2.3 cm  <= 3.0 cm
aorta - descending thoracic:  2.4 cm  <= 2.5 cm
aortic valve - peak velocity:  0.8 m/sec  <= 2.0 m/sec
mitral valve - peak velocity:  1.2 m/sec
mitral valve - mean gradient:  1 mm hg
mitral valve - pressure half time:  53 ms
mitral valve - mva (p [**12-19**] t):  4.2 cm2
mitral valve - e wave:  0.9 m/sec
mitral valve - a wave:  0.5 m/sec
mitral valve - e/a ratio:  1.80
mitral valve - e wave deceleration time:  *127 ms  140-250 ms

findings
left atrium: moderate la enlargement. no mass/thrombus in the [**name prefix (prefixes) **]
[**last name (prefixes) **] laa. all four pulmonary veins identified and enter the left
atrium.

right atrium/interatrial septum: a catheter or pacing wire is
seen in the ra and extending into the rv. no asd by 2d or color
doppler.

left ventricle: wall thickness and cavity dimensions were
obtained from 2d images. normal lv wall thickness. moderately
dilated lv cavity. moderate-severe regional left ventricular
systolic dysfunction. moderately depressed lvef. [intrinsic lv
systolic function likely depressed given the severity of
valvular regurgitation.]

right ventricle: normal rv systolic function.

aorta: normal diameter of aorta at the sinus, ascending and arch
levels. simple atheroma in aortic arch. normal descending aorta
diameter. complex (>4mm) atheroma in the descending thoracic
aorta.

aortic valve: normal aortic valve leaflets (3). no as. no ar.

mitral valve: mildly thickened mitral valve leaflets. no ms.
moderate to severe (3+) mr. [**name13 (stitle) 15110**] to the eccentric mr jet, its
severity may be underestimated (coanda effect).

tricuspid valve: physiologic tr.

pulmonic valve/pulmonary artery: physiologic (normal) pr.

pericardium: no pericardial effusion.

general comments: a tee was performed in the location listed
above. i certify i was present in compliance with hcfa
regulations. the patient was under general anesthesia throughout
the procedure. no tee related complications. the patient appears
to be in sinus rhythm. frequent ventricular premature beats.
patient.

regional left ventricular wall motion:





     n = normal, h = hypokinetic, a = akinetic, d = dyskinetic
conclusions
pre-bypass: the left atrium is moderately dilated. no
mass/thrombus is seen in the left atrium or left atrial
appendage. no atrial septal defect is seen by 2d or color
doppler. left ventricular wall thicknesses are normal. the left
ventricular cavity is moderately dilated. there is moderate to
severe regional left ventricular systolic dysfunction with
hypokinesis of the apex, apical portions of the inferior and
lateral walls as well as the mid portions of the inferior,
inferolateral and inferoseptal walls. overall left ventricular
systolic function is moderately depressed (lvef= 35 %). the
diameters of aorta at the sinus, ascending and arch levels are
normal. there are simple atheroma in the aortic arch. there are
complex (>4mm) atheroma in the descending thoracic aorta. the
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. no aortic
regurgitation is seen. the mitral valve leaflets are mildly
thickened. moderate to severe (3+) mitral regurgitation is seen.
due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (coanda effect). there is no
pericardial effusion.

dr. [**last name (stitle) **] was notified in person of the results in the
operating room.

post bypass

patient is av paced and receiving an infusion of epinephrine,
milrinone and phenylephrine. lvef is 40%. rv function is
unchanged. annuloplasty ring seen in the mitral position. mild
mitral regurgitation seen between the p2 and p3 scallops. dr
[**first name (stitle) **] aware. mean gradient across the mitral valve is 2 mm hg.
aorta intact post decannulation.
  i certify that i was present for this procedure in compliance
with hcfa regulations.

electronically signed by [**name6 (md) 1509**] [**name8 (md) 1510**], md, interpreting
physician [**last name (namepattern4) **] [**2189-1-14**] 16:03

[**known lastname **],[**known firstname **] m [**medical record number 67744**] f  72  [**2116-1-21**]

cardiology report c.cath study date of [**2189-1-6**]



brief history:   72 year old female with coronary artery disease
and
prior mi, status post pci of her lcx and rca, peripheral
vascular
disease, and mitral regurgitation who was recently admitted to
an
outside hospital with congestive heart failure and a non-st
elevation
mi. she is now transferred for cardiac catheterization.

indications for catheterization:
coronary artery disease

procedure:
right heart catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 french pulmonary wedge pressure
catheter,
advanced to the pcw position through an 8 french introducing
sheath.
cardiac output was measured by the fick method.
left heart catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 french angled pigtail catheter,
advanced
to the left ventricle through a 5 french introducing sheath.
coronary angiography: was performed in multiple projections
using a 5
french jl4 and a 5 french jr4 catheter, with manual contrast
injections.
left ventriculography: was performed in the 30 degrees [**doctor last name **]
projection,
using 39 ml of contrast injected at 13 ml/sec, through the
angled
pigtail catheter.
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

hemodynamics results body surface area:  2.13 m2
  hemoglobin: 10.3 gms %
  fick
**pressures
right atrium {a/v/m} 15/14/9
right ventricle {s/ed} 54/15
pulmonary artery {s/d/m} 54/28/45
pulmonary wedge {a/v/m} 36/41/33
left ventricle {s/ed} 135/36
aorta {s/d/m} 135/54/84
**cardiac output
heart rate {beats/min} 80
rhythm n
o2 cons. ind {ml/min/m2} 125
a-v o2 difference {ml/ltr} 46
card. op/ind fick {l/mn/m2} 5.8/2.7
**resistances
systemic vasc. resistance 1035
pulmonary vasc. resistance 166

**% saturation data (nl)
pa main 94
ao 61

other hemodynamic data:      the oxygen consumption was assumed.



left ventriculography:
volumetric data:
          lv ejection fraction (nl 50%-80%).                40
qualitative wall motion:
[**doctor last name **]:
          1. antero basal -    normal
          2. antero lateral -  normal
          3. apical -          normal
          4. inferior -        hypokinetic
          5. postero basal -   normal
other findings:
mitral valve showed the following abnormalities.
          1. regurgitation [**2-18**]+.
aortic valve was normal.


**arteriography results morphology % stenosis collat. from
**right coronary
1) proximal rca   discrete 70
2) mid rca   normal
2a) acute marginal   normal
3) distal rca   normal
4) r-pda   normal
4a) r-post-lat   normal
4b) r-lv   normal

**arteriography results morphology % stenosis collat. from
**left coronary
5) left main   discrete 30
6) proximal lad   normal
6a) septal-1   normal
7) mid-lad   discrete 60
8) distal lad   normal
9) diagonal-1   discrete 60
10) diagonal-2   normal
12) proximal cx   discrete 90
13) mid cx   discrete 99


technical factors:
total time (lidocaine to test complete) = 34 minutes.
arterial time = 18 minutes.
fluoro time = 6.0 minutes.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 94 ml
premedications:
          [**month/day (3) **] 325 mg p.o.
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          fentanyl 25mcg
          furosemide 60mg iv
          nahc03 75ml/hr
          midazolam 0.5mg
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - [**company **], left heart kit
          - [**company **], right heart kit
          5fr [**company **], multipack
          7fr [**company **], pulmonary wedge pressure catheter


comments:
1. selective coronary angiography of this right dominant system
revealed
three vessel disease.  the lmca had a 30% ostial stenosis.  the
lad had
a 60% mid-vessel lesion involving a major diagonal branch.  the
lcx had
a 95% proximal isr and a long 99% isr in the mid and distal
vessel.  the
rca had a 70% proximal isr.
2. resting hemodynamics revealed a severely elevated left heart
filling
pressure with a mean pcwp of 33mmhg.  there was moderate
pulmonary
artery hypertension with a mean pa of 45mmhg.  the cardiac index
was
preserved at 2.7l/min/m2.
3. left venticulography revealed an estimated lvef of 40% with
severe
inferior hypokinesis.  there was severe [**2-18**]+ mitral
regurgitation.

final diagnosis:
1. three vessel coronary artery disease.
2. severe mitral regurgitation.
3. moderate systolic and severe diastolic ventricular
dysfunction.
4. moderate pulmonary hypertension.

attending physician: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].
referring physician: [**name10 (nameis) **],[**first name4 (namepattern1) **] [**last name (namepattern1) 975**]
cardiology fellow: [**last name (lf) **],[**first name3 (lf) **] m.
attending staff: [**last name (lf) **],[**first name3 (lf) **] e.


carotid ultra sound
impression: right ica 60-69% stenosis. left ica 40-59% stenosis.
both have
bulky plaque. antegrade vertebral flow bilaterally. the right
has been
stable since [**2185**]. the left has evidence of mild progression on
today's
study.


brief hospital course:
[**hospital1 1516**] cardiology service brief hospital course:
this is a 72-year-old female with a past medical history
significant for hypertension, diabetes, smoking, cad s/p mi x3
most recently in [**10-25**] complicated by cardiogenic shock, s/p rca
stending x2 and lcx stenting x2, systolic chf with ef of 40%,
pulmonary hypertension, and pvd s/p lower extremity stenting
transfered from an osh for nstemi and chf exacerbation. on her
second day of hospitalization she developed flash pulmonary
edema. given she was in sinus when she flashed there was concern
for ischemic mr. [**first name (titles) **] [**last name (titles) 1834**] cath on [**2189-1-6**] and was found to
have 3vd (lad and isr of lcx and rca) and servere mr. [**first name (titles) **] [**last name (titles) 67745**]s were taken and cardiac [**doctor first name **] referral was made. pt
agreed to cabg. she had egd-colonoscopy to rule out possible
sources of gib which was negative. also developed worsening of
cri, but improved with holding lasix and [**doctor first name 21177**]. developed
recurrent cp with ecg changes and was ultimately sent to ct
surgery for emergent cabg the day following her egd-[**last name (un) **].
.
#. cad: pt s/p mix4 (the latest nstemi this admission) and found
to have 3vd at cath + mr. [**first name (titles) **] [**last name (titles) **] 325mg po daily. held
plavix 75mg po daily for cabg washout but had recent bms to the
lcx in [**10-25**]. continued metoprolol 37.5mg po bid in place of
toprolxl 75mg daily. holding statins for now given history of
adverse events to these and excellent cholesterol panel. lipid
panel: cholest 147, triglyc 134, hdl 60, ldlcalc 60. cath on
[**2189-1-6**] showed severe mr with angio showing that lad with 60%
mid-vessel lesion involving a major diagonal branch, lcx with
95% proximal isr and a long 99% isr in the mid and distal
vessel, and rca with 70% proximal isr. last dose of plavix was
on [**2189-1-6**]. had cp [**2-24**] with ecg changes on the am of [**2189-1-13**]
during bowel prep. resolved completely with ntgx1. again had cp
[**5-27**] overnight 1/27-28/09 resolved after ntg x2. triggered for
cp x2 in <24hrs with 3vd. sent emergently to cabg on the morning
of [**2189-1-13**] for recurrent cp.
.
#. pump: pt with chf with known ef of 40%. pt continues to be in
sinus (chf preivously exacerbated by afib s/p cardioversion).
however, on [**2189-1-4**] pt triggered for sob, hypoxia to high 80s on
room air. pt's exam showed acute worsening of fluid status
concerning for flash pulmonary edema. also concern for ischemic
mr. [**first name (titles) **] [**last name (titles) 21177**] at 5mg po daily ([**12-19**] home dose). lisopril was
held the am of transfer to ct surgery to improve renal function.
continued metoprolol as above. will consider spironolactone for
naturesis in the future. echo on [**2189-1-6**] showed ef of 40%,
systolic dysfunction with akinesis of the inferolateral wall and
hypokinesis of the inferior and anterolateral walls, and severe
unchanged mr. initially on lasix drip, but discontinued lasix iv
and started lasix 80mg po bid. was retaining some additional
fluid so increased lasix to 100mg po bid. this was held on the
day of transfer to ct surgery.
.
#. rhythm: nsr, s/p afib on admission to osh with cardioversion
into sinus.
.
#. renal insufficiency: pt with mild elevation of cr to 1.8 from
lasix, [**date range 21177**], hypovolemia, and bowel prep. held lasix and
lisopril the am of transfer to ct surgery.
.
admission to cardiac surgery post-op. [**2189-1-14**]

pt was taken to the or on [**2189-1-14**] for cabg x4 - lima-lad; svg to
d1, om, rca and mv repair.  please see operative note for
details. the patient arrived to the cardiac icu on milrinone,
epi, neo, propofol and insulin drips. she was readily weaned
from milrinone and epi and extubated on pod#1. chest tubes and
wires were removed. the patient was begun on betablocker and
diuresis and transferred to the floor for ongoing management and
rehab.
patient's insulin [**date range 4319**] were adjusted to achieve glucose
control.
rehab screening was recommended by physical therapy.
postoperative course was uneventful and the patient was
discharged to rehab on pod 6.

medications on admission:
insulin nph 36u [**hospital1 **] and humalog 4u [**hospital1 **]
toprol xl 75mg po daily
lisinorpil 10mg po daily
prilosec 20mg po bid
advil 200mg po daily
[**hospital1 **] 325mg po daily
plavix 75mg po daily
hctz 25mg po daily
iron
colace


discharge medications:
1. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day.
3. insulin nph human recomb 300 unit/3 ml insulin pen sig:
thirty six (36) units subcutaneous twice a day.
4. insulin lispro 100 unit/ml insulin pen sig: four (4) units
subcutaneous twice a day.
5. atrovent hfa 17 mcg/actuation aerosol sig: one (1) puff
inhalation four times a day.
disp:*2 inhaler* refills:*5*
6. xopenex hfa 45 mcg/actuation hfa aerosol inhaler sig: one (1)
puff inhalation four times a day.
disp:*2 inhalers* refills:*5*
7. [**hospital1 **] 10 mg tablet sig: one (1) tablet po once a day.
8. metolazone 5 mg tablet sig: two (2) tablet po daily (daily).

9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
10. simvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
11. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
12. albuterol 90 mcg/actuation aerosol sig: two (2) puff
inhalation q6h (every 6 hours) as needed.
13. ipratropium bromide 17 mcg/actuation aerosol sig: two (2)
puff inhalation qid (4 times a day).
14. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
15. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q4h (every 4 hours) as needed for pain.
16. amiodarone 200 mg tablet sig: two (2) tablet po once a day:
2 daily for 7 days then one daily for one month.
disp:*45 tablet(s)* refills:*0*
17. metoprolol succinate 25 mg tablet sustained release 24 hr
sig: three (3) tablet sustained release 24 hr po daily (daily).

18. potassium chloride 20 meq tab sust.rel. particle/crystal
sig: one (1) tab sust.rel. particle/crystal po twice a day.
disp:*60 tab sust.rel. particle/crystal(s)* refills:*2*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis


discharge condition:
good


discharge instructions:
shower daily, no baths or swimming
no driving for 4 weeks and off all narcotics
no lotions, creams or powders to incisions
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain gretaer than 2 pounds a day or 5 pounds a
week
take all medications as directed


followup instructions:
dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] in 2 weeks
dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3314**] in [**12-19**] weeks ([**telephone/fax (1) 3183**])
dr. [**first name (stitle) **] in 4 weeks
wound clinic in 2 weeks
please call for appointments


                             [**name6 (md) **] [**name8 (md) **] md [**md number(2) 173**]

completed by:[**2189-1-20**]"
67,"admission date: [**2175-6-16**]        discharge date:[**2175-8-16**]

date of birth:  [**2175-6-16**]        sex:  m

service:  nb


interim date:  [**2175-8-16**].

history of present illness:  this is a 27 and [**4-22**] week male
infant, [**month/day (4) **] to a 35 year-old, g1, p0 mother. pregnancy was
complicated by preterm labor, pprom on [**6-3**] with rupture
of membranes times 13 days, resulting in admission and
betamethasone completed [**6-5**].  mother was treated with
ampicillin and erythromycin for possible infection. the baby
was delivered cesarean section for breech position.

prenatal laboratory:  blood type was a positive, antibody
negative, hepatitis b surface antigen negative, rpr
nonreactive, rubella immune and gbs unknown.  at the
delivery, baby was [**name2 (ni) **] with [**name (ni) **] of 6 and 8. resuscitation
included stimulation, facial c-pap and endotracheal tube
placement in the delivery room.

physical examination:  weight was 1160 grams, 50th
percentile.  head circumference was 26.5 cm, 50th percentile.
length was 37 cm, 50th percentile. vital signs:  temperature
was 97.8; pulse was 160; respiratory rate 50; blood pressure
73/42, mean of 53.  oxygen saturation was 95% on 50% fi02.
initially placed on simv 2605 at a rate of 25 per minute.
si02 was 50%.  general:  active, vigorous, well-developed
premature infant with moderate to significant respiratory
distress at rest. skin was warm, pink, mildly delayed
capillary refill with diffuse bruising over the buttocks and
back.  head and neck:  fontanel soft and flat.  ears and
nares were normal. positive red reflex bilaterally. palate
intact.  chest:  coarse, poorly aerated, improved with
positive pressure ventilation. cardiac:  regular rate and
rhythm, loud [**2-19**] holosystolic murmur left sternal border.
abdomen is soft, no hepatosplenomegaly.  no masses. 3 vessel
cord.  genitourinary: 2+ femoral pulses, symmetric, normal
male, testes descended bilaterally, anus patent.
extremities:  warm.  neurologic:  appropriate tone and
activity, vigorous.

dextrose stick 57.

hospital course:  respiratory:  the patient was admitted,
intubated, given surfactant x2 and ventilatory settings were
weaned.  he was placed on c-pap on day of life 3 through 41.
on day of life 41, he was weaned to nasal cannula and he is
currently on 50 ml per minute. he has chronic lung disease
day of life 48, patient was noted to have rales; started on a 3
day course of lasix. a blood gas at that time was 7.38, 57, 53,
35, +6.daily diuretic therapy began. diuril, aldactone and
potassium chloride substitute on day of life 52. infant
responded well (less rales, weaning on nc, less wob). still has
s/sx of bpd, but improved with diuretics and time.
cv: there has been an intermittent murmur diagnosed as pps.  it
is not audible at this time.
apnea of prematurity treated with caffeine day 6 through 55.
gastrointestinal:  constipation was an issue and has been
treated with prune juice and glycerin suppositories as
needed. composition of formula and/or premature slow motility are
most likely the reason(s) for infrequent stools. if stooling
concerns persits despite adjustments in caloric density and prune
juice, would consider r/o hirschprung's.
phototherapy was begun at birth. bilirubin was a
maximum of 5.3. phototherapy was discontinue on day of life
6.  no significant rebound in bilirubin. hyperbilirubinemia
resolved.

fluids, electrolytes and nutrition:  started on
intravenous fluids and parenteral nutrition at birth.
remained n.p.o. until day of life 3 when he was started on
feeds which gradually were advanced.  the patient began on
day of life zero with a uac and a uvc and that was changed to
a peripheral pic line on day of life 5 and was removed on day
of life 10 when feeds were at full capacity.  current formula
is breast milk 30 with promod and the baby is being gavage
fed 100% aside from breast feeding.  the patient's diet is
supplemented with iron and vitamin e as per protocol.

infectious disease:  due to significant pprom and respiratory
distress, rule out sepsis was treated with ampicillin and
gentamycin over a 7 day course.  erythromycin ophthalmic
ointment was placed in the eyes for a green eye discharge.
currently no infectious issues.  cultures: blood culture from
[**2175-6-16**] was negative. a lumbar puncture was performed and a
culture of the spinal fluid was negative. an eye culture wa sent
and was negative for gonorrhea. a respiratory culture grew
aspergillus [**country 11730**] on [**6-17**] with one colony on one plate.
treatment was not initiated for this organism which was
suspected to be a contaminate.

neurology:  head ultrasound on [**6-22**], day of life
6, that showed no intraventricular hemorrhage.  questionable
anterior partial agenesis of the corpus callosum.
[**6-29**] head ultrasound was unchanged showing partial
agenesis of the corpus callosum.  on [**7-19**], unchanged
agenesis of the anterior third of the corpus callosum with
corresponding central hard dysmorphism.
neonatal neurology consult was performed and will follow up
with the patient in clinic after discharge.  a mri at term
should be performed.

audiology:  hearing screen has not yet been performed.
2 eye exams have been performed. [**7-24**] showed immature retina,
zone 2, follow up in 2 weeks. [**8-8**] showed immature
retina, zone 3, follow up in 3 weeks or the second week of
[**month (only) **].

psychosocial:  [**hospital1 18**] social work is involved with the family.
the social worker can be reached at [**telephone/fax (1) 8717**].

current condition:  stable with current regimen and monitoring.

primary care pediatrician:  [**first name8 (namepattern2) 17563**] [**last name (namepattern1) **] in [**location (un) 1887**].

immunizations:  [**7-17**], hepatitis b vaccine.
[**8-15**], pesnar, hib.
[**8-16**], pedia-[**male first name (un) **].
no adverse events.

state screen:  [**6-30**] was negative.
repeat screen sent [**7-28**], pending.

discharge diagnoses:
1.  prematurity. still has bpd, gi,  po feeding issues.
2.  sepsis, ruled out, 7 days of antibiotics.
3.  eye discharge, rx - resolved.
4.  pps murmur. resolved
5.  respiratory distress syndrome/bronchopulmonary dysplasia. on
nc and daily diuretic therapy with kcl replacement.
6.  agenesis of the anterior third of the corpus callosum. will
need mri prior to discharge and neuro follow-up, infant follow-
up clinic.
7.  apnea of prematurity, status post caffeine, resolved.
8.  hyperbilirubinemia, status post phototherapy, resolved.
9.  constipation. ongoing issue. see text in summary.
10. immature retina: no rop. last eye exam [**8-8**]. next 3 weeks
after [**8-8**] or prior to discharge infant can be followed by o'ind
[**doctor last name **] for pediatric ophthalmology in her [**location (un) **], ma office.
11. will need car seat and hearing screen.
12. immunizations up to date.
13. mother identified dr. [**last name (stitle) **] [**last name (namepattern4) **]  as pediatrician ([**location (un) 1887**])
on [**2175-8-16**]. [**known lastname 46527**] mother will contact dr. [**last name (stitle) **] to inform
that she has chosen him as [**known lastname 46527**] pediatric provider. [**name10 (nameis) 59074**] team
has not had contact with dr. [**last name (stitle) **] as of [**2175-8-16**].


                        [**first name8 (namepattern2) 1154**] [**last name (namepattern1) **], md [**md number(2) 56585**]

dictated by:[**last name (namepattern1) 56577**]
medquist36
d:  [**2175-8-16**] 18:15:55
t:  [**2175-8-16**] 19:26:09
job#:  [**job number 64388**]








"
68,"admission date:  [**2150-4-16**]              discharge date:   [**2150-4-21**]


service: medicine

allergies:
nsaids / bactrim

attending:[**first name3 (lf) 358**]
chief complaint:
angioedema

major surgical or invasive procedure:
intubation

history of present illness:
pt is an 85 y/o f with a h/o gave s/p argon treatment last on
[**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc, portal
htn/grade 1 varices but no hx of bleeding varices, cri (baseline
cr = 1.2-1.5) who is transfered from [**hospital3 **] intubated
s/p angioedema. by report the pt has some mild abdominal pain
and some irritation in her throat a day prior to admission to
[**hospital3 **]. the following morning she called her son with
complaints of oral swelling; son states that her speach was
garbled. the son reports that the patient denies having had any
sob, no wheezing, no hives. he called an abmulance who
transported the pt to [**hospital3 **].
.
per omr, the patient present to [**hospital1 18**] pheresis unit on [**2150-4-10**]
for blood transfusion for chronic slow upper gi bleeding. she
had no pretreatment medications given and no adverse events;
vitals on leaving the unit were 97.4 - 67 - 119/55. she has also
been recently treated for a uti with bactrim started on [**2150-4-3**].

.
at st elizabeths', she was hd stable but had a large, edematous
tongue. she recevied decadron, epinephrine, benadryl, famotidine
and hydroxazine in the ed. the ed was unable to intubate and she
was taken to the or. laryngeal edema was noted, but the et tube
was passed successfully. she was then transfered to the ccu. she
received hydroxazine tid and her tongue swelling improved. sbt
was attempted early on but failed likely secondary to sedation.
per report, pt did have a cuff leak. family requested transfer
to [**hospital1 18**] as pt receives all her care here.
.
on arrival in the micu she passed an sbt and was successfully
extubated. she did well throughout the day but continued to have
an o2 requirement. by the time of transfer to the floor she was
on 2l of nc o2 satting 94%. on the floor she is alert and
oriented. she does not know what caused her swelling. she denies
new pills, new medications, or new foods. she feels well and has
no sob, itching, or complaints.
.


past medical history:
# gave - s/p argon treatment, last on last on [**2150-3-11**]
# hepatitis c
# cirrhosis
- child's class a, portal htn, grade 1 varices
- no h/o ascites, encephalopathy, variceal bleeding, synthetic
function intact
# dm type ii
# htn
# iron deficiency anemia
# s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
# hypercholesterolemia
# osteopenia
# insomnia
# angioedema [**3-26**] possibly due to bactrim but as yet not proven

social history:
lives alone in [**location (un) 583**] in [**hospital3 4634**] complex. is widowed.
has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
holidays). worked in food business in sales.


family history:
no family history of allergic diseases

physical exam:
gen: pleasant elderly lady in nad, speaking comfortably, no
cyanosis, jaundice, or dyspnea
vs: 99.4 124/58 82 18 94% on 2l nc
heent: mmm, no op lesions, tongue nl size, neck supple, no lad
or thyromegaly
cv: rr, nl s1 s2 no s3 s4 mrg
pulm: roncherous breath sounds with scattered wheezes and
crackles 1/4 up the lung fields
abd: bs+, nt, ventral hernia, gas on percussion, no masses or
hsm, no fluid wave, + collaterals and angiomata
limsb: no le edema, + clubbing
neuro: perrla, eomi, moving all limbs, reflexes 2+ of the biceps
and petellar tendons.


pertinent results:
admission labs:
[**2150-4-17**] 05:15am blood wbc-7.4 rbc-3.41* hgb-10.2* hct-31.4*
mcv-92 mch-29.9 mchc-32.5 rdw-16.7* plt ct-139*
[**2150-4-17**] 05:15am blood glucose-132* urean-27* creat-1.1 na-143
k-4.3 cl-112* hco3-24 angap-11
[**2150-4-18**] 08:30am blood alt-112* ast-59* ld(ldh)-203 alkphos-99
totbili-1.7*
[**2150-4-17**] 05:15am blood calcium-8.6 phos-2.8 mg-2.4
.
discharge labs:
[**2150-4-21**] 05:50am blood wbc-5.0 rbc-3.13* hgb-9.6* hct-28.4*
mcv-91 mch-30.7 mchc-33.8 rdw-16.9* plt ct-200
[**2150-4-21**] 05:50am blood glucose-91 urean-34* creat-1.4* na-137
k-3.9 cl-103 hco3-24 angap-14
[**2150-4-20**] 05:40am blood alt-55* ast-34 ld(ldh)-182 alkphos-83
totbili-1.3
[**2150-4-20**] 05:40am blood albumin-2.6* calcium-8.3* phos-3.5 mg-2.0

brief hospital course:
85f with a h/o gave s/p argon laser treatment last on [**2150-3-11**],
iron deficiency anemia due to chronic ugib, cirrhosis [**1-19**] hcv,
portal htn with grade 1 varices but no history variceal
bleeding, cri (baseline cr = 1.2-1.5) who is s/p prolonged
intubatation for angioedema of unknown etiology - possibly due
to bactrim. she is doing very well on s/p extubation at this
point. all antihistamines have been discontinued at this point.
she was progressively be restarted on her home meds.
.
# angioedema: resoved. lack of hives, bronchospasm or
hypotension suggests that this was not allergic angioedema but
rather bradykinin related. c3 and c4 were low. c1 esterase
inhibitor pending, [**doctor first name **] neg. per allergy consult at [**hospital 7302**] prior to transfer, non-allergic angioedema
is due to complement depletion (either hereditary or ca related)
or complement activation (infection or transfusion). the patient
did have a transfusion recently which may be related.
medications would also be high on the list of etiologies. common
offenders are nsaids and aceis, but arbs have also been
implicated.  it was discovered that the pt was taking bactrim
when the reaction leading to her admission. this is a possible
offender and has been added to her allergy list. restarted home
meds one by one. all but felodipine have been restarted. had
hives and itching the day prior to discharge which did not
generalize and seemed more of a contact dermatitis on the l arm.
no new medications were started so it is unclear what initiated
this. responded to hydroxyzine x1. also of note, the patient
refused to shower or be washed down this admission which may
contribute to her itchiness.
.
# chronic ugib: received regular blood transfusions as an
outpatient for any hct < 30. in the past she only needed them
infrequently but her transfusion requirements have increased
lately. transfused prior to discharge. [**month (only) 116**] need outpatient
follow up with gi (dr [**first name8 (namepattern2) 1158**] [**last name (namepattern1) 679**] has been recommended by her
outpatient gastroenterologist [**first name4 (namepattern1) 2127**] [**last name (namepattern1) 10113**]).
.
# wheezes and ronchi: related to angioedema and volume overload
most likely. resolved with diuresis and nebulizers.
.
# hx hcv complicated by cirrhosis. no evidence of encephalopathy
now, but is at risk. continued lactulose. continued
spironolactone [aldactone] - 50 mg daily. continue furosemide
[lasix] - 40 mg daily. continue nadolol - 80 mg daily as ppx
against variceal bleeding.
.
# htn: holding home ccb as normotensive. on nadolol as above.
.
# cri: baseline 1.5, was elevated on admission to [**hospital3 5097**] to
1.7. at baseline on discharge.
.
# diabetes: iss in house. discharged on metformin.

medications on admission:
home medications:
felodipine - 10 mg qam and 5 mg qpm
folic acid - 1 mg daily
furosemide [lasix] - 40 mg daily
hydrocortisone acetate [anusol-hc] - 25 mg daily
lactulose 10 gram/15 ml daily
metformin - 1000 mg qam and 500 mg qpm
mupirocin - 2 % ointment [**hospital1 **]
nadolol - 80 mg daily
pantoprazole - 40 mg [**hospital1 **]
spironolactone [aldactone] - 50 mg daily
sucralfate - 1 g tid
zolpidem - 5 mg tablet - [**12-21**] qhs prn
calcium carbonate-vitamin d2 - 500 mg-375 unit [**hospital1 **]
cyanocobalamin - 500 mcg daily
ferrous gluconate - 325 mg 5 times a day
sarna ultra [**hospital1 **]


discharge medications:
1. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one
(1) tablet po twice a day.
disp:*60 tablet(s)* refills:*11*
2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*11*
3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
4. anusol-hc 25 mg suppository sig: one (1) suppository rectal
once a day.
disp:*30 suppositories* refills:*6*
5. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po once a
day.
disp:*450 ml(s)* refills:*11*
6. metformin 500 mg tablet sig: two (2) tablet po qam.
disp:*60 tablet(s)* refills:*5*
7. metformin 500 mg tablet sig: one (1) tablet po qpm.
disp:*30 tablet(s)* refills:*5*
8. nadolol 80 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*5*
10. spironolactone 50 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*5*
11. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
disp:*30 tablet(s)* refills:*0*
12. b-12 dots 500 mcg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*11*
13. ferrous gluconate 325 mg tablet sig: one (1) tablet po five
times a day.
disp:*150 tablet(s)* refills:*11*


discharge disposition:
home

discharge diagnosis:
angioedema

discharge condition:
stable vital signs, at baseline

discharge instructions:
you were admitted at [**first name8 (namepattern2) 1495**] [**hospital **] hospital with angioedema,
or swelling in your mouth and throat. you had a breathing tube
placed for this. you were then transfered to [**hospital1 771**] where you had the breathing tube taken
out. you improved clinically and were discharged to home.
.
please continue to take your medications as ordered. because you
had a likely medication reaction that led to your angioedema you
should throw out your old medications. do not take any
supplements. here is your updated medication list list:
1. stop taking felodipine for now
2. calcium + vitamin d twice daily
3. vitamin b12 daily
4. folic acid daily
5. furosimide 40mg daily
6. anusol daily as needed for hemorrhoids
7. metformin 1000mg (2 pills) in the morining and 500mg (1 pill)
in the evening
8. lactulose 15ml daily to 3 bowel movements per day
9. nadolol 80mg daily
10. pantoprazole (protonix) 40mg twice daily
11. spironolactone 50mg daily
12. zolpidem (ambien) 5mg at night as needed for insomnia
13. iron 5 times daily
.
please attend your follow up appointments.
.
please call your doctor or come to the emergency room if you
experience swelling of you face or tongue, chest pain,
palpitations, shortness of breath, wheezing, bleeding, or other
concerning symptoms.

followup instructions:
md: [**name6 (md) 10160**] [**name8 (md) 10161**], np
specialty: priamry care
date and time: [**last name (lf) 766**], [**5-4**] at 4pm
location: [**hospital3 **]
phone number: [**telephone/fax (1) 250**]
special instructions if applicable: booked with russain
interpreter


completed by:[**2150-4-22**]"
69,"admission date:  [**2124-12-15**]     discharge date:  [**2124-12-16**]

date of birth:   [**2068-7-22**]     sex:  m

service:  micu

history of present illness:   this is a 56 year old man with
a history of lung cancer status post radiation therapy and
chemotherapy and chronic obstructive pulmonary disease, who
presents with acute dyspnea and oropharynx swelling.  the
patient states that he was in his usual state of health when
three hours after eating a dinner of shrimp and scallops,
began to develop burning and warmth of his posterior cervical
neck and forehead.  he went to cvs to get some benadryl and
on the way became progressively short of breath and
complained of upper and lower lip swelling.  the emergency
medical services was activated.  he was found to be
stridorous with a blood pressure of 60/palpation complaining
of his throat closing up.

the patient received epinephrine 0.3 subcutaneously and
benadryl 50 mg intravenous en route to the hospital and his
blood pressure normalized.  the patient was saturating at 98%
on room air.  he received intravenous solu-medrol and
intravenous cimetidine.

the patient reported a history of swelling after a bee sting
30 years ago for which he went to the emergency room and
received intravenous benadryl.  he consumes shellfish
regularly and has had no adverse events in the past.  the
patient is currently on chemotherapy, the cycle beginning in
[**month (only) 359**].  his last dosage of medication being approximately
two weeks prior to presentation.

past medical history:
1.  nonsmall cell lung cancer status post chemotherapy and
radiation therapy found to be non-surgical on thoracotomy.
evidence of metastases to the left adrenal gland.
2.  emphysema.
3.  depression.
4.  status post tonsillectomy.

medications:
1.  chemotherapy.
2.  combivent two puffs four times a day p.r.n.
3.  wellbutrin 150 mg twice a day.

allergies:   no known drug allergies.

physical examination:   vital signs were afebrile.  blood
pressure 94/48; pulse 109; respirations 20; saturation of 98%
on room air.  in general, in no apparent distress, alert and
oriented times three.  the patient is speaking in full
sentences.  no respiratory distress.  heent:  normocephalic,
atraumatic.  pupils are equal, round and reactive to light.
extraocular movements intact.  sclerae anicteric.  there is
swelling of the upper and lower lips and question of swelling
of the tongue; no airway compromise, no lymphadenopathy.
chest is clear to auscultation bilaterally.  cor:
tachycardia, normal s1, s2, no murmurs, rubs or gallops.
abdomen is soft, nontender, nondistended.  no
hepatosplenomegaly or masses.  positive bowel sounds.
extremities are warm and well perfused.  positive for
clubbing.  no cyanosis of edema.  neurological:  cranial
nerves ii through xii are intact.  he moves all extremities.
strength is five out of five.

laboratory:  white blood cell count 3.9, hematocrit 30.4,
platelets 494.  sodium 143, potassium 4.4, chloride 107,
bicarbonate 29, bun 13, creatinine 0.7, glucose 130.  serum
toxicology screen negative.

ekg with sinus tachycardia at the rate of 114.

chest x-ray with ill defined density overlying the right
superior hilum suggestive of a mass.  right lateral pleural
thickening, rib fractures and atelectatic changes consistent
with post surgical change.

hospital course:
1.  anaphylaxis:  the patient was started on intravenous
hydrocortisone, intravenous famotidine and intravenous
diphenhydramine,.  he was admitted and observed in the
medical intensive care unit given his history for previous
anaphylaxis in the setting of p.o. allergen.

the patient remained hemodynamically stable and his
angioedema resolved.  it seemed unusual that the patient
would develop an allergy to shellfish at the age of 56.  it
was suspected that the patient's history of chemotherapy may
have put him at risk for this allergic reaction.

the patient will be discharged with the plan to follow-up
with his primary care physician on [**name9 (pre) 766**], [**12-18**].  he
will be referred to an allergist and is instructed in the use
of an epinephrine pen which he will carry with him at all
times, keeping one in the glove compartment of his car and
one in his house.

the patient will complete a rapid steroid taper.

2.  lung cancer:  this is followed by the patient's
oncologist at the [**hospital3 328**].

3.  tachycardia:  the patient remained in sinus tachycardia
in the low 100s throughout his hospital course.  this was
felt to represent the physiologic response to the patient's
anemia.  this will be followed up at the patient's primary
care physician.

4.  the patient's anemia was felt to be secondary to
chemotherapy.  further evaluation is deferred to the
patient's primary care physician.

condition on discharge:   good.

discharge status:   to home.

discharge diagnoses:
1.  anaphylaxis to shellfish.
2.  nonsmall cell lung cancer.
3.  resting tachycardia.

discharge medications:
1.  prednisone taper, 40 mg times one day, then 20 mg times
one day.
2.  albuterol ipratropium mdi one to two puffs q. six hours
p.r.n.
3.  bupropion 150 mg p.o. twice a day.
4.  benadryl 50 mg p.o. q. six hours p.r.n.
5.  epinephrine pen 1/[**numeric identifier 4856**] syringe, one injection
intramuscular p.r.n. anaphylaxis.

discharge instructions:
1.  the patient will follow-up with his primary care
physician, [**last name (namepattern4) **]. [**last name (stitle) 6512**], at the southern [**hospital 12162**] health center on
[**12-18**], at 11:30 a.m.
2.  the patient will be referred to an allergist for further
evaluation.




dictated by:[**name8 (md) 96586**]

medquist36

d:  [**2124-12-16**]  12:15
t:  [**2124-12-16**]  19:17
job#:  [**job number 96587**]
"
70,"unit no:  [**numeric identifier 97681**]
admission date: [**2162-2-15**]
discharge date: [**2162-2-24**]
sex:
service:


history of present illness:  this is an 81-year-old female
with a history of recent cabg with avr, chf, protein s
deficiency who presented from [**hospital3 **] in the
morning on [**2162-2-14**] with fever and respiratory distress.  she
was felt at [**hospital1 **] to be in chf versus pneumonia and was
given levofloxacin, ceftriaxone, and lasix.  they were unable
to contact her proxy and thus sent her to ems, as her oxygen
saturation decreased to 90 percent on nonrebreather.

in the ambulance, she was given morphine and bipap was
attempted, but her saturations decreased and she was
intubated in the field.

past medical history:  recent cad, status post cabg and avr
in [**11-26**] complicated postoperatively by multiple recurrent
episodes of congestive heart failure versus pulmonary disease
of unclear etiology.

protein s deficiency with recurrent dvts and pes.

schizophrenia.

chronic renal insufficiency with creatinine ranging between
1.3 to 1.5.

chf with an ef of 25 percent by echo in [**11-26**].

copd.

dementia.

history of mrsa.

medications on admission:
1. singulair 10 mg by mouth every day.
2. coumadin.
3. colace 100 mg by mouth two times a day.
4. aricept 10 mg at bedtime.
5. aspirin 81 mg a day.
6. [**doctor first name **] 60 mg a day.
7. protonix 40 mg a day.
8. advair 100/50 mcg.
9. prednisone 5 mg every other day.
10.      celexa.
11.      zyprexa 2.5 mg at bedtime.
12.      toprol xl 100 mg two times a day.
13.      neurontin two times a day.
14.      magnesium gluconate 1 g three times a day.
15.      lasix 60 mg two times a day.
16.      ceftriaxone 1 g.
17.      levofloxacin 500 mg.


allergies:  no known drug allergies.

social history:  the patient quit tobacco several years ago,
lived in [**hospital3 **] prior to her hospitalization in
[**month (only) 1096**]; however, after her operation in [**month (only) 1096**] had a
prolonged hospital course with multiple attempts of
extubation and difficulties with this resulting in severely
deconditioned patient and need for [**hospital3 **]
afterwards.  she has been in there since her discharge in
[**month (only) 404**].  her husband lives in a nursing home.

physical examination:  notable for temperature of 102.6,
blood pressure of 100/39, and assist control 16/450 with 5
peep.  lungs with bilateral coarse rales and rhonchi with
mechanical ventilation in all lung fields.  neurological
examination, the patient opens eyes to voice.  cranial nerves
ii through xii intact, withdraws all 4 extremities to
peripheral painful stimuli, and toes are upgoing on the
right.

laboratory data:  notable labs on admission were white count
of 7.8 with left shift, hematocrit of 27.1, inr of 1.6, and
creatinine of 1.2.

abg 7.28, 67, 341 on ac 14/400.

radiographic studies:  chest x-ray with pulmonary
interstitial edema consistent with chf and left pleural
effusion.

hospital course:  the patient was admitted to the intensive
care unit for further care.  problem list at this time
included respiratory distress, congestive heart failure,
pneumonia, anemia, fever.  in addition, in the emergency
room, she had a left internal jugular line placed, which on
chest x-ray was noted to be cannulating the carotid.  this
was removed, ffp was given, and pressure was held for 1 hour
with no adverse events on follow-up cat scan of the neck.
the patient was noted to have a left-sided pneumothorax,
which in comparison to cat scan from her hospitalization in
[**12-27**] seemed to be there at that time also.

respiratory distress.  the patient was intubated in the
field.  she initially was diuresed and a repeat
echocardiogram demonstrated an ef of 25 percent again with an
lv aneurysm.

she also continued to spike a fever and levofloxacin and
flagyl were started.  on [**2162-2-17**], she continued to have
fevers and bronchoscopy was performed.  during her previous
admission, she had much difficulty being extubated and
bronchoscopy at that time had revealed tracheomalacia and the
patient was given a tracheal and left main stem bronchial
stent, which made it then easy for her to be extubated.  on
the repeat bronchoscopy on [**2162-2-17**], the stents were found to
be in place, and the patient was found to have no further
problems with her tracheomalacia.  however, she continued to
have difficulty with weaning off her vent and with continuous
fevers.

a cat scan of the chest on [**2162-2-19**] demonstrated increased
cervical lymphadenopathy, a small stable pneumothorax,
hydropneumothorax, and left lower lobe consolidation.  two
days later, the bal returned with mrsa positivity, which she
has had in the past.  although this is likely a colonizer,
vancomycin was started in addition to levofloxacin and flagyl
on [**1-/2087**].

in addition, lenis were ordered, which were negative for dvt.

on [**2-23**], the patient was able to tolerate pressure support
in the morning and thus was extubated later in the day on to
bipap.  she eventually was able to tolerate being off of the
bipap overnight, but then had recurrent respiratory distress
in the morning of [**2-24**].  at this time, she refused strongly
and clearly bipap and re-intubation.  she was able to state
back her understanding that she was going to die and
understood that we would make her as comfortable as possible.
she was allowed to discuss this with her family who agreed to
honor her wishes.

the patient's daughter [**name (ni) **] [**name (ni) 30864**] was her proxy and also
went in and spoke to her mother and confirmed that her
mother's wishes were to be cmo.

on [**2162-2-24**], the patient was given iv morphine and made as
comfortable as possible and passed soon after.

a postmortem was declined by the family.

in addition to the above hospital course, there were multiple
other problems that contributed very little to her final
outcome such as a minor gi bleed with hematocrit of 27
requiring 2 units of packed red blood cells, worsening
chronic renal insufficiency up to 1.4 to 1.5 that improved
with hydration, and agitation, anxiety that was treated with
her outpatient psychiatric medications.

discharge diagnoses:  multifocal pneumonia.

congestive heart failure.

chronic pneumothorax.

gastrointestinal bleeding.

anemia.

respiratory distress.

discharge medications:  none.


                        [**first name11 (name pattern1) **] [**last name (namepattern1) **], [**md number(1) 18138**]

dictated by:[**last name (namepattern1) 46369**]
medquist36
d:  [**2162-6-7**] 12:26:33
t:  [**2162-6-8**] 01:45:35
job#:  [**job number 97682**]



"
71,"admission date:  [**2160-6-15**]     discharge date:  [**2160-6-22**]


service:

chief complaint:  ""i've been feeling bad for the last few
days and since yesterday i have been nauseous and vomiting.""

history of present illness:  the patient is a 77-year-old man
who presents with the above chief complaint and his past
medical history includes numerous medical problems including
non q wave mi times two, status post cabg in [**2139**],
hypertension, insulin dependent diabetes mellitus,
hypercholesterolemia, history of tias, history of lower gi
bleed and diverticulosis.  the patient was in his usual state
of health until approximately 4-5 weeks ago when his
degenerative joint disease and disc disease of his lumbar
spine began causing shooting right lower extremity pains.  at
that time the patient was treated with steroid injections and
po prednisone which caused an increase in his blood sugars.
for this increase in blood sugars he was started on humalog
approximately 3-5 days ago as his sugars have been in the
300-400's on his previous regimen.  approximately one week
ago the patient began feeling bad and run down.  the
patient's primary care doctor believed it was due to the high
blood sugars and started the humalog 3-5 days ago.  yesterday
the patient reports the onset of nausea and vomiting after
eating.  he tolerated lunch as his last meal and he has not
taken any po today.  also today he reports the onset of loose
stools times three.  he denied any fevers, abdominal pain,
weight change or urinary symptoms.  he does acknowledge night
sweats and chills at night over the last two days.  he has a
chronic cough secondary to post nasal drip which is
unproductive of sputum.  there is no erythema over the skin
where he injects his insulin.  his exercise tolerance is
approximately one flight of stairs and he is limited by right
lower leg pain.  he also denies any chest pain, shortness of
breath, palpitations or diaphoresis.  he has no pnd.  the
patient finally came to the er as he was not able to take
anything by mouth.

past medical history:  1) insulin dependent diabetes
mellitus.  2) hypertension, poorly controlled.  3) chronic
renal insufficiency.  4) status post non q wave mi times two.
5) status post cabg in [**2139**].  6) hypercholesterolemia.  7)
history of tia.  8) gout.  9) lower gi bleed status post
polyp removal.  10) diverticulosis.  11) allergies and post
nasal drip.

medications:  [**doctor first name **] 60 mg po q d, lopressor 20 mg po q d,
multivitamin, doxazosin 4 mg q h.s., lipitor 20 mg po q d,
allopurinol 300 mg po q d, ranitidine 150 mg po q h.s.,
glyburide 10 mg po bid, diovan 80 mg po q d, enteric coated
aspirin 325 mg po q d, quinine as needed, nph 20-30 units q
a.m., 10-15 units q p.m., humalog sliding scale started three
days ago.

social history:  the patient lives with his wife.  [**name (ni) **] denies
any tobacco or alcohol use.

family history:  noncontributory.

allergies:  morphine makes him nauseous.

physical examination:  vital signs, temperature 99.5, heart
rate 83, blood pressure 170/125, respiratory rate 18, satting
100% on two liters nasal cannula.  in general he is an
elderly man lying in bed in no acute distress.  heent:  he
has alopecia, pupils are equal, round and reactive to light
from 3 to 2 mm, sclera are anicteric.  mucus membranes are
moist.  neck supple, no jugulovenous distension, no
lymphadenopathy, no bruits.  cardiac exam, irregularly
irregular, s1 and s2 normal, no murmurs, gallops or rubs.
lungs are clear to auscultation bilaterally. abdomen, mild
tenderness to deep palpation of the left lower quadrant.  he
is non distended, bowel sounds present and normal.  abdomen
is soft.  gu, normal male genitalia, trace guaiac positive on
exam.  prostate without any nodules, regular and smooth.
extremities, no clubbing, cyanosis or edema. neuro, he is
alert and oriented times three, cranial nerves ii through xii
normal.  reflexes 2+ bilaterally biceps and achilles
strength, [**3-29**] upper extremities bilaterally, in the left
lower extremity is 4+/5 strength in his right big toe and
plantar and dorsiflexion of his foot.  gait and coordination
were not tested.

laboratory data:  white count 14.6, differential with 84
neutrophils, 1 band, 10 lymphs, hematocrit 44.4, platelet
count 134,000, pt 11.7, ptt 21.4, inr 0.9.  sma 7, 137, 5.2
which was hemolyzed, 100, 21, 40, 1.4, glucose 297.  calcium
8.4, phosphorus 4.7, magnesium 2.1, ast 24, alt 28, total
bilirubin 0.9, ck 54, troponin 0.3, alkaline phosphatase 59,
amylase 114, lipase 41, albumin 3.3, uric acid 4.3, tsh is
pending at this time.  chest x-ray showed no signs of
pulmonary edema and no infiltrate.  ekg was irregularly
irregular at 92, axis -30, occasional p waves, looking like
flutter but there are also absent p waves.  intervals are
normal.  there is a q in 3 and f, no st changes, poor r wave
progression.  an echocardiogram from [**2160-4-25**] showed mild
left atrial dilatation, non obstructive focal septal
hypertrophy, depressed lv function 1+ aortic regurg, mild mr
[**first name (titles) **] [**last name (titles) **] fraction could not be estimated at that time.

impression:  this is a 77-year-old man with multiple ongoing
medical problems who presents with generalized complaints of
the last week and a [**11-27**] day history of nausea and vomiting
and loose stool.  he was found to be in new onset atrial
fibrillation in the er.  physical exam was remarkable for the
atrial fibrillation with guaiac positive stool and mild left
lower quadrant tenderness.  labs revealed an increased white
blood cell count with left shift and low albumin.  chest
x-ray and ekg are normal and unchanged respectively.

plan:
cardiac:  the patient has known cad.  his aspirin, beta
blocker, lipitor and [**last name (un) **] will be continued.  his hypertension
will be aggressively controlled.  although ischemia is
unlikely without any changes in ekg, cks will be followed.
the patient is in new onset atrial fibrillation but lopressor
will be increased to 50 mg [**hospital1 **] for rate control.  tsh is
pending after weighing the risks and benefits of heparin.
given the patient's trace guaiac positive stool, history of
lower gi bleed, the decision was made to start the patient on
heparin as he had multiple risk factors for stroke elevating
him into a higher level of category including his past
history of tias.

infectious disease:  he has an elevated white count with a
left shift.  he has night sweats, chills times two days.
cultures of urine, stool and blood will be sent.  blood
cultures will be obtained when the patient's fever curve is
greater than 101.  no empiric antibiotics will be started at
this time.

endocrine:  the patient has poor glucose control.  he will be
written for an insulin sliding scale while in the hospital
and fingersticks will be checked qid.  his oral hypoglycemics
will be held for now.

gi:  he is trace guaiac positive with left lower quadrant
tenderness and a history of diverticulosis.  diverticulitis
is certainly a possibility although given the benign
presentation of his abdomen on exam, it is unlikely.
however, we will continue to follow his abdominal exam.  we
will guaiac all stools and we will follow hematocrit q d on
heparin.  the patient will be given antiemetics as needed to
control the nausea and vomiting.

renal:  the patient has a creatinine of 1.4 with an elevated
bun to creatinine ratio.  he is most likely dehydrated given
his nausea and vomiting and slightly prerenal and will be
hydrated.

musculoskeletal and neuro:  he has decreased strength in his
right lower leg consistent with his past medical history of
djd and disc disease of his lumbar spine.  his pain will be
controlled with non opioids as much as possible as opioids
have given him bad reactions in the past.  the patient was
admitted and this plan was pursued.

hospital course:  on hospital day #2 the patient had no
adverse events overnight.  the stool samples and the tsh are
still pending.  the patient is maintained on heparin and the
plan will be to transition him to coumadin, then to discharge
the patient and bring him back at 1-2 months for tee and
cardioversion at that time after anticoagulation, as it is
unknown how long patient has been in atrial fibrillation.
also on this admission the plan is to control his blood
sugars, hopefully the combined approach will lead to a
resolution of his nausea and vomiting and he can go home.  on
hospital day #3 the patient complained of some right thigh
swelling.  he was neurovascularly intact and this was thought
to be secondary to a muscle pull the patient experienced
approximately five days prior to admission.  there was a
small hematoma.  this is most likely exacerbated because of
the heparin the patient has been on, but the team was not so
concerned about this.  also on the third hospital day the
patient became tachycardic and hypotensive with blood
pressure in the 60's/30's.  the patient was somnolent at this
time.  exam was unchanged from prior.  iv fluids were given
and ekg was done that was unchanged.  the heparin was
discontinued and an ng lavage was performed that showed dark
brown fluid in the stomach with occasional clots which were
gastroccult positive.  with the lavage, the red fluid did not
clear.  a stat hematocrit came back at 26 which was down from
44 on admission, although this is partly due to rehydration,
this is significantly due to an upper gi bleed.  the patient
was transferred to the ccu at that time and transfused two
units of packed red blood cells.  the patient underwent
emergent egd that showed clotted blood in the lower third of
the esophagus and multiple non bleeding diffuse erosions in
the lower third of the esophagus.  the stomach was normal.
in the duodenum there were multiple acute crater ulcers in
the bulb and in the second part of the duodenum.  pigmented
material coating these ulcers suggested recent bleeding in
one of the ulcers.  the patient was treated with proton pump
inhibitor [**hospital1 **], discontinuation of all nsaids and
anticoagulation.  hematocrits were continually followed and
an h. pylori antibody was checked.  the tsh level came back
as normal at this time.  on the fourth hospital day the
patient was transferred back to the floor from the unit after
the egd and the 2 units of packed cells when patient was
stabilized.  on hospital day #5 the patient's main complaint
was his right thigh swelling leading to right thigh weakness
when he stood up.  he denied anymore episodes of
lightheadedness, dizziness, chest pain, shortness of breath,
bright red blood per rectum, melena or vomiting of blood.  at
this time his aspirin was changed to 81 mg from 325 mg and
the patient was not on either heparin or coumadin.  the
patient's hematocrit post transfusion rose to 31 and has
continued to rise since then.  his creatinine and bun bumped
transiently during the patient's hypovolemia episodes.  they
are now trending down.  the nph and regular insulin sliding
scale is controlling the patient's blood sugars.  [**initials (namepattern4) **] [**last name (namepattern4) **]
consult was obtained because the patient is usually followed
in [**last name (un) **], to further optimize the patient's insulin regimen.
the plan is to treat the patient for one month with proton
pump inhibitors, to follow-up the results of the h. pylori,
treat that if positive and to allow the ulcers one month to
heal.  the patient will return for a repeat upper endoscopy
in one month.  at that time if the ulcers are healed,
anticoagulation will be pursued with the eventual goal of
performing a tee and cardioversion either chemical or
electrical, once the patient has been on stable
anticoagulation for one month.  hospital day #6 the patient's
diet was advanced as tolerated.  physical therapy saw the
patient who agreed he was safe for discharge home.  on
hospital day #7 the patient slowly was regaining his strength
in his right leg and mobility.  he was starting to ask to go
home.  on hospital day #8 he was discharged home.  he will
follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 1313**], dr. [**last name (stitle) 19862**] from endocrine
and dr. [**first name (stitle) 1104**] from cardiology.  all of those attendings are
aware of the [**hospital 228**] hospital course.  the patient's
lopressor dose at the time of discharge is 37.5 mg po tid.
the h. pylori result came back positive.  he will be treated
for h. pylori infection.  he will follow-up with gi in [**2-29**]
weeks for repeat upper endoscopy.




                          [**first name11 (name pattern1) **] [**last name (namepattern4) 31943**], m.d.  [**md number(1) 31944**]

dictated by:[**last name (namepattern1) 8228**]

medquist36

d:  [**2161-1-28**]  12:05
t:  [**2161-1-28**]  14:07
job#:  [**job number **]
"
72,"admission date:  [**2125-10-8**]              discharge date:   [**2125-10-19**]

date of birth:  [**2055-7-28**]             sex:   f

service: omed

allergies:
codeine / carboplatin / cisplatin

attending:[**last name (namepattern1) 5062**]
chief complaint:
fatigue, acute hematocrit drop

major surgical or invasive procedure:
none

history of present illness:
initial hx prior to icu admission:
this is a 70 yo f w/ h/o relapsing papillary serous ovarian
cancer last first diagnosed in [**2117**].  she was last admitted to
this hospital for her 7th cycle of cisplatin.  she was given
[**doctor last name **]/taxol once in [**2117**], and was changed to [**doctor last name **]-cytoxan for
low counts in 01/[**2118**].  she tne received six cycles of cisplatin
started in [**1-/2125**] and administered in the hospital because of
the questionable history of allergic reaction to carboplatin.
-
since that admission, she showed signs of fluid retention, both
in her legs and in her ascites but she did not have any evidence
of congestive heart failure based on exam with normal lungs and
flat jvd. there was concern that perhaps her cancer was
progressing and that is the reason for her tense ascites, but
consideration was also given to worsening renal failure as
explanation for increased ascites.  ct scan taken [**2125-9-21**] showed increased ascites, but otherwise stable exam with
mesenteric masses and evidence of peritoneal carcinomatosis that
appear unchanged when compared to [**2125-7-25**].
-
her husband reported some recent confusion during their clinic
visit on [**9-26**].  due to her creatinine clearance of about
20ml/min, the decision was made during this visit to switch the
patient to weekly gemzar despite the stability of dz achieved
w/cisplatin.  due to her decreased creatinine clearance, a
reduced dose of 500 mg per meters squared was chosen.  she was
started on this dose on [**10-3**] and acutely tolerated it well.  the
plan was for weekly gemzar, three weeks on and one week off.
-
the patient first felt different from her normal self on
saturday, when she ""started to feel lousy.""  she saw an
accupuncturist on sat. for posterior neck pain; needles were
inserted into her head, back and ankles.  on sunday, her
weakness progressed to the point that she could no longer stand.
 her husband noted a bloodshot left eye ealier today, now
resolved.  she recently fell on her left buttock.
-
on ros, the patient notes moderate to severe abdominal pain for
the past several days, especially before meals and sometimes
resolved with food.  she sleeps with three pillows.
-
today, the patient's fellow contact[**name (ni) **] her.  she reported the
above symptoms and was told to come to clinic.  her hematocrit
has decreased from 33 to 17 and so she was admitted to omed and
immediately transferred to icu as inr>60.

on transfer back to omed from icu:

mrs. [**known lastname 1661**] is a 70 y/o f with recurrent ovarian ca, s/p cabg,
s/p mv repair, and hypothyroid, presented from onc clinic on
[**2125-10-8**] with weakness, nausea, and decreased po intake since
gemcitabine tx on [**2125-10-3**] and on clinic visit [**10-8**] was found to
be hyptotensive, decrease hct (from 33.0 to 17.1), and inr>60.
patient was initially admitted to omed service, but transferred
to micu for further evaluation. please see micu admit note for
more information on past medical hx and course during stay. in
brief, patient was admitted for hemodynamic stability and work
up of coagulopathic state. mrs. [**known lastname 1661**] denied diarrhea,
hematuria but did report very slight brbpr on toilet paper. she
was trace guiac positive on admission. she had diffuse
ecchymosis over lower extremities, back, and buttocks. she
received 6 units of prbc's with appropriate bump in hct to 34.1
on [**10-16**].  in terms of her coagulopathy, it is thought that a
combination of coumadin (for h/o dvt), decrease po intake, and
recent administration of gemcitabine were instigating factors.
coumadin held on admission. she received 1 unit ffp and was
initially treated with po vitamin k while in micu, with decrease
in inr to 3.0 on morning of [**10-17**]. on [**10-17**] she received 1 mg iv
vitamin k. her initial mixing studies were negative for
inhibitors. shortly after receiving the 6 units of blood,
patient became sob secondary to fluid overloaded state. she was
diuresed and responded well to lasix; however, creatinine began
rising (above baseline of ~2.6) likely because of hypovolumia
and decrease blood flow to kidneys. patient was subsequently
gently hydrated, with impoved renal status.  creatinine 2.8 on
[**10-16**]. during fluid overloaded state, mrs. [**known lastname 1661**] also developed
afib, which per family was new onset. after cardiology consult
and discussion with primary oncology team, it was decided to
cardiovert patient. she tolerated well and is now in nsr.
nutrition is still an issue for patient, as she has decrease
appetite. also, she was seen by pt for gait instability/[**month (only) **]
balance. mrs [**known lastname 1661**] appears well and states that she is feeling
good. she is anxious to get up and walk around the floor.
patient currently denies and n/v/dizziness. no f/c/ns/sob/cp.
she has not urinated since foley d/c'ed this morning but feels
that she might be able to go soon. urinary retention was not a
problem for her prior to admission.


past medical history:
1.relapsing papillary serous ovarian ca as above--hx onc
therapy:
she was diagnosed in [**2117**].

she is status post carboplatin and taxol times one in [**2117**],
changed to [**doctor last name **]- cytoxan because of low counts in 01/[**2118**].

status post cytoxan and cisplatin times two and then cytoxan and

carboplatin times four from [**6-/2119**] to 09/[**2119**].
status post [**doctor last name **] times six until 05/[**2121**].
status post taxol times eight from [**3-/2123**] to 10/[**2123**].
status post oral etoposide times one, discontinued because of
mouth sores in 11/[**2123**].
status post carboplatin times two, discontinued because of an
allergic reaction that occurred in 12/[**2123**].
status post cisplatin times three from [**1-/2124**] to [**4-/2124**],
discontinued because of rising creatinine.
status post weekly taxol but discontinued because of disease
progression.
started on cisplatin 50 mg/m2 in [**9-/2124**] status post two cycles
at that time, discontinued because of rising creatinine.
status post two cycles with navelbine, discontinued because of
disease progression.
status post seven cycles of cisplatin started in [**1-/2125**] and
administered in the hospital because of the questionable history

of allergic reaction to this medication given the fact that she
had an allergic reaction to carboplatin in the past. cisplatin
was discontinued due to rising cr.
status post gemzar treatment last wednesday, [**2125-10-3**]
-
2. yeast infection [**2125-8-29**]
-
3.cad s/p cabg and mvr
-
4. h/o le dvt
-
5.cri
-
6. hyperchol.
-
7. gout
-
8. hypothyroidism


social history:
married, 30 pack yr tob, quitx20 years, no etoh, no ivda.

family history:
mother=[**name (ni) **]
father:prostate ca
brother:pd
m aunt=ovarian ca
cousin=ovarian ca


physical exam:
[**10-8**]:
vitals: 99.4  76-80 (76)  94/42
gen: pale woman relaxing in bed in nad, brighter appearing than
yesterday evening or this morning
neck: supple, perrl, eomi, conjunctivae remain pale, mouth and
oropharynx clear
lungs: ctab
heart: rrr
abd: soft, distended, nt
ext: warm x 4 with pulses x 4
skin: left large ecchymosis on buttocks slighly increased in
size and color since yesterday, bil hands, abdomen

[**10-16**]:
pe:t:98.0  p: 68-75   bp: 86-128/44-99   rr:24 o2:93-98%
gen: patient is pleasant, pale appearing elderly female, nad
heent: perrl - consenusally, eomi, sclerae anicteric; supericial
ulcer on r side of tongue, blood blister on back l tongue; neck:
supple, from, no lad
lungs: cta with bibasilar crackles
cardiac: rrr, no m/g/r
abd: moderate distention-but not firm, no peritoneal signs,
nontender, no masses appreaciated, +bs, resolving ecchymosis on
luq of abd.
ext: 2+ pitting edema of le bilat. diffuse ecchymosis of b/l
buttocks r>l, and upper thighs, mostly resolved on l left
extremity; few small ecchymosis on l wrist. resolving per micu
notes.
neuro: a&ox3; responding appropriately, very talkative, cn2-12
intact with no focal deficit. strength 5/5 throughout.


pertinent results:
crit: baseline mid 20s; [**10-3**] 33  [**10-5**] 17.1  9/21@1430 following
3u 28.6
pt: [**9-5**] 13.7  [**10-8**] >100  [**10-9**] following 1u ffp 24.8, 32.6
ptt: [**9-5**] 23.6  [**10-8**]  150, 143 [**10-9**] following 1u ffp 61.7, 48.8
platelets: [**10-8**] 263 [**10-9**] 162

ct of the chest without iv contrast: there are minor dependent
atelectatic
changes. extensive atherosclerotic changes of the aorta and
coronary arteries
are evident. multiple prominent but nonpathologically enlarged
mediastinal
lymph nodes are identified. there is a large hiatal hernia. no
pleural or
pericardial effusions are present.

ct of the abdomen without iv contrast: there is a
moderate-to-large amount of
ascites within the abdomen, but no evidence of an intra- or
retroperitoneal
hematoma. allowing for the limitations of a noncontrast exam,
the liver,
gallbladder, spleen, pancreas, adrenal glands, and kidneys are
within normal
limits. extensive aortic calcifications are again noted. no
pathologically
enlarged retroperitoneal or mesenteric lymph nodes are
identified in this
limited study. there is no free air.

ct of the pelvis without iv contrast: a large volume of ascites
is present
within the pelvis. the urinary bladder is unremarkable. there is
sigmoid
diverticulosis without diverticulitis.

bone windows: no suspicious lytic or blastic leions are
identified.

impression: moderate-to-large volume of ascites, but no evidence
of intra- or
retroperitoneal hemorrhage.

[**10-9**] chest ap:
portable ap chest: comparison is made with a chest ct scan from
[**2125-10-8**]. again seen is a left subclavian port with the tip in the
svc, in
satisfactory position. there is no pneumothorax. there are
multiple
mediastinal clips and a prosthetic mitral valve. there is stable
cardiomegaly
with mild upper lung zone redistribution. there is a large
hiatal hernia with
associated atelectasis in the left lower lobe. there is
worsening right lower
lobe atelectasis.


brief hospital course:
a/p: mrs. [**known lastname 1661**] is a 70 yo female with h/o recurrent ovarian
cancer who recieved first dose of gemcitabine on [**2125-10-3**] and
presented to clinic on [**10-8**] with hypotension, drop in hct
(33-->17), and inr>30, admitted to icu. icu course c/b fluid
overload, acute on chronic renal fl., and afib. transferred to
omed on [**10-16**] hemodynamically stable, inr 3.0 and 34.1.

1. coagulopathy - patient admitted with an inr >60, 3.0 on [**10-16**].
thought to be [**2-19**] combination of decrease po intake, coumadin,
and gemcatabine.  continue to hold coumadin. as per hpi, treated
with ffp and vitamin k in icu with inr decrease to 3.0. given
1gm vitamin k iv [**10-16**] prior to transfer to floor. inr 2.1 day
prior to discharge and 2.9 on day of discharge. per primary
oncology team, she was given 10mg po vitamin k prior to
discharge and will f/u in clinic in 3 days to have inr
rechecked. coumadin was held on discharge.
2. anemia - patient with chronic anemia, but acute blood loss
internally to buttocks thighs in setting of coagulopathic state.
responded appropriately to 6 units prbc's in icu with hct
remained stabe once transferred to oncology service. she was
receiving procrit about once a week prior to admission to
hospital and received injection 3x/week during admisison. she is
to f/u with primary team on monday to discuss continuation of
procrit.
3. htn: blood pressures had been fluctuating while in icu and
initially holding of metoprolol. outpatient dose of metoprolol
25mg [**hospital1 **] and was restarted and switched to 12.5mg tid for while
in the icu. her blood pressures were well controlled on this
dose and she was discharged on 12.5 mg tid.
4. acute on chronic renal insufficiency - patient with baseline
creatinine of 2.4-2.7. creatinine had increased [**2-19**] to prerenal
azotemia while being diuresed in icu. trending to baseline on
transfer to floor. creatinine was 2.7 on day of discharge.
nephrotoxic medications were avoided during admission.
5. ovarian cancer -  s/p gemcitabine treatment [**10-3**], preceeding
admission and onset of previoulsy discussed adverse events. will
discuss with primary oncologist future treatment plans.
6. nutrition - mrs [**known lastname 1661**] has had poor appetite for some time,
which may have attributed to coagulopathic state.  seen and
evaluated by nutrition service. patient notes that her appetite
is slowly increasing and appeared to be eating about [**date range (1) 5082**] of
food on tray. discussed importance of eating green vegetables -
ie broccoli- but encouraged any po intake for now.
7. constipation - mrs. [**known lastname 1661**] has had difficulty moving bowels
x 1 week despite aggressive treatment. she was managed on senna
and colace and responded well to .5l of golytely to get bowels
started and then occassional miralax.
8. pt: physical therapy evaluated patient today and suggested
3-5 visits/wk to help with balance, gait, and transfers.
suggested possible rehab on discharge, but patient refused and
stated that she preferred home pt. also with ot evaluation with
suggestion of home aide to supervise shower transfers and home
safety evaluations.
9. cad/hyperlipidemia - continue atorvastatin during admission
and on dsicharge.
10. hypothyroid - continued outpatient dose of levothyroxil
during admission and on discharge.
11. episode of afib - patient was noted to be in afib during icu
stay (as per hpi). because of the desire to avoid need for
anticoagulation (if need for cardioversion if in afib >48 hours)
she was successfully  cardioverted on [**10-12**]. nsr throughout rest
of hospitalization.
12. fen: continue protonix, phosphagel, tums, and pneumoboots.
13. code: dnr/dni


medications on admission:
levoxyl 75 mcg p.o. daily, prilosec, coumadin 1mg qd,
lipitor, atenolol, anzemet, celexa, oxycontin b.i.d., iron,
procrit, renagel 40mg qd and ativan daily.

discharge medications:
1. levothyroxine sodium 75 mcg tablet sig: one (1) tablet po qd
(once a day).
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 q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*2*
3. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po
qd (once a day).
disp:*30 tablet(s)* refills:*2*
4. sevelamer hcl 400 mg tablet sig: one (1) tablet po tid (3
times a day).
disp:*90 tablet(s)* refills:*2*
5. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2
times a day).
disp:*120 capsule(s)* refills:*2*
6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day).
disp:*60 tablet(s)* refills:*2*
7. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
8. calcium carbonate 500 mg tablet, chewable sig: one (1)
tablet, chewable po tid w/meals (3 times a day with meals).
disp:*30 tablet, chewable(s)* refills:*2*
9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3
times a day).
10. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as
needed for anxiety.


discharge disposition:
home with service

facility:
[**hospital 119**] homecare

discharge diagnosis:
primary diagnosis:
1. coagulopathy
secondary diagnosis
1. ovarian cancer
2. malignant ascities
3. chronic renal insufficiency
4. congestive heart failure
5. h/o dvt
6. s/p mvr


discharge condition:
stable.

discharge instructions:
please call your pcp or come to the ed if you have notice
worsening bruising, bloody stools, shortness of breath, chest
pain, feves/chills, or other worrisome symptoms.
please follow up on monday in the [**hospital **] clinic to have your
labs drawn.
do not restart coumadin on discharge. please discuss restarting
this medication with your doctor when you return to the [**hospital **]
clinic on [**10-22**].


followup instructions:
1. please return to the oncology clinic on monday, [**2125-10-22**] to have your labs drawn.
2. please call your oncologist for an appointment in [**1-19**] weeks.
3. please call your pcp, [**last name (namepattern4) **]. [**first name (stitle) **] at ([**telephone/fax (1) 95873**] for an
appointment in [**1-19**] weeks.



"
73,"admission date:  [**2121-12-7**]              discharge date:   [**2121-12-12**]

date of birth:  [**2041-5-16**]             sex:   f

service: medicine

allergies:
penicillins / sulfa (sulfonamide antibiotics) / lidocaine

attending:[**first name3 (lf) 2387**]
chief complaint:
acute mental status change

major surgical or invasive procedure:
chest tube placement
right internal jugular central venous line placement


history of present illness:
80 year-old lady with history of dementia presents as
transfer to medicine service. the patient was admitted to the
cv-icu on the night of [**2121-12-7**] because she had a central line
placed in her left subclavian artery at an outside hospital.
this was complicated by a left-sided hemopneumothorax for which
a
chest tube was placed at the outside hospital. the only other
active medical issues upon transfer was the patient's recurrent
acute on chronic renal failure and a recurrent uti.  the patient
had an inr of 4.3 and hct of 23 upon transfer to [**hospital1 18**].  the
goal
upon admission to the vascular service was to transfuse her and
correct her inr.  the subclavian line would be pulled at the
bedside [**2121-12-8**].


past medical history:
a fib, dementia, htn, hypercholesterolemia, s/p cva with
hemiparesis, anxiety disorder, depression, frequent utis, pna,
rib fractures, s/p r hip fracture, hydronephrosis, congenital
upj
obstruction

[**doctor first name **] hx: s/p r total hip replacement x 2


social history:
lives at [**hospital1 11851**] nh; no etoh, dnr/dni


family history:
noncontributory

physical exam:
transfer exam

vs: t 94.7 (ax), hr 73, bp 108/53, rr 20, 94% 3l
gen: anxious, communicates with groans
neck: supple, no bruits
lungs: rhonchi b/l, wheezes b/l, no air leak on chest tube
cv: irregularly irregular, nl s1 and s2
abd: soft, nt, nd
ext: l arm without any sign of ischemia, no c/c/e of le, right
foot slightly cooler than left, 2+ radial and 1+ ulnar on left
vasc:
     fem     [**doctor last name **]     pt     dp
r    2+      2+      d      d
l    2+      2+      d      2+

discharge exam
vs 97/97.2 155/70 70 20 98%ra
gen: nad
heent: mmm, op clear, neck supple
cv: irregular s1+s2, no m/r/g
lungs: ctab anteriorly
abd: s/nt/nd +bs
ext: no c/c/e
neuro: oriented x1 (person). continues to have echolalia
although improved from yesterday.

pertinent results:
[**2121-12-12**] 07:35am blood wbc-10.1 rbc-3.55* hgb-10.5* hct-30.3*
mcv-85 mch-29.5 mchc-34.6 rdw-15.1 plt ct-277
[**2121-12-11**] 07:00am blood wbc-10.2 rbc-3.43* hgb-10.1* hct-28.5*
mcv-83 mch-29.4 mchc-35.4* rdw-15.1 plt ct-306
[**2121-12-10**] 07:07am blood wbc-12.1* rbc-3.84*# hgb-11.4*#
hct-32.2*# mcv-84 mch-29.6 mchc-35.3* rdw-15.4 plt ct-360
[**2121-12-9**] 02:08am blood wbc-8.9 rbc-2.92* hgb-8.6* hct-24.5*
mcv-84 mch-29.3 mchc-34.9 rdw-15.1 plt ct-274
[**2121-12-8**] 04:18pm blood hct-24.8*
[**2121-12-8**] 04:58am blood wbc-9.8 rbc-3.26* hgb-9.7* hct-27.6*
mcv-85 mch-29.9 mchc-35.3* rdw-14.9 plt ct-261
[**2121-12-7**] 08:46pm blood wbc-8.8 rbc-3.09* hgb-8.9* hct-26.3*
mcv-85 mch-28.8 mchc-33.8 rdw-15.1 plt ct-286
[**2121-12-7**] 08:46pm blood neuts-84.6* lymphs-14.6* monos-0.6* eos-0
baso-0.1
[**2121-12-7**] 08:46pm blood hypochr-normal anisocy-normal poiklo-1+
macrocy-normal microcy-normal polychr-1+ ovalocy-1+
schisto-occasional tear dr[**last name (stitle) **]1+
[**2121-12-12**] 07:35am blood plt ct-277
[**2121-12-12**] 07:35am blood pt-13.2 ptt-24.6 inr(pt)-1.1
[**2121-12-12**] 07:35am blood glucose-87 urean-44* creat-1.1 na-148*
k-3.3 cl-113* hco3-27 angap-11
[**2121-12-12**] 07:35am blood calcium-8.1* phos-2.4* mg-1.5*
[**2121-12-10**] 07:07am blood vitb12-1495*
[**2121-12-10**] 07:07am blood tsh-1.2
[**2121-12-7**] 09:20pm blood type-[**last name (un) **] po2-42* pco2-53* ph-7.24*
caltco2-24 base xs--5

cth
1. no evidence of acute intracranial hemorrhage. hypoattenuation
involving
the left basal ganglia extending into the corona radiata may
represent sequela
of previously stated remote cva, however, interposed acute
component cannot be
entirely excluded. mri may be obtained for further evaluation to
exclude
underlying acute component as discussed with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]
at the time of
dictation.

2. minimal sinus disease as described above.

3. right subinsular cortical infarct, old.

note added at attending review: the changes noted above
involving the left
thalamus, caudate body, internal capsule and periventricular
white matter
appear to reflect old infarction, perhaps with old hemorrhage.
there is no
evidence of recent infarction. however, in the setting of
chronic infarction further ischemic injury in the same
distribution can be difficult to detect with non contrast ct.

cxr ([**2121-12-10**])
probable persistent tiny left apical pneumothorax although
difficult to discern from overlying rib shadows.


brief hospital course:
80 year old female with af, dementia, hlp, cva with residual
hemiparesis, anxiety/depression, and congenital upj obstruction
transferred from osh for left subclavian arterial line placement
and presumed uti.

1. uti:patient has history of frequent utis with multiple
admissions in the past year to osh.  she also currently has a
chronic indwelling fc, increasing her risk of uti.  she has been
treated with iv ciprofloxacin since being admitted to the osh.
repeated urine cultures during admission were contaminated.
patient was initially treated with ciprofloxacin, but given past
history of e.coli resistant to quinolones. urinalysis at outside
hospital performed without urine culture.  patient was converted
to ceftriaxone, which she tolerated well even with reported
history of pcn allergy.  on discharge, she was coverted to
cefpodoxime and instructed to complete a total of 7 days on
ceftriaxone/cefpodoxime.

2. anemia: patient was transfused a total of 2u prbc during
admission at [**hospital1 18**]. although unclear, it appears as if she was
also transfused 2u prbc at osh. on discharge, her hct was
stable.

3. left subclavian arterial line placement: upon transfer,
subclavian arterial line was removed and a chest tube was placed
on the left for her hemopneumothorax.  on hospital day 3 her
chest tube was removed without adverse events.  of note, a
follow-up cxr after chest tube removal demonstrated a small
residual pneumonthorax.

4. acute mental status change: most likely multifactorial due to
uti, hospitalization, and medications including morphine and
ativan that the patient received while in the icu.  the patient
at [**hospital1 11851**] has also been receiving remeron, ativan, and
trazadone, which were discontinued. the patient appeared to have
mild improvement in her delirium during her admission. of note,
a non-contrast ct head was performed during her admission that
did not demonstrate an acute intracranial process.

5. acute on chronic renal failure: likely secondary to
intravascular volume depletion.  patient received ivf during her
admisison and on discharge, her creatinine was at baseline at
1.1.

6. afib: patient was initially admitted on atenolol 100 mg po
bid. given her acute on chronic renal failure, she was
transitioned to metoprolol 50 mg po bid.  after her hematocrit
was stabilized, she was restarted on coumadin.  she will need to
have her inr monitored with a goal of [**2-9**].

7. hypertension: beta blocker changed to metoprolol as above.
amlodipine 5 mg daily was added for additional blood pressure
control.

8. steroids: the patient was admitted to [**hospital1 18**] one prednisone,
which was continued during her admission. on discharge, she was
instructed to continue with 10 mg daily prednisone.  although
unclear as to the reason for her steroid use, it appears as if
she was on a scheduled taper at [**hospital1 11851**] of prednisone.  she
was instructed on discharge to follow-up with her physician at
[**name9 (pre) 11851**] or her pcp with regard to prednisone taper.

medications on admission:
coumadin 2 qd, lasix 40 qd, mvi 1 qd, kdur 20
meq qd, atenolol 100 [**hospital1 **], remeron 30 qhs, prednisone 10 qd,
cipro
500 [**hospital1 **] (started [**12-5**]), forastor probiotic 250 [**hospital1 **], tylenol 650
q 4 prn, dulcolax prn, mom prn, trazodone 25 qhs prn, ativan 0.5
mg q4 prn, duonebs prn


discharge medications:
1. vantin 200 mg tablet sig: one (1) tablet po twice a day for 5
days.
disp:*10 tablet(s)* refills:*0*
2. metoprolol tartrate 100 mg tablet sig: one (1) tablet po once
a day.
3. norvasc 5 mg tablet sig: one (1) tablet po once a day.
4. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4
pm.
5. lasix 40 mg tablet sig: one (1) tablet po once a day.
6. multiple vitamin     tablet sig: one (1) tablet po once a
day.
7. prednisone 10 mg tablet sig: one (1) tablet po once a day.
8. duoneb 0.5-2.5 mg/3 ml solution for nebulization sig: one (1)
 inhalation every six (6) hours as needed for shortness of
breath or wheezing.
9. dulcolax 5 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po once a day as needed for
constipation.
10. acetaminophen 325 mg tablet sig: one (1) tablet po q6h
(every 6 hours) as needed for pain.


discharge disposition:
extended care

facility:
[**hospital 11851**] healthcare - [**location (un) 620**]

discharge diagnosis:
primary
- uti
- anemia

secondary
a fib, dementia, htn, hypercholesterolemia, s/p cva with
hemiparesis, anxiety disorder, depression, frequent utis, pna,
rib fractures, s/p r hip fracture, hydronephrosis, congenital
upj
obstruction


discharge condition:
patient was discharged in stable condition.


discharge instructions:
1. you were admitted for a urinary tract infection, which was
treated with antibiotics. you will need to continue these
antibiotics as an outpatient. the instructions for this
medication are:
cefpodoxime 200 mg by mouth twice daily for 5 days (stop on
[**2121-12-17**])

2. you were also admitted for a subclavian arterial line
placement. you received a blood transfusion while admitted. on
discharge your hematocrit was stable.

3. unless otherwise indicated, please resume all of your
medications as take prior to admission. it is very important
that you take your medications as prescribed.  you were admitted
on prednisone, which was continued during your admission. you
will need to follow-up with your pcp or [**name9 (pre) 11851**] physician with
regard to prednisone taper.

4. you will need to have you inr checked on monday, [**12-15**] with a
goal inr of [**2-9**]. you will need to have regular inr checks with
your coumadin adjusted as necessary by your doctor [**first name (titles) **] [**last name (titles) 11851**].

5. it is very important that you make all of your doctor's
appointments.

6. if you develop chest pain, shortness of breath, or other
concerning symptoms, please call your pcp or go to your local
emergency department immediately.

followup instructions:
please follow-up with your pcp [**last name (namepattern4) **] 2 weeks. you can schedule an
appointment by calling [**telephone/fax (1) 6019**].



completed by:[**2121-12-13**]"
74,"admission date:  [**2145-4-9**]              discharge date:   [**2145-4-15**]

date of birth:  [**2064-8-29**]             sex:   m

service: surgery

allergies:
aspirin / lisinopril / morphine

attending:[**first name3 (lf) 695**]
chief complaint:
hepatic mass

major surgical or invasive procedure:
[**2145-4-9**] l hepatectomy, gold fiducial seed placement [**2145-4-9**]


history of present illness:
80-year-old male who underwent a routine chest x-ray and
subsequently
ct scan of the chest that demonstrated a mass in the liver
precipitating a ct scan of the abdomen. this demonstrated a
5.4 x 4.9 cm poorly marginating heterogeneous mass. a ct
guided liver biopsy on [**2-22**] demonstrated infiltrating
poorly differentiated adenocarcinoma. a chest ct scan
demonstrated no evidence of pulmonary metastases.  a
colonoscopy, upper gi and small-bowel follow-through did not
demonstrate any abnormal lesions. he is completely
asymptomatic and was referred for evaluation. a triphasic ct
scan of the abdomen at [**hospital1 18**] demonstrated a mass as primarily
in the medial segment of the left lobe (segment 4) but does
extend into the left lateral segment more superiorly. there
is encasement of the left and middle hepatic veins. the
lesion extends close to the bifurcation of the right anterior
and left portal vein. there is an early branch of the right
posterior portal vein, however, the portal vein does not
appear to be involved. the tumor appears to be more cephalad
to the portal vein. there is no evidence of extrahepatic
spread. the lesion did appear to be resectable with a left
hepatic lobectomy and measured approximately 5.4 x 4.9 cm.
his afp was 4.7, ca19-9 10 and cea less than 1. he has
provided informed consent for hepatic resection. he underwent
a thorough cardiac evaluation preoperatively and was cleared
for surgery. he is now brought to the operating room for left
hepatic lobectomy.


past medical history:
diverticulitis, hyperlipidemia, cardiac murmur,, cad s/p mi in
his 50s. psh: cabg [**2123**], knee surgery [**2136**],partial colectomy
[**2141**] with temporary colostomy with subsequent reversal. states
this was not for a malignancy

social history:
he is a widower and retired carpenter. he has six children. one
has polio, one has had an mi, and the third has type i dm, and
the other three children are healthy

family history:
mother died of a stroke at age 83, father died of heart failure
at age 89. strong family history of cardiac disease.

physical exam:
97.7 62  152/70 20  99%ra, 5'3"", 85.4kg
a&o, no scleral icterus
neck free range of motion. no carotid bruits
lungs bibasilar rales
cor rrr, 2/6 sem loudest @ rsb radiating to bilat neck.
abd obese, normal bowel sounds, no hsm or masses,
ext venostasis changes, no edema\
neuro: no asterixis


pertinent results:
on admission: [**2145-4-9**]
wbc-18.1* rbc-4.29* hgb-13.1* hct-38.9* mcv-91 mch-30.6
mchc-33.7 rdw-13.1 plt ct-241
pt-14.8* ptt-28.6 inr(pt)-1.3*
glucose-125* urean-17 creat-0.8 na-142 k-4.3 cl-108 hco3-23
angap-15
alt-246* ast-293* alkphos-53 totbili-1.5
albumin-3.3* calcium-7.8* phos-3.8 mg-1.9
on discharge: [**2145-4-13**]
wbc-12.1* rbc-3.66* hgb-11.1* hct-33.3* mcv-91 mch-30.4
mchc-33.4 rdw-13.3 plt ct-171
glucose-108* urean-18 creat-0.5 na-138 k-3.9 cl-104 hco3-30
angap-8
alt-98* ast-34 alkphos-62 totbili-0.7 albumin-2.5*

brief hospital course:
on [**2145-4-9**] he underwent left hepatic lobectomy, caudate lobe
resection, placement of gold fiducials and intraoperative
ultrasound for intra-hepatic cholangiocarcinoma. surgeon was dr.
[**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **]. please see operative report for further
details. a jp drain was placed. ebl was 1200cc and this was
replaced with crystalloid. he was extubated in the or then
transferred directly to the sicu for monitoring. on pod 1, the
patient was transferred to the floor from the sicu with no
adverse events.

neuro: an epidural was in place for pain control. when
appropriate, the epidural was removed, and the patient was put
on iv dilaudid.  when the patient was tolerating po pain
medications, he was transitioned to oral medication with good
relief of his pain.

cv: the patient was monitored on telemetry throughout his stay.
he received perioperative beta blockade.  when the patient
complained of nausea, ekgs were obtained, which were stable.
the patient was put on home medications when he was tolerating
adequate oral intake.

pulm:  good pulmonary toilet and early ambulation were
encouraged.

gi/gu/fen:  the patient's intake and output were closely
monitored throughout his stay.  the patient's ivf were adjusted,
and the patient was bolused when appropriate post operatively to
maintain adequate urine output and vital signs.  on pod1, the
patient received sips of clears, which was advanced to clears on
pod2.  the patient's foley was removed when the patient was
urinating adequately.  on pod 3, the patient was transitioned to
a regular diet, whcih he tolerated well, and was restarted on
most home medications (except cholesterol lowering medications,
which were to be started on discharge given the patient's
transaminitis).  the patient's jp drain was left in place as the
output was bilious.  he was instructed on home jp care and how
to record outputs for follow up, as the patient will be
discharged to rehab with the jp in place.  on pod 5, the patient
complained of nausea briefly, for which an ekg was obtained, and
was stable.  a jp bilirubin was obtained as well, which was
34.7.

heme: the patient's cbc was routinely followed; the patient did
not require a post operative transfusion

id:  the patient's fever curve and white blood count were
closely examined for signs of infection.  the patient's wound
was monitored as well, without signs of infection.
other: a physical therapy consult was obtained, who recommended
that the patient be discharged to a rehabilitation facility;
both the patient and his family were in agreement.  on pod 5,
the central venous line was removed.

path report as follows:  portal lymph node (a):fragments of
lymph node(s):  no tumor.
ii.  liver, left lobe (b-g):cholangiocarcinoma,  mild steatosis.

liver: resection synopsis macroscopic
specimen type:  left lateral segmentectomy.
focality:  solitary
tumor size:greatest dimension:  7.5 cm.  additional dimensions:
7.0 cm x 4.4 cm.

microscopic
histologic type:  cholangiocarcinoma, intrahepatic.
histologic grade:  g1:  well differentiated.

extent of invasion
primary tumor:  pt1:  solitary tumor with no vascular invasion.
regional lymph nodes:  pnx:  cannot be assessed.

lymph nodes none in specimen 2
distant metastasis:  pmx:  cannot be assessed.

margins:parenchymal margin:  involved by invasive carcinoma.
(less than 0.5 mm).
bile duct margin: cannot be assessed. other margins: cannot be
assessed
clinical: liver lesion; cholangiocarcinoma. specimen
submitted-1. portal lymph node 2. liver lobe. prior biopsy
outside showed tumor immunostains positive for ck-7,  negative
for ck20, heppar and ttf-1.

on discharge, the patient was doing well, tolerating a regular
diet.  his vital signs were stable, and the patient was
afebrile.  he was ambulating and voiding without difficulty.
the patient was discharged to a rehabilitation facility for
further care.

medications on admission:
simvastatin 40 mg', zetia 10 mg', atenolol 25 mg', zantac 300

discharge medications:
1. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection q8h (every 8 hours).
2. insulin regular human 100 unit/ml solution sig: one (1)
injection asdir (as directed): per insulin flowsheet.
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q6h (every 6 hours) as needed for pain.
5. ranitidine hcl 150 mg tablet sig: two (2) tablet po hs (at
bedtime).
6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
7. 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
8. ondansetron 4 mg iv q8h:prn nausea/vomiting
9. sodium chloride 0.9%  flush 3 ml iv daily:prn
peripheral iv - inspect site every shift
10. simvastatin 40 mg tablet sig: one (1) tablet po once a day.

11. zetia 10 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
extended care

facility:
[**hospital 12414**] healthcare center - [**location (un) 12415**]

discharge diagnosis:
cholangio ca


discharge condition:
good


discharge instructions:
please call dr.[**name (ni) 1369**] office [**telephone/fax (1) 673**] if fever, chills,
nausea, vomiting, inability to eat, increased abdominal pain,
incision redness/bleeding/drainage or jaundice.
continue jp drain care as instructed.  please record all daily
drain outputs, and bring information to your follow up
appointment with dr. [**last name (stitle) **]. please call dr[**name (ni) 1369**] office if
drainage increases in volume, develops purulence or foul odor.
it is currently bilious (greenish/yellow) in appearance due to
bile leak which is expected to decrease over time
incision care:  keep clean and dry.
-you may shower, and wash surgical incisions.
-avoid swimming and baths until your follow-up appointment.
-please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-your staples will be removed during at your follow up
appointment.
-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 vomiting and cannot keep in fluids or your
medications.
* you are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* you see blood or dark/black material when you vomit or have a
bowel movement.
* your skin, or the whites of your eyes become yellow.
* 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.

* do not drive or operate heavy machinery while taking any
narcotic pain medication.  you may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* continue to ambulate several times per day.
* no heavy ([**11-17**]  lbs) until your follow up appointment.


followup instructions:
provider: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **]  [**telephone/fax (1) 78154**]  call to schedule
appointment

please follow up with dr. [**last name (stitle) **] wednesday [**4-21**] @ 4:20pm; call
his office at ([**telephone/fax (1) 3618**] for any questions or changes.


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 707**] md, [**md number(3) 709**]

"
75,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
76,"admission date:  [**2170-12-31**]              discharge date:   [**2171-1-2**]


service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 106**]
chief complaint:
fatigue, stemi

major surgical or invasive procedure:
cardiac catheterization with a bare metal stent to left anterior
descending coronary artery

history of present illness:
[**age over 90 **]f with unknown pmhx presented to [**hospital3 4107**] this
afternoon after being found in her home, unable to get up from
toilet, complaining of fatigue. at [**hospital1 **] she was noted to have
st elevations on ecg in inferior and lateral leads. she was
given a full dose aspirin, high dose statin, plavix load and a
heparin bolus. she was transferred directly to the [**hospital1 18**] cath
lab and underwent left heart catheterization. she was found to
have a tight lesion in the proximal lad, and a bms was deployed.
she tolerated the procedure well. she was brought to the ccu for
further monitoring. she was noted to have persistent stes on ecg
post-catheterization.
.
on arrival to the ccu, she was tachycardic but was otherwise
stable. she had no complaints. she did not recall exactly what
prompted her ed referral and did not know why she was here. she
knew that her friend had tried calling her and that she was
unable to come to the phone but is unable to tell me more than
that. she denies current chest pain or having ever had chest
pain. no sob, doe, pnd, orthopnea. no syncope or presyncope. no
palpitations. she notes that she has had slight bilateral lower
extremity swelling for the past three days. other ros is
negative.


past medical history:
1. cardiac risk factors:: diabetes-, dyslipidemia-, hypertension
?
2. cardiac history: none
-cabg: n/a
-percutaneous coronary interventions: n/a
-pacing/icd: n/a
3. other past medical history:
osteoporosis
scarlet fever as a child
? hypertension


social history:
-tobacco history: never
-etoh: 1 scotch per night
-illicit drugs: none
pt lives alone, is twice widowed, her second husband passed away
in [**2151**]. she has a house cleaner weekly and a close friend in
the area. she is responsible for her own bills and cooking. she
walks with a cane, admits that she has been having more
difficulty at home with stairs.


family history:
non-contributory

physical exam:
vs 96.9 113 119/66 19 98% 2l nc
general: elderly, frail appearing woman, very pleasant. nad
heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. small
xanthalesma near palpebral fissure
neck: supple with jvp to the angle of the jaw.
cardiac: tachycardic, regular. very distant. unable to
appreciate clear heart sounds.
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.
extremities: no femoral bruits. r groin site c/d/i, non-tender,
no hematoma. trace b/l le edema to mid tibia. extremities cool,
sensation intact.
skin: no stasis dermatitis, ulcers. b/l heels and sacrum pink,
blanching.
pulses:
right: femoral 2+ dp 1+ pt 1+
left: femoral 2+ dp 1+ pt 1+


pertinent results:
admission labs:
[**2170-12-31**] 10:23pm blood wbc-15.2* rbc-4.13* hgb-12.1 hct-36.2
mcv-88 mch-29.2 mchc-33.3 rdw-14.4 plt ct-475*
[**2170-12-31**] 10:23pm blood pt-14.2* ptt-29.1 inr(pt)-1.2*
[**2170-12-31**] 10:23pm blood glucose-172* urean-18 creat-0.6 na-132*
k-4.5 cl-96 hco3-25 angap-16
[**2170-12-31**] 10:23pm blood calcium-8.3* phos-2.9 mg-1.7
.
discharge labs:
[**2171-1-2**] 06:30am blood wbc-14.2* rbc-3.32* hgb-9.8* hct-29.2*
mcv-88 mch-29.5 mchc-33.5 rdw-14.3 plt ct-400
[**2171-1-2**] 06:30am blood pt-13.7* ptt-29.7 inr(pt)-1.2*
[**2171-1-2**] 06:30am blood glucose-103 urean-13 creat-0.5 na-134
k-4.0 cl-97 hco3-27 angap-14
[**2171-1-2**] 06:30am blood albumin-2.9* calcium-7.8* phos-2.8 mg-1.7
.
cardiac enzymes:
[**2170-12-31**] 10:23pm blood ck(cpk)-207* ck-mb-6 ctropnt-0.43*
[**2171-1-1**] 04:50am blood ck(cpk)-161* ck-mb-5 ctropnt-0.46*
[**2171-1-2**] 06:30am blood ck(cpk)-127  ck-mb-3 ctropnt-0.37*
.
metabolic profile:
[**2171-1-1**] 04:50am blood %hba1c-5.5
[**2171-1-1**] 04:50am blood triglyc-91 hdl-40 chol/hd-2.8 ldlcalc-53
.
anemia studies:
[**2171-1-1**] 04:50am blood caltibc-194* vitb12-191* folate-11.3
ferritn-313* trf-149*
.
c.cath study date of [**2170-12-31**] 1. selective coronary angiography
of this right dominant system demonstrated single vessel
coronary artery disease.  the lmca was without significant
disease.  the lad had 80-90% serial lesions in the proximal lad
just before d1.  the lcx and rca had no significant coronary
artery disease. 2. limited resting hemodynamics demonstrated
normal systemic arterial pressure of 107/63 mmhg. 3. successful
ptca and stenting of the proximal lad with a 2.5 x 28 mm
minivision bms which was deployed at 14 atm. the proximal stent
was post dilated with a 2.75 x 12 quantum maverick balloon at 14
atm. final angiography revealed no residual stenosis in the
stent, no dissection and timi iii flow.  (see ptca comments) 4.
right femoral arteriotomy site was closed with a 6 french mynx
device. final diagnosis: 1. one vessel coronary artery disease.
2. acute anterior myocardial infarction, managed by acute ptca.
ptca and stenting of the proximal lad.
.
portable tte (complete) done [**2171-1-1**] at 11:56:38 am the left
atrium is dilated. the left ventricular cavity size is normal.
there is moderate to severe regional left ventricular systolic
dysfunction with mid to distal anterior and septal akinesis with
apical akinesis/dyskinesis. right ventricular chamber size and
free wall motion are normal. the aortic arch is mildly dilated.
the aortic valve leaflets are moderately thickened. there is a
minimally increased gradient consistent with minimal aortic
valve stenosis. mild (1+) aortic regurgitation is seen. the
mitral valve leaflets are mildly thickened. trivial mitral
regurgitation is seen. the tricuspid valve leaflets are mildly
thickened. there is mild pulmonary artery systolic hypertension.
there is a small pericardial effusion. there is brief right
atrial diastolic collapse. left ventricle - ejection fraction:
30% to 35%.

brief hospital course:
[**age over 90 **]f with no prior cardiac history presented with stemi, now s/p
bms to lad. echo showed systolic chf with ef 30-35%. pt was
medically optimized and discharged to rehabilitation in stable
condition.
.
# coronaries: single vessel cad, s/p 2 bms to lad. hba1c for
risk stratification 5.5, so wnl. lipid panel: cholest 111,
triglyc 91, hdl 40, ldlcalc 53, so all within acceptable ranges.
started high dose statin with atorvastatin 80mg po hs for recent
mi and discharged on atorvastatin 40mg po hs for ongoing lipid
management over high dose for risk of adverse events in this
elderly patient. trended ces until falling. ck peaked at 207 on
the day of transfer. continued asa 325mg po daily and plavix
75mg po daily for thombotic ppx. initialy beta blocker therapy
with metoprolol tartrate 25 mg po bid. discharged on toprol xl
50mg po daily.
.
# pump: patient stated that she has a history of lower extremity
swelling over the past several weeks which is new. no echo in
our system. tte this admisison showed ef 30-355 with apical
hypokinesis. held off anticoagulation for apical hypokinesis
given age and risk factors. will continue on asa + plavix for
antiaggregation therapy and as thrombosis ppx. started
lisinopril 2.5 mg po daily for decreased ef and chf.
.
# rhythm: currently in sinus tachycardia with low-normal blood
pressures, given large territory of infarct tachycaridia is
likely compensatory mechanism to maintain co. initially held
bblockers to avoid precipitating cardiogenic shock. was able to
titrate up bblockade. telemetry showed frequent pacs. pt very
pre-renal with falling hct. unclear if this is due to dilution
or hemorrhage. ultimately believed to be due to hypovolemia.
encouraged pos and improved.
.
# leukocytosis: pt with ongoing leukocytosis. unclear if this is
due to recent mi, infection, or clonal process such as cll. cbc
with diff with 17% lymphcytes. this may be early cll but
ultimately was felt to be reactive leukocytosis from the mi.
cdiff, ua, ucx all negative.
.
# hyponatremia - na on admission was 132 and fell to 130.
improved with improvement of volume status and was ultimately
believed to be [**12-17**] hypovolemia.
.
# anemia - patient with drop in hct this admission. ultimately
the admisison hct was believed to be hemoconcentrated. amemia
studies were sent which showed mild iron and b12 def. added
supplementation. stools were guaiac negative.

medications on admission:
fosomax 70mg qweek
pred forte 1% 1gtt l eye qid
vigamox 0.5% 1gtt l eye qid
combigen 1gtt both eyes [**hospital1 **]
aspirin 81mg daily
tums daily
occuvite


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).
3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6
hours) as needed for pain, fever.
4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
5. prednisolone acetate 1 % drops, suspension sig: one (1) drop
ophthalmic qid (4 times a day).
6. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day)
as needed for constipation.
7. toprol xl 50 mg tablet sustained release 24 hr sig: one (1)
tablet sustained release 24 hr po once a day.
8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1)
tablet po daily (daily).
9. cyanocobalamin 250 mcg tablet sig: one (1) tablet po daily
(daily).
10. calcium with vitamin d 600-400 mg-unit tablet sig: one (1)
tablet po twice a day.
11. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily):
hold sbp< 100.
12. atorvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
13. alphagan p 0.1 % drops sig: one (1) drop ophthalmic three
times a day: 1 drop ou tid.
14. vigamox 0.5 % drops sig: one (1) drop os ophthalmic four
times a day: 1 drop os qid
until your ophthalmology appointment .
15. xalatan 0.005 % drops sig: one (1) drop ophthalmic at
bedtime: 1 drop qhs ou.


discharge disposition:
extended care

facility:
[**hospital3 7**] & rehab center - [**hospital1 8**]

discharge diagnosis:
st elevation myocardial infarction
iron defeciency anemia
chronic systolic congestive heart failure, ef 30%
.
secondary:
osteoporosis
scarlet fever as a child
? hypertension


discharge condition:
stable vital signs, afebrile, chest pain free

discharge instructions:
you had a heart attack and a bare metal stent was placed in your
left coronary artery to fix a blockage. your heart function is
weakened now and you will need to be followed closely for signs
of fluid retention that include swelling in your feet, trouble
breathing, or a dry cough. you were started on multiple new
medicines to help your heart work better:
new medicines:
- plavix (clopidogrel) 75mg daily to prevent blood clots and
keep the arteries of your heart open. do not stop taking this
medication unless told to by your cardiolgist. stopping this
medications prematurely could lead to a heart attack.
- aspirin 325mg daily to prevent blood clots
- iron tablets and vitamin b12 to treat your anemia and help
your body make more red blood cells
- colace and senna to prevent constipation
- metoprolol succinate (toprol xl)50mg daily to slow your heart
rate and help your heart pump better
- atorvastatin (lipitor) 40mg before bed to treat high
cholesterol
- lisinopril 2.5mg daily to keep your blood pressure low and
help your heart pump better
.
please call your doctor if you have any chest pain, trouble
breathing, nausea, fevers, cough or any unusual bleeding.
.
weigh yourself every morning. please call your doctor if you
gain more than 3lbs in a day or 10lbs in a week.
adhere to 2000mg sodium diet

followup instructions:
we have made you a follow up appointment to see your
cardiologist as below.
cardiology:
[**last name (lf) **],[**first name3 (lf) 251**] t. phone: [**telephone/fax (1) 4475**] date/time: [**1-15**] at 2:45
pm



completed by:[**2171-1-2**]"
77,"admission date:  [**2180-3-29**]              discharge date:   [**2180-4-2**]

date of birth:  [**2099-1-25**]             sex:   f

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 7333**]
chief complaint:
chest pain

major surgical or invasive procedure:
2units prbcs transfused


history of present illness:
this is an 81 yo female with history of cad, htn, ?gib in the
past was transferred from [**hospital3 4107**] for management of
melena, doe and chest tightness.  the episode begain this
morning.  she was walking to the bathroom and began to
experience sob, along with 8/10 'chest tightness', +nausea,
+diaphoresis.  she denies vomiting, palpitations or radiating
pain.  this episode lasted for 5 minutes and resolved on its
own.  she was taken to her pcps office by her daughter and was
then referred to the [**name (ni) **] [**1-31**] ecg changes and concern for acs.
she reports similar episodes for the past two days, 4-5 episodes
each day, but today's episode was worse, which was the reason
she sought medical attention.  she was sent to [**hospital1 **] er where
she had witnessed melena, documented as guaiac positive.

at [**hospital1 **], she was hemodynamically stable.  her trop i was found
to be 7.37.  hct 26.6.  ecg showed st depressions ii, iii, avf,
v3-v5, st elevation avr. patient was given lopressor, 1uprbc,
tylenol, lasix 40mg x 1.  cxr showed small right pleural
effusion with minimal basilar atelectasis.  she was transferred
to [**hospital1 18**] ccu for further management.

on arrival here, the patient was asymptomatic.  she denied any
chest pain, sob, n/v, diarrhea, abd pain.  last bm was this
morning.  no fevers, chills.  +dry cough for the past few days.


past medical history:
cad s/p mi and cabg in [**2162**] at [**hospital1 112**]
hypertension
hypothyroidism
anxiety

cardiac risk factors: htn, former smoker 30 pack year, quit 15
years ago
cardiac history:
-cabg:  [**2162**]
-percutaneous coronary interventions:  [**12-5**]


social history:
lives alone, has daughter, 50 year pack history tobacco, quit 15

years ago, no etoh, no drugs. from poland.

family history:
unknown, parents died when she was young.

physical exam:
vs:
general: nad, lying comfortably in bed
heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were
pink. op clear, mmm
neck: supple with jvp of 10 cm.
cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3
or s4.
lungs: no chest wall deformities, scoliosis or kyphosis. resp
were unlabored, no accessory muscle use. ctab, no crackles,
wheezes or rhonchi.
abdomen: soft, non-tender, non-distended
extremities: no c/c/e
rectal: normal tone, minimal black specks of stool, guaiac
positive



pertinent results:
osh lab data:
[**2180-3-29**]: wbc 5.8, hct 26.6, plt 153
na 135, k 4.6, cl 103, co2 25, bun 31, cr 1.0
pt 12.6, ptt 32.4, inr 1.14
troponin i  7.37, bnp 1340
.
labs on admission:
[**2180-3-29**] 08:45pm   glucose-103 urea n-30* creat-1.0 sodium-139
potassium-3.9 chloride-102 total co2-26 anion gap-15
[**2180-3-29**] 08:45pm   ck(cpk)-140
[**2180-3-29**] 08:45pm   ck-mb-16* mb indx-11.4* ctropnt-1.12*
[**2180-3-29**] 08:45pm   calcium-8.7 phosphate-5.1* magnesium-2.2
[**2180-3-29**] 08:45pm   wbc-4.9 rbc-3.22* hgb-9.7* hct-27.9* mcv-87
mch-30.1 mchc-34.8 rdw-16.4*
[**2180-3-29**] 08:45pm   neuts-61.9 lymphs-28.0 monos-7.5 eos-2.1
basos-0.5
[**2180-3-29**] 08:45pm   plt count-153
[**2180-3-29**] 08:45pm   pt-12.8 ptt-24.1 inr(pt)-1.1

ecg:  nsr, 1mm st depressions i, ii, v2-v5, <1mm std v6, 1mm st
elevation avr
.
cxr:
.
ct chest:
.

brief hospital course:
# nstemi:  ms. [**known lastname **] had diffuse ecg changes and troponin leak
in the setting of melena and ugib.  global ecg changes and
troponin leak were consistent with demand ischemia in the
setting of her ugib.  enzymes trended down and she remained
chest pain free during her hospitalization. initially we held
her asa, plavix, metoprolol, lasix in setting of bleed. she was
started on a statin given her history of severe cad and no
reported adverse events in her prior history with statins. as
her stent was placed >1 month ago and was bare metal the plavix
was stopped, not to be restarted. she was continued on 81mg
aspirin for stent restenosis. metoprolol was restarted prior to
discharge once her blood pressure was found to be stable and she
had no evidence of further bleeding.  she was taking lasix as an
outpatient for unclear reasons, thus this was not restarted.
the patient was instructed to follow up with her primary
cardiologist, dr. [**last name (stitle) 10543**], in [**hospital1 **] for evaluation of possible
diagnostic cardiac catheterization given her ischemic event in
the setting of a gi bleed.  at this follow up visit, she should
discuss the future need for lasix.

# ugib:  the patient has a history of gave syndrome per her
records from dr.[**name (ni) 49335**] office, her primary
gastroenterologist.  she presented to [**hospital3 **] with
melena.  at that time she has a hct of 26 which was down from 31
on her last admission in 12/[**2178**].  on transfer to [**hospital1 18**], 2 large
bore ivs were placed and she was started on her first unit of
prbcs.  at [**hospital1 18**], serial hcts were monitored and remained stable
after transfusion of 4 units of prbcs total. she was initially
on ppi iv bid and then switched to oral once daily (40mg). in
the meantime gi was consulted and said in the setting of no
acute bleeding, there was no need for emergent egd.  she should
follow up with her primary gastroenterologist for outpatient egd
in the next 2-4 weeks. prior to discharge she was restarted on
her iron and sucralfate.

# htn: initially held metoprolol, lasix in setting of bleed.
metoprolol was restarted prior to discharge, however lasix was
held given not clear reason for lasix use.  blood pressures were
well controlled on metoprolol only.

# hypothyroidism: continued levoxyl

# anxiety: held lorazepam at first but then restarted when
patient was started back on pos.

# decreased breath sounds on rll:  cxr was initially ordered to
evaluate this finding on physical exam.  a ct scan was
recommended for follow up.  ct scan showed pleural thickening on
the right, either indicative of fat or fluid however not
evidence of infection.  the patient never reported symptoms of
dyspnea or cough during her hospitalization.  a small 2mm
pulmonary nodule was noted on her ct scan.  as she has a long
history of tobacco abuse, it would be indicated to follow this
nodule as an outpatient.

# access: 2 large bore pivs
# prophylaxis: ppi as above, hold home colace
# code: full code, confirmed with patient
# comm: with patient, hct is daughter [**name (ni) **] [**name (ni) 110**] [**telephone/fax (1) 81673**]


medications on admission:
aspirin 81 mg daily (took this morning)
lorazepam 0.5 mg q8h prn
colace 100 mg po bid
levothyroxine 175 mcg daily
omeprazole 20 mg [**hospital1 **]
clopidogrel 75 mg daily (took this morning)
metoprolol tartrate 25 mg [**hospital1 **]
nitroglycerin 0.3 mg prn chest pain
lasix 40mg daily
kcl 20 meq p0 daily
hydromorphone 2mg (one) tab tid
sucralfate qid
ferrous sulfate daily

discharge medications:
1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable
po daily (daily).
disp:*30 tablet, chewable(s)* refills:*2*
2. lorazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a
day) as needed for foot cramps.
3. levothyroxine 175 mcg tablet sig: one (1) tablet po daily
(daily).
4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2
times a day).
5. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one
(1) tablet po once a day.
6. sucralfate 1 gram tablet sig: one (1) tablet po four times a
day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day.
8. atorvastatin 80 mg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*2*


discharge disposition:
home with service

facility:
[**hospital3 **] vna

discharge diagnosis:
primary diagnoses:
gave
upper gib
anemia
nstemi in the setting of ugib

secondary diagnoses:
cad


discharge condition:
the patient was afebrile and hemodynamically stable without
chest pain prior to discharge.


discharge instructions:
you were admitted to the hospital with chest pain. you had low
blood counts because you were bleeding from your stomach. this
caused you to have strain on your heart which caused your chest
pain. you were given a blood transfusion and the pain went away.
the gi doctors here [**name5 (ptitle) **] not feel that you need to have another
procedure to look at your stomach because you have had several
that have all showed the same thing.

medication changes:
these medications were discontinued, do not restart these
medications on discharge:
-  plavix
-  lasix
.
these medications were started, please take them as prescribed
on discharge:

-  atorvastatin 80mg daily
.
these medications were continued, please take them as
prescribed:
-  aspirin 81mg daily
-  iron
-  sucralfate
-  levothyroxine
-  lorazepam
-  omeprazole to 20mg two times daily
.
please come back to the hospital or call your primary care
physician if you have fainting or near-fainting, dizziness,
light-headedness, shortness of breath, chest pain, jaw pain, arm
pain, abdominal pain, nausea, blood in your stools, black tarry
stools, leg swelling, or any other concerning symptoms.

followup instructions:
please follow up with dr. [**last name (stitle) 10543**] in the next 2-4 weeks.

please follow up with dr. [**first name (stitle) 15532**] in [**2-2**] weeks to schedule
outpatient upper endoscopy.

please follow up with dr. [**last name (stitle) 1005**] in about 4 weeks. he will
check your liver tests to make sure you can take the high doses
of the statin we gave you.



completed by:[**2180-4-2**]"
78,"admission date:  [**2132-12-2**]              discharge date:   [**2132-12-12**]

date of birth:  [**2084-1-7**]             sex:   m

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
1. diagnostic laparoscopy with conversion to open roux-en-y
gastric bypass.
2. exploratory laparotomy.
3. placement of gastrostomy tube.
4. application of fibrin glue to gastro-j and jj.


history of present illness:
[**known firstname 108243**] has class iii morbid obesity, weight 349.8 pounds,
height 69.5 inches and bmi 50.9.  previous weight loss efforts
have included optifast, off-label prescription weight loss
medications fenfluramine/phentermine.  he has not tried any
popular weight loss diets or used over-the-counter
ephedra-containing appetite suppressants/herbal supplements.  he
does not remember what his weight at age 21 was but he is at his
highest weight currently. he has been struggling with weight
""all my life"".  factors contributing to excess weight include
large portions, grazing, late night eating, and too many
carbohydrates in saturated fats and lack of exercise regimen
until recently when he started elliptical and treadmill at a gym
3 times per week. he denied history of eating disorders but does
have eating issues stating that he always eats and is never
satisfied and even if he is full he will still eat.  he comments
that the more food he sees the more food he will eat.  he does
have depression with adhd on medication but no hospitalizations
for psychological issues.


past medical history:
pmh:
-hypertension
-type 2 diabetes hemoglobin a1c of 7.6%
-obstructive sleep apnea on bipap
-hyperlipidemia
-mild asthma
-vertigo
-fatty liver

psh:
-fistulotomy
-hemorrhoidectomy with rubber band ligation x 2, [**2125**].


social history:
he denied tobacco or recreational drug usage, no alcohol and has
occasional
caffeinated beverage.  he is disabled having been injured at
work with a head injury.  he is married living with his wife age
45 and they have two daughters ages 15 and 24 and a
granddaughter living with them.


family history:
family history is noted for stroke in his parents and history of
diabetes and obesity.  his brother and daughter both had
[**name (ni) 33554**] gastric bypass procedures done for morbid obesity at
the [**hospital 882**] hospital.

physical exam:
vital signs:  temperature 98.3, heart rate 86, blood pressure
119/70, respiratory rate 20, oxygen saturation 100% on room air
constitutional: no acute distress, anxious for discharge
neuro: alert and oriented to person, place and time
cardiac: regular rate and rhythm; no murmurs/ rubs/ gallops;
normal s1 s2
lungs: clear to auscultation, bilaterally; no wheezes/ rales/
rhonchi
abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding; g-tube to gravity; jp drain x 1 w/ serous fluid
wounds: abdominal midline incision without erythema or
induration
extremities: no cyanosis, clubbing, edema

pertinent results:
[**2132-12-2**] 07:00pm blood hct-41.6
[**2132-12-3**] 05:29am blood hct-40.9
[**2132-12-3**] 12:25pm blood wbc-13.7*# rbc-4.66 hgb-14.6 hct-43.4
mcv-93 mch-31.3 mchc-33.5 rdw-13.8 plt ct-201
[**2132-12-4**] 04:35am blood wbc-13.9* rbc-4.30* hgb-13.4* hct-39.9*
mcv-93 mch-31.1 mchc-33.5 rdw-13.8 plt ct-176
[**2132-12-3**] 12:25pm blood plt ct-201
[**2132-12-4**] 04:35am blood plt ct-176
[**2132-12-3**] 12:25pm blood glucose-243* urean-19 creat-1.2 na-141
k-4.2 cl-101 hco3-27 angap-17
[**2132-12-4**] 04:35am blood glucose-225* urean-16 creat-0.9 na-141
k-4.0 cl-104 hco3-27 angap-14
[**2132-12-4**] 04:35am blood calcium-9.0 phos-1.9* mg-1.8
[**2132-12-4**] 08:30am blood po2-235* pco2-48* ph-7.39 caltco2-30 base
xs-3
[**2132-12-4**] 08:30am blood glucose-237* lactate-1.4 na-141 k-4.1
cl-102 calhco3-28
[**2132-12-4**] 08:30am blood freeca-1.11*
[**2132-12-5**] 02:14am blood albumin-3.2* calcium-8.3* phos-2.1*
mg-1.9
[**2132-12-5**] 03:51am blood type-art po2-69* pco2-40 ph-7.44
caltco2-28 base xs-2
[**2132-12-5**] 02:14am blood albumin-3.2* calcium-8.3* phos-2.1*
mg-1.9
[**2132-12-5**] 02:14am blood alt-301* ast-107* ld(ldh)-236
ck(cpk)-[**2083**]* alkphos-41 amylase-22 totbili-2.5*
[**2132-12-5**] 08:24pm blood ck(cpk)-2110*
[**2132-12-5**] 02:14am blood pt-15.6* ptt-25.6 inr(pt)-1.4*
[**2132-12-5**] 02:14am blood plt ct-148*
[**2132-12-5**] 02:14am blood wbc-11.7* rbc-3.88* hgb-12.5* hct-35.8*
mcv-92 mch-32.1* mchc-34.9 rdw-13.8 plt ct-148*
[**2132-12-6**] 02:21am blood glucose-228* urean-16 creat-0.9 na-142
k-3.7 cl-109* hco3-23 angap-14
[**2132-12-6**] 07:28pm blood glucose-260* urean-17 creat-0.8 na-144
k-3.3 cl-111* hco3-24 angap-12
[**2132-12-5**] 02:14am blood albumin-3.2* calcium-8.3* phos-2.1*
mg-1.9
[**2132-12-6**] 02:21am blood albumin-3.2* calcium-8.5 phos-1.7* mg-1.8
[**2132-12-6**] 04:08am blood type-art po2-87 pco2-37 ph-7.45
caltco2-27 base xs-1
[**2132-12-6**] 10:32am blood type-art po2-60* pco2-37 ph-7.47*
caltco2-28 base xs-3
[**2132-12-6**] 07:53pm blood type-art po2-63* pco2-33* ph-7.49*
caltco2-26 base xs-2
[**2132-12-6**] 10:32am blood glucose-239* lactate-1.8 na-143 k-3.5
[**2132-12-6**] 04:08am blood freeca-1.11*
[**2132-12-6**] 10:32am blood freeca-1.15
[**2132-12-6**] 02:21am blood ctropnt-<0.01
[**2132-12-6**] 02:21am blood alt-230* ast-82* alkphos-48 totbili-2.0*
[**2132-12-6**] 02:21am blood plt ct-162
[**2132-12-6**] 02:21am blood wbc-11.8* rbc-3.95* hgb-12.6* hct-36.6*
mcv-93 mch-31.8 mchc-34.4 rdw-13.7 plt ct-162
[**2132-12-6**] 07:28pm blood glucose-260* urean-17 creat-0.8 na-144
k-3.3 cl-111* hco3-24 angap-12
[**2132-12-7**] 01:10am blood calcium-8.9 phos-2.2* mg-2.0
[**2132-12-7**] 01:10am blood alt-187* ast-70* alkphos-54 totbili-1.4
[**2132-12-7**] 01:10am blood plt ct-192
[**2132-12-7**] 01:10am blood wbc-11.2* rbc-4.00* hgb-12.6* hct-37.6*
mcv-94 mch-31.6 mchc-33.6 rdw-13.6 plt ct-192
[**2132-12-8**] 01:13am blood glucose-263* urean-16 creat-0.7 na-142
k-3.7 cl-108 hco3-25 angap-13
[**2132-12-8**] 01:13am blood calcium-8.8 phos-3.2 mg-1.8
[**2132-12-8**] 01:13am blood alt-144* ast-46* alkphos-55 totbili-1.0
[**2132-12-8**] 01:13am blood plt ct-208
[**2132-12-8**] 01:13am blood wbc-9.8 rbc-4.21* hgb-13.3* hct-39.8*
mcv-95 mch-31.5 mchc-33.3 rdw-13.9 plt ct-208
[**2132-12-9**] 02:37am blood glucose-122* urean-22* creat-0.9 na-144
k-3.4 cl-110* hco3-27 angap-10
[**2132-12-9**] 02:37am blood plt ct-228
[**2132-12-9**] 02:37am blood wbc-11.8* rbc-4.30* hgb-13.4* hct-40.5
mcv-94 mch-31.2 mchc-33.1 rdw-14.0 plt ct-228
[**2132-12-10**] 06:50am blood glucose-123* urean-24* creat-1.1 na-144
k-3.8 cl-108 hco3-30 angap-10
[**2132-12-10**] 06:50am blood calcium-8.4 phos-3.5 mg-1.9
[**2132-12-10**] 06:50am blood plt ct-220
[**2132-12-10**] 06:50am blood wbc-12.3* rbc-3.89* hgb-11.9* hct-37.0*
mcv-95 mch-30.5 mchc-32.1 rdw-14.1 plt ct-220

[**2132-12-3**] ugi sgl contrast w/ kub:
high density material within the jp drain, suggests extraluminal
leak. no
definite leak is visualized, though there is a possible linear
focus of
extraluminal contrast near the gastrojejunostomy. no holdup or
stenosis

[**2132-12-4**] chest (portable ap)
impression:
1. mediastinal and hilar venous engorgement.
2. retrocardiac atelectasis with possible small bilateral
pleural effusions.

[**2132-12-5**] chest (portable ap)
impression:
no pulmonary edema


brief hospital course:
the patient presented to pre-op on [**2132-12-2**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic gastric banding. the patient was difficult to
intubate due to thickened neck circumference.  also, there was
difficulty placing the [**last name (un) **]-gastric tube into the stomach,
therefore, an open roux-en-y gastric bypass was performed.
otherwise, there were no adverse events in the operating room;
please see the operative note for details. pt was extubated,
taken to the pacu until stable, then transferred to the [**hospital1 **] for
observation.

on hospital day #1 an ugi was performed, which showed high
density material within the jp drain, suggestive of an
intraluminal leak.  given the results of the study, the patient
was monitored closely with [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube to low,
intermittent suction, a jp drain to bulb suction, and strictly
nothing by mouth.  the patient remained clinically stable
without abdominal exam changes throughout the day, however,
overnight the patient became persistently tachycardic to the
120s.  therefore, the decision was made to return to the
operating room for exploratory surgical intervention.

on post-operative day #2, the patient underwent an exploratory
laparotomy, placement of a gastrostomy tube and application of
fibrin glue to the gastro-jejunostomy and j-j anastomosis.
intra-operatively, no leak was identified.  there were no
adverse events in the operating room; please see operative note
for details.  the patient remained intubated, was brought to the
pacu until stable, then transferred to the surgical intensive
care unit for close observation.

neuro: the patient was alert and oriented throughout his
hospitalization except for brief period of visual hallucinations
which he experienced in the intensive care unit.  the
hallucinations, which were treated with intravenous haldol,
resolved without further occurrence; pain was initially managed
with a morphine pca, which required an increase in dosing on
post-operative day #1 due incisional abdominal pain.  in the
intensive care unit, the patient was managed briefly with
intravenous morphine, which was transition ed to rectal and then
oral tylenol, with well-controlled pain.

cv: on post-operative day #1 the patient remained stable from a
cardiovascular standpoint, however, overnight the patient became
persistently tachycardic as described above.  post-operatively,
in the intensive care unit, the patient became hypertensive to
the 170-180s.  he was initially managed with intravenous
metoprolol and hydralazine.  labetalol was trialed, but he
eventually required a nicardipine drip.  on post-operative day
#6/ #4, intravenous enalapril was added to the regimen as
nicardipine was weaned.  the patient was subsequently managed
successfully with intravenous metoprolol and enalapril until he
resumed an oral diet.  oral medication management included
losartan and amlodipine at the suggestion of his primary care
provider who will see him next week.

pulmonary: the patient self-extubated in the intensive care unit
on post-operative day #3/#1 and was maintained on cpap.  he
developed a brief period of respiratory distress which resolved
once the cpap mask was adjusted for his [**last name (un) **]-gastric tube.
arterial blood gasses were within acceptable limits at this
time.  on the floor, the patient was weaned from oxygen and
maintained on cpap at night due to known obstructive sleep
apnea.  he subsequently remained stable from a pulmonary
standpoint.  good pulmonary toilet, and incentive spirometry
were encouraged

gi/gu/fen: on post-operative day #1 the patient was npo, given
intravenous fluids and had [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube in place for
decompression of his gastric pouch. following his ugi study
described above, the patient was kept strictly npo with a
[**last name (un) **]-gastric tube maintained to low, intermittent wall suction.
the jp drain was maintained on bulb suction. serial abdominal
exams were performed every 2-3 hours until the patient returned
to the operating room.  upon return to the operating room, a
g-tube was placed which remained to gravity throughout the
remainder of his hospitalization.  total parenteral nutrition
was initiated in the intensive care unit and continued until the
patient was tolerating a stage 3 diet on post-operative day
#10/#8.  the patient tolerated an oral diet well.  patient's
intake and output were closely monitored with adjustments made
to the intravenous fluids as needed.  electrolytes were
monitored and repleted as needed routinely.  the patient's foley
catheter was discontinued on post-operative day #8/#6  without
subsequent issues with voiding. on day of discharge, one of the
two jp drains was pulled and the central line was discontinued.

id: on post-operative day #1 the patient remained afebrile with
a stable white blood cell count.  on post-operative day #2,
while in the pacu, the patient spiked a temperature.  pan
culture was performed with negative results.  intravenous
ciprofloxacin and metronidazole were initiated and continued
through post-operative day #9/#7.  the patient remained afebrile
without signs and symptoms of infection throughout the remainder
of his hospital course.

heme: the patient's hematocrit level was monitored routinely
without signs of bleeding.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.




medications on admission:
hydrochlorothiazide 12.5 mg daily
avapro 150 mg daily
lantus insulin 70 units twice daily
actos 45 mg daily
metformin 1000 mg twice daily
simvastatin 10 mg daily
baby aspirin 81 mg daily
modafinil 200 mg twice a day
strattera 60 mg daily for adhd
flintstones complete multivitamins daily
vitamin d [**2122**] units


discharge medications:
1. simvastatin 10 mg tablet sig: one (1) tablet po daily
(daily): please crush.
2. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times
a day).
disp:*60 capsule(s)* refills:*2*
3. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po bid (2
times a day) for 1 months.
disp:*600 ml* refills:*0*
4. multivitamin,tx-minerals     tablet sig: one (1) tablet po
daily (daily): please crush.
5. losartan 50 mg tablet sig: two (2) tablet po bid (2 times a
day): please crush.
disp:*120 tablet(s)* refills:*2*
6. vitamin d 2,000 unit capsule sig: one (1) capsule po once a
day.
7. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily):
please crush.
disp:*30 tablet(s)* refills:*2*
8. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a
day): please crush.
disp:*60 tablet(s)* refills:*2*


discharge disposition:
home with service

facility:
care group

discharge diagnosis:
1. obesity, body mass index of 51.
2. obstructive sleep apnea.
3. type 2 diabetes.
4. hypertension.
5. metabolic x syndrome
6. tachycardia, etiology unknown.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance
diet, do not drink out of a straw or chew gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-7**] pounds for 6 weeks. you may
resume moderate
exercise at your discretion, no abdominal exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
an appointment with your dr. [**last name (stitle) 1699**] has been scheduled for
[**2132-12-17**] at 3 pm.  it is imperative that you keep this
appointment.

provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2132-12-17**] 11:45
provider: [**first name4 (namepattern1) **] [**last name (namepattern1) 8021**], rd,ldn phone:[**telephone/fax (1) 305**]
date/time:[**2132-12-17**] 12:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2132-12-24**] 11:00



completed by:[**2132-12-12**]"
79,"admission date:  [**2130-4-26**]              discharge date:   [**2130-5-3**]

date of birth:  [**2048-7-7**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 3223**]
chief complaint:
incarcerated right inguinal hernia
left lower extremity cellulitis


major surgical or invasive procedure:
[**2130-4-26**]: right inguinal herniorraphy with mesh


history of present illness:
81m with right inguinal hernia with non-reducible bulge since
noon today.  pain in right groin since then. noted some
discomfort as early as this morning. has had some nausea
throughout day as well.  no vomiting or other abdominal pain.
has not noted a hernia before.  additionally left leg has been
red for a couple of weeks; has been using cream and has not seen
a physician for it.  did not notice that it was swolen.


past medical history:
past medical history: hearing impaired (fluent with sign
language), chronic 1st degree heart block, recurrent atrial
fibrillation/ atrial flutter, s/p dccv [**2120-1-24**], s/p dccv
[**2121-8-8**], bradycardia, elevated psa, htn, hyperlipidemia, m.r.,
basal cell ca s/p excision

past surgical history: none


social history:
lives alone. works for [**company 2318**], independent in adls. no tobacco,
rare etoh.


family history:
mother breast cancer, leg cancer, stomach cancer. father cva.
brother w/ cabg at 64yrs.


physical exam:
on admission:
vitals:97.2 95 182/91 16 100%
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: rrr, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds. right groin with palpable
non-reducible
large hernia, hernia contents extending into scrotum as well,
ttp.
dre: normal tone, no gross or occult blood
ext: no le edema, le warm and well perfused


pertinent results:
[**2130-4-29**]
labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3*
mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93
urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12
[**2130-4-29**] 05:30am blood calcium-8.5 phos-2.4* mg-2.0

[**2130-4-28**]:
chest (portable ap):
severe bilateral opacities appear to be unchanged with no change
in the element of pulmonary edema. cardiomegaly is severe. known
pericardial effusion is most likely present. consolidations in
the left lower lobe are slightly asymmetric and might represent
superimposed abnormality such as infectious process, please
correlate clinically.

[**2130-4-27**]:
echo: impression: mildly depressed left ventricular systolic
function. moderately dilated right ventricle. focal asymetric
hypertrophy of the basal antero-septum. heavily calcified aortic
valve. moderate amount of pericardial effusion with no evidence
of tamponade physiology.

ecg: atrial fibrillation with rapid ventricular response and
probable ventricular premature beats. slight intraventricular
conduction delay may be incomplete left bundle-branch block.
delayed r wave progression may be due to intraventricular
conduction delay, left ventricular hypertrophy or possible prior
septal myocardial infarction, although is non-diagnostic. st-t
wave abnormalities are non-specific but cannot exclude
myocardial ischemia. clinical correlation is suggested. since
the previous tracing of [**2130-4-26**] the rate is faster and lateral
lead st-t wave changes appear more prominent.

chest (portable ap): findings: as compared to the previous
radiograph, there is unchanged massive cardiomegaly. in
addition, there is evidence of mild to moderate pulmonary edema.
presence of co-existing pneumonia cannot be excluded. no
pneumothorax.

bilat lower ext veins port: impression: no dvt in the right or
left lower extremity.

labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30*
11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm
blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33*

[**2130-4-26**]:
ecg: atrial fibrillation. slight intraventricular conduction
delay may be incomplete left bundle-branch block. delayed r wave
progression with late precordial qrs transition may be due to
intraventricular conduction delay, left ventricular hypertrophy
or possible prior anterior wall myocardial infarction, although
is non-diagnostic. st-t wave abnormalities are non-specific.
since the previous tracing of [**2130-3-28**] the ventricular rate is
faster and the qtc interval is shorter.

labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1*
mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1
inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98
hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 [**2130-4-26**] 05:50pm
blood ctropnt-<0.01


brief hospital course:
the patient presented to the emergency department on [**2130-4-26**] due to a non-reducible right groin bulge with associated
pain and nausea.  additionally, the patient reported left leg
erythema which had been present for a few weeks without fevers.
given physical findings consistent with incarcerated hernia, the
patient was taken to the operating room where he underwent a
laparoscopic right inguinal hernia repair with mesh. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

shortly following transfer to the general surgical [**hospital1 **], the
patient was triggered for lethargy, hypoxia and atrial
fibrillation with rapid ventricular response.  intravenous
metoprolol and lasix were administered and the patient was
maintained on a non-rebreather with improved oxygenation.  he
was subsequently transferred to the trauma intensive care unit
for further management.

neuro: the patient was somnolent post-operatively, which was
deemed post-operative baseline by the als interpreter, who
reportedely knew patient well.  the somnolence resolved by pod1
and he remained alert and oriented throughout the remainder of
his hospitalization.  the patient is deaf at baseline and was
able to communicate via an als interpreter.  pain was well
controlled with oral tylenol and intermittent intravenous
hydromorphone.
cv: the patient has baseline rate controlled atrial fibrillation
on warfarin.    however, as described above, he developed a fib
with rvr on pod 0, which responsed to intravenous metoprolol
without recurrence.  additionally, an ekg obtained upon transfer
to the icu revealed st changes; cycled cardiac enzymes were
negative.  an echocardiogram was obtained and revealed mildly
depressed left ventricular systolic function, a moderately
dilated right ventricle, focal asymetric hypertrophy of the
basal antero-septum, heavily calcified aortic valve and a
moderate amount of pericardial effusion with no evidence of
tamponade physiology.  his home medication regimen was resumed
and the patient remained stable from a cardiovascular standpoint
for the remainder of his hospitalization; vital signs were
routinely monitored.
pulmonary: as described above, the patient experienced an
episode of hypoxia on pod 0, likely due to pulmonary edema.
intravenous lasix was administered with immediate effect.  upon
arrival to the icu, the patient was placed on bipap, which was
weaned to nasal cannula on pod 1.  the patient remained stable
from a pulmonary standpoint for the remainder of his
hospitalization and was weaned off supplemental oxygen entirely
on pod 3. good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
gi/gu/fen: the diet was advanced to regular on pod 1, which was
well tolerated.   patient's intake and output were closely
monitored; electrolytes were repleted routinely.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.  the left lower extremity
cellulitis improved on intravenous cefazolin and treatment was
transitioned to oral antibiotics on pod 4, which will continue
for an additional seven days.
skin: a deep tissue injury to the sacrum was identified while in
the icu.  aggressive skin care was provided via nursing without
evidence of further skin breakdown.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to
ambulate early and often.  additionally, given the events of
pod0, a lower extremity ultrasound was obtained and was negative
for a dvt.
rehab: the patient received physical therapy while hospitalized
due to deconditioning, but was deemed unsuitable for discharge
to home.  short term rehabilitation was recommended to maximize
independence and regain conditioning and independence.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating with a walker and physical therapy, voiding
without assistance, and pain was well controlled.  the patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
he will be discharged to a rehab facility for additional
physical therapy.


medications on admission:
atenolol 25mg daily
finasteride 5mg daily
simvastatin 20mg daily
verapamil er 240mg daily
coumadin 1mg daily
vitamin d2 1,000 units daily
vitamin e 400 units daily

discharge medications:
1. verapamil 240 mg tablet extended release sig: one (1) tablet
extended release po q24h (every 24 hours).
2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every
8 hours).
3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm.
4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five
(5) ml po q6h (every 6 hours) as needed for cough.
5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day): hold for loose stool.
6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily).

7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
8. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
9. bisacodyl 10 mg suppository sig: one (1) suppository rectal
hs (at bedtime) as needed for constipation.
10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).

11. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every
6 hours) for 7 days.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - [**location (un) 550**]

discharge diagnosis:
incarcerated right inguinal hernia
left lower extremity cellulitis


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 an incarcerated right
inguinal hernia and subsequently underwent surgical repair with
mesh.  additionally, you were noted to have cellulitis on the
lower aspect of your left leg, which was treated with
antibiotics.  during your stay, you also received treatment from
a physical therapist, who recommended discharge to a
rehabiliation facility to furhter improve your conditioning and
independence.  you are now preparing for disharge to a
rehabiliation facility with the following instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service at [**telephone/fax (1) 600**] to make a
follow-up appointment within 2 weeks.
please contact your primary care provider to make [**name initial (pre) **] follow-up
appointment within 1 week from discharge from the rehabilitation
facility.
provider: [**first name11 (name pattern1) 5445**] [**initial (namepattern1) **] [**last name (namepattern4) 5446**], dpm phone:[**telephone/fax (1) 543**]
date/time:[**2130-5-22**] 3:50
provider: [**first name8 (namepattern2) 6118**] [**last name (namepattern1) 6119**], rn,ms,[**md number(3) 1240**]:[**telephone/fax (1) 1971**]
date/time:[**2130-6-16**] 10:00


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

completed by:[**2130-5-3**]"
80,"admission date:  [**2133-5-18**]              discharge date:   [**2133-6-1**]

date of birth:  [**2107-3-17**]             sex:   f

service: surgery

allergies:
penicillins / shellfish

attending:[**first name3 (lf) 301**]
chief complaint:
1. obesity with body mass index of 52.
2. fatty liver.
3. gallstones.
4. sleep apnea.
5. gastroesophageal reflux.
6. polycystic ovary syndrome.


major surgical or invasive procedure:
1.laparoscopic cholecystectomy converted to open; open roux-en-y
gastric bypass.

2.exploratory laparotomy for removal of foreign body.


history of present illness:
[**known firstname 4890**] has class iii morbid obesity with weight of 303.7 pounds
as of [**2133-4-29**] with her initial screen weight on [**2133-4-7**] as 304.6
pounds, height 64 inches and bmi of 52.1.  her previous weight
loss efforts have included 3 months of prescription weight loss
medication orlistat (xenical) in [**2131**] losing 10 pounds that she
gained back in two months, 4 months of slim-fast in [**2131**] without
results and she also took over-the-counter herbal preparation
green tea for weight loss in [**2132**] but achieved no results.  she
has not taken over-the-counter ephedra-containing appetite
suppressants.  her weight at age 21 was 260 pounds her lowest
adult weight with her highest weight being 307.8 pounds on
[**2133-4-21**].  she weighed 220 pounds one year ago.  she states she
developed a significant weight problems since her teenage years
and cites as factors contributing to her excess weight genetics,
late night eating, large portions, too many carbohydrates in
saturated fats as well as lack of exercise.  she denies history
of eating disorders or depression.  she has not been seen by a
therapist nor has she been hospitalized for mental health issues
and she is not on any psychotropic medications.


past medical history:
gastroesophageal reflux, hyperlipidemia with elevated
triglycerides, obstructive sleep apnea testing use cpap, vitamin
d deficiency, polycystic ovary syndrome, fatty liver and
cholelithiasis

social history:
she has been smoking two cigarettes a day for 6 years and quit
one month ago and has been using chantix for smoking cessation.
she denied recreational
drug usage and has alcoholic beverage on rare occasion, does
drink both caffeinated and carbonated beverages. she is a
student at [**location (un) 6188**]
community college studying hospitality.  she is single and has
no children.  she lives with her sister at age 34 and 3 nieces.


family history:
father living age 54 with obesity and sister living age 27 with
asthma.

physical exam:
vitals on discharge: temp-97.8 bp-120/77 p-104 rr-20 o2 100%
room air

constitutional: no acute distress; comfortable appearing
neuro: alert and oriented to person, place and time
cardiac: regular, rate and rhythm, nl s1,s2
lungs: cta bilaterally, no respiratory distress
abd: soft, nd, + peri-incisional tenderness, no rebound
tenderness/ guarding
wounds: abdominal midline incision superior aspect intact.
inferior aspect open: wound bed- 100% red granulation tissue,
drainage- serosanguinous, periwound edges- no erythema, no
edema.
ext: no edema

pertinent results:
laboratory results:
[**2133-5-18**] 06:32pm blood hct-33.6*
[**2133-5-19**] 09:05am blood wbc-12.4* rbc-4.34 hgb-11.8* hct-34.3*
mcv-79* mch-27.2 mchc-34.5 rdw-15.0 plt ct-338 neuts-88.7*
lymphs-6.9* monos-4.2 eos-0.1 baso-0.1 glucose-125* urean-7
creat-0.7 na-139 k-4.1 cl-105 hco3-27 angap-11 alt-141* ast-122*
alkphos-44 amylase-27 totbili-0.9 albumin-3.5 calcium-8.3*
phos-2.7 mg-1.5*
[**2133-5-19**] 08:00pm blood type-art po2-74* pco2-46* ph-7.40
caltco2-30 base xs-2
[**2133-5-20**] 03:30am blood wbc-13.0* rbc-3.81* hgb-10.5* hct-30.2*
mcv-79* mch-27.5 mchc-34.7 rdw-14.9 plt ct-329 glucose-105*
urean-6 creat-0.7 na-137 k-4.1 cl-103 hco3-29 angap-9 alt-119*
ast-103* alkphos-41 amylase-23 [**2133-5-20**] 02:06pm blood
calcium-8.6 phos-1.8* mg-1.9
[**2133-5-20**] 03:09pm blood type-art rates-/20 peep-5 po2-81*
pco2-54* ph-7.38 caltco2-33* base xs-4 intubat-not intuba
[**2133-5-21**] 01:59am blood wbc-11.5* rbc-3.50* hgb-9.7* hct-28.4*
mcv-81* mch-27.7 mchc-34.2 rdw-14.8 plt ct-298 glucose-78
urean-7 creat-0.6 na-139 k-3.8 cl-100 hco3-31 angap-12
calcium-7.9* phos-2.6* mg-1.9
[**2133-5-22**] 01:46am blood wbc-11.4* rbc-3.40* hgb-9.4* hct-27.1*
mcv-80* mch-27.8 mchc-34.8 rdw-15.0 plt ct-347 glucose-81
urean-6 creat-0.5 na-134 k-3.5 cl-95* hco3-28 angap-15
calcium-8.2* phos-2.5* mg-1.8
[**2133-5-23**] 06:40am blood wbc-13.7* rbc-3.49* hgb-9.7* hct-28.2*
mcv-81* mch-27.9 mchc-34.5 rdw-14.8 plt ct-365

[**2133-5-19**] chest (portable ap):
impression: findings concerning for retained sponge within the
right upper quadrant of the abdomen

[**2133-5-19**] abdomen (supine & erect):
impression: apparent interval removal of a retained sponge

[**2133-5-20**] chest (portable ap):
the lung volumes are low. the heart size is top normal, probably
exaggerated  by the presence of low lung volumes and portable
character of the study. there is a right perihilar opacity that
might represent infectious process or may be a combination of
infection and asymmetric pulmonary edema. left lung demonstrates
mild interstitial pulmonary edema. bilateral pleural effusions
cannot be excluded. no appreciable pneumothorax is seen.

[**2133-5-20**] cta chest w&w/o c&recon:
impression:
1. no evidence of pulmonary emboli. bilateral moderate
atelectasis.
2. no evidence of intra-abdominal fluid collection with close
attention paid to the region of the hepatic fossa of the
gallbladder as well as at the jejunostomy and gastrojejunostomy
site.

[**2133-5-21**] chest (portable ap):
impression:
1. stable bibasilar atelectasis and right upper lung zone linear
atelectasis.
2. no focal consolidation, pneumothorax or pulmonary edema.

[**2133-5-23**] chest (pa & lat):
impression:
findings concerning for developing pneumonia and possibly mild
fluid overload.

[**2133-5-24**] abdomen (supine & erect):
air in the colon and scattered small bowel segments, nonspecific
bowel gas pattern. no frank obstruction.no radiopaque foreign
body is identified.
clips are present in the right upper quadrant.

[**2133-5-24**] chest (pa & lat):
impression: developing pneumonia.

[**2133-5-25**] [**last name (un) **] dup extext bil (map/dvt): no evidence of deep vein
thrombosis either right or left lower extremity

microbilogy results:
[**2133-5-20**] urine culture (final [**2133-5-22**]): escherichia
coli.>100,000 org/ml
[**2133-5-20**] blood culture, routine (final [**2133-5-26**]): no growth.
[**2133-5-20**] mrsa screen (final [**2133-5-23**]):    no mrsa isolated.
[**2133-5-24**] blood culture:
[**2133-5-24**] urine culture: no growth
[**2133-5-26**] sputum gram stain (final [**2133-5-26**]): [**12-1**] pmns and >10
epithelial cells/100x field. gram stain indicates extensive
contamination with upper respiratory secretions. bacterial
culture results are invalid.
[**2133-5-26**] abdominal wound: no growth


brief hospital course:
pt was evaluated by anaesthesia and taken to the operating room
for laparoscopoic converted to open cholecystectomy and
roux-en-y gastric bypass. there were no adverse events in the
operating room; please see the operative note for details.
pt was extubated, taken to the pacu until stable, then
transferred to the [**hospital1 **] for observation.

pod 0 ([**2133-5-18**]): the patient was tachycardic (hr 120-130's)and
was given a bolus of 1 litre of intravenous fluids.

pod 1 ([**2133-5-19**]): the patient continued to be tachycardic during
the early morning hours. she was afebrile and had no pain. she
was scheduled for an urgent ugi of the abdomen to rule out any
leak. an abdominal film done at this time showed evidence of a
retained foreign body possibly a sponge in the right upper
quadrant of the abdomen.
she was then taken to the or for an emergent exploratory
laparotomy to remove the sponge. please see the operative note
for details. she was not extubated and transferred to the pacu
where she was extubated after a few hours. she was kept on bipap
overnight on which she stayed very stable.

pod 2 ([**2133-5-20**]): she was transferred to the trauma icu where
she had a brief episode of desaturation to 80% on 4 l of o2. she
was tachycardic and hemodynamically stable through out this
period. a ct angiogram of the chest was performed and ruled out
any pulmonary embolism. she required  15 l of o2/min during the
day and this was further weaned down to 10 l/min overnight. her
diet was advanced to stage 1 which was tolerated very well. she
also recieved intravenous lasix 20 mg twice since she was
thought to be fluid overloaded.

pod 3 ([**2133-5-21**]): she continued to do well on the 10l/min  of o2
which was further weaned down to 4l/min. she had a fever spike
to 102 f when she was pan cultured. her urine culture grew
e.coli and she was then started on ciprofloxacin. she recieved a
few hous of cpap overnight.

pod 4 ([**2133-5-22**]): she was transferred to the floor and her diet
was advanced to stage ii. this was tolerated well.

pod 5 ([**2133-5-23**]): diet was advanced to stage iii which was
tolerated well. there was an increase in the wbc count from 11.4
to 13.7. a chest x-ray was done given her persistent o2
requirement, which was concerning for a possible developing
pneumonia.

pod 6 ([**2133-5-24**]): she had a fever spike to 101.9f when she was
pan cultured again. a chest x-ray was done that showed
developing pneumonia. also there was an increase in the wbc
count noted.

pod 7 ([**2133-5-25**]): she did well during the day except for being
tachycardic to 130's & occasionally 140's with activity. she
stayed completely asymptomatic throught this period. in view of
her rising white count and recent chest x-ray, intavenous
vancomycin and cefepime were started empirically.

pod 8([**2133-5-26**]): the lower part of abdominal wound appeared
erythematous and was hence opened. wound swabs were sent for
gram stain & culture. the gram stain did not show any organisms.
she had a fever spike to 101.7f during the day. otherwise, she
conitnued to do well on stage iii. her tachycardia was better
than the day before and her hr stayed in the 120's and
occasionally in 130's with activity.

pod 9([**2133-5-27**]): the jp was removed and an infectious disease
consult was sought. a repeat chest x-ray was done and blood and
urine cultures were sent following their recommendations. she
stayed afebrile through out the day.

pod 10 ([**2133-5-28**]): the abdominal wound was examined and a wound
vac dressing was placed. her white cell count was down from 14.7
to 11.7.

pod 11 ([**2133-5-29**]): she remained afebrile with continued
intravenous antibiotics; a wound vac remained in place; her
tachycardia had resolved and vital signs remained stable.

pod 12 ([**2133-5-30**]): no new events

pod 13 ([**2133-5-31**]): no new events

pod 14 ([**2133-6-1**]): antibiotics were discontinued with completion
of a 7 day course.  the vac was removed and the wound was
dressed with dry, sterile gauze. the patient's sister was given
instruction and demonstrated efficiency in performing the
dressing changes.  the patient did not have a cpap machine at
home, therefore, it was arranged to have one delivered to her
home.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.  a cpap machine will be
delivered to her home with mask fitting and instruction for
machine operation.


medications on admission:
omeprazole 20mg od, mvi 1 tab od, vitd 5000u od

discharge medications:
1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2
times a day) as needed for constipation for 10 days.
disp:*200 ml* refills:*0*
2. oxycodone 5 mg/5 ml solution sig: one (1)  po every 4-6 hours
as needed for pain for 10 days: please do not drive or operate
heavy machinery while taking this medication.
disp:*100 ml* refills:*0*
3. multivitamin,tx-minerals     tablet sig: one (1) tablet po
bid (2 times a day): chewable.
4. vitamin d 5,000 unit tablet sig: one (1) tablet po once a
day: please crush.
5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule; do
not chew beads.


discharge disposition:
home with service

facility:
caregroup vna

discharge diagnosis:
1. obesity with body mass index of 52.
2. fatty liver.
3. gallstones.
4. sleep apnea.
5. gastroesophageal reflux.
6. polycystic ovary syndrome.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-21**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
please perform dressing changes with dry, sterile gauze twice
daily as instructed or more frequently as needed.  please
contact dr. [**last name (stitle) 15645**] office if you have increased drainage from
the wound requiring more frequent changes.  also, please call
dr. [**last name (stitle) **] if you develop redness surrounding the wound and/ or
fevers greater than 101f.


followup instructions:
provider: [**first name8 (namepattern2) **] [**doctor last name **], rd,ldn phone:[**telephone/fax (1) 305**]
date/time:[**2133-6-3**] 11:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2133-6-3**] 12:00



completed by:[**2133-6-8**]"
81,"admission date:  [**2101-10-4**]              discharge date:   [**2101-10-12**]

date of birth:  [**2049-10-8**]             sex:   f

service: surgery

allergies:
motrin / erythromycin base

attending:[**first name3 (lf) 3200**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2101-10-4**]:
1. laparoscopic sleeve gastrectomy and concomitant laparoscopic
cholecystectomy.

[**2101-10-7**]:
1. exploratory laparoscopy converted to laparotomy.
2. abdominal washout.
3. oversewing of the gastric sleeve staple line.
4. evacuation of clot.
5. liver biopsy.


history of present illness:
[**known firstname **] has class iii morbid obesity with a weight of 344 pounds as
of [**2101-6-27**] with her initial screen weight 340 pounds on [**2101-5-31**],
height 66 inches and bmi of 55.5.  her previous weight loss
efforts have included weight watchers x 36 months [**2098**]-present
losing 50 pounds, the [**doctor last name 1729**] diet in [**2096**] for 6 months losing 24
pounds, slim-fast x 12 months and [**2094**] losing [**street address(1) 91840**]
visits x 4 as well as pcp counseling since [**2084**].  she is also
undergoing behavioral therapy for past 36 months.  she has not
taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements.  she stated that her weight at age 21 was 250
pounds her lowest adult weight and her highest weight was 384
pounds in [**2097-6-23**].  she has had weight issues since age 14
shortly before she was diagnosed with polycystic ovary syndrome
and when she graduated from high school she weighed 350 pounds.
she subsequently lost 100 pounds and had maintained the loss for
the following 15 years.  in [**2091**] she was diagnosed with lupus
and was
placed on high doses of prednisone and gained 180 pounds over
the course of 5 years.  factors contributing to her excess
weight include grazing a large portions, some refined
carbohydrates and saturated fats as well as stressful and
emotional eating.  her current exercise routine is one hour
twice per week of aqua-aerobics, one hour of personal training
in a pool and one hour of personal training in the gym with
resistance training and weights.  she attributes difficulty with
exercise because of her large pannus and impedance of her
mobility.  she denied history of eating disorders and does have
depression/anxiety, is followed by a therapist working on weight
issues, has not been hospitalized for mental health issues and
she is on psychotropic
medication that she does find useful (zoloft).


past medical history:
past medical history:  her medical history is significant for,
1.  polycystic ovarian syndrome.
2.  rheumatoid arthritis.
3.  discoid lupus.
4.  diabetes mellitus.
5.  depression.
6.  obstructive sleep apnea.
7.  cpap.

past surgical history:  the patient denies any significant
surgical history.


social history:
she used to smoke two packs of cigarettes daily for 20 years but
quit in [**2084**], denies recreational drug usage, no alcohol and
does consume caffeinated beverages.  she works as an underwriter
and is married living with her husband age 65 retired and her
stepson aged 24.


family history:
her family history is noted for mother living at age 70 with
diabetes and obesity; paternal grandmother deceased age 78 with
heart disease, hyperlipidemia, stroke and arthritis; maternal
grandmother deceased age 62 of
cancer.

physical exam:
vs:

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd:
wounds:
ext:

pertinent results:
[**2101-10-10**] 04:57am blood wbc-9.5 rbc-3.21* hgb-9.7* hct-30.0*
mcv-93 mch-30.3 mchc-32.5 rdw-14.0 plt ct-294
[**2101-10-9**] 03:35pm blood wbc-8.9 rbc-3.22* hgb-9.7* hct-30.6*
mcv-95 mch-30.1 mchc-31.8 rdw-14.0 plt ct-292
[**2101-10-9**] 02:37am blood wbc-8.7 rbc-2.99* hgb-8.9* hct-28.0*
mcv-94 mch-29.7 mchc-31.7 rdw-14.2 plt ct-281
[**2101-10-8**] 02:58pm blood hct-28.8*
[**2101-10-8**] 09:27am blood hct-29.4*
[**2101-10-8**] 01:19am blood wbc-8.2 rbc-3.10* hgb-9.3* hct-28.7*
mcv-92 mch-30.1 mchc-32.5 rdw-14.3 plt ct-267
[**2101-10-7**] 03:30pm blood wbc-12.0* rbc-3.33* hgb-10.2* hct-30.5*
mcv-92 mch-30.7 mchc-33.5 rdw-14.5 plt ct-264
[**2101-10-7**] 12:15pm blood wbc-10.4 rbc-3.27* hgb-10.0* hct-30.4*
mcv-93 mch-30.5 mchc-32.8 rdw-14.3 plt ct-280
[**2101-10-7**] 06:40am blood hct-25.1*
[**2101-10-6**] 11:16pm blood hct-28.3*
[**2101-10-6**] 04:00pm blood wbc-9.8# rbc-3.02*# hgb-9.0*# hct-27.5*
mcv-91 mch-29.9 mchc-32.9 rdw-14.6 plt ct-249
[**2101-10-6**] 10:35am blood hct-28.3*
[**2101-10-5**] 05:27pm blood hct-29.7*
[**2101-10-4**] 10:10pm blood hct-30.5*
[**2101-10-4**] 05:58pm blood hct-31.1*
[**2101-10-4**] 02:44pm blood hct-34.9*
[**2101-10-7**] 12:15pm blood fibrino-657*
[**2101-10-9**] 02:37am blood glucose-132* urean-4* creat-0.5 na-143
k-3.5 cl-108 hco3-29 angap-10
[**2101-10-8**] 01:19am blood glucose-153* urean-6 creat-0.5 na-145
k-3.7 cl-110* hco3-31 angap-8
[**2101-10-7**] 03:30pm blood glucose-174* urean-8 creat-0.6 na-142
k-3.7 cl-107 hco3-26 angap-13
[**2101-10-5**] 05:27pm blood glucose-136* urean-8 creat-0.8 na-145
k-4.2 cl-107 hco3-28 angap-14
[**2101-10-9**] 02:37am blood calcium-7.8* phos-3.2 mg-1.7
[**2101-10-8**] 01:19am blood calcium-7.7* phos-2.6* mg-2.0
[**2101-10-7**] 03:30pm blood calcium-7.9* phos-2.6* mg-1.8
[**2101-10-5**] 05:27pm blood calcium-8.3* phos-2.9 mg-1.7
[**2101-10-7**] 12:27pm blood type-art po2-145* pco2-41 ph-7.40
caltco2-26 base xs-0
[**2101-10-7**] 10:35am blood type-art po2-199* pco2-42 ph-7.41
caltco2-28 base xs-2
[**2101-10-7**] 12:27pm blood glucose-146* lactate-1.2 na-140 k-3.6
cl-110*
[**2101-10-7**] 10:35am blood glucose-115* lactate-0.8 na-141 k-3.2*
cl-111*
[**2101-10-7**] 12:27pm blood hgb-11.2* calchct-34
[**2101-10-7**] 12:27pm blood freeca-0.99*
[**2101-10-7**] 10:35am blood freeca-0.97*

imaging:
[**2101-10-5**] ugi sgl contrast w/ kub: impression:
expected post-operative appearance of sleeve gastrectomy without
obstruction or leak

[**2101-10-5**] ecg: sinus tachycardia. delayed r wave transition. left
ventricular hypertrophy. possible prior inferior myocardial
infarction. compared to the previous tracing of [**2101-5-31**] the
ventricular rate is faster and the suggestion of a possible
prior inferior myocardial infarction is new. delayed r wave
progression was not previously seen.



brief hospital course:
the patient presented to pre-op on [**2101-10-4**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic sleeve gastrectomy and laparascopic
cholecystectomy. there were no adverse events in the operating
room; please see the operative note for details. pt was
extubated, taken to the pacu until stable, then transferred to
the [**hospital1 **] for observation.

on pod1, the patient's hematocrit trended downward to 28 (from
41.1 pre-op) with concomittant tachycardia to 110s and
sanguinous jp drainage, therefore, she was transfused a total of
2 units of prbcs; heparin was discontinued. of note, on pod1,
the patient complained of epigastric pain radiating to her left
arm; an ekg was reassuring and troponin was within normal
limits.

an ugi series, also performed on pod1, was negative for a leak,
therefore, her diet was advanced to stage 1, which was well
tolerated.  urine output remained adequate and the patient was
ambulating with assistance.

on pod3, due to persistent mild tachycardia, sanguinous jp
output and decreasing hematocrit levels to 25 requiring an
additional 2 units of prbcs, the patient returned to the
operating room where she underwent an exploratory laparoscopy
converted to laparotomy, abdominal washout, oversewing of the
gastric sleeve staple line, evacuation of clot and liver biopsy;
see operative note for details.  post-procedure the patient was
transferred to the surgical intensive care unit for close
observation.

the patient remained stable in the icu with resolution of
tachycardia and stable hematocrit levels.  pain was well
controlled with a dilaudid pca.  an ngt, placed
intra-operatively was discontinued and methylene blue dye was
administered orally without subsequent change in character of jp
drain output, therefore, her diet was advanced to stage 1 and
well tolerated. also, given concern for local tissue ischemia of
small portion of patient's wound, a few staples were removed and
a dry dressing was applied and changed twice daily.

on pod [**5-25**], the patient was transferred to the general surgical
[**hospital1 **].  while on the floor, she continued to have stable vital
signs and hematocrit levels; subcutaneous heparin was resumed on
[**10-8**].  her diet was advanced to stage 3, which was well
tolerated; fsbg was monitored and metformin was resumed at half
dose upon discharge.  the dilaudid pca, ivf and foley were
discontinued; po meds were initiated. pt evaluated the patient
and provided acute treatment with recommendations for continued
home pt upon discharge. ot was also consulted but did not
identify any acute ot needs.

on pod [**8-28**], the patient was discharged to home with visiting
nursing services and home physical therapy.  she continued to do
well, was afebrile with stable vital signs.  the patient was
tolerating a stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled.  both jp drains were
removed prior to discharge.

the patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
she will follow-up with dr. [**last name (stitle) **] in clinic in 1 week.

medications on admission:
preadmission medications listed are correct and complete.
information was obtained from patientwebomr.
1. hydroxychloroquine sulfate 200 mg po bid
2. metformin (glucophage) 1000 mg po bid
3. sertraline 50 mg po daily
4. vitamin e 1000 unit po daily
5. vitamin d 5000 unit po daily
6. multivitamins w/minerals 1 tab po daily
7. cinnamon bark *nf* dosage uncertain tablets oral daily
8. calcet creamy bites *nf* (calcium citrate-vitamin d3) 500 mg
calcium -400 unit oral [**hospital1 **]
9. fish oil (omega 3) 1000 mg po frequency is unknown


discharge medications:
1. oxycodone liquid 5-10 mg po q4h:prn pain
rx *oxycodone 5 mg/5 ml [**6-2**] ml by mouth every four (4) hours
disp #*150 milliliter refills:*0
2. ranitidine (liquid) 150 mg po bid
rx *ranitidine hcl 15 mg/ml 10 ml by mouth twice a day disp
#*600 milliliter refills:*0
3. acetaminophen (liquid) 650 mg po q6h:prn pain
rx *acetaminophen 325 mg/10.15 ml 20 ml by mouth every six (6)
hours disp #*300 milliliter refills:*0
4. calcet creamy bites *nf* (calcium citrate-vitamin d3) 500 mg
calcium -400 unit oral [**hospital1 **]
5. fish oil (omega 3) 1000 mg po daily
6. multivitamins w/minerals 1 tab po daily
7. vitamin d 5000 unit po daily
8. miconazole powder 2% 1 appl tp tid
rx *miconazole nitrate [anti-fungal] 2 % 1 application twice a
day disp #*90 gram refills:*0
9. nystatin oral suspension 5 ml po qid:prn thrush duration: 7
doses
swish and spit
rx *nystatin 100,000 unit/ml 5 ml by mouth four times a day disp
#*140 milliliter refills:*0
10. docusate sodium (liquid) 100 mg po bid:prn constipation
rx *docusate sodium 50 mg/5 ml 10 ml by mouth twice a day disp
#*150 milliliter refills:*0
11. metformin (glucophage) 500 mg po bid
rx *metformin [riomet] 500 mg/5 ml 500 mg by mouth twice a day
disp #*300 milliliter refills:*1
12. sertraline 50 mg po daily
rx *sertraline 20 mg/ml 50 mg by mouth daily disp #*75
milliliter refills:*1


discharge disposition:
home with service

facility:
[**hospital1 **] vna, [**hospital1 1559**]

discharge diagnosis:
morbid obesity
diabetes mellitus.
cholelithiasis.
chronic cholecystitis.
sleep apnea.
intraabdominal bleeding after laparoscopic gastric sleeve and
cholecystectomy.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except for the following changes.
1. please reduce your metformin to 500 mg, twice daily. please
check your blood sugars twice daily and report elevated or low
readings to your prescribing [**provider number 34259**]. please hold hydroxychloroquine (plaquenil).  discuss your
ability to resume this medication with dr. [**last name (stitle) **] at your
follow-up visit.
*crush all pills*

you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. nystatin oral swish four times per day as needed to treat
oral thrush.
6. miconazole powder applied twice daily to affected area.
5. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-7**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: tuesday [**2101-10-18**] at 1 pm
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: tuesday [**2101-10-18**] at 1:30 pm
with: [**first name11 (name pattern1) 177**] [**last name (namepattern4) 13365**], md [**telephone/fax (1) 3201**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2101-10-13**]"
82,"admission date:  [**2146-6-15**]              discharge date:   [**2146-6-28**]

date of birth:  [**2081-10-25**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1556**]
chief complaint:
colon cancer
s/p jejunoileal bypass in [**2109**]

major surgical or invasive procedure:
[**2146-6-15**]: rt hemicolectomy, reversal of jejunoileal bypass, liver
biopsy (tru-cut needle).
[**2146-6-27**]: exploratory laparotomy with washout, repair of
perforation in ileum, placement of vacuum-assisted closure
dressing.


history of present illness:
64-year-old man with a history of colonic polyps, who on
screening colonoscopy ([**2146-5-17**]) demonstrated an ulcerated,
clamshell, nonobstructing mass in the cecum.  the length was
approximately 3 cm.  biopsy confirmed invasive
adenocarcinoma grade ii.  otherwise, he has had no change in his
health. no blood per rectum, no weight loss, no abdominal pain.
he currently has [**12-24**] formed bowel movements per day.  he does
experience loose bowel movements if he eats fatty foods or
cheese.

past medical history:
past medical history:
1.  myocardial infarction, [**2143**].
2.  right-sided nephrolithiasis.
3.  morbid obesity (bmi 44.3 kg/m2).
4.  hypertension.
5.  history of colonic polyps.

past surgical history:
1.  jejunoileal bypass, [**2109**] (16 inches of jejunum anastomosis
    to the last 6 inches of ileum) appendectomy was performed at

    that time.
2.  open cholecystectomy with choledochostomy tube and
    gastrostomy tube for acute gallstone pancreatitis, [**2109**].
3.  ureteroscopy with stenting, 05/[**2144**].  this was complicated
    by bradycardia into the 20s.
4.  cardiac pacemaker placement, [**2145-4-6**].
5.  right flank incision with stone extraction, [**2145-5-5**].
6.  cystoscopic attempted stone extraction and stenting,
    [**2145-5-21**].
7.  surgical extraction of right renal stone, [**2145-6-4**].
8.  cardiac stents (drug-eluting), [**2143**].
9.  right shoulder surgery, [**2140**], no metallic implants.

social history:
he does not smoke, drink excessively or use
drugs.  he manages an insurance firm.  he is accompanied by his
wife and daughter today.


family history:
significant for mother with [**name (ni) 2481**] disease,
father with [**name (ni) 5895**] disease.


physical exam:
bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi:
44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99.

physical examination:  general:  he is alert, oriented, in no
acute distress.  heent:  pupils are equal, round and reactive to
light.  sclerae anicteric.  oropharynx is clear.  neck:  supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly or nodules.  trachea is midline.  lungs:  clear to
auscultation bilaterally.  heart:  regular.  abdomen:  obese.
he
has a right subcostal incision (cholecystectomy).  he has a
right
lower abdominal transverse incision (intestinal bypass).  he has
a right flank incision (renal surgery).  there are no obvious
hernias.  there is no tenderness.  genitourinary:  penis is
circumcised.  testicles are descended bilaterally.  extremities:

without edema.  neurologic:  grossly nonfocal.


pertinent results:
[**2146-6-15**] 04:50pm   glucose-187* urea n-12 creat-1.0 sodium-141
potassium-4.1 chloride-104 total co2-27 anion gap-14
[**2146-6-15**] 04:50pm   estgfr-using this
[**2146-6-15**] 04:50pm   calcium-9.2 phosphate-3.9 magnesium-1.4*
[**2146-6-15**] 04:50pm   wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6*
mcv-77* mch-23.8* mchc-30.8* rdw-15.5
[**2146-6-15**] 04:50pm   plt count-102*
[**2146-6-15**] 12:44pm   type-art rates-/12 tidal vol-700 po2-330*
pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 12:44pm   glucose-153* lactate-2.1* na+-135 k+-3.8
cl--101
[**2146-6-15**] 12:44pm   hgb-10.7* calchct-32 o2 sat-97
[**2146-6-15**] 12:44pm   freeca-1.19
[**2146-6-15**] 10:53am   type-art rates-/12 tidal vol-700 po2-84*
pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 10:53am   na+-135
[**2146-6-15**] 10:53am   hgb-10.3* calchct-31 o2 sat-94

brief hospital course:
the patient presented to pre-op on [**2146-6-15**]. pt was evaluated by
anaesthesia and taken to the operating room where a laparoscopic
adjustable gastric band placement was performed. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout the
hospitalization; until her was intubated and sedated. pain was
well controlled with iv pain medications.
cv: vital signs were routinely monitored. the patient remained
stable from a cardiovascular standpoint until he developed
tachycardia and hypotension on [**2146-6-27**]. following that the
patient was placed on multiple pressors by the icu team. cardiac
enzymes were initially negative, a tee revealed a hyperdynamic
myocardium.
pulmonary: vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. the patient remained
stable from a pulmonary standpoint until [**2146-6-27**] when he
developed shortness of breath, new and increasing oxygen
requirement and desaturation. cta of the chest revealed no
evidence of pe, but the patient had evidence of worsening
pulmonary function and ards. he was intubated and his peep was
optimized using an intraesophageal balloon. he remained
intubated until the decision of comfort measures only was
executed terminally extubating the patient.

gi/gu/fen: he was kept npo with ng tube to suction. the patient
was initially putting out about 7-8 liters of bilious fluid a
day. this was adequately replaced with iv fluids. the patient
was later decreasing his ng tube outputs to 4 liters by day 6
post-operatively. the patient passed gas on the 5th day
post-operatively, and bowel movements pod6. tpn was started due
to the elevated ng outputs (dark green bile). patient's intake
and output were closely monitored.
 pod#12, the patient decompensated with sudden onset chest and
shoulder pain, shortness of breath, tachypnea, new oxygen
requirement, ekg new right bundle branch block, and transient
abdominal pain.
the patient was taken to the or and exploration revealed a total
of 5 liters of fluid non bilious. he was found to have one small
hole at the proximal anastomosis and purulent pocket. 3 drains
were placed. subsequently the patient developed multiple organ
system failure, with acute renal failure requiring continuous
venovenous hemodialysis. worsening refractory metabolic acidosis
requiring multiple boluses and iv drip bicarbonate. acute liver
failure was also noted with inr>3 and liver transaminases >[**2133**].


id: the patient's fever curves were closely watched for signs of
infection. the
patient developed sepsis as discussed above with multiple
organisms (k. pneumonia, b. fragilis,...) the patient was placed
on broad spectrum iv antibiotics.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

 the patient was showing signs of multiple organ system collapse
with refractory hypotension and acidosis despite maximal medical
therapy. a family meeting was conducted with the family deciding
that the patient's wishes would be to withdraw care at that
point. the patient was extubated terminally and the patient
passed away shortly after on [**2146-6-28**] at 17:37.

medications on admission:
medications - prescription
atorvastatin -  (prescribed by other provider) - 40 mg tablet -
1
tablet(s) by mouth once a day
hydrochlorothiazide -  (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth once a day
sildenafil [viagra] -  (prescribed by other provider) - dosage
uncertain
valsartan [diovan] -  (prescribed by other provider) - 80 mg
tablet - 1 tablet(s) by mouth once a day

medications - otc
aspirin -  (prescribed by other provider) - 81 mg tablet,
chewable - 1 tablet(s) by mouth once a day
cholecalciferol (vitamin d3) [vitamin d] -  (prescribed by other
provider) - dosage uncertain


discharge medications:
none

discharge disposition:
expired

discharge diagnosis:
cecal cancer with positive lymph node
reversal of jejunoileal bypass
liver cirrhosis secondary to jejunoileal bypass
acute respiratory distress syndrome
acute liver failure
acute renal failure
intraabdominal severe septic shock

discharge condition:
dead

discharge instructions:
na

followup instructions:
na


completed by:[**2146-7-26**]"
83,"admission date:  [**2115-10-14**]              discharge date:   [**2115-10-24**]

date of birth:  [**2076-6-1**]             sex:   f

service: surgery

allergies:
zofran

attending:[**first name3 (lf) 1556**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2115-10-14**]:
1. laparoscopic roux-en-y gastric bypass.
2. endoscopy
[**2115-10-17**]:
1. exploratory laparotomy.
2. small-bowel resection with primary anastomosis.
3. gastrostomy tube placement.


history of present illness:
[**known firstname **] has class iii morbid obesity with a weight of 228.4
pounds as of [**2115-8-20**] (her initial screen weight on [**7-8**]/level was
231.5 pounds), height of 63 inches and bmi of 41.8.  her
previous weight loss efforts have included self-initiated diet
for 3 months in [**2115**] losing 5 pounds, 12 weeks weight watchers
in [**2106**] losing 3 pounds, 8 weeks of the [**doctor last name 1729**] diet in [**2104**]
losing only 5 pounds, 4 months of over-the-counter
ephedra-containing metabolife in [**2102**] losing 10 pounds and two
months of slim-fast in [**2098**] losing 19 to 20 pounds.  she has not
taken prescription weight loss medications.  her highest adult
weight was 234.6 pounds in [**month (only) 205**] and she weight 224 pounds one
year ago.  she stated she has been struggling with weight since
childhood and cites as factors contributing to her excess weight
large portions, genetics, too many carbohydrates in saturated
fats and convenience heating as well as lack of exercise.  she
stated that she currently is not exercising due to physical
limitations/knee problems.  she denied history of eating
disorders and does have issues with depression/anxiety but has
not been followed by a therapist in no are hospitalized for
mental health issues and she is on psychotropic medication
(celexa).


past medical history:
pmh: morbid obesity, hypertension, hypothyroidism,
osteoarthritis of the cervical spine with neck pain, migraine or
tension headaches, shoulder impingement syndrome, bilateral
carpal tunnel syndrome, eczema, allergic rhinitis, ovarian
cysts, uterine fibroids, sciatica and vertigo

psh: bilateral breast reduction, bilateral carpal tunnel repair
and appendectomy


social history:
she denied tobacco or recreational drug usage, has occasional
glass of beer/wine once or twice per week and does drink both
carbonated and caffeinated beverages.  she is employed as [**initials (namepattern4) **] [**last name (namepattern4) **]
collector for utilities company.  she is divorced and she has
one son age 22.


family history:
her family history is noted for mother living age 56 with
hyperlipidemia and arthritis; sister living age 35 with obesity.

physical exam:
vs upon discharge: 97.8, 75, 152/95, 18

constitutional: appropriate affect, pleasant and cooperative.
neuro: alert and oriented x4, nad.
cardiac: rrr, n s1, s2 no mrg.
lungs: lungs clear to auscultate bilaterally.
abdomen: obese, soft, nondistended, tender to deep palpation.
gtube clamped.
wounds: midline incision with staples, open to air; umbilicus
with small amt serous drainage. gtube insertion site without
drainage or erythema.
ext: + pedal pulses bilaterally, warm to touch.


pertinent results:
labs:
[**2115-10-19**] 07:00am blood wbc-9.8 rbc-3.54* hgb-10.8* hct-30.7*
mcv-87 mch-30.5 mchc-35.2* rdw-12.7 plt ct-[**numeric identifier 92387**]/05/11 07:40am
blood calcium-9.2 phos-2.7 mg-2.1 glucose-100 urean-8 creat-0.6
na-139 k-3.7 cl-102 hco3-28 angap-13 hct-34.5*
[**2115-10-18**] 01:45am blood wbc-13.3*# rbc-4.21 hgb-12.5 hct-37.9
mcv-90 mch-29.8 mchc-33.1 rdw-12.6 plt ct-321
[**2115-10-15**] 07:15am blood hct-31.0*
[**2115-10-15**] 07:45pm blood hct-31.1*
[**2115-10-14**] 11:54am blood hct-35.2*

imaging:
[**2108-10-15**] ugi sgl contrast w/ kub:
normal appearance of post-roux-en-y stomach with no evidence of
leak or obstruction

[**2115-10-16**]: abdomen (supine & erect):
impression: small bowel dilation with air-fluid levels
concerning for small bowel obstruction.

[**2115-10-17**]: ct abd & pelvis with contrast:
impression:
1. small bowel obstruction likely complete distal to the
roux-en-y anastomosis with dilation of both limbs of the
roux-en-y gastric bypass resulting in distention of the excluded
stomach.
2. the transition point is not definitely identified, however it
is not in
relation to the abdominal wall hernia and there is no mass or
internal hernia. thus this is most likely due to an adhesion.
3. umbilical hernia containing omentum with surrounding fluid
collection.


brief hospital course:
the patient presented to pre-op on [**2115-10-14**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic roux-en-y gastric bypass and endoscopy. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

on pod 3, the patient was noted to have a complete small bowel
obstruction.  she was taken back to the operating room where she
underwent an exploratory laparotomy, small-bowel resection with
primary anastomosis and gastrostomy tube placement.  again, she
was extubated and taken to the pacu.  once deemed stable, she
was brought to the surgical icu for further management.
post-operative recovery in the sicu was uneventful, therefore,
the patient was transferred to the general surgical [**hospital1 **] on pod
[**4-12**].

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed on pod0 with a
morphine pca, which required adjustment to dilaudid in the pacu
due to inadequately controlled pain.  the patient required an
increase in the amount of dilaudid on pod1 with improved pain
control.  following return to the operating room on pod3/0, the
patient's pain was adequately controlled with a morphine pca,
which was transitioned to oral roxicet once tolerating a stage 2
diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially kept npo on pod0 with complaints of
intermittent nausea, which was managed with intravenous
phenergan.  a methylene blue dye test, performed on pod0, and an
upper gi study, performed on pod1, were both negative for a
leak. given normal test results and improved nausea, the diet
was advanced to a bariatric stage 1 and then a stage 2 diet.
the patient initially tolerated the diet advancement, however,
on the evening of pod 2, the patient's abdomen became
progressively distended. jp output had also significantly
increased during the day on pod2 and and changed from
serosanguinous to serous.  additionally, a small area of
induration without fluctuance or erythema was noted at the
midline port site.  a kub was obtained later that evening, which
suggested 'small bowel dilation with air-fluid levels concerning
for small bowel obstruction'.  the following day, pod3, an
abdominal ct scan was obtained and suggested 'small bowel
obstruction likely complete distal to the roux-en-y anastomosis
with dilation of both limbs of the roux-en-y gastric bypass
resulting in distention of the excluded stomach' without
definitive identification of a transition point.  it was also
suggested that the obstruction was not related to the abdominal
wall hernia, which was described as an umbilical hernia
containing omentum with surrounding fluid collection, but was
most likely due to an adhesion. given these findings, the
patient was brought back to the operating room where she
underwent an exploratory laparatomy as described above.
post-operatively, the patient had a g-tube to gravity for
gastric decompression.  her diet was resumed on pod [**9-17**]
following return of bowel function, which was well tolerated.
jp drainage decreased significantly and was removed prior to
discharge from the hospital.  a foley catheter, which was placed
intra-operatively, was removed on pod1; urine output was
adequate throughout the hospitalization. on pod [**10-18**], jp drain
was discontinued prior to discharge.
id: intravenous cefazolin was administered prophylactically for
24 hours following the roux-en-y gastric bypass.  however,
intravenous metronidazole and ciprofloxacin were intitiated
following repair of the strangulated hernia and continued until
pod [**9-17**]. the patient's fever curves were closely watched for
signs of infection, of which there were none.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
amlodipine 10 mg daily
lisinopril 20 mg daily
atenolol 50 mg daily
levothyroxing 225 mcg daily
citalopram 20 mg daily
mvi w/ minerals 1 tablet daily
vitamin d (dosage uncertain)

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day:
crush.
2. lisinopril 20 mg tablet sig: one (1) tablet po once a day:
crush.
3. levothyroxine 200 mcg tablet sig: one (1) tablet po once a
day: crush.
4. levothyroxine 25 mcg tablet sig: one (1) tablet po once a
day: crush.
5. citalopram 20 mg tablet sig: one (1) tablet po once a day.
6. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable. tablet(s)
7. vitamin d-3  oral
8. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**5-21**] ml
po every 4-6 hours as needed for pain.
disp:*250 ml* refills:*0*
9. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
disp:*300 ml* refills:*0*
10. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a
day for 1 months.
disp:*600 ml* refills:*0*
11. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*


discharge disposition:
home with service

facility:
[**location (un) 15739**] district vna

discharge diagnosis:
1. hypertension.
2. morbid obesity.
3. osteoarthritis.
4. depression.
5.  strangulated hernia comprised of small intestine.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
provider: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd phone:[**telephone/fax (1) 305**]
date/time:[**2115-10-31**] 8:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 9325**], md phone:[**telephone/fax (1) 305**]
date/time:[**2115-10-31**] 9:15



completed by:[**2115-10-24**]"
84,"admission date:  [**2199-9-22**]              discharge date:   [**2199-10-2**]

date of birth:  [**2143-12-23**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 598**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
[**2199-9-23**]: laparascopic repair of gastric ulcer


history of present illness:
55f w/ h/o carotid stenosis/le claudication and diverticulosis
(last c-scope ~ 1 yr ago @ osh) presents with an acute onset of
epigastric pain 4 hours prior to arrival in ed. she was seen at
[**hospital3 **] and was reportedly hypotensive
initially to sbp 80s.  upright cxr showed a question of bowel
gas vs free air below left diaphragm. there was no ct scanner
available at [**hospital1 **] due to power outage and so patient was
transferred here for further eval/management. the patient
reports recent h/o of nausea vomiting (from ""some stomach bug"")
and diarrhea x2 days (described as ""dark"" but no brbpr) but
wasn't sure about passing flatus recently.  she denies fevers or
chills, nausea/vomiting, hematemesis, history of gi
bleeds/diverticulitis, cp, sob.


past medical history:
past medical history: htn, hypercholesterolemia, diverticulosis
(last c-scope ~1yr ago), carotid stenosis, le claudication

past surgical history: tonsillectomy


social history:
lives in [**location 2624**] w/ husband, occupation is assistant to husband
in furniture business, +tobacco smoking h/o ~35yrs on/off,
social etoh, no ivdu


family history:
n/c

physical exam:
on admission:
physical exam:
vitals: 96.5  104  106/79  20  98% 4l nasal cannula
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: tachycardic, regular rhythm, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: hypoactive bowel sounds, soft, mild distension, +ttp
midepigastrium/luq w/ focal rebound, no palpable masses
ext: no le edema, le warm and well perfused


pertinent results:
labs:
[**2199-10-2**] 07:05am blood wbc-7.4 rbc-3.30* hgb-11.0* hct-31.4*
mcv-95 mch-33.4* mchc-35.2* rdw-13.4 plt ct-567* glucose-94
urean-8 creat-0.4 na-143 k-3.9 cl-105 hco3-29 angap-13
calcium-8.8 phos-3.5 mg-2.3

[**2199-9-29**] 02:42pm blood gastrin-pnd

[**2199-9-26**] 10:01am blood vanco-6.9* 03:29am blood type-art
po2-111* pco2-33* ph-7.45 caltco2-24 base xs-0

[**2199-9-24**] 01:18am blood pt-13.7* ptt-34.2 inr(pt)-1.2* [**2199-9-24**]
01:18am blood probnp-988* [**2199-9-24**] 01:33am blood lactate-0.9

[**2199-9-22**] 04:15pm blood wbc-10.1 rbc-4.19* hgb-14.5 hct-40.0
mcv-95 mch-34.6* mchc-36.2* rdw-13.5 plt ct-433 neuts-85*
bands-1 lymphs-10* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0
hypochr-1+ anisocy-occasional poiklo-occasional macrocy-1+
microcy-normal polychr-occasional stipple-occasional
how-jol-occasional pappenh-1+ pt-11.9 ptt-20.8* inr(pt)-1.0
glucose-106* urean-15 creat-0.9 na-136 k-4.7 cl-101 hco3-23
angap-17 alt-18 ast-20 alkphos-67 amylase-159* totbili-0.7
lipase-58 calcium-9.7 phos-4.8* mg-1.6
glucose-98 lactate-1.6 na-135 k-4.2 cl-102 10:53pm blood
hgb-12.1 calchct-36 hgb-13.8 calchct-41 10:53pm blood
freeca-1.25

imaging:
[**2199-9-22**]:
cxr: impression: pneumoperitoneum. please correlate with ct
abdomen
ct abd & pelvis with contrast: impression: pneumoperitoneum with
active intraperitoneal spillage of oral (water soluble)
contrast, likely secondary to a perforated duodenal ulcer.
please note, given the mural edema and mucosal irregularity in
the gastric antrum, malignancy cannot be excluded.

[**2199-9-24**]:
impression: cta chest w&w/o c&recons, non-coronary: impression:
1. no evidence of pulmonary embolism.
2. multifocal consolidations concerning for pneumonia.
3. new bilateral pleural effusions and bilateral lower lobe
atelectasis.

[**2199-9-25**]:
ecg: impression: sinus rhythm. possible septal myocardial
infarction, age indeterminate. low voltage in the limb leads. no
previous tracing available for comparison

[**2199-9-27**]:
chest (portable ap): impression: since [**2199-9-26**], there
is mild interval worsening of the pulmonary edema. again, stable
left lung base atelectasis and bilateral mild pleural effusions.


[**2199-9-29**]:
impression: normal upper gi without evidence of leak.


brief hospital course:
ms. [**known lastname **] presented to an osh [**2199-9-22**] with acute onset
epigastric pain and hypotension.  an upright cxr was obtained at
the osh suggested a possible bowel gas pattern under the left
diaphragm versus free air.  the patient was subsequently
transferred to the [**hospital1 18**] emergency department for further
management.  an abdominal ct scan was obtained and revealed
pneumoperitoneum with active intraperitoneal spillage of oral
(water soluble) contrast attributed to a perforated duodenal
ulcer.  intravenous fluids, pain, and nausea medication were
administered.  intravenous ciprofloxacin was also administered.
the patient was then taken emergently to the operating room
where a perforated gastric ulcer was identified and a
laparascopic repair of the perforated gastric ulcer was
performed.  there were no adverse events in the operating room;
please see operative note for details.  pt was extubated, taken
to the pacu until stable, then transferred to the surgical
intensive care unit for further management. the patient remained
in the intensive care unit until pod 4.  she was then
transferred to the general surgical [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed with a dilaudid pca.
 pain medication was transitioned to oral oxycodone once
tolerating a diet.
cv: the patient required intraoperative pressors, which were
resumed on pod0, in addition to a fluid bolus, in the sicu due
to hypotension.  pressors were discontinued on pod2.
additionally, a lasix drip was initiated on pod1 due to. .; the
lasix drip was transitioned to [**hospital1 **] intravenous dosing on pod 4
and discontinued on pod 9; electrolytes were repleted prn.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially kept npo. patient's intake and
output were closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
toprol xl 200 mg daily
amlodipine 5 mg daily
lisinopril 20 mg daily
aspirin 81 mg daily
cilostazol 100 mg [**hospital1 **]
lovastatin 40 mg daily
ambien 5 mg q hs prn
aspirin 81 mg daily
caltrate + d 600 mg- 400 mg [**hospital1 **]
glucosamine 1000 mg daily

discharge medications:
1. oxycodone 5 mg tablet sig: one (1) tablet po every four (4)
hours as needed for pain.
disp:*50 tablet(s)* refills:*0*
2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily).

3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every
6 hours): do not exceed 3000 mg per 24 hour period.
4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
disp:*30 tablet, delayed release (e.c.)(s)* refills:*2*
5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid
(2 times a day).
disp:*60 tablet(s)* refills:*0*
6. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).

7. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day as needed for constipation.
disp:*30 capsule(s)* refills:*0*
8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable
po once a day.
9. cilostazol 100 mg tablet sig: one (1) tablet po twice a day.

10. lovastatin 40 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
perforated gastric ulcer


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
you were admitted to the hospital with abdominal pain.  an
abdominal ct scan was obtained and was suspicious for an
intestinal perforation , therefore, you were taken to the
operating room and subsequently underwent a laparascopic repair
of a perforated gastric ulcer.  you recovered in the hospital
and are now preparing for discharge to home with the following
instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications except for the
following changes:
1.  stop toprol xl(extended releas metoprol).  a new
prescription for twice daily metoprolol has been provided to
you.  please notify your primary care provider of this change.
please seek immediate medical attention if you experience a
severe headache, blurred vision, weakness, difficulty speaking
and/ dizziness.
2.  please take 20 mg lisinopril daily (current home dose 40 mg
daily).  please follow the above instructions regarding your
blood pressure.
also, please take any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-4**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service to make a follow-up
appointment within 2 weeks.
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2200-2-26**] 12:30
provider: [**name10 (nameis) 14633**],equipment [**name10 (nameis) **] lmob (nhb) phone:[**telephone/fax (1) 1237**]
date/time:[**2200-2-26**] 12:30
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2200-2-26**] 1:15


                             [**first name8 (namepattern2) **] [**name8 (md) **] md [**md number(2) 601**]

completed by:[**2199-10-2**]"
85,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
86,"admission date:  [**2120-2-21**]       discharge date:  [**2120-3-27**]

date of birth:   [**2075-1-21**]       sex:  m

service:  [**hospital1 **]

addendum:

the patient was not discharged as initially thought on
[**2120-3-23**].  he remained inpatient and date of discharge will
be in the future.

hospital course:
1.  infectious disease - no active issues since the previous
discharge summary.  fevers were followed and the patient will
be cultured if he spikes.

2.  hypertension - the patient's blood pressure continued to
be well controlled on multiple medications.

3.  gastrointestinal bleed - the patient had no active
bleeding.  hematocrit was followed as needed and remained
stable.

4.  type 2 diabetes mellitus - the patient continued to have
good blood sugar control on regular insulin sliding scale.

5.  medication ingestion - on the evening of [**2120-3-23**], the
patient was observed to be ingesting multiple medications by
the sitter in his room. the patient had obtained these
medications from a box in his belongings.  it is unclear how
many pills the patient took and exactly which type of
medications were taken.  they were most likely
antihypertensives and psychiatric medications.   the patient
was given activated charcoal.  he was transferred to the
[**hospital ward name 332**] intensive care unit for close monitoring of his blood
sugar, electrocardiogram and vital signs.  the patient
remained in the [**hospital ward name 332**] intensive care unit for approximately
24 hours with no adverse events.  at that time, the
toxicology service felt any possibility of danger or adverse
events from the medications had passed.   the patient was
transferred back to the [**hospital1 139**] firm and had no resultant
problems from the medication ingestion.

6.  deep vein thrombosis - on [**2120-3-24**], it was noted on
examination that the patient's right leg was significantly
swollen in comparison to his left lower extremity.  a lower
extremity ultrasound was obtained which showed a partially
occluded thrombus in the right common femoral vein.  flow was
seen around the thrombus but the vein was not compressible.
no deep vein thrombosis was present in the left lower
extremity. the patient was very cautiously started on
anticoagulation with enoxaparin and coumadin.  given his
history of gastrointestinal bleeds, his hematocrit is being
followed very closely.  in addition, the patient has had
several falls during the admission and is a fall risk in the
future.  he will have a one to one sitter at all times.  in
addition, a custom made helmet is being obtained for the
patient to wear when he is awake.

the remainder of this dictation will be finished at a later
time.




                            [**first name11 (name pattern1) 2515**] [**last name (namepattern4) 4517**], m.d.  [**md number(1) 4521**]

dictated by:[**name8 (md) 315**]
medquist36

d:  [**2120-3-27**]  17:37
t:  [**2120-3-27**]  18:00
job#:  [**job number 102686**]
"
87,"admission date:  [**2127-12-7**]              discharge date:   [**2127-12-17**]

date of birth:  [**2063-4-18**]             sex:   f

service: surgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1556**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
1. exploratory laparotomy.
2. lysis of adhesions.
3. oversew of colonic deserosalization.


history of present illness:
64 year old female who presents with sudden onset of
periumbilical pain that started early this morning at around
5am. abdominal pain is mid abdomen with no radiation; relieved
by pain meds and no definite aggravating factors. associated
nausea and vomiting ~6 times. bilious; no blood. denies any
fevers, chills. bowel movements this morning; flatus last night.


past medical history:
- ovarian cancer, diagnosed in [**2109**] and treated with tah bso and
6 runs of chemotherapy complicated by deep vein thrombosis in
left lower extremity and was on coumadin briefly
- bladder cancer, diagnosed in [**2114**] and treated with cystecomy
and ileal conduit and stoma
- documented to have chronic anemia of unknown etiology
- pt. reported last colonoscopy 5 years ago with no abnormal,
she did have polyp removed during colonoscopy 10 years ago but
was not sure if malignancy was found.
-osteoporosis

psychiatric history:
patient has a diagnosis of ""psychotic disorder"" and has been
treated by her primary care provider successfully with
thorazine. she does not see any therapists or psychiatrists at
this time. she saw dr. [**last name (stitle) 100898**] in therapy 1x/mo for 6yrs
until she changed her insurance in [**month (only) 547**]. she reports trying
zoloft for a short time in [**2111**] but did not mention results.

hospitalizations: [**2111**] - ""[**first name4 (namepattern1) **] [**last name (namepattern1) **] accomodations""
                  [**2110**] - [**hospital1 336**]
                  [**2092**] - [**hospital1 **] [**hospital1 **] 4

patient reports 1 prior suicide attempt in [**2084**] when she
""stopped eating and wearing warm clothes and stayed out all
night, everything to excess."" she was then hospitalized for
pneumonia, no history of hurting herself.

social history:
born in mission [**doctor last name **] and raised in [**location (un) 669**], one of 11 children
(10 per omr). she reports 7 living (omr notes say 6) and all
except two sisters are in the [**name (ni) 86**] area.  lives alone. remote
smoker, no drugs/etoh


family history:
she had ten siblings. malignancy in the family: deceased sister:
ovarian ca
sister: breast cancer brother : ca brain brother: liver cancer
father: prostate cancer; mother's sister had schizophrenia.

physical exam:
constitutional: comfortable
chest: clear to auscultation
cardiovascular: regular rate and rhythm, normal first and second
heart sounds
abdominal: diffuse tenderness to palpation. no guarding or
rebound tenderness to palpation. abdomen nondistended, soft.
extr/back: no cyanosis, clubbing or edema
skin: no rash, warm and dry
neuro: speech fluent
psych: normal mood, normal mentation


pertinent results:
[**2127-12-7**] 02:45pm urine  hours-random
[**2127-12-7**] 02:45pm urine  gr hold-hold
[**2127-12-7**] 02:45pm urine  color-yellow appear-clear sp [**last name (un) 155**]-1.016
[**2127-12-7**] 02:45pm urine  blood-tr nitrite-neg protein-25
glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-7.0 leuk-sm
[**2127-12-7**] 02:45pm urine  rbc-0-2 wbc-[**4-18**] bacteria-many yeast-none
epi-0-2
[**2127-12-7**] 02:11pm   k+-4.1
[**2127-12-7**] 02:02pm   glucose-129* urea n-28* creat-1.4* sodium-144
potassium-4.1 chloride-108 total co2-26 anion gap-14
[**2127-12-7**] 12:30pm   glucose-137* urea n-31* creat-1.4* sodium-143
potassium-5.1 chloride-104 total co2-28 anion gap-16
[**2127-12-7**] 12:30pm   alt(sgpt)-13 ast(sgot)-32 alk phos-75 tot
bili-0.3
[**2127-12-7**] 12:30pm   lipase-55
[**2127-12-7**] 12:30pm   calcium-9.6
[**2127-12-7**] 12:30pm   wbc-6.3# rbc-3.65* hgb-10.6* hct-32.6* mcv-89
mch-29.2 mchc-32.7 rdw-13.9
[**2127-12-7**] 12:30pm   neuts-87.4* lymphs-9.4* monos-2.4 eos-0.5
basos-0.3
[**2127-12-7**] 12:30pm   plt count-190

[**2127-12-8**] abdominal ct w/ contrast: 1. high-grade small-bowel
obstruction, with dilation of the mid small bowel up to 3.4 cm.
the proximal and distal small bowel are decompressed and two
closely approximated transition points are seen in the
mid-abdomen, concerning for a closed loop obtruction, possibly
secondary to either internal hernia or
adhesion. while there is associated wall edema, mesenteric
fluid, and
adjacent ascites, there is no pneumatosis or portal venous air
identified to definitively suggest ischemia.
2. status post right nephroureterectomy and radical cystectomy,
with
unremarkable appearance of urostomy in the right lower quadrant.
no definite evidence of metastatic disease. small nodular
density at the left lung base is stable, though attention on
followup is warranted.
3. stable 4 mm hypodensity within the body of the pancreas,
unchanged.
4. ivc filter in standard position.

[**2127-12-12**] ekg: sinus rhythm with sinus arrhythmia. borderline low
limb lead voltage. diffuse non-specific st-t wave abnormalities.
compared to the previous tracing of [**2127-12-8**] findings are
similar.



brief hospital course:
ms. [**known lastname 20400**] presented to the emergency department on [**2127-12-7**] with complaints of sudden onset abdominal pain at the
umbilical level associated with nausea and vomiting and not
relieved with over the counter pain medication.  an abdominal
x-ray was obtained, which indicated a small bowel obstruction.
therefore, [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube was placed and the patient was
transferred to the general surgical [**hospital1 **] for management.

on hospital day #1 the patient developed worsening abdominal
pain.  additionally, an abdominal ct scan had beeb obtained,
which revealed a high grade small bowel obstruction.  given the
worsening abdominal exam and the results of the ct scan, the
patient was brought to the operating room, where an exploratory
laparotomy, lysis of adhesions and oversew of colonic
deserosaliazation was performed.  there were no adverse events
in the operating room; please see the operative note for
details. pt was extubated, taken to the pacu until stable, then
transferred to the surgical intensive care unit for close
observation.

on hosptial day #2 the patient remained stable, was weaned from
the ventilator and extubated.  she was subsequently transferred
to the general surgical [**hospital1 **] for further management.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially controlled with intravenous
dilaudid.  the patient reported complete resolution of pain by
post-operative day #5 and did not require pain medication for
the remainder of her hospitalization.

cv: the patients vital signs were routinely monitored. she
became hypertensive in the intensive care unit with a systolic
blood pressure in the 160s.  additionally, she had 8 beats of
non-sustained ventricular tachycardia on post-operative day #4.
she was maintained on intravenous metoprolol which was initiated
in the intensive care unit and continued until post-operative
day #8; her blood pressure and heart rate remained within
acceptable limits without metoprolol administration.

pulmonary: the patient tolerated extubation postoperatively
without difficulty and maintained appropriate oxygen saturation
levels throughout her admission.

gi/gu/fen: she was initially npo with iv fluids and a
[**last name (un) **]-gastric tube, which was removed on post-operative day #4.
diet was advanced sequentially, which was well tolerated,
however, oral liquid and solid intake was initially suboptimal.
nutritional supplements were then provided with each meal with
improved overall oral intake; she will continue this regimen at
home to optimize her nutritional status  patient's intake and
output were closely monitored, and iv fluid was adjusted when
necessary; electrolytes were routinely monitored and repleted as
necessary.

id: the patient's white blood cell counts and fever curves were
monitored routinely throughout her admission and did not show
any signs of intrabdominal or wound infections.

hematology: the patient's complete blood count was examined
routinely; no transfusions were required.

prophylaxis: the patient received subcutaneous heparin and
venodyne boots were used during this stay; she was encouraged to
get up and ambulate as early as possible.

rehab: given her prolonged hospital course and operation, a
physical therapy consult was requested.  she was evaluted on
post-operative day #8 and deemed safe for discharge home without
additional physical therapy requirements.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding via her urostomy tube, and pain was
well controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
risperidone 1 mg tab qpm
vitamin d 800 unit tab daily
calcium 1200 mg chewable tab daily

discharge medications:
1. risperidone 0.5 mg tablet sig: two (2) tablet po hs (at
bedtime).
2. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2)
tablet po daily (daily).
3. calcium 500 mg tablet sig: 2.5 tablets po once a day.


discharge disposition:
home

discharge diagnosis:
small bowel obstruction


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-23**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.


followup instructions:
please call dr. [**last name (stitle) **] at [**telephone/fax (1) 3201**] to make a follow-up
appointment for friday, [**2127-12-26**].
provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 6198**], md phone:[**telephone/fax (1) 22**]
date/time:[**2127-12-12**] 3:30



completed by:[**2127-12-18**]"
88,"admission date:  [**2189-12-30**]       discharge date: [**2190-1-5**]


service:  neurology

date of discharge:  pending at this time.

history of the present illness:  [**known firstname **] [**known lastname 102182**] is an
88-year-old retired ophthalmologist with the past medical
history of cll in remission, peripheral neuropathy,
hypertension times 20 years, history of irregular heart
beats, history of gastritis and history of gout.  the patient
presented originally for elective stenting of left internal
carotid artery.  he is known to have bilateral high-grade
stenoses.  in [**month (only) 359**] of this year he had had some repeated
episodes of difficulty expressing himself and difficulty
finding words, but no focal weakness.  he was worked up at
that time for presumed tia and he was found to have the
carotid stenosis, as described above.  on the day of
admission he underwent elective stenting and he was doing
well.  however, during the procedure it was noted acutely
that he was not moving his right hand and face well and that
he had difficulty responding to questions, and he became
progressively less verbal, although he was still alert.
angiogram was done emergently, which revealed likely
occlusion of the left angular branch of the middle cerebral
artery on the left, but because the patient could not
tolerate the placement of the catheter, he could not receive
intra-arterial tpa.  he was started reapro and heparin and
transferred to the pacu.  the ct done at that time showed no
bleed and only slight contrast extravasation.

past medical history:  history is as described above.

allergies:  the patient has allergies to codeine and
tetracycline.

outpatient medications:
1.  cardura.
2.  allopurinol.
3.  prilosec.
4.  baby aspirin.

at the time that he was seen in the neurological icu he was
on a integrilin 3 ml per hour, heparin, zantac, labetalol
p.r.n. for blood pressure control.

social history:  history is significant for the fact that he
quit smoking 30 years ago and before that he smoked one pack
per day.  he does not use alcohol at present.  he is a
retired ophthalmologist.  he was previously head of the
department of ophthalmologist at the [**hospital1 190**].

physical examination:  on examination, vital signs were blood
pressure 165/56, pulse 60, respirations 20 and temperature
908.5.  heart showed a regular rate and rhythm with
occasional pvcs intruding.  lungs were clear to auscultation.
abdomen was soft, and nontender.  neurological examination
revealed that the patient is alert, awake, and only saying
minimal words.  he was not able to say the date.  he
initially called the thumb the ""thumble"" and after that,
during all subsequent questions he would simply repeat
thumble in a perseverative fashion.  he was able to repeat
accurately.  he could read simple sentences.  he could not
write.  his comprehension was intact for some simple
commands, but inconsistent overall.

on motor examination, he was moving the right arm left, but
he was able to lift it and did not have any appreciable
drift.  his hand seemed somewhat clumsy, but this was
difficult to assess.  it was not clear whether he was apraxic
or simply weak.  he was able to move his lower extremities
equally well.  on cranial nerve examination, he had equal and
round and reactive pupils.  extraocular movements were
intact and he blinks to threat bilaterally.  he had a right
facial droop.  tongue was midline.  it was difficult to
assess sensation secondary to language.  coordination tests
were not able to be done secondary to comprehension problems.

hospital course:  the patient was kept in the icu under the
care of neurology and his blood pressure was controlled at
140 to 150 systolic.  he was kept flat initially.  he
initially tolerated the heparin and integrilin well, but on
the day after admission it was noted that his hematocrit had
dropped to 30 from a preoperative level of 37.  the following
day, he had had a drop to 29.  he then dropped to 25.7.  the
heparin and reapro were held.  urinalysis and stool guaiac
were obtained, which were negative for bleed.  he was given
two units of packed red blood cells and the hematocrit came
up nicely.

while he was in the unit, he also received some
neo-synephrine for blood pressure support.  this was able to
be discontinued on [**2189-12-31**] and he did not have any change
in his symptoms or clinical condition following this.

slowly, over the course of his hospital stay, the aphasia,
which was predominately a conduction aphasia previously,
began to resolve.  he was more fluent, able to comprehend
complex commands, and had a very mild residual anomia for
low-frequency words.

following the discontinuation of the integrilin and heparin,
he was started on aspirin and plavix.  he was also seen by pt
and occupational therapy who felt that he would do well with
three to five outpatient visits per week for continued
rehabilitation of the right upper extremity.  bedside swallow
test was performed, which demonstrated that he could swallow
thickened liquids and diet was advanced as tolerated with no
adverse events.

discharge planning:  this will be included as an addendum to
the current dictation.

discharge diagnosis:
1.  acute stroke.
2.  hypertension.
3.  history of cll in remission.
4.  gout.
5.  history of irregular heart beat.
6.  peripheral neuropathy.
7.  history of gastritis.

medications:
1.  aspirin at 325 mg p.o.q.d.
2.  plavix 75 mg p.o.q.d.

other medications:  other medications will be included in the
discharge addendum.




                            [**doctor last name **] [**name8 (md) 8346**], m.d.  [**md number(1) 8347**]

dictated by:[**last name (namepattern1) **]
medquist36

d:  [**2190-1-4**]  14:08
t:  [**2190-1-4**]  14:14
job#:  [**job number **]
"
89,"admission date:  [**2144-3-7**]              discharge date:   [**2144-3-18**]

date of birth:  [**2103-11-10**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 3200**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
1. exploratory laparotomy with [**location (un) **] patch of the duodenal
ulcer.
2. repair of internal hernia at the jejunojejunostomy.
3. upper endoscopy.
4. gastrostomy tube.


history of present illness:
patient is a 40 yo female transferred from [**hospital3 **] with past medical history gastric bypass who presented
with diffuse abdominal pain.  patient with complaints of
intermittent pain and constipation for over a week.  her pain
has become gradually worse and constant she rates her pain as a
[**10-26**] diffuse pain with associated nausea.  she denies any
vomiting.  patient is passing flatus and is tolerating a regular
diet.  she denies any diarrhea, any brbpr.  patient seen at osh
with ngt placed.  she was transferred to [**hospital1 18**] for further
evaluation and management.


past medical history:
pmh: anxiety

psh: lap gastric bypass [**2133**]


social history:
lives with boyfriend, 2 cats.  not working. smokes 1-1.5 packs
of cigarettes per day.  heavy alcohol use history, less
recently.  denies drug use.  no recent travel.  history of
domestic violence including current relationship.


family history:
obesity

physical exam:
vital signs:  t 99.2, hr 82, bp 104/61, rr 18, o2 96% ra

constitutional: no acute distress
neuro: alert and oriented to person, place and time
cardiac: rrr
lungs: no acute respiratory distress
abdomen: soft, non-tender. no active bleeding
wounds: open midline abdominal wound 80% granular, 20% fibrotic,
no active drainage. wound edges are clean. there is one proximal
and one distal simple interrupted 2-0 prolene suture
extremities: symmetric 2+ le edema, pulses palpable, no calf
pain b/l

pertinent results:
admission labs [**2144-3-7**]:
wbc-4.3 rbc-4.60 hgb-9.3 hct-34.6 plt ct-307 pt-11.9 ptt-19.5
inr(pt)-1.0
neuts-83 bands-9 lymphs-3 monos-5 eos-0 baso-0 atyps-0 metas-0
myelos-0
hypochr-2+ anisocy-2+ poiklo-3+ macrocy-1+ microcy-1+
polychr-occasional ovalocy-1+ tear dr[**last name (stitle) 833**]
[**name (stitle) 15924**]
glucose-123 urean-14 creat-0.9 na-135 k-3.9 cl-106 hco3-15
alt-9 ast-18 totbili-0.2
totprot-6.3 albumin-3.4 globuln-2.9 calcium-8.1 phos-4.2 mg-2.0
hgb-9.6 calchct-29 freeca-1.12
.
wbc trend:          k+ trend
[**3-7**]: 8.6          3.9
[**3-8**]: 7.2          3.6
[**3-9**]: 7.8          3.3
[**3-10**]: 7.4          3.7
[**3-11**]: 7.5          2.8
[**3-12**]: 9.3          3.3
[**3-13**]: 9.7          3.3
[**3-15**]: 10.6         2.8
[**3-16**]: 4.3          3.8
[**3-17**]:              3.4
[**3-18**]:              4.1
.
urine:
blood-lg nitrite-neg protein-30 glucose-neg ketone-150
bilirub-neg urobiln-neg ph-5.0 leuks-neg
urine color-yellow appear-clear sp [**last name (un) **]-1.014
.
blood cx negative x 3, h.pylori abx negative, mrsa screen:
negative
.
abdominal wound swab:
gram stain (final [**2144-3-14**]):
      2+   (1-5 per 1000x field):   polymorphonuclear
leukocytes.
      no microorganisms seen.

   wound culture (final [**2144-3-18**]):
      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..
      full work up per dr.[**first name (stitle) **],d [**2144-3-16**].
      full work up cancelled per dr.[**last name (stitle) **] [**2144-3-17**].

   anaerobic culture (final [**2144-3-18**]):    no anaerobes isolated.

.
g-tube wound swab:
gram stain (final [**2144-3-16**]):
      no polymorphonuclear leukocytes seen.
      no microorganisms seen.

   wound culture (final [**2144-3-18**]):    no growth.

   anaerobic culture (preliminary):    results pending.
.
cardiology report ecg study date of [**2144-3-7**]:
sinus tachycardia. baseline artifact makes evaluation of st-t
waves in limb leads difficult. no previous tracing available for
comparison. suggest repeat tracing if clinically indicated.
.
radiology report chest (portable ap) study date of [**2144-3-8**]:
et tube is in standard placement at the thoracic inlet, right
jugular line
ends in the upper svc. moderately severe left lower lobe
atelectasis, small left pleural effusion, and moderate right
pleural effusion are all new. the heart is not enlarged. dr. [**last name (stitle) **]
[**last name (stitle) **] paged.
.
radiology report chest (portable ap) study date of [**2144-3-11**]:
no consolidations suggestive of pneumonia, but persistent
right-sided effusion and mild interstitial edema.
.
radiology report chest (pa & lat) study date of [**2144-3-13**]
there are low lung volumes. cardiomediastinal contours are
unchanged. a
small right pleural effusion has decreased in amount. right
lower lobe
opacity is a combination of pleural effusion and consolidation,
given the
clinical suspicion of pneumonia, these area could correspond to
a focus of
pneumonia. mild vascular congestion is stable. left lower lobe
atelectasis
has improved.
.
radiology report small bowel only (gastrograf) study date of
[**2144-3-13**]
no evidence of duodenal leak status post duodenal ulcer repair.
.
radiology report bilat lower ext veins study date of [**2144-3-17**]
no evidence of deep vein thrombosis in either leg.
.


brief hospital course:
ms. [**known lastname 84323**] was transferred from an outside hospital on [**3-7**], [**2144**] for further management based upon ct scan results
suggestive of fluid in the abdomen and extravasation of
contrast. as she appeared to decompensate clinically, she
required an emergent exploratory laparotomy due to concerns of a
perforated duodenal ulcer.  pre-operative consent was obtained
and the patient was taken to the operating room for exploratory
laparotomy with [**location (un) **] patch of the duodenal ulcer, repair of
internal hernia at the jejunojejunostomy, upper endoscopy and
gastrostomy tube placement.  there were no adverse events in the
operating room; please see the operative note for details. the
patient remained intubated was taken to the pacu until stable,
then transferred to the surgical intensive care and finally the
general surgical [**hospital1 **] for further observation.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed with a pca and then
transitioned to oral dilaudid once tolerating a stage 2 diet.
her pain was well controlled with oral dilaudid, however, she
did occassionally require intravenous breakthrough medication
with good effect.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the pt was weaned from the ventilator and extubated
shortly after arriving in the sicu.  she remained stable from a
pulmonary standpoint; vital signs were routinely monitored. good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. it was initially believed
that the pt may have developed hospital acquired pneumonia - she
was impirically started on v/az/f. her temperature came down.
(subsequently, her abdominal incisional wound dehisced &
drained, so it was then believed that this wound infection
resulted in her temperature spikes, not pneumonia. she was
switched to po antibiotics - levo & flagyl)
gi/gu/fen: she was kept npo post-operatively with maintenance
intravenous fluids.  a gastrograffin study via her g-tube was
performed on post-operative 5, this study negative for any type
of leak or obstruction.  on post-operative day 7, her diet was
advanced to a bariatric stage 5 diet, which was well tolerated.
on post-operative day 9, the g-tube was clamped and jp #2 was
removed.  there was no bilious drainage present in the remaining
jp drain, therefore, the g-tube remained clamped.  on
post-opertive day 10, this drain was also removed.
additionally, the patient required frequent potassium repletion
due to persistent hypokalemia, which had resovled prior to
discharge.  she did not experience any adverse effects from the
hypokalemia.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none. as mentioned above, it was
initially believed that the pt may have developed ha pna,
however, it was later found out that her temp spikes likely are
related to the wound infection.
electrolytes: the pt was found to have hypokalemia +
hypocalcemia while in house. her potassium & calcium were
repleted accordingly.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.  the pt will be sent home
with oral iron due to iron deficiency anemia (dosage recommended
by bariatric dietitian) and she was encouraged to follow-up with
the hematologist and bariatric dietitian.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.
social:  the pt was initially placed on a ciwa scale due to a
history of etoh abuse.  she did not exhibit any signs or
symptoms of withrdrawal, therefore, the ciwa monitoring was
discontinued.  additionally, a history of past domestic violence
was identified during the initial nursing assessement, including
a history with her current boyfriend who was released from jail
recently.  she was seen by the social worker and reported
feeling safe at home and that her boyfriend has not either
physically or emotionally abused her since being released from
jail.  please defer to social work notes for further details.
of note, a representative from the domestic violence prevention
and treatment team provided resources to the patient.
dispo:

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 5
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
none (advil in excessive amounts)

discharge medications:
1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every
6 hours) as needed for pain/fever: do not exceed 4000 mg in a 24
hour period. tablet(s)
2. levofloxacin 500 mg tablet sig: one (1) tablet po daily
(daily) for 10 days.
3. hydromorphone 2 mg tablet sig: 1-2 tablets po every four (4)
hours as needed for pain: please do not drive or operative heavy
machinery while taking this medication.
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig:
1-2 puffs inhalation q6h (every 6 hours) as needed for
congestion, wheezing, shortness of breath.
6. senna 8.8 mg/5 ml syrup sig: five (5) ml po twice a day as
needed for constipation.
7. vitron c  sig: one (1) tablet po three times a day.
8. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every
8 hours) for 10 days.
9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day: open capsule; do
not chew beads.


discharge disposition:
home with service

facility:
[**location (un) 932**] vna

discharge diagnosis:
1. perforated duodenal ulcer.
2. internal hernia.
3. anterior gj ulcer, not perforated.
4. peritonitis.
5. hypokalemia + hypocalcemia


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 a perforated duodenal
ulcer, and an internal hernia, which were repaired during your
surgery. also, an ulcer at the gastrojejunal anastamosis was
noted.  you will be going home with a gastrostomy tube in place.
 please see instructions below for the care of this drain. also,
it has been discussed with you that you must not ever take
nsaids (including but not limited to ibuprofen, motrin, advil,
naproxen, aspirin).  if you are unsure if a medication is
considered an nsaid you must ask your primary care provider or [**name initial (pre) **]
[**name9 (pre) 109961**] pharmacist before taking the medication.  also, you
must not smoke or drink alcohol.

 please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**5-26**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.
general drain care:
*please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*if the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. call
the doctor, nurse practitioner, or vna nurse if the amount
increases significantly or changes in character. be sure to
empty the drain frequently. record the output, if instructed to
do so.
*wash the area gently with warm, soapy water.
*keep the insertion site clean and dry otherwise.
*avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.


followup instructions:
please call dr. [**first name (stitle) **] [**name (stitle) **] at [**telephone/fax (1) 18462**] to make a follow-up
appointment.  this physician will be your new primary care
provider as discussed with his office, which is the same office
as your previous physician who is no longer at this site.
please note he will not be seeing patients until [**2144-4-20**].  dr.
[**first name4 (namepattern1) **] [**last name (namepattern1) **] will be the covering physician if needed.

please call dr. [**last name (stitle) **] at [**telephone/fax (1) 3201**] to make an appointment
within 2 weeks.

please contact the hematology department at [**telephone/fax (1) 39833**] for
further management of your iron status.

please contact the bariatric dietitian at [**telephone/fax (1) 305**]



completed by:[**2144-3-19**]"
90,"name:  [**known lastname 133**],[**known lastname 133**] f                 unit no:   [**numeric identifier 9811**]

admission date:  [**2147-11-30**]              discharge date:   [**2147-12-12**]

date of birth:  [**2061-12-31**]             sex:   m

service: surgery

allergies:
penicillins / tequin / biaxin / amoxicillin / ceclor / trimox

attending:[**first name3 (lf) 5964**]
addendum:
the pt was not discharged on [**12-6**] as anticipated, but stayed at
[**hospital1 8**] on the floor until [**2147-12-12**].  during that time the pt
completed a 7 day course of aztreonam for a uti.  there were no
adverse events or other medical issues.  the pt was discharged
to a rehab facility on [**12-12**].

discharge disposition:
extended care

facility:
[**hospital6 41**] - [**location (un) 42**]

                             [**first name11 (name pattern1) 1080**] [**last name (namepattern4) 3711**] md, [**md number(3) 5966**]

completed by:[**2147-12-12**]"
91,"chief complaint: hypotension, fever, chronic renal failure, anemia
   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:
   levophed at slightly lower dose this am. cvp has ranged from [**6-27**].
   oxygenation has remained good on trach mask.
   hct stable.
   24 hour events:
   history obtained from [**hospital 85**] medical records
   allergies:
   penicillins
   unknown;
   sulfa (sulfonamides)
   unknown;
   last dose of antibiotics:
   acyclovir - [**2150-11-4**] 03:30 am
   metronidazole - [**2150-11-4**] 07:49 am
   daptomycin - [**2150-11-5**] 12:00 pm
   ciprofloxacin - [**2150-11-6**] 02:12 am
   meropenem - [**2150-11-6**] 04:12 am
   vancomycin - [**2150-11-6**] 05:38 am
   infusions:
   norepinephrine - 0.04 mcg/kg/min
   other icu medications:
   heparin sodium (prophylaxis) - [**2150-11-6**] 08:00 am
   other medications:
   famotidine, renagel, vasopressin, atrovent, albuterol
   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:
   flowsheet data as of  [**2150-11-6**] 11:37 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.6
c (99.7
   tcurrent: 37.6
c (99.7
   hr: 86 (75 - 89) bpm
   bp: 98/40(60) {78/32(55) - 117/49(330)} mmhg
   rr: 27 (16 - 34) insp/min
   spo2: 95%
   heart rhythm: 1st av (first degree av block)
   height: 63 inch
   cvp: 7 (-2 - 15)mmhg
   total in:
                                                                  3,794 ml
                                                                    940 ml
   po:
   tf:
                                                                    631 ml
                                                                    341 ml
   ivf:
                                                                  2,174 ml
                                                                    529 ml
   blood products:
                                                                    750 ml
   total out:
                                                                      0 ml
                                                                      0 ml
   urine:
   ng:
   stool:
   drains:
   balance:
                                                                  3,794 ml
                                                                    940 ml
   respiratory support
   o2 delivery device: trach mask
   spo2: 95%
   abg: ///19/
   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
   head, ears, nose, throat: normocephalic, no(t) endotracheal tube, ng
   tube, no(t) og tube, trach tube
   cardiovascular: (pmi normal, no(t) hyperdynamic), (s1: normal, no(t)
   absent), (s2: normal, distant, no(t) loud, no(t) widely split , no(t)
   fixed), no(t) s3, no(t) s4, 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), (breath
   sounds: clear : anterior and lateral)
   abdominal: soft, non-tender, bowel sounds present, no(t) distended,
   no(t) tender: , obese
   extremities: right: bka, left: 1+ edema, no(t) cyanosis, no(t) clubbing
   musculoskeletal: no(t) muscle wasting, unable to stand
   skin:  warm, no(t) rash: , no(t) jaundice
   neurologic: attentive, follows simple commands, responds to: verbal
   stimuli, oriented (to): person, place, movement: purposeful, no(t)
   sedated, no(t) paralyzed, tone: not assessed
   labs / radiology
   7.9 g/dl
   335 k/ul
   162 mg/dl
   4.2 mg/dl
   19 meq/l
   4.7 meq/l
   66 mg/dl
   101 meq/l
   138 meq/l
   25.6 %
   14.0 k/ul
        [image002.jpg]
                            [**2150-11-4**]  01:50 am
                            [**2150-11-4**]  05:25 am
                            [**2150-11-4**]  11:03 am
                            [**2150-11-4**]  03:40 pm
                            [**2150-11-4**]  09:52 pm
                            [**2150-11-5**]  04:01 am
                            [**2150-11-5**]  04:31 am
                            [**2150-11-5**]  03:48 pm
                            [**2150-11-6**]  04:01 am
   wbc
   19.5
   20.5
   13.9
   9.7
   14.0
   hct
   29.2
   28.2
   24.1
   20.1
   25.8
   25.6
   plt
   [**telephone/fax (3) 6568**]90
   335
   cr
   3.4
   3.8
   3.7
   3.7
   4.1
   4.2
   tropt
   0.46
   0.49
   tco2
   27
   23
   24
   glucose
   [**telephone/fax (3) 6569**]78
   224
   162
   other labs: pt / ptt / inr:23.1/40.2/2.2, ck / ckmb /
   troponin-t:34/3/0.49, alt / ast:22/13, alk phos / t bili:113/0.2,
   amylase / lipase:22/23, differential-neuts:80.8 %, band:0.0 %,
   lymph:14.4 %, mono:4.4 %, eos:0.2 %, lactic acid:0.8 mmol/l,
   albumin:2.4 g/dl, ldh:96 iu/l, ca++:7.8 mg/dl, mg++:2.3 mg/dl, po4:6.5
   mg/dl
   imaging: cxr: bilateral alveolar infiltrates and probable bilateral
   effusions
   assessment and plan
 renal failure, end stage (end stage renal disease, esrd)
 sepsis, severe (with organ dysfunction)
 hypotension (not shock)
 impaired skin integrity
 respiratory failure, acute (not ards/[**doctor last name **])
 diabetes mellitus (dm), type i
 peripheral vascular disease (pvd) with critical limb ischemia
   copd
   anemia
   patient's hemodynamics improved. we reduced dose of levophed on rounds
   without adverse events. use patient's mental status as marker of
   adequate perfusion. try to remove levophed today. maintain vasopressin
   an additional 24 hours.
   continue antibiotics.
   o2 sat down slightly. cxr suggests that there may be increased lung
   water. getting closer to need for dialysis.
   hct stable. not at transfusion threshold now.
   icu care
   nutrition: tube feeds
   nutren 2.0 (full) - [**2150-11-5**] 07:29 pm 30 ml/hour
   glycemic control:  regular insulin sliding scale
   lines:
   dialysis catheter - [**2150-11-4**] 01:10 am
   arterial line - [**2150-11-4**] 03:44 pm
   multi lumen - [**2150-11-4**] 06:30 pm
   prophylaxis:
   dvt: sq uf heparin
   stress ulcer: ppi
   vap:
   comments: not applicable.
   communication:  comments:
   code status: full code
   disposition :icu
   total time spent: 30 minutes
   patient is critically ill
"
92,"chief complaint:  abdominal pain
   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:
   37 year old male with hx alcoholic pancreatitis s/p distal pancr.
   presented after 4 wk alcohol binge with n/v/abd pain no hematemsis.
   last drink 24 h before admission. no cp/f/sob/tremors
   in ed 97.6, 76, 145/84, r 20, sats 96% ra. received 4 liters ivf;
   levaquin/flagyl, dilaudid and transferred to floor. ct abd without
   contrast confirmed pancreatitis.
      on floor, rec'd 2.5 liters fluid but became hypoxic, tachycardic,
   agitated. repeat labs showed worsening acidosis and increasing lactate.
   transferred here with p140, rr 26, sats 96% on 100% fm
   patient admitted from: [**hospital1 19**] [**hospital1 158**]
   patient unable to provide history: sedated/intubated
   allergies:
   shellfish
   anaphylaxis;
   topamax (oral) (topiramate)
   diarrhea;
   augmentin (oral) (amox tr/potassium clavulanate)
   diarrhea;
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   wellbutrin, fioricet [**hospital1 7**] prn, klonipin, gemfibrozil, methadone,
   oxycodone, seroquel, zanaflex, advair, flovent, albuterol
   past medical history:
   family history:
   social history:
   hx etoh pancreatitis [**2194**] c/b ards, splenic hematoma s/p splenectomy
   gerd
   htn
   osa not on cpap
   chronic pain
   hyper triglycridemia
   hx etoh withdrawals/dt's
   ruq abscess s/p draininge
   asthma
   depression hx suicide attempts (last age 18)
   occupation:
   drugs:
   tobacco: former 17 pack year history
   alcohol: ++. [**6-26**] drinks daily recently
   other: lives with mother and sister
   review of systems:
   constitutional: no(t) fatigue, no(t) weight loss
   eyes: no(t)  blurry vision, no(t) conjunctival edema
   ear, nose, throat: no(t) dry mouth, no(t) epistaxis, no(t) og / ng tube
   cardiovascular: no(t) chest pain, no(t) palpitations, no(t) edema
   nutritional support: no(t) tube feeds, no(t) parenteral nutrition
   respiratory: no(t) dyspnea, no(t) wheeze
   gastrointestinal: abdominal pain, nausea, emesis, no(t) diarrhea, no(t)
   constipation
   genitourinary: no(t) dysuria
   musculoskeletal: no(t) joint pain, no(t) myalgias
   integumentary (skin): no(t) jaundice, no(t) rash
   endocrine: no(t) hyperglycemia, no(t) history of thyroid disease
   heme / lymph: no(t) lymphadenopathy, no(t) coagulopathy
   neurologic: no(t) numbness / tingling, no(t) headache
   psychiatric / sleep: no(t) agitated, no(t) suicidal
   allergy / immunology: no(t) immunocompromised
   flowsheet data as of [**2201-9-5**] 09:58 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.4
c (99.4
   tcurrent: 37.4
c (99.4
   hr: 147 (142 - 147) bpm
   bp: 145/110(115) {145/103(109) - 150/110(115)} mmhg
   rr: 26 (26 - 26) insp/min
   spo2: 90%
             total in:
             1,205 ml
   po:
             tf:
   ivf:
   1,205 ml
   blood products:
   total out:
                                                                      0 ml
                                                                    600 ml
   urine:
   600 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    605 ml
   respiratory
   o2 delivery device: endotracheal tube
   spo2: 90%
   abg: 7.39/30/54 on 2 liters; 7.37/33/102 on 100% fm
   ve: 11.3 l/min
   pao2 / fio2: 170
   physical examination
   general: wd white male, intubated/sedated
   head, ears, nose, throat: endotracheal tube, og tube
   peerl
   chest: old trach scar
   lungs: few scattered rhonchi, symmetrical expansion
   cardiovascular: tachycardic, rr
   abdomen: distended, tympanic,  tender to palpation epig, no
   guarding/rebound
   ext: no cce
   skin: normal turgor
    neurologic: sedated, responds to pain
   labs / radiology
   270
   0.8
   12
   22-->16
   104
   4 (3.8)
   142 (135)
        [image002.jpg]
                             [**2201-9-5**]  07:46 pm
   wbc
                                 23.7-->24.6
   hct
                                  38->-42.8
   plt
                                     332
   tc02
                                     20
   other labs: pt / ptt / inr:13.4/29.5/1.1, ck / ckmb /
   troponin-t:176/2/<0.01, alt / ast:55/59, alk phos / t bili:83/0.6,
   amylase / lipase:376-->[**telephone/fax (1) 1368**]-->1292, lactic acid:3.9 mmol/l,
   ca++:8.2, mg++:1.2
   fluid analysis / other labs: ag 16-->22 this am-->18 this afternoon
   ldh 216
   lactate: 3.2-->1.8-->4.2
   imaging: abd/pelvic ct: extensive pancreatitis
   cxr this afternoon pre-intub: limited inspiration with atelectasis.
   post intub: ett1.5 above carina (will pull); +effusions
   ecg: pseudonormalization of biphasic t waves v3-6
   assessment and plan
   etoh pancreatitis: on ed arrival, had relatively low [**name (ni) 1369**] criteria,
   but acutely worsening status since admission.
     *fluid resuscitation; bowel rest
     *surgery consulted
     *question of whether pt has necrotic pancreatitis, which could not be
   assessed on last scan due to lack of iv contrast
         [**hospital 1370**] medical chart. recently, pt had gotten ct's without iv
   contrast due to history of shellfish allergy, although he actually got
   an iv contrasted ct in [**2194**] with no mention of adverse events in his
   discharge summary. discussed with surgery, radiology and reviewed
   uptodate literature on association between iodine and shellfish (not
   believed to be a definite association). given his critically ill
   status, feel a ct is indicated but will still pre-med with h1/h2
   blockers and 1 dose of steroids
   acute resp failure: electively intubated given worsening resp distress
   with plans for further resucitation. abg pending
   etoh abuse: previously, concern for dt's. now on midazolam/fentanyl gtt
   will titrate
   lactate acidosis: mild improvement after additional fluid resuscitation
   fen: repleting mg. on bowel rest; will event. need tpn
   chronic pain: hold usual meds; receiving fentanyl gtt
   access: needs cvl
   icu care
   nutrition:
   glycemic control:
   lines / intubation:
   18 gauge - [**2201-9-5**] 06:37 pm
   20 gauge - [**2201-9-5**] 06:37 pm
   22 gauge - [**2201-9-5**] 06:58 pm
   comments:
   prophylaxis:
   dvt:
   stress ulcer:
   vap: hob elevation, mouth care
   comments:
   communication:  comments:
   code status: full code
   disposition:
   total time spent:
   patient is critically ill
"
93,"chief complaint:  abdominal pain
   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:
   37 year old male with hx alcoholic pancreatitis s/p distal pancr.
   presented after 4 wk alcohol binge with n/v/abd pain no hematemsis.
   last drink 24 h before admission. no cp/f/sob/tremors
   in ed 97.6, 76, 145/84, r 20, sats 96% ra. received 4 liters ivf;
   levaquin/flagyl, dilaudid and transferred to floor. ct abd without
   contrast confirmed pancreatitis.
      on floor, rec'd 2.5 liters fluid but became hypoxic, tachycardic,
   agitated. repeat labs showed worsening acidosis and increasing lactate.
   transferred here with p140, rr 26, sats 96% on 100% fm
   patient admitted from: [**hospital1 19**] [**hospital1 158**]
   patient unable to provide history: sedated/intubated
   allergies:
   shellfish
   anaphylaxis;
   topamax (oral) (topiramate)
   diarrhea;
   augmentin (oral) (amox tr/potassium clavulanate)
   diarrhea;
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   wellbutrin, fioricet [**hospital1 7**] prn, klonipin, gemfibrozil, methadone,
   oxycodone, seroquel, zanaflex, advair, flovent, albuterol
   past medical history:
   family history:
   social history:
   hx etoh pancreatitis [**2194**] c/b ards, splenic hematoma s/p splenectomy
   gerd
   htn
   osa not on cpap
   chronic pain
   hyper triglycridemia
   hx etoh withdrawals/dt's
   ruq abscess s/p draininge
   asthma
   depression hx suicide attempts (last age 18)
   occupation:
   drugs:
   tobacco: former 17 pack year history
   alcohol: ++. [**6-26**] drinks daily recently
   other: lives with mother and sister
   review of systems:
   constitutional: no(t) fatigue, no(t) weight loss
   eyes: no(t)  blurry vision, no(t) conjunctival edema
   ear, nose, throat: no(t) dry mouth, no(t) epistaxis, no(t) og / ng tube
   cardiovascular: no(t) chest pain, no(t) palpitations, no(t) edema
   nutritional support: no(t) tube feeds, no(t) parenteral nutrition
   respiratory: no(t) dyspnea, no(t) wheeze
   gastrointestinal: abdominal pain, nausea, emesis, no(t) diarrhea, no(t)
   constipation
   genitourinary: no(t) dysuria
   musculoskeletal: no(t) joint pain, no(t) myalgias
   integumentary (skin): no(t) jaundice, no(t) rash
   endocrine: no(t) hyperglycemia, no(t) history of thyroid disease
   heme / lymph: no(t) lymphadenopathy, no(t) coagulopathy
   neurologic: no(t) numbness / tingling, no(t) headache
   psychiatric / sleep: no(t) agitated, no(t) suicidal
   allergy / immunology: no(t) immunocompromised
   flowsheet data as of [**2201-9-5**] 09:58 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.4
c (99.4
   tcurrent: 37.4
c (99.4
   hr: 147 (142 - 147) bpm
   bp: 145/110(115) {145/103(109) - 150/110(115)} mmhg
   rr: 26 (26 - 26) insp/min
   spo2: 90%
             total in:
             1,205 ml
   po:
             tf:
   ivf:
   1,205 ml
   blood products:
   total out:
                                                                      0 ml
                                                                    600 ml
   urine:
   600 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    605 ml
   respiratory
   o2 delivery device: endotracheal tube
   spo2: 90%
   abg: 7.39/30/54 on 2 liters; 7.37/33/102 on 100% fm
   ve: 11.3 l/min
   pao2 / fio2: 170
   physical examination
   general: wd white male, intubated/sedated
   head, ears, nose, throat: endotracheal tube, og tube
   peerl
   chest: old trach scar
   lungs: few scattered rhonchi, symmetrical expansion
   cardiovascular: tachycardic, rr
   abdomen: distended, tympanic,  tender to palpation epig, no
   guarding/rebound
   ext: no cce
   skin: normal turgor
    neurologic: sedated, responds to pain
   labs / radiology
   270
   0.8
   12
   22-->16
   104
   4 (3.8)
   142 (135)
        [image002.jpg]
                             [**2201-9-5**]  07:46 pm
   wbc
                                 23.7-->24.6
   hct
                                  38->-42.8
   plt
                                     332
   tc02
                                     20
   other labs: pt / ptt / inr:13.4/29.5/1.1, ck / ckmb /
   troponin-t:176/2/<0.01, alt / ast:55/59, alk phos / t bili:83/0.6,
   amylase / lipase:376-->[**telephone/fax (1) 1368**]-->1292, lactic acid:3.9 mmol/l,
   ca++:8.2, mg++:1.2
   fluid analysis / other labs: ag 16-->22 this am-->18 this afternoon
   ldh 216
   lactate: 3.2-->1.8-->4.2
   imaging: abd/pelvic ct: extensive pancreatitis
   cxr this afternoon pre-intub: limited inspiration with atelectasis.
   post intub: ett1.5 above carina (will pull); +effusions
   ecg: pseudonormalization of biphasic t waves v3-6
   assessment and plan
   etoh pancreatitis: on ed arrival, had relatively low [**name (ni) 1369**] criteria,
   but acutely worsening status since admission.
     *fluid resuscitation; bowel rest
     *surgery consulted
     *question of whether pt has necrotic pancreatitis, which could not be
   assessed on last scan due to lack of iv contrast
         [**hospital 1370**] medical chart. recently, pt had gotten ct's without iv
   contrast due to history of shellfish allergy, although he actually got
   an iv contrasted ct in [**2194**] with no mention of adverse events in his
   discharge summary. discussed with surgery, radiology and reviewed
   uptodate literature on association between iodine and shellfish (not
   believed to be a definite association). given his critically ill
   status, feel a ct is indicated but will still pre-med with h1/h2
   blockers and 1 dose of steroids
   acute resp failure: electively intubated given worsening resp distress
   with plans for further resucitation. abg pending
   etoh abuse: previously, concern for dt's. now on midazolam/fentanyl gtt
   will titrate
   lactate acidosis: mild improvement after additional fluid resuscitation
   fen: repleting mg. on bowel rest; will event. need tpn
   chronic pain: hold usual meds; receiving fentanyl gtt
   access: needs cvl
   icu care
   nutrition:
   glycemic control:
   lines / intubation:
   18 gauge - [**2201-9-5**] 06:37 pm
   20 gauge - [**2201-9-5**] 06:37 pm
   22 gauge - [**2201-9-5**] 06:58 pm
   comments:
   prophylaxis:
   dvt: hep sq
   stress ulcer: iv ppi
   vap: hob elevation, mouth care
   comments:
   communication:  comments:
   code status: full code
   disposition: icu
   total time spent: 80 minutes
   patient is critically ill
"
94,"cervical injury, other (including ligamentous, suspected injury
   requiring collar)
   assessment:
   s/p c4 fx and c3-c6 fusion
   to or to for tracheostomy and peg after multiple failed extubation
   attempts
   on cmv 50 % 550x14 5 peep although over breathing with rr mid 20
   action:
   sent to or for percutanous trach and peg
   response:
   tolerated procedure with no adverse events per anesthesia
   trach site with some bloody drainage
   peg site cdi
   sats low 90
s first hour after or with very coarse lung sounds despite
   suction
 improved when cough reflex returned
   placed on cpap briefly but unable to tolerate d/t rr up to mid 30
   plan:
   continue on iv abx to treat pneumonia, wean to trach collar, npo 24
   post op and will remain on tpn until tube feeds initiated.
"
95,"title:
   chief complaint:
   24 hour events:
 transthoracic echo - at [**2184-9-30**] 09:29 am
   - worsening ability to cough (likely cannot close glottis), no gag
   reflex, stridorous this am
   - ddx: increased secretions and mucus plugging (more likely) vs pe
   (unlikely)
   - aggressive pulmonary toileting/chest pt
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - screening for pulmonary rehab
   - ent looked down patient's throat and saw greenish secretions caked in
   back of throat --> started saline nebs in addition to continuing
   humidified air with mask
   - dced scopolamine (pt did not receive it previously b/c he refused it)
   - because pt appears to have increased blood pressures at night, likely
   bc all bp meds are in am, his atenolol was switched to start in pm
   [**10-1**] with metoprolol one-time dosing for the am to carry him over
   - goal to help treat metabolic alkalosis by replacing k+ to 4.5--> was
   replaced to 4.4 ; likely has the respiratory acidosis (tachypnea) in
   response to a worsening metabolic alkalosis
   allergies:
   no known drug allergies
   last dose of antibiotics:
   infusions:
   other icu medications:
   furosemide (lasix) - [**2184-9-30**] 05:00 am
   morphine sulfate - [**2184-9-30**] 06:00 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  [**2184-10-1**] 04:13 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 36.9
c (98.5
   tcurrent: 36.9
c (98.5
   hr: 101 (83 - 126) bpm
   bp: 169/55(82) {93/39(55) - 171/102(112)} mmhg
   rr: 32 (17 - 32) insp/min
   spo2: 90%
   heart rhythm: st (sinus tachycardia)
   wgt (current): 57.2 kg (admission): 58.9 kg
   height: 67 inch
                  total in:
                                                                  1,505 ml
                                                                    252 ml
   po:
                  tf:
                                                                  1,145 ml
                                                                    252 ml
   ivf:
   blood products:
   total out:
                                                                  2,360 ml
                                                                    400 ml
   urine:
                                                                  1,860 ml
                                                                    400 ml
   ng:
   stool:
   drains:
   balance:
                                                                   -855 ml
                                                                   -148 ml
   respiratory support
   o2 delivery device: face tent
   spo2: 90%
   abg: 7.43/55/77/34/9
   pao2 / fio2: 193
   physical examination
   gen: awake, alert and oriented
   heent:  secretions in back of throat, no gag reflex when suctioned
   neck: no lad. jvp flat
   cv: rrr, no murmurs
   lungs: diffuse rhonchi anteriorly, likely upper airway
   abd: soft, nondistended, [**last name (lf) 10115**], [**first name3 (lf) **] tube in place
   ext: no edema
   labs / radiology
   745 k/ul
   8.1 g/dl
   154 mg/dl
   0.6 mg/dl
   34 meq/l
   4.4 meq/l
   19 mg/dl
   93 meq/l
   135 meq/l
   24.9 %
   16.3 k/ul
        [image002.jpg]
                             [**2184-9-24**]  04:26 pm
                             [**2184-9-25**]  05:05 am
                             [**2184-9-25**]  05:35 am
                             [**2184-9-26**]  04:59 am
                             [**2184-9-27**]  03:53 am
                             [**2184-9-28**]  04:25 am
                             [**2184-9-29**]  03:21 am
                             [**2184-9-30**]  04:08 am
                             [**2184-9-30**]  07:03 am
                             [**2184-9-30**]  03:55 pm
   wbc
   17.6
   21.0
   24.6
   21.7
   16.9
   16.3
   hct
   23.7
   24.4
   26.9
   25.5
   23.0
   23.5
   24.9
   plt
   532
   552
   546
   598
   629
   745
   cr
   0.5
   0.6
   0.6
   0.6
   0.6
   0.5
   0.6
   tco2
   36
   38
   glucose
   150
   157
   175
   182
   147
   182
   154
   other labs: pt / ptt / inr:14.5/33.7/1.3, ck / ckmb /
   troponin-t:/5/0.01, alt / ast:28/33, alk phos / t bili:102/0.7, amylase
   / lipase:15/16, lactic acid:1.4 mmol/l, albumin:2.1 g/dl, ldh:191 iu/l,
   ca++:8.9 mg/dl, mg++:1.9 mg/dl, po4:4.0 mg/dl
   assessment and plan
   68 yo m with pmh of stage iii squamous cell throat ca admitted for [**hospital 10251**]
   transferred from oncology service for hypoxic respiratory distress.
   # respiratory failure: likely secondary  to pna and secretions and s/p
   successful extubation [**9-26**].  sputum culture grew out gnr, speciation
   pending.  also has mssa in sputum.  worsening ability to cough (likely
   cannot close glottis), no gag reflex, stridorous this am.  he did
   complete a full course of antibiotics for the pneumonia (levofloxacin,
   cefepime, vancomycin) and is no longer septic.  currently increased wob
   and patient
s cough is decreasing in effort. ddx: increased secretions
   and mucus plugging (more likely) vs  pe
   - aggressive pulmonary toileting/chest pt
   - continue nebs, suctioning, mie
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - talk to ent about trach position and risk of causing damage in
   context of tumor
   - screening for pulmonary rehab; will touch base with case management
   today.
   # metabolic alkalosis:  hypokalemia may be contributing.  [**month (only) 51**] have also
   had some contraction alkalosis with the lasix.  this may be the cause
   of worsening tachypnea early this am to compensate for a worsening
   alkalosis.
   - help treat metabolic alkalosis by replacing k+ to 4.5 ; likely has
   the respiratory acidosis in response to a worsening metabolic alkalosis
   # stage iii squamous cell throat ca:  followed by dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**].
   is s/p xrt and cetuximab, last dose [**2184-6-21**].
   - pt noted to have a increased right neck mass per nursing
   - f/u onc recs (dr. [**first name (stitle) 3805**] following): can consider ct neck if the
   neck mass seems to be impeding the airway
   - s&s following
   - oncologist believes that patient has 50% survival chance, so trach
   may be beneficial to prevent adverse events in the meantime w increased
   secretions and possib mucus plugging complications
   .
   # htn:  he continues to get all meds in am; has increased bp in am just
   prior to meds.
   - will check bp this pm at [**2174**]; if elevated with give metoprolol
   - will change atenolol to evening dose tomorrow since she already
   received her am dose.
   - continue home po meds atenelol 100mg daily and hctz 25mg daily
   - continue lisinopril 5 mg daily as bp still uncontrolled (re-started
   [**9-25**])
   .
   # anemia: consistent with acd. b12, folate levels are wnl.  hct stable
   at 23 now, though have trended down over hospitalization.
   - hold iron supplements in setting of icu
   - continue to monitor daily hcts and transfuse if <21 or active
   bleeding
   .
   # hyponatremia:  na improved and stable at 133 this am.  [**month (only) 51**] have been
   hypovolemic hyponatremia.
   - continue to trend
   - urine lytes if na decreases
   .
   # h/o cva:  per notes, had h/o of 'small strokes'.  no residual
   deficits.
   - continue asa 325mg qd
   .
   # depression: currently stable
   - can consider anti-depressants if patient
s symptoms worsen
   - f/u sw recs if any
   # hyperglycemia: continue hiss
   icu care
   nutrition:
   fibersource hn (full) - [**2184-9-30**] 11:55 am 60 ml/hour
   glycemic control:
   lines:
   20 gauge - [**2184-9-28**] 08:00 pm
   prophylaxis:
   dvt: subq heparin
   stress ulcer:  ppi
   vap:  vap bundle
   comments:
   communication:  comments:
   code status: full
   disposition: - screen for pulmonary rehab pending
"
96,"title:
   chief complaint:
   24 hour events:
   - worsening ability to cough (likely cannot close glottis), no gag
   reflex, stridorous this am
   - ddx: increased secretions and mucus plugging (more likely) vs pe
   (unlikely)
   - aggressive pulmonary toileting/chest pt
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - screening for pulmonary rehab
   - ent looked down patient's throat and saw greenish secretions caked in
   back of throat --> started saline spray in addition to continuing
   humidified air with mask
   - because pt appears to have increased blood pressures at night, likely
   bc all bp meds are in am, his atenolol was switched to start in pm
   [**10-1**] with metoprolol one-time dosing for the am to carry him over
   - goal to help treat metabolic alkalosis by replacing k+ to 4.5--> was
   replaced to 4.4 ; likely has the respiratory acidosis (tachypnea) in
   response to a worsening metabolic alkalosis
   allergies:
   no known drug allergies
   last dose of antibiotics:
   infusions:
   other icu medications:
   furosemide (lasix) - [**2184-9-30**] 05:00 am
   morphine sulfate - [**2184-9-30**] 06:00 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  [**2184-10-1**] 04:13 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 36.9
c (98.5
   tcurrent: 36.9
c (98.5
   hr: 101 (83 - 126) bpm
   bp: 169/55(82) {93/39(55) - 171/102(112)} mmhg
   rr: 32 (17 - 32) insp/min
   spo2: 90%
   heart rhythm: st (sinus tachycardia)
   wgt (current): 57.2 kg (admission): 58.9 kg
   height: 67 inch
                  total in:
                                                                  1,505 ml
                                                                    252 ml
   po:
                  tf:
                                                                  1,145 ml
                                                                    252 ml
   ivf:
   blood products:
   total out:
                                                                  2,360 ml
                                                                    400 ml
   urine:
                                                                  1,860 ml
                                                                    400 ml
   ng:
   stool:
   drains:
   balance:
                                                                   -855 ml
                                                                   -148 ml
   respiratory support
   o2 delivery device: face tent
   spo2: 90%
   abg: 7.43/55/77/34/9
   pao2 / fio2: 193
   physical examination
   gen: awake, alert and oriented
   heent:  secretions in back of throat, no gag reflex when suctioned
   neck: no lad. jvp flat
   cv: rrr, no murmurs
   lungs: diffuse rhonchi anteriorly, likely upper airway
   abd: soft, nondistended, [**last name (lf) 10115**], [**first name3 (lf) **] tube in place
   ext: no edema
   labs / radiology
   762 k/ul
   8.8 g/dl
   196 mg/dl
   0.6 mg/dl
   35 meq/l
   4.1 meq/l
   19 mg/dl
   93 meq/l
   135 meq/l
   26.3 %
   17.5 k/ul
        [image002.jpg]
                             [**2184-9-24**]  04:26 pm
                             [**2184-9-25**]  05:05 am
                             [**2184-9-25**]  05:35 am
                             [**2184-9-26**]  04:59 am
                             [**2184-9-27**]  03:53 am
                             [**2184-9-28**]  04:25 am
                             [**2184-9-29**]  03:21 am
                             [**2184-9-30**]  04:08 am
                             [**2184-9-30**]  07:03 am
                             [**2184-9-30**]  03:55 pm
   wbc
   17.6
   21.0
   24.6
   21.7
   16.9
   16.3
   hct
   23.7
   24.4
   26.9
   25.5
   23.0
   23.5
   24.9
   plt
   532
   552
   546
   598
   629
   745
   cr
   0.5
   0.6
   0.6
   0.6
   0.6
   0.5
   0.6
   tco2
   36
   38
   glucose
   150
   157
   175
   182
   147
   182
   154
   other labs: pt / ptt / inr:14.4/32.7/1.2, ck / ckmb /
   troponin-t:/5/0.01, alt / ast:28/33, alk phos / t bili:102/0.7, amylase
   / lipase:15/16, lactic acid:1.4 mmol/l, albumin:2.1 g/dl, ldh:191 iu/l,
   ca++:9.1 mg/dl, mg++:2.1 mg/dl, po4:4.6 mg/dl
   echo: pending read
   blood cx: ngtd
   all other cultures negative
   assessment and plan
   68 yo m with pmh of stage iii squamous cell throat ca admitted for [**hospital 10251**]
   transferred from oncology service for hypoxic respiratory distress.
   # respiratory failure: likely secondary  to pna and secretions and s/p
   successful extubation [**9-26**].  sputum culture grew out gnr, speciation
   pending.  also has mssa in sputum.  worsening ability to cough (likely
   cannot close glottis), no gag reflex, stridorous this am.  he did
   complete a full course of antibiotics for the pneumonia (levofloxacin,
   cefepime, vancomycin) and is no longer septic.  currently increased wob
   and patient
s cough is decreasing in effort. ddx: increased secretions
   and mucus plugging (more likely) vs  pe
   - aggressive pulmonary toileting/chest pt
   - continue nebs, suctioning, mie, saline spray
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - ent: since no surgery of neck, it does not matter where trach is
   placed
   - screening for pulmonary rehab; will touch base with case management
   today.
   # metabolic alkalosis:  hypokalemia may be contributing.  [**month (only) 51**] have also
   had some contraction alkalosis with the lasix.  this may be the cause
   of worsening tachypnea early this am to compensate for a worsening
   alkalosis.
   - help treat metabolic alkalosis by replacing k+ to 4.5 ; likely has
   the respiratory acidosis in response to a worsening metabolic alkalosis
   - gave 40 meq of k this am
   # stage iii squamous cell throat ca:  followed by dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**].
   is s/p xrt and cetuximab, last dose [**2184-6-21**].
   - pt noted to have a increased right neck mass per nursing
   - f/u onc recs (dr. [**first name (stitle) 3805**] following): can consider ct neck if the
   neck mass seems to be impeding the airway
   - s&s following
   - oncologist believes that patient has 50% survival chance, so trach
   may be beneficial to prevent adverse events in the meantime w increased
   secretions and possib mucus plugging complications
   .
   # htn:  he continues to get all meds in am; has increased bp in am just
   prior to meds.
   - will check bp this pm at [**2174**]; if elevated with give metoprolol
   - will change atenolol to evening dose tomorrow since she already
   received her am dose.
   - continue home po meds atenelol 100mg daily and hctz 25mg daily
   - continue lisinopril 5 mg daily as bp still uncontrolled (re-started
   [**9-25**])
   .
   # anemia: consistent with acd. b12, folate levels are wnl.  hct stable
   at 23 now, though have trended down over hospitalization.
   - hold iron supplements in setting of icu
   - continue to monitor daily hcts and transfuse if <21 or active
   bleeding
   .
   # hyponatremia:  na improved and stable at 135 this am.  [**month (only) 51**] have been
   hypovolemic hyponatremia.
   - continue to trend
   - urine lytes if na decreases
   .
   # h/o cva:  per notes, had h/o of 'small strokes'.  no residual
   deficits.
   - continue asa 325mg qd
   .
   # depression: currently stable
   - can consider anti-depressants if patient
s symptoms worsen
   - f/u sw recs if any
   # hyperglycemia: continue hiss
   icu care
   nutrition:
   fibersource hn (full) - [**2184-9-30**] 11:55 am 60 ml/hour
   glycemic control:
   lines:
   20 gauge - [**2184-9-28**] 08:00 pm
   prophylaxis:
   dvt: subq heparin
   stress ulcer:  ppi
   vap:  vap bundle
   comments:
   communication:  comments:
   code status: full
   disposition: - screen for pulmonary rehab pending
"
97,"title:
   chief complaint:
   24 hour events:
   - at 5am pt desat to 77%, pt ashen w/ rr in 40s and increasingly
   labored. increased o2 to 70%, o2 sat increased to low 80s. unable to
   suction anything orally. rt gave nebs and used the in-exsufflator with
   good effect. pt able to cough out large amount of thick tan secretions
   and breathing more comfortably.
   - ent looked down patient's throat and saw greenish secretions caked in
   back of throat --> started saline spray in addition to continuing
   humidified air with mask
   - because pt appears to have increased blood pressures at night, likely
   bc all bp meds are in am, his atenolol was switched to start in pm
   [**10-1**] with metoprolol one-time dosing for the am to carry him over
   allergies:
   no known drug allergies
   last dose of antibiotics:
   infusions:
   other icu medications:
   furosemide (lasix) - [**2184-9-30**] 05:00 am
   morphine sulfate - [**2184-9-30**] 06:00 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  [**2184-10-1**] 04:13 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 36.9
c (98.5
   tcurrent: 36.9
c (98.5
   hr: 101 (83 - 126) bpm
   bp: 169/55(82) {93/39(55) - 171/102(112)} mmhg
   rr: 32 (17 - 32) insp/min
   spo2: 90%
   heart rhythm: st (sinus tachycardia)
   wgt (current): 57.2 kg (admission): 58.9 kg
   height: 67 inch
                  total in:
                                                                  1,505 ml
                                                                    252 ml
   po:
                  tf:
                                                                  1,145 ml
                                                                    252 ml
   ivf:
   blood products:
   total out:
                                                                  2,360 ml
                                                                    400 ml
   urine:
                                                                  1,860 ml
                                                                    400 ml
   ng:
   stool:
   drains:
   balance:
                                                                   -855 ml
                                                                   -148 ml
   respiratory support
   o2 delivery device: face mask at 50%
   spo2: 90%
   abg: 7.43/55/77/34/9
   pao2 / fio2: 193
   physical examination
   gen: awake, alert and oriented
   heent:  secretions in back of throat, no gag reflex when suctioned
   neck: no lad. jvp flat
   cv: rrr, no murmurs
   lungs: diffuse rhonchi anteriorly, likely upper airway
   abd: soft, nondistended, [**last name (lf) 10115**], [**first name3 (lf) **] tube in place
   ext: no edema
   labs / radiology
   762 k/ul
   8.8 g/dl
   196 mg/dl
   0.6 mg/dl
   35 meq/l
   4.1 meq/l
   19 mg/dl
   93 meq/l
   135 meq/l
   26.3 %
   17.5 k/ul
        [image002.jpg]
                             [**2184-9-24**]  04:26 pm
                             [**2184-9-25**]  05:05 am
                             [**2184-9-25**]  05:35 am
                             [**2184-9-26**]  04:59 am
                             [**2184-9-27**]  03:53 am
                             [**2184-9-28**]  04:25 am
                             [**2184-9-29**]  03:21 am
                             [**2184-9-30**]  04:08 am
                             [**2184-9-30**]  07:03 am
                             [**2184-9-30**]  03:55 pm
   wbc
   17.6
   21.0
   24.6
   21.7
   16.9
   16.3
   hct
   23.7
   24.4
   26.9
   25.5
   23.0
   23.5
   24.9
   plt
   532
   552
   546
   598
   629
   745
   cr
   0.5
   0.6
   0.6
   0.6
   0.6
   0.5
   0.6
   tco2
   36
   38
   glucose
   150
   157
   175
   182
   147
   182
   154
   other labs: pt / ptt / inr:14.4/32.7/1.2, ck / ckmb /
   troponin-t:/5/0.01, alt / ast:28/33, alk phos / t bili:102/0.7, amylase
   / lipase:15/16, lactic acid:1.4 mmol/l, albumin:2.1 g/dl, ldh:191 iu/l,
   ca++:9.1 mg/dl, mg++:2.1 mg/dl, po4:4.6 mg/dl
   echo: pending read
   blood cx: ngtd
   all other cultures negative
   assessment and plan
   68 yo m with pmh of stage iii squamous cell throat ca admitted for [**hospital 10251**]
   transferred from oncology service for hypoxic respiratory distress.
   # respiratory failure: likely secondary  to pna and secretions and s/p
   successful extubation [**9-26**].  sputum culture grew out gnr, speciation
   pending.  also has mssa in sputum.  worsening ability to cough (likely
   cannot close glottis), no gag reflex, stridorous this am.  he did
   complete a full course of antibiotics for the pneumonia (levofloxacin,
   cefepime, vancomycin) and is no longer septic.  currently increased wob
   and patient
s cough is decreasing in effort. ddx: increased secretions
   and mucus plugging (more likely) vs  pe
   - aggressive pulmonary toileting/chest pt
   - continue nebs, suctioning, mie, saline spray
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - ent: since no surgery of neck, it does not matter where trach is
   placed
   - screening for pulmonary rehab; will touch base with case management
   today.
   # metabolic alkalosis:  hypokalemia may be contributing.  [**month (only) 51**] have also
   had some contraction alkalosis with the lasix.  this may be the cause
   of worsening tachypnea early this am to compensate for a worsening
   alkalosis.
   - help treat metabolic alkalosis by replacing k+ to 4.5 ; likely has
   the respiratory acidosis in response to a worsening metabolic alkalosis
   - gave 40 meq of k this am
   # stage iii squamous cell throat ca:  followed by dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**].
   is s/p xrt and cetuximab, last dose [**2184-6-21**].
   - pt noted to have a increased right neck mass per nursing
   - f/u onc recs (dr. [**first name (stitle) 3805**] following): can consider ct neck if the
   neck mass seems to be impeding the airway
   - s&s following
   - oncologist believes that patient has 50% survival chance, so trach
   may be beneficial to prevent adverse events in the meantime w increased
   secretions and possib mucus plugging complications
   .
   # htn:  he continues to get all meds in am; has increased bp in am just
   prior to meds.
   - will check bp this pm at [**2174**]; if elevated with give metoprolol
   - will change atenolol to evening dose tomorrow since she already
   received her am dose.
   - continue home po meds atenelol 100mg daily and hctz 25mg daily
   - continue lisinopril 5 mg daily as bp still uncontrolled (re-started
   [**9-25**])
   .
   # anemia: consistent with acd. b12, folate levels are wnl.  hct stable
   at 23 now, though have trended down over hospitalization.
   - hold iron supplements in setting of icu
   - continue to monitor daily hcts and transfuse if <21 or active
   bleeding
   .
   # hyponatremia:  na improved and stable at 135 this am.  [**month (only) 51**] have been
   hypovolemic hyponatremia.
   - continue to trend
   - urine lytes if na decreases
   .
   # h/o cva:  per notes, had h/o of 'small strokes'.  no residual
   deficits.
   - continue asa 325mg qd
   .
   # depression: currently stable
   - can consider anti-depressants if patient
s symptoms worsen
   - f/u sw recs if any
   # hyperglycemia: continue hiss
   icu care
   nutrition:
   fibersource hn (full) - [**2184-9-30**] 11:55 am 60 ml/hour
   glycemic control:
   lines:
   20 gauge - [**2184-9-28**] 08:00 pm
   prophylaxis:
   dvt: subq heparin
   stress ulcer:  ppi
   vap:  vap bundle
   comments:
   communication:  comments:
   code status: full
   disposition: - screen for pulmonary rehab pending
"
98,"title:
   chief complaint:
   24 hour events:
   - towards a.m, pt started becoming tachypneic with hr in mid 120
s, ,
   bp in mid 160-170 systolic. pt very wheezy.  pt appears to be in
   distress,  although he deniesit. says he feels fine. lasix 10 mg iv and
   morphine 1 mg iv given  with very little effect. neb treatments  given
   with mild response: mie given with chest pt with minimal to mild
   improvement. still with diminished cough, attempting to cough, with
   very minimal production of sputum.
   hr started to increase around 0000, peaked in the 120s and continues to
   be 110s. rr has been in the 20s, peaked into the 30s this am and now in
   the 20s
   spo2: off face tent decreased to 90-91%; increased on face tent to mid
   to upper 90s.
   - per oncologist given function prior to this episode doesn't feel that
   a trach is necessary at this point
   - pt had fall where he tried to walk to bed, did not hit his head, no
   loc
   allergies:
   no known drug allergies
   last dose of antibiotics:
   infusions:
   other icu medications:
   heparin sodium (prophylaxis) - [**2184-9-29**] 08:00 am
   furosemide (lasix) - [**2184-9-30**] 05:00 am
   morphine sulfate - [**2184-9-30**] 05:10 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  [**2184-9-30**] 06:28 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.1
c (98.7
   tcurrent: 37.1
c (98.7
   hr: 121 (86 - 121) bpm
   bp: 170/94(112) {128/56(74) - 175/96(112)} mmhg
   rr: 31 (19 - 32) insp/min
   spo2: 99%
   heart rhythm: st (sinus tachycardia)
   wgt (current): 61 kg (admission): 58.9 kg
   height: 67 inch
                  total in:
                                                                  1,440 ml
                                                                    266 ml
   po:
                  tf:
                                                                  1,440 ml
                                                                    266 ml
   ivf:
   blood products:
   total out:
                                                                  2,565 ml
                                                                    550 ml
   urine:
                                                                  2,565 ml
                                                                    550 ml
   ng:
   stool:
   drains:
   balance:
                                                                 -1,125 ml
                                                                   -284 ml
   respiratory support
   o2 delivery device: aerosol-cool, face tent
   spo2: 99%
   abg: ///33/
   physical examination
   gen: awake, alert and oriented
   heent:  secretions in back of throat, no gag reflex when suctioned
   neck: no lad. jvp flat
   cv: rrr, no murmurs
   lungs: diffuse rhonchi anteriorly, likely upper airway
   abd: soft, nondistended, [**last name (lf) 10115**], [**first name3 (lf) **] tube in place
   ext: no edema
   labs / radiology
   745 k/ul
   8.1 g/dl
   182 mg/dl
   0.5 mg/dl
   33 meq/l
   4.0 meq/l
   15 mg/dl
   92 meq/l
   133 meq/l
   24.9 %
   16.3 k/ul
        [image002.jpg]
                             [**2184-9-23**]  04:23 pm
                             [**2184-9-24**]  04:43 am
                             [**2184-9-24**]  04:26 pm
                             [**2184-9-25**]  05:05 am
                             [**2184-9-25**]  05:35 am
                             [**2184-9-26**]  04:59 am
                             [**2184-9-27**]  03:53 am
                             [**2184-9-28**]  04:25 am
                             [**2184-9-29**]  03:21 am
                             [**2184-9-30**]  04:08 am
   wbc
   16.5
   17.6
   21.0
   24.6
   21.7
   16.9
   16.3
   hct
   22.7
   23.0
   23.7
   24.4
   26.9
   25.5
   23.0
   23.5
   24.9
   plt
   [**telephone/fax (3) 10369**]46
   598
   629
   745
   cr
   0.5
   0.5
   0.6
   0.6
   0.6
   0.6
   0.5
   tco2
   36
   glucose
   132
   150
   157
   175
   182
   147
   182
   other labs: pt / ptt / inr:14.5/33.7/1.3, ck / ckmb /
   troponin-t:/5/0.01, alt / ast:28/33, alk phos / t bili:102/0.7, amylase
   / lipase:15/16, lactic acid:1.4 mmol/l, albumin:2.1 g/dl, ldh:191 iu/l,
   ca++:8.9 mg/dl, mg++:1.9 mg/dl, po4:4.0 mg/dl
   no new culture data
   assessment and plan
   68 yo m with pmh of stage iii squamous cell throat ca admitted for [**hospital 10251**]
   transferred from oncology service for hypoxic respiratory distress.
   # respiratory failure: likely secondary  to pna and secretions and s/p
   successful extubation [**9-26**].  sputum culture grew out gnr, speciation
   pending.  also has mssa in sputum.  worsening ability to cough (likely
   cannot close glottis), no gag reflex, stridorous this am.  he did
   complete a full course of antibiotics for the pneumonia (levofloxacin,
   cefepime, vancomycin) and is no longer septic.  currently increased wob
   and patient
s cough is decreasing in effort. ddx: increased secretions
   and mucus plugging (more likely) vs  pe
   - aggressive pulmonary toileting/chest pt
   - continue nebs, suctioning, mie
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - talk to ent about trach position and risk of causing damage in
   context of tumor
   - screening for pulmonary rehab; will touch base with case management
   today.
   # metabolic alkalosis:  hypokalemia may be contributing.  [**month (only) 51**] have also
   had some contraction alkalosis with the lasix.  this may be the cause
   of worsening tachypnea early this am to compensate for a worsening
   alkalosis.
   - help treat metabolic alkalosis by replacing k+ to 4.5 ; likely has
   the respiratory acidosis in response to a worsening metabolic alkalosis
   # stage iii squamous cell throat ca:  followed by dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**].
   is s/p xrt and cetuximab, last dose [**2184-6-21**].
   - pt noted to have a increased right neck mass per nursing
   - f/u onc recs (dr. [**first name (stitle) 3805**] following): can consider ct neck if the
   neck mass seems to be impeding the airway
   - s&s following
   - oncologist believes that patient has 50% survival chance, so trach
   may be beneficial to prevent adverse events in the meantime w increased
   secretions and possib mucus plugging complications
   .
   # htn:  he continues to get all meds in am; has increased bp in am just
   prior to meds.
   - will check bp this pm at [**2174**]; if elevated with give metoprolol
   - will change atenolol to evening dose tomorrow since she already
   received her am dose.
   - continue home po meds atenelol 100mg daily and hctz 25mg daily
   - continue lisinopril 5 mg daily as bp still uncontrolled (re-started
   [**9-25**])
   .
   # anemia: consistent with acd. b12, folate levels are wnl.  hct stable
   at 23 now, though have trended down over hospitalization.
   - hold iron supplements in setting of icu
   - continue to monitor daily hcts and transfuse if <21 or active
   bleeding
   .
   # hyponatremia:  na improved and stable at 133 this am.  [**month (only) 51**] have been
   hypovolemic hyponatremia.
   - continue to trend
   - urine lytes if na decreases
   .
   # h/o cva:  per notes, had h/o of 'small strokes'.  no residual
   deficits.
   - continue asa 325mg qd
   .
   # depression: currently stable
   - can consider anti-depressants if patient
s symptoms worsen
   - f/u sw recs if any
   # hyperglycemia: continue hiss
   icu care
   nutrition:
   fibersource hn (full) - [**2184-9-28**] 07:06 pm 60 ml/hour
   glycemic control:
   lines:
   20 gauge - [**2184-9-28**] 08:00 pm
   prophylaxis:
   dvt: subq heparin
   stress ulcer:  ppi
   vap:  vap bundle
   comments:
   communication:  comments:
   code status: full code  ([**hospital unit name 1**] team attempted to have discussion about
   code status today, but pt was very focused on just going home and did
   not cooperate with discussion) - - need to readdress code status, per
   the wife he had previously said that he didn't want to be intubated
   again, but not able to understand any questions about code status and
   the wife [**name (ni) 10420**]'t commit
   disposition: - screen for pulmonary rehab pending
"
99,"title:
   chief complaint:
   24 hour events:
   - at 5am pt desat to 77%, pt ashen w/ rr in 40s and increasingly
   labored. increased o2 to 70%, o2 sat increased to low 80s. unable to
   suction anything orally. rt gave nebs and used the in-exsufflator with
   good effect. pt able to cough out large amount of thick tan secretions
   and breathing more comfortably. currently moving from face mask to face
   tent at fio2 at 50%. desats more on face tent to low 90s high 80s and
   high 90s on face mask.
   - ent looked down patient's throat and saw greenish secretions caked in
   back of throat --> started saline spray in addition to continuing
   humidified air with mask
   - because pt appears to have increased blood pressures at night, likely
   bc all bp meds are in am, his atenolol was switched to start in pm
   [**10-1**] with metoprolol one-time dosing for the am to carry him over
   allergies:
   no known drug allergies
   last dose of antibiotics:
   infusions:
   other icu medications:
   furosemide (lasix) - [**2184-9-30**] 05:00 am
   morphine sulfate - [**2184-9-30**] 06:00 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  [**2184-10-1**] 04:13 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 36.9
c (98.5
   tcurrent: 36.9
c (98.5
   hr: 101 (83 - 126) bpm
   bp: 169/55(82) {93/39(55) - 171/102(112)} mmhg
   rr: 32 (17 - 32) insp/min
   spo2: 90%
   heart rhythm: st (sinus tachycardia)
   wgt (current): 57.2 kg (admission): 58.9 kg
   height: 67 inch
                  total in:
                                                                  1,505 ml
                                                                    252 ml
   po:
                  tf:
                                                                  1,145 ml
                                                                    252 ml
   ivf:
   blood products:
   total out:
                                                                  2,360 ml
                                                                    400 ml
   urine:
                                                                  1,860 ml
                                                                    400 ml
   ng:
   stool:
   drains:
   balance:
                                                                   -855 ml
                                                                   -148 ml
   respiratory support
   o2 delivery device: face mask at 50%
   spo2: 90%
   abg: 7.43/55/77/34/9
   pao2 / fio2: 193
   physical examination
   gen: awake, alert and oriented
   heent:  secretions in back of throat, no gag reflex when suctioned
   neck: no lad. jvp flat
   cv: rrr, no murmurs
   lungs: diffuse rhonchi anteriorly, likely upper airway
   abd: soft, nondistended, [**last name (lf) 10115**], [**first name3 (lf) **] tube in place
   ext: no edema
   labs / radiology
   762 k/ul
   8.8 g/dl
   196 mg/dl
   0.6 mg/dl
   35 meq/l
   4.1 meq/l
   19 mg/dl
   93 meq/l
   135 meq/l
   26.3 %
   17.5 k/ul
        [image002.jpg]
                             [**2184-9-24**]  04:26 pm
                             [**2184-9-25**]  05:05 am
                             [**2184-9-25**]  05:35 am
                             [**2184-9-26**]  04:59 am
                             [**2184-9-27**]  03:53 am
                             [**2184-9-28**]  04:25 am
                             [**2184-9-29**]  03:21 am
                             [**2184-9-30**]  04:08 am
                             [**2184-9-30**]  07:03 am
                             [**2184-9-30**]  03:55 pm
   wbc
   17.6
   21.0
   24.6
   21.7
   16.9
   16.3
   hct
   23.7
   24.4
   26.9
   25.5
   23.0
   23.5
   24.9
   plt
   532
   552
   546
   598
   629
   745
   cr
   0.5
   0.6
   0.6
   0.6
   0.6
   0.5
   0.6
   tco2
   36
   38
   glucose
   150
   157
   175
   182
   147
   182
   154
   other labs: pt / ptt / inr:14.4/32.7/1.2, ck / ckmb /
   troponin-t:/5/0.01, alt / ast:28/33, alk phos / t bili:102/0.7, amylase
   / lipase:15/16, lactic acid:1.4 mmol/l, albumin:2.1 g/dl, ldh:191 iu/l,
   ca++:9.1 mg/dl, mg++:2.1 mg/dl, po4:4.6 mg/dl
   echo: pending read
   blood cx: ngtd
   all other cultures negative
   assessment and plan
   68 yo m with pmh of stage iii squamous cell throat ca admitted for [**hospital 10251**]
   transferred from oncology service for hypoxic respiratory distress.
   # respiratory failure: likely secondary  to pna and secretions and s/p
   successful extubation [**9-26**].  sputum culture grew out gnr, speciation
   pending.  also has mssa in sputum.  worsening ability to cough (likely
   cannot close glottis), no gag reflex, stridorous this am.  he did
   complete a full course of antibiotics for the pneumonia (levofloxacin,
   cefepime, vancomycin) and is no longer septic.  currently increased wob
   and patient
s cough is decreasing in effort. ddx: increased secretions
   and mucus plugging (more likely) vs  pe
   - aggressive pulmonary toileting/chest pt
   - continue nebs, suctioning, mie, saline spray
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - ent: since no surgery of neck, it does not matter where trach is
   placed
   - screening for pulmonary rehab; will touch base with case management
   today.
   # metabolic alkalosis:  hypokalemia may be contributing.  [**month (only) 51**] have also
   had some contraction alkalosis with the lasix.  this may be the cause
   of worsening tachypnea early this am to compensate for a worsening
   alkalosis.
   - help treat metabolic alkalosis by replacing k+ to 4.5 ; likely has
   the respiratory acidosis in response to a worsening metabolic alkalosis
   - gave 40 meq of k this am
   # stage iii squamous cell throat ca:  followed by dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**].
   is s/p xrt and cetuximab, last dose [**2184-6-21**].
   - pt noted to have a increased right neck mass per nursing
   - f/u onc recs (dr. [**first name (stitle) 3805**] following): can consider ct neck if the
   neck mass seems to be impeding the airway
   - s&s following
   - oncologist believes that patient has 50% survival chance, so trach
   may be beneficial to prevent adverse events in the meantime w increased
   secretions and possib mucus plugging complications
   .
   # htn:  he continues to get all meds in am; has increased bp in am just
   prior to meds.
   - will check bp this pm at [**2174**]; if elevated with give metoprolol
   - will change atenolol to evening dose tomorrow since she already
   received her am dose.
   - continue home po meds atenelol 100mg daily and hctz 25mg daily
   - continue lisinopril 5 mg daily as bp still uncontrolled (re-started
   [**9-25**])
   .
   # anemia: consistent with acd. b12, folate levels are wnl.  hct stable
   at 23 now, though have trended down over hospitalization.
   - hold iron supplements in setting of icu
   - continue to monitor daily hcts and transfuse if <21 or active
   bleeding
   .
   # hyponatremia:  na improved and stable at 135 this am.  [**month (only) 51**] have been
   hypovolemic hyponatremia.
   - continue to trend
   - urine lytes if na decreases
   .
   # h/o cva:  per notes, had h/o of 'small strokes'.  no residual
   deficits.
   - continue asa 325mg qd
   .
   # depression: currently stable
   - can consider anti-depressants if patient
s symptoms worsen
   - f/u sw recs if any
   # hyperglycemia: continue hiss
   icu care
   nutrition:
   fibersource hn (full) - [**2184-9-30**] 11:55 am 60 ml/hour
   glycemic control:
   lines:
   20 gauge - [**2184-9-28**] 08:00 pm
   prophylaxis:
   dvt: subq heparin
   stress ulcer:  ppi
   vap:  vap bundle
   comments:
   communication:  comments:
   code status: full
   disposition: - screen for pulmonary rehab pending
"
100,"title:
   chief complaint:
   24 hour events:
   - towards a.m, pt started becoming tachypneic with hr in mid 120
s, ,
   bp in mid 160-170 systolic. pt very wheezy.  pt appears to be in
   distress,  although he deniesit. says he feels fine. lasix 10 mg iv and
   morphine 1 mg iv given  with very little effect. neb treatments  given
   with mild response: mie given with chest pt with minimal to mild
   improvement. still with diminished cough, attempting to cough, with
   very minimal production of sputum.
   hr started to increase around 0000, peaked in the 120s and continues to
   be 110s. rr has been in the 20s, peaked into the 30s this am and now in
   the 20s
   spo2: off face tent decreased to 90-91%; increased on face tent to mid
   to upper 90s.
   - per oncologist given function prior to this episode doesn't feel that
   a trach is necessary at this point
   - pt had fall where he tried to walk to bed, did not hit his head, no
   loc
   allergies:
   no known drug allergies
   last dose of antibiotics:
   infusions:
   other icu medications:
   heparin sodium (prophylaxis) - [**2184-9-29**] 08:00 am
   furosemide (lasix) - [**2184-9-30**] 05:00 am
   morphine sulfate - [**2184-9-30**] 05:10 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  [**2184-9-30**] 06:28 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.1
c (98.7
   tcurrent: 37.1
c (98.7
   hr: 121 (86 - 121) bpm
   bp: 170/94(112) {128/56(74) - 175/96(112)} mmhg
   rr: 31 (19 - 32) insp/min
   spo2: 99%
   heart rhythm: st (sinus tachycardia)
   wgt (current): 61 kg (admission): 58.9 kg
   height: 67 inch
                  total in:
                                                                  1,440 ml
                                                                    266 ml
   po:
                  tf:
                                                                  1,440 ml
                                                                    266 ml
   ivf:
   blood products:
   total out:
                                                                  2,565 ml
                                                                    550 ml
   urine:
                                                                  2,565 ml
                                                                    550 ml
   ng:
   stool:
   drains:
   balance:
                                                                 -1,125 ml
                                                                   -284 ml
   respiratory support
   o2 delivery device: aerosol-cool, face tent
   spo2: 99%
   abg: ///33/
   physical examination
   gen: awake, alert and oriented
   heent:  secretions in back of throat, no gag reflex when suctioned
   neck: no lad. jvp flat
   cv: rrr, no murmurs
   lungs: diffuse rhonchi anteriorly, likely upper airway
   abd: soft, nondistended, [**last name (lf) 10115**], [**first name3 (lf) **] tube in place
   ext: no edema
   labs / radiology
   745 k/ul
   8.1 g/dl
   182 mg/dl
   0.5 mg/dl
   33 meq/l
   4.0 meq/l
   15 mg/dl
   92 meq/l
   133 meq/l
   24.9 %
   16.3 k/ul
        [image002.jpg]
                             [**2184-9-23**]  04:23 pm
                             [**2184-9-24**]  04:43 am
                             [**2184-9-24**]  04:26 pm
                             [**2184-9-25**]  05:05 am
                             [**2184-9-25**]  05:35 am
                             [**2184-9-26**]  04:59 am
                             [**2184-9-27**]  03:53 am
                             [**2184-9-28**]  04:25 am
                             [**2184-9-29**]  03:21 am
                             [**2184-9-30**]  04:08 am
   wbc
   16.5
   17.6
   21.0
   24.6
   21.7
   16.9
   16.3
   hct
   22.7
   23.0
   23.7
   24.4
   26.9
   25.5
   23.0
   23.5
   24.9
   plt
   [**telephone/fax (3) 10369**]46
   598
   629
   745
   cr
   0.5
   0.5
   0.6
   0.6
   0.6
   0.6
   0.5
   tco2
   36
   glucose
   132
   150
   157
   175
   182
   147
   182
   other labs: pt / ptt / inr:14.5/33.7/1.3, ck / ckmb /
   troponin-t:/5/0.01, alt / ast:28/33, alk phos / t bili:102/0.7, amylase
   / lipase:15/16, lactic acid:1.4 mmol/l, albumin:2.1 g/dl, ldh:191 iu/l,
   ca++:8.9 mg/dl, mg++:1.9 mg/dl, po4:4.0 mg/dl
   no new culture data
   assessment and plan
   68 yo m with pmh of stage iii squamous cell throat ca admitted for [**hospital 10251**]
   transferred from oncology service for hypoxic respiratory distress.
   # respiratory failure: likely secondary  to pna and secretions and s/p
   successful extubation [**9-26**].  sputum culture grew out gnr, speciation
   pending.  also has mssa in sputum.  worsening ability to cough (likely
   cannot close glottis), no gag reflex, stridorous this am.  he did
   complete a full course of antibiotics for the pneumonia (levofloxacin,
   cefepime, vancomycin) and is no longer septic.  currently increased wob
   and patient
s cough is decreasing in effort. ddx: increased secretions
   and mucus plugging (more likely) vs  pe
   - aggressive pulmonary toileting/chest pt
   - continue nebs, suctioning, mie
   - conversation w wife about trach; if potentially curable, trach may
   help him do better for longer
   - readdress code status
   - talk to social work about scheduling meeting
   - talk to ent about trach and risk of causing damage in context of
   tumor
   - screening for pulmonary rehab.
   # metabolic alkalosis:  hypokalemia may be contributing.  [**month (only) 51**] have also
   had some contraction alkalosis with the lasix.  this may be the cause
   of worsening tachypnea early this am to compensate for a worsening
   alkalosis.
   - help treat metabolic alkalosis by replacing k+ to 4.5 ; likely has
   the respiratory acidosis (tachypnea) in response to a worsening
   metabolic alkalosis
   # stage iii squamous cell throat ca:  followed by dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**].
   is s/p xrt and cetuximab, last dose [**2184-6-21**].
   - pt noted to have a increased right neck mass per nursing
   - f/u onc recs (dr. [**first name (stitle) 3805**] following): can consider ct neck if the
   neck mass seems to be impeding the airway
   - s&s following
   - oncologist believes that patient has 50% survival chance, so trach
   may be beneficial to prevent adverse events in the meantime w increased
   secretions and possib mucus plugging complications
   .
   # htn:  better controlled
   - continue home po meds atenelol 100mg daily and hctz 25mg daily
   - continue lisinopril 5 mg daily as bp still uncontrolled (re-started
   [**9-25**])
   .
   # anemia: consistent with acd. b12, folate levels are wnl.  hct stable
   at 23 now, though have trended down over hospitalization.
   - hold iron supplements in setting of icu
   - continue to monitor daily hcts and transfuse if <21 or active
   bleeding
   .
   # hyponatremia:  na improved and stable at 133 this am.  [**month (only) 51**] have been
   hypovolemic hyponatremia.
   - continue to trend
   - urine lytes if na decreases
   .
   # h/o cva:  per notes, had h/o of 'small strokes'.  no residual
   deficits.
   - continue asa 325mg qd
   .
   # depression: currently stable
   - can consider anti-depressants if patient
s symptoms worsen
   - f/u sw recs if any
   # hyperglycemia: continue hiss
   icu care
   nutrition:
   fibersource hn (full) - [**2184-9-28**] 07:06 pm 60 ml/hour
   glycemic control:
   lines:
   20 gauge - [**2184-9-28**] 08:00 pm
   prophylaxis:
   dvt: subq heparin
   stress ulcer:  ppi
   vap:  vap bundle
   comments:
   communication:  comments:
   code status: full code  ([**hospital unit name 1**] team attempted to have discussion about
   code status today, but pt was very focused on just going home and did
   not cooperate with discussion) - - need to readdress code status, per
   the wife he had previously said that he didn't want to be intubated
   again, but not able to understand any questions about code status and
   the wife [**name (ni) 10420**]'t commit
   disposition: - screen for pulmonary rehab pending
"
101,"clinician:  resident
   lumbar puncture procedure note
   patient draped aind positioned in sterile fashion. lp performed under
   the supervision of dr. [**last name (stitle) 12106**]. opening pressure was recorded as
   16mmhg. a total of 12 cc were collected for laboratory and micro
   testing. patient tolerated the procedure well and no adverse events
   were noted.
"
102,"clinician:  resident
   lumbar puncture procedure note
   patient draped aind positioned in sterile fashion. lp performed under
   the supervision of dr. [**last name (stitle) 12106**]. opening pressure was recorded as
   16mmhg. a total of 12 cc were collected for laboratory and micro
   testing. patient tolerated the procedure well and no adverse events
   were noted.
"
103,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: intermittently opens eyes and possibly answers
   yes/no questions. waxing and [**doctor last name 533**]. no focal signs.
   - f/u 24 hour eeg (completed yesterday at noon)
   - avoid sedating meds
   - check abg this morning for acid/base abnormalities
   .
   # ileus: abdomen protruberant but not distended. good stool output.
   tolerating tube feeds
   - continue tube feeds
   - serial abdominal exam
   - kub prn if redistends
   # a fib/flutter: on digoxin and labetalol, nifedipine d/c
   historically difficult to control, s/p ablation. takes sotalol as
   outpatient
   - c/w daily digoxin
   - verify therapeutic dig levels
   - increase labetalol to 600 mg tid
   - ep consult today
   # fevers: daily low-grade fevers. infectious workup unrevealing, aside
   from past mrsa in sputum. dvt may represent source
   - will send c. diff given new stool output (low index of suspicion for
   infection)
   # dvt: on heparin gtt since yesterday. non occluding thrombi per u/s
   report. [**month (only) 51**] represent source of fevers.
   - c/w conservative heparin gtt for goal ptt 60-80, given recent ich
   - serial neuro exams to detect early re-bleed
   - d/w neurosurg long-term oral anti-coagulation
   # hypertension: on ace/[**last name (un) **] as outpatient, these have been held for [**last name (un) **]
   during hospitalization. given plateau in creatinine improvement, he may
   have new baseline and may warrant re-initiation of ace/[**last name (un) **] therapy
   - pending ep recs, start short acting captopril
   - continue labetalol as above
   # mrsa pneumonia: on day 12 of 14 day vanco course. respiratory status
   stable.
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   - follow periodic abgs
   # aocki: creatinine has plateaued at 1.5, with historical baseline of
   1.2. [**month (only) 51**] represent new baseline. good urine output
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # skull fracture/sah/sdh: course of cipro/dexamethasone ear drops now
   complete. ct unrevealing for worsening or new fractures.
   # etoh: holding benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: added standing glargine to sliding scale for elevated
   fingersticks; glipizide held
   # fen: tube feeds. dobhoff to be placed today
   # proph: pantoprazole, heparin gtt
   # access: triple lumen, right radial line, picc
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 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
   resident note, including the assessment and plan.  68m with etoh,
   s/p fall with ich, course c/b ams, difficult to control a-fib, resp
   failure now extubated, low grade fevers. leni with dvt, started on hep
   gtt. continue titrating labetolol for improved heart rate control.
   100.8--> 96.2  100  135/71  24  98% nc
   somnolent, awake intermittently, not following commands
   scant basilar rales
   [**last name (un) **], tachy
   distended, + bs, soft and nt
   2+ edema
   7.43/39/79  wbc 9.4  hct 11.2  cr 1.5 inr 1.2
   cxr with new picc in position, l basilar atelectasis/sm eff, no sig
   change
   in a-fib/flutter. hr control remains suboptimal.  will
   uptitrate labetolol, continuing dig, level pending, ep consulted for
   additional input.  bp control also remains suboptimal, consider
   resuming ace-i monitoriing renal function closely. his acute on cri is
   improving, cr possibly at new baseline, urine outpt remains
   adequate.  will adjust meds/ vanco dosing for improving gfr.  his ms
   remains altered--? delirium, neuro is following, eeg is pending, no
   evidence of new ic process on repeat imaging.   will check abg to r/o
   co2 retention/narcosis. he is on vanco day [**12-13**] for mrsa pna. he
   continues to have low grade fevers, no leukocytosis, ? [**2-1**] dvt.  now on
   heparin.  infection w/u has otherwise been unremarkable. will send c
   diff given stool output. he is tolerating tfs well.    follow abd
   exams, kubs for abd distention.  continue glargine and ssi for improved
   bs control.  icu: ppi, hep gtt, picc. pt following. continue case
   management screening/ for rehab.
   remainder of plan as outlined in resident note.
   patient is critically ill
   total time: 50 min
   ------ protected section addendum entered by:[**name (ni) 215**] [**last name (namepattern1) 216**], md
   on:[**2129-2-8**] 15:54 ------
"
104,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: seems more alert, eyes open, tracking, trying
   to speak
   - f/u 24 hour eeg (completed yesterday at noon)
   .
   # hypernatremia: serum [na+] 146
 144
   -  continue with free water po and flushes with tube feeds
   - check pm lytes.
   - note urine osmolality not c/w di
   # ileus: good stool output, ileus resolving. just written for tubefeeds
   but can start to take occasional gentle po
   - continue tube feeds
 when mental status improved, will order
   speech/swallow evaluation and advance diet as tolerated
   - serial abdominal exam
   # a fib/flutter: loaded with digoxin, also continues on esmolol gtt.
   known to be difficult to rate control in past.
   - c/w daily po digoxin
   - discontinue esmolol gtt today
   # hypertension:
   - continue labetalol po and will increase to tid today if becomes more
   hypertensive with esmolol off
   - continue nifedipine po
   # respiratory failure: respiratory status stable, with reasonable abgs
   now extubated
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   # [**last name (un) **]: creatinine improvement continuing
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # rash: cefepime has been d/c
d, rash resolved.
   # skull fracture: course of cipro/dexamethasone ear drops now complete
   # sah/sdh: ct unrevealing for worsening or new fractures.
   # etoh: now beyond duration during which withdrawal expected. holding
   benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: increased sliding scale for elevated fingersticks;
   glipizide held
   # fen: tube feeds now
   # proph: pantoprazole, pneumoboots
   # access: triple lumen, right radial line
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status: full code
   disposition:
"
105,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   physical examination
   general: intubated, opens eyes to verbal stimulus, can squeeze fingers
   and barely wiggle toes on command
   heent: sclera anicteric, dried blood in op and nares. mmm
   neck: supple
   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
   gu: no foley
   ext: 1+ edema b/l warm, well perfused, rue dsg c/d/i. cap refill <3 sec
   bl.
   labs / radiology
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
 bacteremia
   assessment and plan
   61 year old female with biphenotypic leukemia admitted with persistent
   neutropenia and high grade vre bacteremia attributed to line infection
   and septic thrombophlebitis now pod #0 s/p excision right basilic [**hospital 13196**]
   transferred from or intubated with transient hypotension.
   .
   # hypotension: resolved at present. most concerning for evolving sepsis
   given known bacteremia and immunocompromised status. cardiogenic,
   hypovolemic, or obstructive etiology less likely.
   - no need for bolus at present give pt is normotensive
   - if needed, would bolus with 1l d5 3amps bicarb as resuscitation fluid
   given renal failure metabolic acidosis and maintain map>65
   - changed sedation from propofol to dexmedetomidine to decrease
   hypotension, but weaning sedation nonetheless
   - maintain pivs, would like to avoid central access if possible given
   need for line holiday given high grade vre bacteremia
   - broad abx (dapto and zosyn) as below
   - if pressors/central line needed, will discuss placing hd catheter
   with vip port with renal since likely to need hd
   - if hd needed will need hd catheter placed, will d/w reanl
   # vre bacteremia: patient with high grade vre bacteremia but recent
   blood cx [**2-9**] ngtd and now has had removal of one source of infection
   (basilic vein) as well as picc. could also consider endocarditis as
   possibility but tte negative
   - continue daptomycin per id recommendations; continue zosyn for broad
   coverage and fever and neutropenia
   - appreciate id recommendations
   - consider adding linezolid if continues to have positive blood cx or
   increased mic to dapto
   - consider tee while intubated but unlikely to currently change
   management, will make sure to discuss with bmt and id
   # anuric arf: patient with rapidly progressive renal failure last 48
   hours, likely related to atn from hypotension as well as gentamycin (3
   doses [**date range (1) 120**]). uop 275cc last 24 hours, previously 850cc prior 24
   hours. nephrology following and medicatiosn redosed for creatinine
   clearance, may need cvvh next 24-72 hours if remains anuric/oliguric.
   - avoid nephrotoxic agents
   - appreciate renal recommendations
   - if hypotensive again, recommend maintaining renal perfusion and
   correct metaboli acidosis with boluses d5 with bicarb
   - renally dose meds, will discuss holding acyclovir with bmt
   # intubation: kept intubated overnight for white cell infusion. patient
   remained post-operatively intubated for unclear reasons. per
   anesthesia, had tachypnea pre-op but cxr relatively clear and without
   infiltrate other than possible pulmonary edema but difficult to
   interpret in setting of low lung volumes. oxygen saturations 100% on
   60%.
   - decrease fio2 to 40% and check abg
   - change to psv ventilation
   - short acting sedation to enable probable extubation in am
   - will wait to make sure no procedures need to be completed before
   extubation, will d/w consulting teams
   #) biphenotypic leukemia/pancytopenia: wbc improved from 0.2 to 0.5
   after infusion. patient is s/p hyper cvad x 2, mec and clofarabine and
   ara-c, now with persistent neutropenia and thrombocytopenia and
   decreased ability to clear infection and bacteremia.
   - monitor cbc w/diff after granulocyte infusion
   - maintain an active type and screen
   - transfuse for platelets<10,000 or any signs of bleeding and hct<24
   - touch base with renal and bmt if we should continue ppx with
   voriconazole and acyclovir
   - continue neupogen
   #) h/o positive ppd: continue prior regimen of moxifloxacin 400mg daily
   as per prior id recs
   # fen: npo, replete lytes, bolus 1l d5w with bicarb
   # ppx: pneumoboots and thrombocytopenia, ppi
   access: peripherals
   code:  full confirmed with patient and husband
   communication: [**name2 (ni) **]
   disposition: pending clinical improvement
   icu care
   nutrition:
   glycemic control: blood sugar well controlled
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   prophylaxis:
   dvt: boots
   stress ulcer: ppi
   vap: hob elevation, mouth care, daily wake up, rsbi
   comments:
   communication: icu consent signed comments:
   code status:
   disposition:
"
106,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   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
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
   icu care
   nutrition:
   glycemic control:
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   arterial line - [**2150-2-11**] 10:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
"
107,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   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
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
   assessment and plan
   61 year old female with biphenotypic leukemia admitted with persistent
   neutropenia and high grade vre bacteremia attributed to line infection
   and septic thrombophlebitis now pod #0 s/p excision right basilic [**hospital 13196**]
   transferred from or intubated with transient hypotension
   .
   # hypotension: patient initially transferred to [**hospital unit name 1**] with hypotension
   on peripheral neo but upon arrival, weaned off pressors immediately
   with maps in 60s. hypotension most likely related to sedation intra-op
   but also concerning for evolving sepsis given known bacteremia and
   immunocompromised status. cardiogenic or obstructive etiology less
   likely.
   - bolus with 1l d5 3amps bicarb as resuscitation fluid given renal
   failure and maintain map>65
   - change sedation from propofol to dexmedetomidine to decrease
   hypotension
   - maintain pivs, would like to avoid central access if possible given
   need for line holiday
   - broad abx (dapto and zosyn) as below
   - if pressors/central line needed, will discuss placing hd catheter
   with vip port with renal since likely to need hd
   # vre bacteremia: patient with high grade vre bacteremia but recent
   blood cx [**2-9**] ngtd and now has had removal of one source of infection
   (basilic vein) as well as picc. could also consider endocarditis as
   possibility but tte negative
   - continue daptomycin per id recommendations; continue zosyn for broad
   coverage and fever and neutropenia
   - appreciate id recommendations
   - consider adding linezolid if continues to have positive blood cx or
   increased mic to dapto
   - consider tee while intubated but unlikely to currently change
   management
   # arf: patient with rapidly progressive renal failure last 48 hours,
   likely related to atn from hypotension as well as gentamycin (3 doses
   [**date range (1) 120**]). uop 275cc last 24 hours, previously 850cc prior 24 hours.
   nephrology following and medicatiosn redosed for creatinine clearance,
   may need cvvh next 24-72 hours if remains anuric/oliguric.
   - avoid nephrotoxic agents
   - appreciate renal recommendations
   - maintain renal perfusion and correct metaboli acidosis with boluses
   d5 with bicarb
   - renally dose meds, will discuss holding acyclovir with bmt
   # intubation: patient remains intubated for unclear reasons. per
   anesthesia, had tachypnea pre-op but cxr relatively clear and without
   infiltrate other than possible pulmonary edema but difficult to
   interpret in setting of low lung volumes. oxygen saturations 100% on
   60%. no reason to expect she will be difficult to extubate but given
   granulocyte infusion overnight will keep intubated for now for airway
   protection and risk of hemodynamic instability
   - decrease fio2 to 40% and check abg
   - change to psv ventilation
   - short acting sedation to enable extubation in am
   #) biphenotypic leukemia/pancytopenia: patient is s/p hyper cvad x 2,
   mec and clofarabine and ara-c, now with persistent neutropenia and
   thrombocytopenia and decreased ability to clear infection and
   bacteremia
   - granulocyte infusion overnight per bmt recommendations with
   premedication and cbc pre and post
   - maintain an active type and screen
   - transfuse for platelets<10,000 or any signs of bleeding and hct<24
   - continue ppx with voriconazole and acyclovir
   - continue neupogen
   #) h/o positive ppd: continue prior regimen of moxifloxacin 400mg daily
   as per prior id recs
   # fen: npo, replete lytes, bolus 1l d5w with bicarb
   # ppx: pneumoboots and thrombocytopenia, ppi
   access: peripherals
   code:  full confirmed with patient and husband
   communication: [**name2 (ni) **]
   disposition: pending clinical improvement
   icu care
   nutrition:
   glycemic control: blood sugar well controlled
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   prophylaxis:
   dvt: boots
   stress ulcer: ppi
   vap: hob elevation, mouth care, daily wake up, rsbi
   comments:
   communication: icu consent signed comments:
   code status:
   disposition:
   icu care
   nutrition:
   glycemic control:
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   arterial line - [**2150-2-11**] 10:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
"
108,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: intermittently opens eyes and possibly answers
   yes/no questions. waxing and [**doctor last name 533**]. no focal signs.
   - f/u 24 hour eeg (completed yesterday at noon)
   - avoid sedating meds
   - check abg this morning for acid/base abnormalities
   .
   # ileus: abdomen protruberant but not distended. good stool output.
   tolerating tube feeds
   - continue tube feeds
   - serial abdominal exam
   - kub prn if redistends
   # a fib/flutter: on digoxin and labetalol, nifedipine d/c
   historically difficult to control, s/p ablation. takes sotalol as
   outpatient
   - c/w daily digoxin
   - verify therapeutic dig levels
   - increase labetalol to 600 mg tid
   - ep consult today
   # fevers: daily low-grade fevers. infectious workup unrevealing, aside
   from past mrsa in sputum. dvt may represent source
   - will send c. diff given new stool output (low index of suspicion for
   infection)
   # dvt: on heparin gtt since yesterday. non occluding thrombi per u/s
   report. [**month (only) 51**] represent source of fevers.
   - c/w conservative heparin gtt for goal ptt 60-80, given recent ich
   - serial neuro exams to detect early re-bleed
   - d/w neurosurg long-term oral anti-coagulation
   # hypertension: on ace/[**last name (un) **] as outpatient, these have been held for [**last name (un) **]
   during hospitalization. given plateau in creatinine improvement, he may
   have new baseline and may warrant re-initiation of ace/[**last name (un) **] therapy
   - pending ep recs, start short acting captopril
   - continue labetalol as above
   # mrsa pneumonia: on day 12 of 14 day vanco course. respiratory status
   stable.
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   - follow periodic abgs
   # aocki: creatinine has plateaued at 1.5, with historical baseline of
   1.2. [**month (only) 51**] represent new baseline. good urine output
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # skull fracture/sah/sdh: course of cipro/dexamethasone ear drops now
   complete. ct unrevealing for worsening or new fractures.
   # etoh: holding benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: added standing glargine to sliding scale for elevated
   fingersticks; glipizide held
   # fen: tube feeds. dobhoff to be placed today
   # proph: pantoprazole, heparin gtt
   # access: triple lumen, right radial line, picc
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status: full code
   disposition:
"
109,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   physical examination
   general: intubated, opens eyes to verbal stimulus, can squeeze fingers
   and barely wiggle toes on command
   heent: sclera anicteric, dried blood in op and nares. mmm
   neck: supple
   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
   gu: no foley
   ext: 1+ edema b/l warm, well perfused, rue dsg c/d/i. cap refill <3 sec
   bl.
   labs / radiology
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
 bacteremia
   assessment and plan
   61 year old female with biphenotypic leukemia admitted with persistent
   neutropenia and high grade vre bacteremia attributed to line infection
   and septic thrombophlebitis now pod #0 s/p excision right basilic [**hospital 13196**]
   transferred from or intubated with transient hypotension.
   .
   # hypotension: resolved at present. most concerning for evolving sepsis
   given known bacteremia and immunocompromised status. cardiogenic,
   hypovolemic, or obstructive etiology less likely.
   - no need for bolus at present give pt is normotensive
   - if needed, would bolus with 1l d5 3amps bicarb as resuscitation fluid
   given renal failure metabolic acidosis and maintain map>65
   - changed sedation from propofol to dexmedetomidine to decrease
   hypotension, but weaning sedation nonetheless
   - maintain pivs, would like to avoid central access if possible given
   need for line holiday given high grade vre bacteremia
   - broad abx (dapto and zosyn) as below
   - if pressors/central line needed, will discuss placing hd catheter
   with vip port with renal since likely to need hd
   - if hd needed will need hd catheter placed, will d/w reanl
   # vre bacteremia: patient with high grade vre bacteremia but recent
   blood cx [**2-9**] ngtd and now has had removal of one source of infection
   (basilic vein) as well as picc. could also consider endocarditis as
   possibility but tte negative
   - continue daptomycin per id recommendations; continue zosyn for broad
   coverage and fever and neutropenia
   - appreciate id recommendations
   - consider adding linezolid if continues to have positive blood cx or
   increased mic to dapto
   - consider tee while intubated but unlikely to currently change
   management, will make sure to discuss with bmt and id
   # anuric arf: patient with rapidly progressive renal failure last 48
   hours, likely related to atn from hypotension as well as gentamycin (3
   doses [**date range (1) 120**]). uop 275cc last 24 hours, previously 850cc prior 24
   hours. nephrology following and medicatiosn redosed for creatinine
   clearance, may need cvvh next 24-72 hours if remains anuric/oliguric.
   - avoid nephrotoxic agents
   - appreciate renal recommendations
   - if hypotensive again, recommend maintaining renal perfusion and
   correct metaboli acidosis with boluses d5 with bicarb
   - renally dose meds, will discuss holding acyclovir with bmt
   # intubation: kept intubated overnight for white cell infusion. patient
   remained post-operatively intubated for unclear reasons. per
   anesthesia, had tachypnea pre-op but cxr relatively clear and without
   infiltrate other than possible pulmonary edema but difficult to
   interpret in setting of low lung volumes. oxygen saturations 100% on
   60%.
   - decrease fio2 to 40% and check abg
   - change to psv ventilation
   - short acting sedation to enable probable extubation in am
   - will wait to make sure no procedures need to be completed before
   extubation, will d/w consulting teams
   #) biphenotypic leukemia/pancytopenia: wbc improved from 0.2 to 0.5
   after infusion. patient is s/p hyper cvad x 2, mec and clofarabine and
   ara-c, now with persistent neutropenia and thrombocytopenia and
   decreased ability to clear infection and bacteremia.
   - monitor cbc w/diff after granulocyte infusion
   - maintain an active type and screen
   - transfuse for platelets<10,000 or any signs of bleeding and hct<24
   - touch base with renal and bmt if we should continue ppx with
   voriconazole and acyclovir
   - continue neupogen
   #) h/o positive ppd: continue prior regimen of moxifloxacin 400mg daily
   as per prior id recs
   # fen: npo, replete lytes, bolus 1l d5w with bicarb
   # ppx: pneumoboots and thrombocytopenia, ppi
   access: peripherals
   code:  full confirmed with patient and husband
   communication: [**name2 (ni) **]
   disposition: pending clinical improvement
   icu care
   nutrition:
   glycemic control: blood sugar well controlled
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   prophylaxis:
   dvt: boots
   stress ulcer: ppi
   vap: hob elevation, mouth care, daily wake up, rsbi
   comments:
   communication: icu consent signed 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: 61f aml/all dx [**11-10**], neg bmbx p/w diarrhea,
   vomitting and vre bacteremia in the setting of septic picc-related
   thrombophlebitis. developed epistaxis and gib on heparin, sent to or
   yesterday for clot extraction. bp improved overnight but remains
   anuric, art line placed, granulocyte infusion well tolerated.
   exam notable for tm 97.4 bp 130/70 hr 110 rr 18 with sat 99 on psv 5/5,
   uop 20cc since midnight. ill appearing. coarse bs b. rrr s1s2 2/6sm.
   soft +bs. rue dressing c/d/i. soft +bs. 2+ edema. labs notable for wbc
   0.2k, hct 26, k+ 3.6, cr 2.8. cxr with low volumes.
   agree with plan to manage post-op respiratory failure with sbt now and
   potential extubation as her mental status resolves and procedures are
   completed. bp improved somewhat with volume, continue broad abx
   coverage for vre sepsis / febrile neutropenia. arf is progressive, hold
   off on further volume loading, rd meds and d/w bmt re holding acyclovir
   and placing vip hd line. for all/aml - nad on bmbx but pancytopenic s/p
   granulocyte infusion, continue gcsf, brc transfusion, platelets for
   procedures. continue moxifloxacin for +ppd. remainder of plan as
   outlined above.
   patient is critically ill
   total time: 35 min
   ------ protected section addendum entered by:[**name (ni) 453**] [**last name (namepattern1) 775**], md
   on:[**2150-2-12**] 04:53 pm ------
"
110,"subdural hemorrhage (sdh)
   pregnancy
   assessment:
   pt 12 weeks 6 days pregnant.
   action:
   doppler used overnight to confirm fetal heartbeat. ob us done this
   afternoon. fetal heartbeat and movement noted. gestational age
   confirmed by measurement. awaiting formal report.
   response:
   no adverse events to fetus or pt noted this shift
   plan:
   monitor prn.
   assessment:
   r frontal sdh and r temporal sah. pt a&o x3. following all commands. no
   noted deficits. pt has history of epilepsy but no treatment or seizures
   for last [**4-15**] yrs. pt is developmentally delayed but lives and works
   independently.
   action:
   q2hr neuro checks. rpt head ct.
   response:
   pt remains neurologically intact. verbal report per tsicu resident of
   ct showing very small increase in bleed.
   plan:
   continue to monitor in tsicu.
   fracture, other
   assessment:
   l distal clavicular fracture. no c/o pain from pt. sling for when pt
   oob.
   action:
   sling off when pt resting in bed. sling when oob. offer analgesics prn
   and position changes to aid comfort. educate pt re: use of sling.
   response:
   pt resting comfortably and compliant with sling.
   plan:
   continue to offer anagesics prn and ensure sling on when oob.
"
111,"pt well known, who was recently admitted to [**hospital1 1**] for hypoxic and
   hypercarbic respiratory failure after being found unresponsive at home
   by her husband, treated for pna with vanco/levo/zosyn, s/p trach after
   prolonged wean, course c/b arf and drug fever, transferred to [**hospital1 664**]
   on [**2193-2-17**]. transferred back to [**hospital1 **] [**2-21**], in ed abd ct done showing
   diffuse colitis, t101. transfer to micu for mgt bacteremia and resp
   failure
    early this am, pt becoming tachycardic throughout night, now hr
   120-130
s sinus. received mult ivf bolus
 despite this. her lactate is
   now up to 2.5 and wbc to 30. also hct from 20 to 30 despite fluid
   resuscitation.
   to ir today for hd line placed, placed rij with out adverse events.  ct
   abdomen today indicative of large amounts of free air.  pt to or for
   surgery.
   husband, [**name (ni) 851**], [**name (ni) 1850**], was very upset.  lives two hours away, likely
   en route here now.  this rn [**name (ni) 1850**] sw as pt was very distraught on
   phone and in prior discussions indicated no support systems.  sw
   [**name (ni) 1850**] husband by phone.  please note there is an on call sw until
   9pm this evening, that should have been made aware of mr. [**known lastname **] and
   can be paged to see him.
   respiratory failure, chronic
   assessment:
   pt trached on ac 60%/550/14/15 peep, small amts of  tan-yellow
   secretions, overbreathing vent to 20-30
s. vbg
s worsening slightly.
   action:
   suctioned q4 for thick tan-yellow secretions, mdi
s, pulm toilet
   response:
   sats 96-99%, rr 23-30
   plan:
   continue mech vent, wean as tolerated. follow sats/ vbgs
   fever (hyperthermia, pyrexia, not fever of unknown origin)/sepsis
   assessment:
   lactate trending up 2.7. pt still febrile,
   action:
    tylenol given.  cont. to monitor. cont. on abx. cont. trending
   lactate. cont. ivf.
   response:
   worsening septic picture. t down to 101.  tachycardic, tachypnic this
   am. lactate trending up.
   plan:
   cont. to monitor.
   colitis, c-diff
   assessment:
   pt with ct showing diffuse colitis, peg clamped, bs hypoactive, c/o abd
   pain/nausea on admission. noted rebound tenderness on exam.  c-dff +
   results.  liquid golden, foul smelling stool.  noted hemoconcentration,
   despite multiple ivf bolus
   action:
   to ct, study indicative of large amounts of free air, to or for
   perforated bowel.  neo. gtt for low u/o and map.  and pt has become
   increasingly tachycardic.  vanco enemas, po as well continues on iv
   lasix.  tf on hold.
   response:
   c. diff +.stool  guiac negative; continue to hold tf, denies nausea.
   plan:
   or then tosicu. cont. abx therapy. supportive care.
   impaired skin integrity
   assessment:
   pt now on air bed, using assistive devices to turn pt more freq. noted
   new area on left (favors this side) mid back blistering since
   yesterday. allevyn dressing applied to blistering area.
   action:
   turning q2-4 now w/devices in place to assist.
   response:
   cont freq turns.
"
112,"chief complaint:  angioedema
   hpi:
   pt is an 85 y/o f with a h/o gave s/p argon treatment last on [**2150-3-11**],
   iron deficiency anemia, cirrhosis [**1-19**] hepc, portal htn/grade 1 varices
   but no hx of bleeding varices, cri (baseline cr = 1.2-1.5) who is
   transfered from [**hospital3 2546**] intubated s/p angioedema. the following
   history is obtained from her son as the patient is intubated. he states
   that she reported some mild abdominal pain and some irritation in her
   throat a day prior to admission to [**hospital3 2546**]. the following
   morning she called her son with complaints of oral swelling; son states
   that her speach was garbled. the son reports that the patient denies
   having had any sob, no wheezing, no hives. he called an abmulance who
   transported the pt to [**hospital3 2546**].
   .
   per omr, the patient present to [**hospital1 1**] pheresis unit on [**2150-4-10**] for
   blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications given and no adverse events; vitals on leaving
   the unit were 97.4 - 67 - 119/55. she has also been recently treated
   for a uti with bactrim started on [**2150-4-3**].
   .
   at st elizabeths', she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate in the ed and she
   was taken to the or. laryngeal edema was noted, but the et tube was
   passed successfully. she was then transfered to the ccu. she received
   hydroxyzine tid and her tongue swelling improved. sbt was attempted
   early on but failed likely secondary to sedation. per report, pt did
   have a cuff leak. family requested transfer to [**hospital1 1**] as pt receives all
   her care here.
   patient admitted from: transfer from other hospital
   history obtained from family / [**hospital 380**] medical records
   patient unable to provide history: language barrier
   allergies:
   nsaids
   please avoid du
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   home medications:
   felodipine - 5 mg tablet sustained release 24 hr - 3 tablet(s) by mouth
   once a day (2 tabs in a.m. and 1 tab in the p.m
   folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day
   furosemide [lasix] - 40 mg tablet - 1 tablet(s) by mouth once a day
   hydrocortisone acetate [anusol-hc] - 25 mg suppository - one rectally
   daily
   lactulose -  (prescribed by other provider) - 10 gram/15 ml solution -
   15 ml by mouth once a day for encephalopathy; goal of [**2-18**] bms qd
   metformin - 500 mg tablet - 2 (two) tablet(s) by mouth every morning
   and one tablet every evening.
   mupirocin - 2 % ointment - topical twice a day as needed for lesion or
   rash
   nadolol - 80 mg tablet - 1 (one) tablet(s) by mouth qam
   pantoprazole - 40 mg tablet, delayed release (e.c.) - one tablet(s) by
   mouth twice daily
   spironolactone [aldactone] - 50 mg tablet - one tablet(s) by mouth
   daily
   sucralfate - 1 gram tablet - 1 tablet(s) by mouth thre times per day
   zolpidem [ambien] - 5 mg tablet - 1/4-1 tablet(s) by mouth at bedtime
   as needed for insomnia
   calcium carbonate-vitamin d2 [oyster shell calcium-vit d3] - 500 mg-375
   unit tablet - 1 (one) tablet(s) by mouth twice a day
   cyanocobalamin - 500 mcg tablet - 1 tablet(s) by mouth once a day
   ferrous gluconate - 325 mg tablet - 1 tablet(s) by mouth 5 times a day
   pramoxine-menthol-petrolatum [sarna ultra] - 1 %-0.5 %-30 % cream -
   apply to affected areas one to two times per day
   past medical history:
   family history:
   social history:
   # gave - s/p argon treatment, last on last on [**2150-3-11**]
   # hepatitis c
   # cirrhosis
   - child's class a, portal htn, grade 1 varices
   - no h/o ascites, encephalopathy, variceal bleeding, synthetic
   function intact
   # dm type ii
   # htn
   # iron deficiency anemia
   # s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
   # hypercholesterolemia
   # osteopenia
   # insomnia
   no hx angioedema
   occupation:
   drugs:
   tobacco:
   alcohol:
   other: lives alone in [**location (un) 2471**] in [**hospital3 718**] complex. is widowed.
   has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
   holidays). worked in food business in sales.
   review of systems:
   flowsheet data as of [**2150-4-16**] 08:21 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 35.8
c (96.4
   tcurrent: 35.8
c (96.4
   hr: 84 (84 - 95) bpm
   bp: 119/53(69) {119/53(69) - 127/56(74)} mmhg
   rr: 19 (19 - 26) insp/min
   spo2: 96%
   heart rhythm: sr (sinus rhythm)
                  total in:
                  po:
                  tf:
   ivf:
   blood products:
   total out:
                                                                      0 ml
                                                                     50 ml
   urine:
   50 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    -50 ml
   respiratory
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (spontaneous): 398 (398 - 398) ml
   ps : 10 cmh2o
   rr (spontaneous): 25
   peep: 5 cmh2o
   fio2: 50%
   pip: 16 cmh2o
   spo2: 96%
   ve: 11.5 l/min
   physical examination
   gen: intubated awake alert with tube in place
   heent: ncat,oropharynx clear and without erythema or exudate, tongue is
   normal sized w/o any edema
   neck: supple, no lad, no appreciable jvd
   cv: rrr, normal s1s2, [**12-23**] holosystolic blowing murmur at apex.
   pulm: ctab, no w/r/r, good air movement bilaterally
   abd: soft, obese, ntnd, easily reduced umbilical hernia,
   normoactive bowel sounds, no organomegaly
   ext: warm and well perfused, full and symmetric distal pulses,
   no pedal edema
   neuro: awake, alert
   skin; no hives
   labs / radiology
   140
   1.1
   47
   22
   107
   5.5
   135
   32.5
   7.8
        [image002.jpg]
   assessment and plan:
   assessment and plan:  pt is an 85 y/o f with a h/o gave s/p argon
   treatment last on [**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc,
   portal htn/grade 1 varices but no hx of bleeding varices, cri (baseline
   cr = 1.2-1.5) who is transfered from [**hospital3 2546**] intubated s/p
   angioedema.
   .
   # angioedema: resoved. lack of hives, bronchospasm or hypotension
   suggests that this was not allergic angioedema but rather bradykinin
   related. c3 and c4 were low. c1 esterase inh pending, [**doctor first name **] neg per
   allergy consult at [**hospital3 5692**], non-allergic angioedema is due to
   completment depletion ([**1-19**] hereditary or carelated) or complement
   activation (infection or transfusion). the patient did have a
   transfusion recently which may be related. medications would also be
   high on the list of etiologies.  nsaids? [**last name (un) 284**]?
   - cont hydroxyzine from one more day
   - check cuff leak and extubate in am
   - hold all non-essential possible culprit meds: [**last name (un) 284**], felodipine, lasix,
   nadolol, bactrim
   - f/u complement studies at [**hospital3 2546**]
   - consider allergy consult
   - contact blood bank re risk of angioedema with transfusion as pt will
   need future transfuse and may be at risk for recurrent episode
   .
   # hx  cirrhosis:
   - cont lactulose
   .
   #cri: baseline 1.5, was elevated on admission to [**hospital3 5692**] to 1.7 now
   down to 1.1
   - monitor.
   icu care
   nutrition:
   glycemic control:
   lines:
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
   ------ protected section ------
   i have seen and examined the patient with the resident and agree with
   the assessment and plan with the following modifications/changes:
   85 year old with resolving angioedema transferred from osh.  remains
   intubated at this time and is hemodynamically stable.
   per son, swelling of tongue much improved.
   a:
   1)       angioedema
   2)       respiratory failure secondary to angioedema
   p:
   1)       review med records for report of grade view of airway
   2)       extubation in the am
   critically ill
   time spent: 30 minutes
   ------ protected section addendum entered by:[**name (ni) **] [**last name (namepattern1) 402**], md
   on:[**2150-4-17**] 10:40 am ------
"
113,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   angioedema
   assessment:
   action:
   response:
   plan:
"
114,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
   demographics
   attending md:
   [**location (un) **] [**doctor first name **] a.
   admit diagnosis:
   tongue swelling
   code status:
   full code
   height:
   admission weight:
   58.6 kg
   daily weight:
   allergies/reactions:
   nsaids
   please avoid du
   precautions:
   pmh:  anemia, diabetes - oral [**doctor last name **], gi bleed, hepatitis
   cv-pmh:  hypertension
   additional history: hep c cirrhosis, portal htn w/ grade i varices,
   ascites, encephalopathy, variceal bleeding, dm 2, right renal
   nephrectomy for renal cell ca (15 yrs ago), hypercholesterolemia,
   osteopenia, insomnia,
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:122
   d:54
   temperature:
   98.7
   arterial bp:
   s:
   d:
   respiratory rate:
   22 insp/min
   heart rate:
   85 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   nasal cannula
   o2 saturation:
   96% %
   o2 flow:
   3 l/min
   fio2 set:
   50% %
   24h total in:
   655 ml
   24h total out:
   415 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2150-4-17**] 05:15 am
   potassium:
   4.3 meq/l
   [**2150-4-17**] 05:15 am
   chloride:
   112 meq/l
   [**2150-4-17**] 05:15 am
   co2:
   24 meq/l
   [**2150-4-17**] 05:15 am
   bun:
   27 mg/dl
   [**2150-4-17**] 05:15 am
   creatinine:
   1.1 mg/dl
   [**2150-4-17**] 05:15 am
   glucose:
   132 mg/dl
   [**2150-4-17**] 05:15 am
   hematocrit:
   31.4 %
   [**2150-4-17**] 05:15 am
   finger stick glucose:
   159
   [**2150-4-17**] 06:00 pm
   valuables / signature
   patient valuables: none
   other valuables:
   clothes:  sent home with:
   wallet / money:
   no money / wallet
   cash / credit cards sent home with:
   jewelry:
   transferred from: micu-7
   transferred to: [**hospital ward name 4126**]
   date & time of transfer:  [**2150-4-17**] 1830
"
115,"chief complaint:  angioedema
   hpi:
   pt is an 85 y/o f with a h/o gave s/p argon treatment last on [**2150-3-11**],
   iron deficiency anemia, cirrhosis [**1-19**] hepc, portal htn/grade 1 varices
   but no hx of bleeding varices, cri (baseline cr = 1.2-1.5) who is
   transfered from [**hospital3 2546**] intubated s/p angioedema. the following
   history is obtained from her son as the patient is intubated. he states
   that she reported some mild abdominal pain and some irritation in her
   throat a day prior to admission to [**hospital3 2546**]. the following
   morning she called her son with complaints of oral swelling; son states
   that her speach was garbled. the son reports that the patient denies
   having had any sob, no wheezing, no hives. he called an abmulance who
   transported the pt to [**hospital3 2546**].
   .
   per omr, the patient present to [**hospital1 1**] pheresis unit on [**2150-4-10**] for
   blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications given and no adverse events; vitals on leaving
   the unit were 97.4 - 67 - 119/55. she has also been recently treated
   for a uti with bactrim started on [**2150-4-3**].
   .
   at st elizabeths', she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate in the ed and she
   was taken to the or. laryngeal edema was noted, but the et tube was
   passed successfully. she was then transfered to the ccu. she received
   hydroxyzine tid and her tongue swelling improved. sbt was attempted
   early on but failed likely secondary to sedation. per report, pt did
   have a cuff leak. family requested transfer to [**hospital1 1**] as pt receives all
   her care here.
   patient admitted from: transfer from other hospital
   history obtained from family / [**hospital 380**] medical records
   patient unable to provide history: language barrier
   allergies:
   nsaids
   please avoid du
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   home medications:
   felodipine - 5 mg tablet sustained release 24 hr - 3 tablet(s) by mouth
   once a day (2 tabs in a.m. and 1 tab in the p.m
   folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day
   furosemide [lasix] - 40 mg tablet - 1 tablet(s) by mouth once a day
   hydrocortisone acetate [anusol-hc] - 25 mg suppository - one rectally
   daily
   lactulose -  (prescribed by other provider) - 10 gram/15 ml solution -
   15 ml by mouth once a day for encephalopathy; goal of [**2-18**] bms qd
   metformin - 500 mg tablet - 2 (two) tablet(s) by mouth every morning
   and one tablet every evening.
   mupirocin - 2 % ointment - topical twice a day as needed for lesion or
   rash
   nadolol - 80 mg tablet - 1 (one) tablet(s) by mouth qam
   pantoprazole - 40 mg tablet, delayed release (e.c.) - one tablet(s) by
   mouth twice daily
   spironolactone [aldactone] - 50 mg tablet - one tablet(s) by mouth
   daily
   sucralfate - 1 gram tablet - 1 tablet(s) by mouth thre times per day
   zolpidem [ambien] - 5 mg tablet - 1/4-1 tablet(s) by mouth at bedtime
   as needed for insomnia
   calcium carbonate-vitamin d2 [oyster shell calcium-vit d3] - 500 mg-375
   unit tablet - 1 (one) tablet(s) by mouth twice a day
   cyanocobalamin - 500 mcg tablet - 1 tablet(s) by mouth once a day
   ferrous gluconate - 325 mg tablet - 1 tablet(s) by mouth 5 times a day
   pramoxine-menthol-petrolatum [sarna ultra] - 1 %-0.5 %-30 % cream -
   apply to affected areas one to two times per day
   past medical history:
   family history:
   social history:
   # gave - s/p argon treatment, last on last on [**2150-3-11**]
   # hepatitis c
   # cirrhosis
   - child's class a, portal htn, grade 1 varices
   - no h/o ascites, encephalopathy, variceal bleeding, synthetic
   function intact
   # dm type ii
   # htn
   # iron deficiency anemia
   # s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
   # hypercholesterolemia
   # osteopenia
   # insomnia
   no hx angioedema
   occupation:
   drugs:
   tobacco:
   alcohol:
   other: lives alone in [**location (un) 2471**] in [**hospital3 718**] complex. is widowed.
   has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
   holidays). worked in food business in sales.
   review of systems:
   flowsheet data as of [**2150-4-16**] 08:21 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 35.8
c (96.4
   tcurrent: 35.8
c (96.4
   hr: 84 (84 - 95) bpm
   bp: 119/53(69) {119/53(69) - 127/56(74)} mmhg
   rr: 19 (19 - 26) insp/min
   spo2: 96%
   heart rhythm: sr (sinus rhythm)
                  total in:
                  po:
                  tf:
   ivf:
   blood products:
   total out:
                                                                      0 ml
                                                                     50 ml
   urine:
   50 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    -50 ml
   respiratory
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (spontaneous): 398 (398 - 398) ml
   ps : 10 cmh2o
   rr (spontaneous): 25
   peep: 5 cmh2o
   fio2: 50%
   pip: 16 cmh2o
   spo2: 96%
   ve: 11.5 l/min
   physical examination
   gen: intubated awake alert with tube in place
   heent: ncat,oropharynx clear and without erythema or exudate, tongue is
   normal sized w/o any edema
   neck: supple, no lad, no appreciable jvd
   cv: rrr, normal s1s2, [**12-23**] holosystolic blowing murmur at apex.
   pulm: ctab, no w/r/r, good air movement bilaterally
   abd: soft, obese, ntnd, easily reduced umbilical hernia,
   normoactive bowel sounds, no organomegaly
   ext: warm and well perfused, full and symmetric distal pulses,
   no pedal edema
   neuro: awake, alert
   skin; no hives
   labs / radiology
   140
   1.1
   47
   22
   107
   5.5
   135
   32.5
   7.8
        [image002.jpg]
   assessment and plan:
   assessment and plan:  pt is an 85 y/o f with a h/o gave s/p argon
   treatment last on [**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc,
   portal htn/grade 1 varices but no hx of bleeding varices, cri (baseline
   cr = 1.2-1.5) who is transfered from [**hospital3 2546**] intubated s/p
   angioedema.
   .
   # angioedema: resoved. lack of hives, bronchospasm or hypotension
   suggests that this was not allergic angioedema but rather bradykinin
   related. c3 and c4 were low. c1 esterase inh pending, [**doctor first name **] neg per
   allergy consult at [**hospital3 5692**], non-allergic angioedema is due to
   completment depletion ([**1-19**] hereditary or carelated) or complement
   activation (infection or transfusion). the patient did have a
   transfusion recently which may be related. medications would also be
   high on the list of etiologies.  nsaids? [**last name (un) 284**]?
   - cont hydroxyzine from one more day
   - check cuff leak and extubate in am
   - hold all non-essential possible culprit meds: [**last name (un) 284**], felodipine, lasix,
   nadolol, bactrim
   - f/u complement studies at [**hospital3 2546**]
   - consider allergy consult
   - contact blood bank re risk of angioedema with transfusion as pt will
   need future transfuse and may be at risk for recurrent episode
   .
   # hx  cirrhosis:
   - cont lactulose
   .
   #cri: baseline 1.5, was elevated on admission to [**hospital3 5692**] to 1.7 now
   down to 1.1
   - monitor.
   icu care
   nutrition:
   glycemic control:
   lines:
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
"
116,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
"
117,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   angioedema
   assessment:
   pt arrived to micu 7 in nad. denies cp/sob or any difficulty breathing.
   psv 50% 10/5. ls cta. tongue slightly protruding/deviating to left side
   of mouth. pt suctioned for significant amt of thick blood tinged oral
   secretions. rr teens -20
s. afebrile.
   action:
   cxr o/n to assess ett/ogt placement (wnl) frequent mouth care o/n. sbt
   in place @ 0600 & doing well.
   response:
   tolerating sbt @ this time. oral secretions have decreased. tongue
   swelling appears to have also decreased.
   plan:
   extubation this am. pt is a known difficult intubation per transfer
   note from st. e
s. cont to monitor resp. status.
          pt
s son [**doctor first name 4215**] at bedside and spoke w/ this rn and micu
   team. pt is [**name (ni) **] speaking only but follows gestures/commands very
   well.
"
118,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   action:
   response:
   plan:
"
119,"infection
   assessment:
   pt febrile yesterday to 104, thick yellow secretions, suspected
   infection/peritoneal abcess.
   action:
   pt taken to or for peritoneal/drain washout, 1 gram vancomycin given
   interoperatively.
   response:
   no adverse events in or, no ebl, vs stable per report, returned to unit
   ventilated.
   plan:
   continue to monitor for s/s of infection, tx as indicated.
   respiratory failure, acute (not ards/[**doctor last name 2**])
   assessment:
   pt on trache mask on 10l o2 at 35%, coughing up thick yellow secretions
   but unable to fully clear them himself.  ls ronchorous/crackles. pt
   then went to or for washout, returned vented.
   action:
   sxn prn
   response:
   pt maintaining sat of 100%
   plan:
   keep vented [**name6 (md) **] pre md [**last name (titles) 5502**], keep trache cuff fully inflated to
   minimize risk of aspiration.
   tachycardia, other
   assessment:
   hr 95-110
   action:
   lopressor q 6 hours, methadone q 12 hrs, repositioned for comfort.
   response:
   hr wnl s/p lopressor but then slowly increases towards dose time.
   plan:
   ? increase dose frequency or amount.
"
120,"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
"
121,"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
"
122,"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
"
123,"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
"
124,"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:
"
125,"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
"
126,"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:
"
127,"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
"
128,"patient extubated on [**2149-8-19**] without any adverse events. kept
   overnight for observation as the family would like to make her comfort
   measures only and have her transported home to be with them. this case
   has been followed closely by social services and case management,
   arrangement were made in collaboration with family members for hospice
   care at home and for oxygen therapy as needed.
   this morning it is the consensus of the medical team that the client is
   stable enough to be transported home via ambulance in the company of
   family. she left the unit at approximately 1030, discharge paper work
   completed and necessary documents given. the grand daughter of patient
   did collect home medications from the [**company **] pharmacy prior to
   leaving.
"
129,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension; one ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: ercp [**2179-2-13**]
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   90% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 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:
"
130,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   patient started on clear liquid diet this am [**2-14**], tol well. pt
   remains alert/ oriented, denies pain. vss. afebrile. ambulates in room,
   tol well, steady gait. wbc trending down, cont on ns at 100ml/hour per
   surgery. cont unasyn iv. voids per urinal , 1bm this am.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension, 1ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: [**2179-2-13**] ercp
   latest vital signs and i/o
   non-invasive bp:
   s:123
   d:53
   temperature:
   97
   arterial bp:
   s:
   d:
   respiratory rate:
   13 insp/min
   heart rate:
   66 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   96% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   2,520 ml
   24h total out:
   825 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2179-2-14**] 04:09 am
   potassium:
   3.5 meq/l
   [**2179-2-14**] 04:09 am
   chloride:
   113 meq/l
   [**2179-2-14**] 04:09 am
   co2:
   18 meq/l
   [**2179-2-14**] 04:09 am
   bun:
   23 mg/dl
   [**2179-2-14**] 04:09 am
   creatinine:
   0.8 mg/dl
   [**2179-2-14**] 04:09 am
   glucose:
   66 mg/dl
   [**2179-2-14**] 04:09 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 am
   valuables / signature [**2179-2-14**]
   patient valuables: wristwatch
   other valuables:
   clothes:  jacket, jeans, tshirt, underwear, hat, belt, boots,
   toiletries
   wallet / money:  brown leather wallet, no money, one bankcard
   cash / credit cards sent home with:
   jewelry:
   transferred from: [**hospital ward name **] 4
   transferred to: 917
   date & time of transfer:  [**2179-2-14**] 1300
"
131,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   patient started on clear liquid diet this am [**2-14**], tol well. pt
   remains alert/ oriented, denies pain. vss. afebrile. ambulates in room,
   tol well, steady gait. wbc trending down, cont on ns at 100ml/hour per
   surgery. cont unasyn iv. voids per urinal , 1bm this am.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension; one ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy, [**doctor first name **]-[**doctor last name **] 2 [**2140**],
   aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: ercp [**2179-2-13**]
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   97
   o2 flow:
   ra
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 am
   valuables / signature
   patient valuables: wristwatch
   other valuables:
   clothes:  jacket, jeans, tshirt, underwear, hat, belt, boots,
   toiletries
   wallet / money:  brown leather wallet, no money, one bankcard
   cash / credit cards sent home with:
   jewelry:
   transferred from: [**hospital ward name **] 4
   transferred to: 917
   date & time of transfer:
"
132,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
"
133,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   90% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 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:
"
134,"68 yr old man presented to [**hospital 11358**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
"
135,"clinician:  resident
   patient became acutely hypotensive during morning rounds.  he consented
   to central venous and arterial line placements.  the patient was
   prepped and draped in a sterile fashion for a left subclavian central
   venous line.  the vein was canulated, but resistance was met when
   threading the catheter.  this was concerning for a possible left
   subclavian clot and the procedure was aborted.  the patient was then
   reprepped for a right femoral central line, which was successfully
   placed without events.  additionally, a left radial arterial line was
   placed under sterile conditions without adverse events.  a
   post-procedure cxr was obtained given multiple attempts made for a left
   subclavian line; no pneumothorax or hemothorax was present.
"
136,"[**2133-9-15**] 4:15 pm
 tunneled central line placemen                                  clip # [**clip number (radiology) 103627**]
 reason: 72 year old man with hepatorenal syndrome on chronic hd, pul
 ********************************* cpt codes ********************************
 * [**numeric identifier 4860**] exch central tunneled w/o port                                         *
 ****************************************************************************
 ______________________________________________________________________________
 [**hospital 2**] medical condition:
  72 year old man with hepatorenal syndrome on chronic hd, pulled out his
  tunneled line at the rehab, needs hd line replaced
 reason for this examination:
  72 year old man with hepatorenal syndrome on chronic hd, pulled out his
  tunneled line at the rehab, needs hd line replaced
 ______________________________________________________________________________
                                 final report
 indication:  patient with chronic renal failure, discontinued his right-sided
 tunneled hemodialysis line.

 operators:  dr. [**last name (stitle) 5928**] [**name (stitle) 997**] (fellow) and dr. [**first name8 (namepattern2) 1617**] [**name (stitle) 291**] (attending)
 performed the procedure.

 anesthesia:  moderate sedation was provided by applying divided doses of 150
 mcg of fentanyl and 2 mg of versed.

 procedure performed:  placement of tunneled hemodialysis line using the old
 tract via the right side of the chest and right-sided venotomy.

 procedure details:  written informed consent was obtained from the healthcare
 proxy after discussing the risk, benefits, and possible complications of the
 procedure.

 given a recent history of elevated white cell count of unclear etiology, the
 [**name (ni) 103628**] was rechecked in the hospital at the day of the examination and found to
 be trending down.  as previous elevation of blood cell count was not
 accompanied by positive blood cultures, it was agreed between multiple
 attendings to go ahead and replace the tunneled line.

 accordingly, the patient was placed supine on the imaging table and the right
 chest and neck prepped and draped in the usual sterile fashion.  a
 preprocedure timeout was performed as per [**hospital1 51**] protocol.

 using a microsheath a 0.035 glidewire, the old right chest/neck tunnel was
 easily recannulated and access regained into the venous system.  after the
 glidewire had been parked in the upper ivc, a kumpe catheter was inserted to
 exchange for an amplatz catheter.  after re-dilating the tract using 7 and 9
 french dilators, a peel-away sheath was introduced.  over the latter, a 10
 french 23 cm tunneled hemodialysis catheter could be passed down with its tip
 parked in the right atrium.  the peel-away sheath was removed and the catheter
 secured with 2-0 silk sutures and a sterile dressing.  the patient tolerated
 the procedure well and there were no adverse events in a total post-procedural
 monitoring time of more than one hour.

 impression:  successful placement of tunneled hemodialysis catheter over the
                                                             (over)

 [**2133-9-15**] 4:15 pm
 tunneled central line placemen                                  clip # [**clip number (radiology) 103627**]
 reason: 72 year old man with hepatorenal syndrome on chronic hd, pul
 ______________________________________________________________________________
                                 final report
 (cont)
 old right chest, right internal jugular vein tract.  the tip is located in the
 right atrium and the catheter is ready for use.

"
137,"nsg note [**3-4**] 0700-1900
neuro: pt awake, off propofol. follows for simple commands. oriented to place only. perseverating her last name. see neuro assess under care-vue flow. md [**first name (titles) 7161**] [**last name (titles) 10089**] psych eval consult to be called when pt less confused. pt being ""called out"" [**name6 (md) 20**] micu md. [**first name (titles) **] [**last name (titles) **] pending. restraints off x's 4 extremeties, csm's wnl. combative at times, pulling at o2, lines ect. very difficult for rn to leave room r/t pt safety - pt remains safe while rn in room. no adverse events noted at this time r/t safety.


cv: nsr on telemetry. a-line l radial dc'd per orders. elevated bp after extubation. - no new orders at this time. cont. to assess. 160-170 systolic. color pink.

resp: pt extubated @12noon to ofm 70%. 1400 placed to nc 4l cont. pleth sats remain 98-100%. pt c congested cough and unable to expectorate by herself - cough too weak - frequent chest pt by nursing.ls rhonchorous after ext.

gi: ngt removed. adb soft ntnd. +flatus. rectal tube dc'd tis am. no stool since.

gu: foley bsd - u/o & bp stable. u/o has picked up from noc's. currently ~ 125cc/hr. clear yellow. bun 5 this am. creat - wnl.

skin - hemmatoma to l dorsal asspect of shoulder - this as noted on admission. skin integ. intact. complete bath and linen change.

social - refer to neur note above. pt code status remains full. pt husband present and very supportive - bringing [**male first name (un) 2952**] present. support provided and questions answered.
"
138,"ccu nursing progress note
please see nursing admission summary

s:  denies c/o itching.  asking many questions re: asa desensitization therapy

o:  see flow sheet for objective data.

pt. premedicated with 25 mg po benadryl 45 minutes prior to start of asa desensitization. patient received progressively increasing doses of asa according to protocol.  rn in room continuously throughout protocol and for 45 minutes after the last dose.  patient without vs changes, no wheezing, no edema, no rash.  patient instructed to immediately notify nurse of any itching, or change in sensation through the night.

pt. given info and explained the purpose of health care proxy.    [**name (ni) **] does not wish to complete the form this evening, but says that he might be willing to do it tomorrow (""doesn't want to jinx himself."")  does state that he would designate his wife as proxy anyways, so legally, he's not sure if it makes any difference.  have explained that not all patients designate their spouse to be proxy, and it gives the health care providers a more clear indication of his wishes.

pt is pre-cath for tomorrow.  pt. does not have any further questions re:  cath procedure.

a:  s/p successful completion of asa desensitization protocol without adverse events.

p:  monitor for delayed allergic reaction. follow pre cath orders.  re-assess wishes regarding health care proxy tomorrow.
"
139,"micu nsg, 7a -7p
events:  pt had neg epg in am, to angiography for head and neck angiogram in pm.

neuro:  essentially unchanged.  alert, oriented x2. perl.  expressive aphasia, answering mostly yes,no, occ. word answers.  follows commands.  has not moved right arm or hand today.  lifts right leg only slightly.  lifts and holds left arm and leg.  no c/o pain.  medicated w midazolam and fentanyl at 1115 for epg, no adverse events.

cv:  bp 140-168/72-77 w no antihypertensive medications.  hr 76-80, nsr, no ectopy.  repleted k, mag, calcium.  inr 1.1.  tmax 99.4.
hct stable and increasing w blood products.  0900 hct 28.1, repeat sent at 1500, next one due at 2100, q 6h.  received 1upc at 1000.

resp:  99-100% o2 sat on ra.  ls clear.  rr 19-22.

gi:  egp negative.  +bs.  no stool, but staining melena, passing gas.  ng tube in place w sm, yellow residual, ob neg.  npo except for meds.

endo:  2 u reg ins. for fs 135 per riss.

social:  visited by aunt [**name (ni) **] - spokesperson.  with [**doctor first name **], social worker and [**name (ni) **], pt decided to allow knowledge of herself out to [**name (ni) **], [**name (ni) **] (aunts), and [**name (ni) 5525**], her neice.  others are to get information from them.
gu/flds:  uo very adeq at 40-180/hr, cl,yel urine.  pt + 1500 today, 2675 los.

plan:  to have colonoscopy in micu [**doctor first name **] am, approx 1100.  monitor hcts for further bleeding.
"
140,"micu npn 7p-7a
this is a 55 y/o female with hx cervical ca with xrt and htn. presented to osh, after neighbor found her confused, with rhabdo, leukocytosis, hypotension, arf (resolved with flds), and uti. found to have mssa bacteremia that seeded to left hip (confirmed by tap)and left knee. ct with multi infarcts (septic emboli). also noted to have nstemi and question abscess vs tumor to spine. transferred to [**hospital1 10**] for further w/u on [**3-27**].

since admit pt had left knne tapped that was mssa. went to or on [**3-28**] for i&d of left hip and knee. then started on pca dilaudid. [**3-29**] tee confirmed vegetation on aortic valve. [**3-31**] mri of c-spine was neagtyive and started on decadron. [**4-1**] left knee washout. [**4-2**] thoracic and lumbar mri. hospital course shows that she has had 3units of prbc's for hct trending down. hemodynamics and resp status have been stable. has been aaox3 with no adverse events. pain controlled with pca and prns. mssa treated with nafcillin and has been afebrile with wbc wnl. surveillance bls cx's ngtd.

neuro: patient has had a rough night. at beginning of shift with daughter in room she was aaox3 and cooperative. was weepy when daughter left. as shift has progressed patient has become more delirious. she remains oriented but has increasingly become more anxious, frustrated, agitated, and paranoid. has been found several times pulling off gown, leads, and cuff. when asked what is wrong or what she is doing she will say she is frustrated or doesn't know what to do next and begin to cry. ?steroid induced psychosis. ativan 2mg x2 as well as ambien for sleep has not helped. md aware. she is moving all extremities much more easily with less pain. has decreased the use of her pca and has been seen pulling herself on her side. will follow commands appropiately. mri pending from yesterday. soft wrist restraints placed this morning as she continously interferes with proper monitoring and care needed.

cardiac: hr 101-120 st with no ectopy. ^hr [**2-10**] anxiety. bp 125-155/66-87, on lopressor and lisinopril. pp by doppler. hct continues to trend down, 22.6 from 25.3. no signs of bleeding other than blood collecting in the drains.

resp: remains on room air with rr 14-30 and sats 95-100%. ls clear with diminished bases. no cough/cong/sob.

gi/gu: abd soft and obese with +bs. mushroom cath removed as stool becoming to thick. is brown. uop 40-60cc/hr amber/yellow with sediment. creat rising to 1.3 from 1.1.

fen: cvp 6-11, anasarca. +12l los. lytes per carevue. house diet but poor intake. needs encouragement. albumin low.

id: tmax 99.1 with wbc 8 down from 11. continues on nafcillin. cx's ngtd.

skin: rash to back improved, sarna lotion apllied. dsg changed to left hip, weeping lge amount of serous fld. staples intact. dsd and ace wrap to left knee, small amount of blood oozing through. jp drains intact. groins with yeast rash, mycostatin powder applied.

access: rij cvl.

social/dispo: full code. husband and daughter visiting last noc. awaiting read of yesterday's m
"
141,"addendum

r sided pleural effusion tapped for 1 liter of straw colored fluid.
follow-up cxr to be done.

no adverse events during procedure. pt maintained [** **] 97-99% while on 2l nc.

"
142,"neuro: pt gcs 14 -15. mae. l ue a little weaker than r ue - d/t pain? pt legally blind but does some have some sight in r eye. + sensation to cold/wet/tactile all the way up to shoulders. assessed per anesthesia this am and by nursing t/o day. states feels ""colder in bilat le and in l chest area"" just ""cold"" over r chest area. pt verbalizes needs appropriately.

cv: sr - st. no ectopy. vs stable as per flowsheet. skin warm and diaphoretic to touch at times. cap refill less than 3 secs t/o ext and pink. t max 101.2 orally - tx'd with tylenol with + effects. r ij cordis rewired to a tlc with adverse events. + pulses in l ue brachial, radial and ulnar - checked q 4 hours as ordered.

pulm: 0730 [** **] this am. pt tolerated without diff. attempted t mask today. able to maintain for approx 2 hours. requiring fentanyl for pain control and when dozing off experienced periods of apnea. pt placed back on vent and tolerating without diff. breathing over vent and sats > 96%. cuff remains down on trach and do not suction remains in effect. encourage tcbd and freq repositioning as tolerated. r ct to h2o seal and putting out minimial sang. drainage.

gu: abd soft round and nontender. taking clears as tolerated when off vent. no bm today. foley to straight drain without any tension on tubing. goal for uop 200 - 300 cc/ hour.

pain: has been an issue today in l shoulder area and intermittently in r thoracotomy incision. attempted fentanyl pca without successful pain control and increased bupivicane infusion via epidural to 10/hour. currently on fentanyl gtt at 50 mcg/hour and pt is dozing - wakes with ease and states it is ""better"". repositioning and hot packs applied to l shoulder as pt requests.

plan: to cont to obs and manage pain as needed. monitor uop and administer fluids as ordered as well as continue q 4 hour blood draws. encourage tcdb.

[**first name8 (namepattern2) **] [**last name (namepattern1) 4290**], rn
"
143,"t/sicu nsg note
(continued)
d.
      lower extremity incisions as noted on careview flowsheet: lle lateral incision has moderate to large s/s drainage; ortho team aware.
      pre-exhiting right ischial pressure ulcer is unchanged. family states that this pressure ulcer occurred with patient's hospitalization ~ 7 months ago.

social- family visiting post-op; spoke with ortho and icu residents and this rn- progress update provided and plans for weekend care and ongoing support with intubation was discussed.

assess- 86 yo female s/p repair of bilateral femur fractures s/p fall out of bed at nursing home residence. lue fracture/dislocation was not able to be reduced. see orders for ortho care directives. tolerated or procedure without adverse events.
        low urine output post-op: fluid bolus without change.

plan- to remain intubated possibly over weekend with possible surgical repair of lue injury on monday. to reassess every day. provide necessary sedation to tolerate ett. provide analgesia for pain. monitor hemodynamic repsonse. provide oral care per vap protocol.
code status currently 'full code' for peri-operative interval- to reassess each day per patient condition and intubation status.
resume all rpevious medications and care per orders.

"
144,"resp care

pt gvn atrovent neb @ 2100 and 0200. rr ~ 20 , hr 60, spo2 95%. no adverse events overnight.
"
145,"nursing progress note
events: pt intubated at approx 1300 for increasing lack of airway protection with no adverse events.

neuro: pt now sedated on propofol for toleration of ett. when lightened, pt remains unresponsive. pt has [**last name (un) **] cough and gag. opens eyes spontaneously, but does not focus. perrla, 3mm, brisk. does not respond to verbal stimulus. pt postures with all extremeties to noxious stimuli. non-purposeful movement (posturing) in all extremeties. pt does not appear to be in pain.

cv: nsr/st, rare ectopy. pt very hyperdynamic with stimuli/coughing. hr 80-120, sbp 100-170's. +pp. lytes repleted as ordered.

resp: cmv 500x12/5/50. abg wnl. sats 98-100%. rr 20-low 30's with sx'ing. ls coarse bilaterally. pt sx'd several times for copious amts thick white secretions.

gi: abd soft, nt, ascites. awaiting vac dsg to be placed by trauma team. ngt to lis draining min amts bilious fluid. +bs. pt had one sm soft brown bm this shift totaling approx 2 [**1-19**] for today. pt received lactulose x2.

gu: foley draining adequate amts clear [**location (un) **] urine.

endo: riss, no coverage required.

id: tm 101.1. pt started on kefzol this morning. also receiving rifaximin.

skin: midline abd incision stapled and ota. lower portion has staples removed and awaiting vac dsg to be placed by trauma team. [**location (un) **] straps in place, wound draining copious amts serous fluid. also, small blister on coccyx.

social: social work involved in trying to track down possible family members in [**male first name (un) 3106**] for decision making.

plan: cont neuro checks q4hrs. light sedation for ett tolerance. pulm toilet. titrate lactulose to 3 lrge bms per day. frequent labs and repletions. awaiting pending cx results. follow up with sw on gaurdianship.
"
146,"fellow procedure note
lumbar puncture: baby was prepped and draped in the usual sterile fashion and placed in lld position.  0.5 ml of lidocaine was injected into skin.  a 22 guage 1.5inch sterile spinal needle was introduced into the l5/s1 intervertebral space and approx. 2 cc of yellow/clear csf was withdrawn, slightly tinged w/blood.  these specimens were sent for gram stain, culture, tp, glucose, and stat cell count.  baby tolerated the procedure without adverse events.
"
147,"neonatology - procedure note
procedure: central line placement
indication: hypoglycemia

line placement for administration of higher glucose concentration in infant with hypoglycemia. [**initials (namepattern4) **] [**last name (namepattern4) 355**], [**last name (namepattern4) 1**] discussed plan with parents.

 sterile technique maintained throughout procedure: cap, gown, gloves, masks, sterile drapes. betadine & alcohol for prep. infant offered sucrose nipple and non-nutritive sucking throughout procedure. infant's extremities secured by nurse. attempted to place 5.0 fr uvc double-lumen catheter but unable to advance beyond 9 cm. 3.5 fr uac inserted to 19.5 cm and sutured in place. ebl < 1 cc. no adverse events during the procedure. babygram showed placement to t9. d15w to infuse at 100 cc/kg/d and follow d-sticks.
"
148,"varizig consent note
i met with [**doctor last name **] and [**known firstname 613**] [**known lastname 4366**] to discusse the risk/benfits of varizig because of her exposure to varicella.  we discussed circumstances of her exposure to her brother in very close proximity during the period of his highest viral shedding.  we discussed the incubation period of varicella.  we discussed the complications associated with varicella in an immunocompromised host.

i explained to the family that i had spoken with one of the research scientist who worked on varizig for cangene.  they explained to me the potential side effect and the adverse events reported.  there have been some who have developed fever and muscle ache at the injection site. there have not been any cases of death associated with the varizig. we discussed in detail the dosing and timing of dose related to exposure.  i talked to the fff enteprises the distributors of the varizig.  i also had an in depth discussion with the [**hospital1 187**] pharmacy.

i explained the the family the experimental nature of varizig. i explained that there was very little experience with giving the varizig in an infant as small as [**known lastname 4367**].  i also explained  that we had very limited other options.

i talked to the family with nurse [**first name8 (namepattern2) 2660**] [**last name (namepattern1) 2502**] present. the family agreed that the varizig should be given.  i wanted the family to take a little more time to think about it.  i let them take the hour long drive home.

an hour later, i called  the family at home.  i spoke with [**doctor last name **].  i reviewed the information we had previously discussed. i reviewed the irb informed consent with the family.  they continued to agree that [**known lastname 4367**] should be given the varizig.  they agreed to sign the consent form when they returned to the hospital.
"
149,"admission date:  [**2108-6-26**]              discharge date:   [**2108-7-2**]

date of birth:  [**2049-2-6**]             sex:   f

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2108-6-26**]: laparascopic sleeve gastrectomy


history of present illness:
[**known firstname **] has class iii extreme morbid obesity with weight of
364.3 pounds as of [**2108-5-29**] (her initial screen weight on [**2108-5-22**]
was 368 pounds), height of 65 inches and bmi 60.6.  her previous
weight loss efforts have included hmr for one year in [**2104**]
losing 20 pounds, off-label prescription weight loss medication
combination of fenfluramine/phentermine (""fen/phen"") in [**2092**] for
one year losing 70 pounds and [**street address(1) 41635**] visits on/off over
the past 5 years with very little weight loss.  she has exercise
for two years at curves for women losing 50 pounds and one year
of [**location (un) 86**] sports club in [**2106**] to [**2107**] losing 20 pounds. in all
of her efforts whatever weight she loss she was unable to
maintain from no more than one year.  she denied taking
over-the-counter ephedra-containing appetite suppressant/herbal
supplements.  her weight at age 21 was 150 pounds with her
lowest adult weight 125 pounds and her highest weight being 377
pounds earlier this year (2/[**2108**]).  she weighed 192 pounds at
age 33, 200 pounds at age 38, 286 pounds at age 46 and 325
pounds at the age of 50.  she stated she developed a significant
[**last name 4977**] problem at the age of 35 and has been struggling with
weight since birth of her second child and quit  smoking in
[**2081**].  factors contributing to her excess weight include large
portions, genetics, too many carbohydrates and emotional eating.
 for exercise she does water aerobics 60 minutes 5 days per week
since [**month (only) 359**] and lap swimming 90 minutes 5 days per week.  she
denied history of eating disorders and does have depression but
has not been followed by a therapist nor has she been
hospitalized for mental health issues and she is on psychotropic
medication (sertraline).


past medical history:
past medical history:  notable for fatty liver, rotator cuff
tendinitis, right shoulder, obstructive sleep apnea, type 2
diabetes with a1c of 6%, dyslipidemia, gastroesophageal reflux,
osteoarthritis of the knees, aortic valve regurgitation, past
depression.

past surgical history:  c-section x 2, carpal tunnel, right hand

social history:
she smoked one to two packs a day for 25 years quit [**2091**], no
recreational drugs, has occasional alcohol, drinks caffeinated
beverages.  she is a retired teacher, is divorced and has two
adult children

family history:
her family history is noted for father deceased age 58 with
heart disease, hyperlipidemia and obesity; mother living with
hyperlipidemia; sister deceased at 36 years of age secondary to
bulimia; maternal and paternal grandparents with heart
disorders.

physical exam:
vs: t 98, hr 86, bp 149/65, rr 18, o2 97%ra

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd: soft, appropriate peri-incisional tenderness, no rebound
tenderness/guarding
wounds: abd lap sites with steri-strips cdi, no periwound
erythema, + periwound ecchymosis
ext: no edema

pertinent results:
labs:
[**2108-6-27**] 07:40am blood hct-36.2
[**2108-6-26**] 04:21pm blood hct-38.4
[**2108-6-28**] 09:38am blood type-art po2-70* pco2-47* ph-7.40
caltco2-30 base xs-2
[**2108-6-30**] 06:40am blood wbc-5.6 rbc-4.21 hgb-11.3* hct-36.6
mcv-87 mch-26.7* mchc-30.7* rdw-15.2 plt ct-184 neuts-81.0*
lymphs-12.6* monos-3.6 eos-2.7 baso-0.1

imaging:
[**2108-6-27**]:
ugi sgl contrast w/ kub:
impression:  no evidence of obstruction or leak.


brief hospital course:
the patient presented to pre-op on [**2108-6-26**]. pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparascopic sleeve gastrectomy. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout
hospitalization; pain was initially managed with a pca and then
transitioned to oral roxicet once tolerating a stage 2 diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient was triggered on pod2 for desaturations
with an increased oxygen requirement.  the patient was
subsequently transferred to the tsicu on pod2 where she was
weaned to 3l nasal cannula; vancomycin was initiated as empiric
therapy.  she was subsequently transferred back to the general
surgical [**hospital1 **] on pod3 and weaned completely from o2 on pod5.
good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization. the pt was
maintained on cpap overnight for known sleep apnea.
gi/gu/fen: the patient was initially kept npo.  on pod1, an
upper gi study, which was negative for a leak, therefore, the
diet was advanced sequentially to a bariatric stage 2 diet,
which was well tolerated. however, on pod2, during period of
acute oxygen desaturation, the pt was made npo.  a methylene
blue dye test was performed without change in character of drain
output which remained serosanguinous throughout the admission.
the patient's diet was resumed and she was able to tolerate a
stage 3 diet without incident. patient's intake and output were
closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none; empiric treatment with
vancomycin was administered from pod2 through pod5 as described
above.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
metformin 500 mg [**hospital1 **]
omeprazole 20 mg daily
sertraline 50 mg daily
simvastatin 20 mg daily
vitamin d3 5000 units daily
multivitamin with minerals 1 tablet daily

discharge medications:
1. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*
2. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day
for 1 months.
disp:*600 ml* refills:*0*
3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**6-21**] ml
po every four (4) hours as needed for pain.
disp:*250 ml* refills:*0*
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day.
disp:*250 ml* refills:*0*
5. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable/crushable; no gummy.
6. metformin 500 mg tablet sig: 0.5 tablet po twice a day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule;
sprinkle contents onto applesauce, swallow whole.
8. sertraline 50 mg tablet sig: one (1) tablet po once a day.
9. simvastatin 20 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
morbid obesity


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except:
1.  please decrease your metformin to 250 mg twice daily.
please continue to monitor blood sugars and report elevated or
low readings to your prescribing provider.

crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:15 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:30 am
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2108-7-2**]"
150,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
151,"admission date:  [**2160-6-15**]     discharge date:  [**2160-6-22**]


service:

chief complaint:  ""i've been feeling bad for the last few
days and since yesterday i have been nauseous and vomiting.""

history of present illness:  the patient is a 77-year-old man
who presents with the above chief complaint and his past
medical history includes numerous medical problems including
non q wave mi times two, status post cabg in [**2139**],
hypertension, insulin dependent diabetes mellitus,
hypercholesterolemia, history of tias, history of lower gi
bleed and diverticulosis.  the patient was in his usual state
of health until approximately 4-5 weeks ago when his
degenerative joint disease and disc disease of his lumbar
spine began causing shooting right lower extremity pains.  at
that time the patient was treated with steroid injections and
po prednisone which caused an increase in his blood sugars.
for this increase in blood sugars he was started on humalog
approximately 3-5 days ago as his sugars have been in the
300-400's on his previous regimen.  approximately one week
ago the patient began feeling bad and run down.  the
patient's primary care doctor believed it was due to the high
blood sugars and started the humalog 3-5 days ago.  yesterday
the patient reports the onset of nausea and vomiting after
eating.  he tolerated lunch as his last meal and he has not
taken any po today.  also today he reports the onset of loose
stools times three.  he denied any fevers, abdominal pain,
weight change or urinary symptoms.  he does acknowledge night
sweats and chills at night over the last two days.  he has a
chronic cough secondary to post nasal drip which is
unproductive of sputum.  there is no erythema over the skin
where he injects his insulin.  his exercise tolerance is
approximately one flight of stairs and he is limited by right
lower leg pain.  he also denies any chest pain, shortness of
breath, palpitations or diaphoresis.  he has no pnd.  the
patient finally came to the er as he was not able to take
anything by mouth.

past medical history:  1) insulin dependent diabetes
mellitus.  2) hypertension, poorly controlled.  3) chronic
renal insufficiency.  4) status post non q wave mi times two.
5) status post cabg in [**2139**].  6) hypercholesterolemia.  7)
history of tia.  8) gout.  9) lower gi bleed status post
polyp removal.  10) diverticulosis.  11) allergies and post
nasal drip.

medications:  [**doctor first name **] 60 mg po q d, lopressor 20 mg po q d,
multivitamin, doxazosin 4 mg q h.s., lipitor 20 mg po q d,
allopurinol 300 mg po q d, ranitidine 150 mg po q h.s.,
glyburide 10 mg po bid, diovan 80 mg po q d, enteric coated
aspirin 325 mg po q d, quinine as needed, nph 20-30 units q
a.m., 10-15 units q p.m., humalog sliding scale started three
days ago.

social history:  the patient lives with his wife.  [**name (ni) **] denies
any tobacco or alcohol use.

family history:  noncontributory.

allergies:  morphine makes him nauseous.

physical examination:  vital signs, temperature 99.5, heart
rate 83, blood pressure 170/125, respiratory rate 18, satting
100% on two liters nasal cannula.  in general he is an
elderly man lying in bed in no acute distress.  heent:  he
has alopecia, pupils are equal, round and reactive to light
from 3 to 2 mm, sclera are anicteric.  mucus membranes are
moist.  neck supple, no jugulovenous distension, no
lymphadenopathy, no bruits.  cardiac exam, irregularly
irregular, s1 and s2 normal, no murmurs, gallops or rubs.
lungs are clear to auscultation bilaterally. abdomen, mild
tenderness to deep palpation of the left lower quadrant.  he
is non distended, bowel sounds present and normal.  abdomen
is soft.  gu, normal male genitalia, trace guaiac positive on
exam.  prostate without any nodules, regular and smooth.
extremities, no clubbing, cyanosis or edema. neuro, he is
alert and oriented times three, cranial nerves ii through xii
normal.  reflexes 2+ bilaterally biceps and achilles
strength, [**3-29**] upper extremities bilaterally, in the left
lower extremity is 4+/5 strength in his right big toe and
plantar and dorsiflexion of his foot.  gait and coordination
were not tested.

laboratory data:  white count 14.6, differential with 84
neutrophils, 1 band, 10 lymphs, hematocrit 44.4, platelet
count 134,000, pt 11.7, ptt 21.4, inr 0.9.  sma 7, 137, 5.2
which was hemolyzed, 100, 21, 40, 1.4, glucose 297.  calcium
8.4, phosphorus 4.7, magnesium 2.1, ast 24, alt 28, total
bilirubin 0.9, ck 54, troponin 0.3, alkaline phosphatase 59,
amylase 114, lipase 41, albumin 3.3, uric acid 4.3, tsh is
pending at this time.  chest x-ray showed no signs of
pulmonary edema and no infiltrate.  ekg was irregularly
irregular at 92, axis -30, occasional p waves, looking like
flutter but there are also absent p waves.  intervals are
normal.  there is a q in 3 and f, no st changes, poor r wave
progression.  an echocardiogram from [**2160-4-25**] showed mild
left atrial dilatation, non obstructive focal septal
hypertrophy, depressed lv function 1+ aortic regurg, mild mr
[**first name (titles) **] [**last name (titles) **] fraction could not be estimated at that time.

impression:  this is a 77-year-old man with multiple ongoing
medical problems who presents with generalized complaints of
the last week and a [**11-27**] day history of nausea and vomiting
and loose stool.  he was found to be in new onset atrial
fibrillation in the er.  physical exam was remarkable for the
atrial fibrillation with guaiac positive stool and mild left
lower quadrant tenderness.  labs revealed an increased white
blood cell count with left shift and low albumin.  chest
x-ray and ekg are normal and unchanged respectively.

plan:
cardiac:  the patient has known cad.  his aspirin, beta
blocker, lipitor and [**last name (un) **] will be continued.  his hypertension
will be aggressively controlled.  although ischemia is
unlikely without any changes in ekg, cks will be followed.
the patient is in new onset atrial fibrillation but lopressor
will be increased to 50 mg [**hospital1 **] for rate control.  tsh is
pending after weighing the risks and benefits of heparin.
given the patient's trace guaiac positive stool, history of
lower gi bleed, the decision was made to start the patient on
heparin as he had multiple risk factors for stroke elevating
him into a higher level of category including his past
history of tias.

infectious disease:  he has an elevated white count with a
left shift.  he has night sweats, chills times two days.
cultures of urine, stool and blood will be sent.  blood
cultures will be obtained when the patient's fever curve is
greater than 101.  no empiric antibiotics will be started at
this time.

endocrine:  the patient has poor glucose control.  he will be
written for an insulin sliding scale while in the hospital
and fingersticks will be checked qid.  his oral hypoglycemics
will be held for now.

gi:  he is trace guaiac positive with left lower quadrant
tenderness and a history of diverticulosis.  diverticulitis
is certainly a possibility although given the benign
presentation of his abdomen on exam, it is unlikely.
however, we will continue to follow his abdominal exam.  we
will guaiac all stools and we will follow hematocrit q d on
heparin.  the patient will be given antiemetics as needed to
control the nausea and vomiting.

renal:  the patient has a creatinine of 1.4 with an elevated
bun to creatinine ratio.  he is most likely dehydrated given
his nausea and vomiting and slightly prerenal and will be
hydrated.

musculoskeletal and neuro:  he has decreased strength in his
right lower leg consistent with his past medical history of
djd and disc disease of his lumbar spine.  his pain will be
controlled with non opioids as much as possible as opioids
have given him bad reactions in the past.  the patient was
admitted and this plan was pursued.

hospital course:  on hospital day #2 the patient had no
adverse events overnight.  the stool samples and the tsh are
still pending.  the patient is maintained on heparin and the
plan will be to transition him to coumadin, then to discharge
the patient and bring him back at 1-2 months for tee and
cardioversion at that time after anticoagulation, as it is
unknown how long patient has been in atrial fibrillation.
also on this admission the plan is to control his blood
sugars, hopefully the combined approach will lead to a
resolution of his nausea and vomiting and he can go home.  on
hospital day #3 the patient complained of some right thigh
swelling.  he was neurovascularly intact and this was thought
to be secondary to a muscle pull the patient experienced
approximately five days prior to admission.  there was a
small hematoma.  this is most likely exacerbated because of
the heparin the patient has been on, but the team was not so
concerned about this.  also on the third hospital day the
patient became tachycardic and hypotensive with blood
pressure in the 60's/30's.  the patient was somnolent at this
time.  exam was unchanged from prior.  iv fluids were given
and ekg was done that was unchanged.  the heparin was
discontinued and an ng lavage was performed that showed dark
brown fluid in the stomach with occasional clots which were
gastroccult positive.  with the lavage, the red fluid did not
clear.  a stat hematocrit came back at 26 which was down from
44 on admission, although this is partly due to rehydration,
this is significantly due to an upper gi bleed.  the patient
was transferred to the ccu at that time and transfused two
units of packed red blood cells.  the patient underwent
emergent egd that showed clotted blood in the lower third of
the esophagus and multiple non bleeding diffuse erosions in
the lower third of the esophagus.  the stomach was normal.
in the duodenum there were multiple acute crater ulcers in
the bulb and in the second part of the duodenum.  pigmented
material coating these ulcers suggested recent bleeding in
one of the ulcers.  the patient was treated with proton pump
inhibitor [**hospital1 **], discontinuation of all nsaids and
anticoagulation.  hematocrits were continually followed and
an h. pylori antibody was checked.  the tsh level came back
as normal at this time.  on the fourth hospital day the
patient was transferred back to the floor from the unit after
the egd and the 2 units of packed cells when patient was
stabilized.  on hospital day #5 the patient's main complaint
was his right thigh swelling leading to right thigh weakness
when he stood up.  he denied anymore episodes of
lightheadedness, dizziness, chest pain, shortness of breath,
bright red blood per rectum, melena or vomiting of blood.  at
this time his aspirin was changed to 81 mg from 325 mg and
the patient was not on either heparin or coumadin.  the
patient's hematocrit post transfusion rose to 31 and has
continued to rise since then.  his creatinine and bun bumped
transiently during the patient's hypovolemia episodes.  they
are now trending down.  the nph and regular insulin sliding
scale is controlling the patient's blood sugars.  [**initials (namepattern4) **] [**last name (namepattern4) **]
consult was obtained because the patient is usually followed
in [**last name (un) **], to further optimize the patient's insulin regimen.
the plan is to treat the patient for one month with proton
pump inhibitors, to follow-up the results of the h. pylori,
treat that if positive and to allow the ulcers one month to
heal.  the patient will return for a repeat upper endoscopy
in one month.  at that time if the ulcers are healed,
anticoagulation will be pursued with the eventual goal of
performing a tee and cardioversion either chemical or
electrical, once the patient has been on stable
anticoagulation for one month.  hospital day #6 the patient's
diet was advanced as tolerated.  physical therapy saw the
patient who agreed he was safe for discharge home.  on
hospital day #7 the patient slowly was regaining his strength
in his right leg and mobility.  he was starting to ask to go
home.  on hospital day #8 he was discharged home.  he will
follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 1313**], dr. [**last name (stitle) 19862**] from endocrine
and dr. [**first name (stitle) 1104**] from cardiology.  all of those attendings are
aware of the [**hospital 228**] hospital course.  the patient's
lopressor dose at the time of discharge is 37.5 mg po tid.
the h. pylori result came back positive.  he will be treated
for h. pylori infection.  he will follow-up with gi in [**2-29**]
weeks for repeat upper endoscopy.




                          [**first name11 (name pattern1) **] [**last name (namepattern4) 31943**], m.d.  [**md number(1) 31944**]

dictated by:[**last name (namepattern1) 8228**]

medquist36

d:  [**2161-1-28**]  12:05
t:  [**2161-1-28**]  14:07
job#:  [**job number **]
"
152,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
153,"admission date:  [**2130-4-26**]              discharge date:   [**2130-5-3**]

date of birth:  [**2048-7-7**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 3223**]
chief complaint:
incarcerated right inguinal hernia
left lower extremity cellulitis


major surgical or invasive procedure:
[**2130-4-26**]: right inguinal herniorraphy with mesh


history of present illness:
81m with right inguinal hernia with non-reducible bulge since
noon today.  pain in right groin since then. noted some
discomfort as early as this morning. has had some nausea
throughout day as well.  no vomiting or other abdominal pain.
has not noted a hernia before.  additionally left leg has been
red for a couple of weeks; has been using cream and has not seen
a physician for it.  did not notice that it was swolen.


past medical history:
past medical history: hearing impaired (fluent with sign
language), chronic 1st degree heart block, recurrent atrial
fibrillation/ atrial flutter, s/p dccv [**2120-1-24**], s/p dccv
[**2121-8-8**], bradycardia, elevated psa, htn, hyperlipidemia, m.r.,
basal cell ca s/p excision

past surgical history: none


social history:
lives alone. works for [**company 2318**], independent in adls. no tobacco,
rare etoh.


family history:
mother breast cancer, leg cancer, stomach cancer. father cva.
brother w/ cabg at 64yrs.


physical exam:
on admission:
vitals:97.2 95 182/91 16 100%
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: rrr, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds. right groin with palpable
non-reducible
large hernia, hernia contents extending into scrotum as well,
ttp.
dre: normal tone, no gross or occult blood
ext: no le edema, le warm and well perfused


pertinent results:
[**2130-4-29**]
labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3*
mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93
urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12
[**2130-4-29**] 05:30am blood calcium-8.5 phos-2.4* mg-2.0

[**2130-4-28**]:
chest (portable ap):
severe bilateral opacities appear to be unchanged with no change
in the element of pulmonary edema. cardiomegaly is severe. known
pericardial effusion is most likely present. consolidations in
the left lower lobe are slightly asymmetric and might represent
superimposed abnormality such as infectious process, please
correlate clinically.

[**2130-4-27**]:
echo: impression: mildly depressed left ventricular systolic
function. moderately dilated right ventricle. focal asymetric
hypertrophy of the basal antero-septum. heavily calcified aortic
valve. moderate amount of pericardial effusion with no evidence
of tamponade physiology.

ecg: atrial fibrillation with rapid ventricular response and
probable ventricular premature beats. slight intraventricular
conduction delay may be incomplete left bundle-branch block.
delayed r wave progression may be due to intraventricular
conduction delay, left ventricular hypertrophy or possible prior
septal myocardial infarction, although is non-diagnostic. st-t
wave abnormalities are non-specific but cannot exclude
myocardial ischemia. clinical correlation is suggested. since
the previous tracing of [**2130-4-26**] the rate is faster and lateral
lead st-t wave changes appear more prominent.

chest (portable ap): findings: as compared to the previous
radiograph, there is unchanged massive cardiomegaly. in
addition, there is evidence of mild to moderate pulmonary edema.
presence of co-existing pneumonia cannot be excluded. no
pneumothorax.

bilat lower ext veins port: impression: no dvt in the right or
left lower extremity.

labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30*
11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm
blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33*

[**2130-4-26**]:
ecg: atrial fibrillation. slight intraventricular conduction
delay may be incomplete left bundle-branch block. delayed r wave
progression with late precordial qrs transition may be due to
intraventricular conduction delay, left ventricular hypertrophy
or possible prior anterior wall myocardial infarction, although
is non-diagnostic. st-t wave abnormalities are non-specific.
since the previous tracing of [**2130-3-28**] the ventricular rate is
faster and the qtc interval is shorter.

labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1*
mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1
inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98
hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 [**2130-4-26**] 05:50pm
blood ctropnt-<0.01


brief hospital course:
the patient presented to the emergency department on [**2130-4-26**] due to a non-reducible right groin bulge with associated
pain and nausea.  additionally, the patient reported left leg
erythema which had been present for a few weeks without fevers.
given physical findings consistent with incarcerated hernia, the
patient was taken to the operating room where he underwent a
laparoscopic right inguinal hernia repair with mesh. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

shortly following transfer to the general surgical [**hospital1 **], the
patient was triggered for lethargy, hypoxia and atrial
fibrillation with rapid ventricular response.  intravenous
metoprolol and lasix were administered and the patient was
maintained on a non-rebreather with improved oxygenation.  he
was subsequently transferred to the trauma intensive care unit
for further management.

neuro: the patient was somnolent post-operatively, which was
deemed post-operative baseline by the als interpreter, who
reportedely knew patient well.  the somnolence resolved by pod1
and he remained alert and oriented throughout the remainder of
his hospitalization.  the patient is deaf at baseline and was
able to communicate via an als interpreter.  pain was well
controlled with oral tylenol and intermittent intravenous
hydromorphone.
cv: the patient has baseline rate controlled atrial fibrillation
on warfarin.    however, as described above, he developed a fib
with rvr on pod 0, which responsed to intravenous metoprolol
without recurrence.  additionally, an ekg obtained upon transfer
to the icu revealed st changes; cycled cardiac enzymes were
negative.  an echocardiogram was obtained and revealed mildly
depressed left ventricular systolic function, a moderately
dilated right ventricle, focal asymetric hypertrophy of the
basal antero-septum, heavily calcified aortic valve and a
moderate amount of pericardial effusion with no evidence of
tamponade physiology.  his home medication regimen was resumed
and the patient remained stable from a cardiovascular standpoint
for the remainder of his hospitalization; vital signs were
routinely monitored.
pulmonary: as described above, the patient experienced an
episode of hypoxia on pod 0, likely due to pulmonary edema.
intravenous lasix was administered with immediate effect.  upon
arrival to the icu, the patient was placed on bipap, which was
weaned to nasal cannula on pod 1.  the patient remained stable
from a pulmonary standpoint for the remainder of his
hospitalization and was weaned off supplemental oxygen entirely
on pod 3. good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
gi/gu/fen: the diet was advanced to regular on pod 1, which was
well tolerated.   patient's intake and output were closely
monitored; electrolytes were repleted routinely.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.  the left lower extremity
cellulitis improved on intravenous cefazolin and treatment was
transitioned to oral antibiotics on pod 4, which will continue
for an additional seven days.
skin: a deep tissue injury to the sacrum was identified while in
the icu.  aggressive skin care was provided via nursing without
evidence of further skin breakdown.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to
ambulate early and often.  additionally, given the events of
pod0, a lower extremity ultrasound was obtained and was negative
for a dvt.
rehab: the patient received physical therapy while hospitalized
due to deconditioning, but was deemed unsuitable for discharge
to home.  short term rehabilitation was recommended to maximize
independence and regain conditioning and independence.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating with a walker and physical therapy, voiding
without assistance, and pain was well controlled.  the patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
he will be discharged to a rehab facility for additional
physical therapy.


medications on admission:
atenolol 25mg daily
finasteride 5mg daily
simvastatin 20mg daily
verapamil er 240mg daily
coumadin 1mg daily
vitamin d2 1,000 units daily
vitamin e 400 units daily

discharge medications:
1. verapamil 240 mg tablet extended release sig: one (1) tablet
extended release po q24h (every 24 hours).
2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every
8 hours).
3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm.
4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five
(5) ml po q6h (every 6 hours) as needed for cough.
5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day): hold for loose stool.
6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily).

7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
8. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
9. bisacodyl 10 mg suppository sig: one (1) suppository rectal
hs (at bedtime) as needed for constipation.
10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).

11. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every
6 hours) for 7 days.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - [**location (un) 550**]

discharge diagnosis:
incarcerated right inguinal hernia
left lower extremity cellulitis


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 an incarcerated right
inguinal hernia and subsequently underwent surgical repair with
mesh.  additionally, you were noted to have cellulitis on the
lower aspect of your left leg, which was treated with
antibiotics.  during your stay, you also received treatment from
a physical therapist, who recommended discharge to a
rehabiliation facility to furhter improve your conditioning and
independence.  you are now preparing for disharge to a
rehabiliation facility with the following instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service at [**telephone/fax (1) 600**] to make a
follow-up appointment within 2 weeks.
please contact your primary care provider to make [**name initial (pre) **] follow-up
appointment within 1 week from discharge from the rehabilitation
facility.
provider: [**first name11 (name pattern1) 5445**] [**initial (namepattern1) **] [**last name (namepattern4) 5446**], dpm phone:[**telephone/fax (1) 543**]
date/time:[**2130-5-22**] 3:50
provider: [**first name8 (namepattern2) 6118**] [**last name (namepattern1) 6119**], rn,ms,[**md number(3) 1240**]:[**telephone/fax (1) 1971**]
date/time:[**2130-6-16**] 10:00


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

completed by:[**2130-5-3**]"
154,"admission date:  [**2146-6-15**]              discharge date:   [**2146-6-28**]

date of birth:  [**2081-10-25**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1556**]
chief complaint:
colon cancer
s/p jejunoileal bypass in [**2109**]

major surgical or invasive procedure:
[**2146-6-15**]: rt hemicolectomy, reversal of jejunoileal bypass, liver
biopsy (tru-cut needle).
[**2146-6-27**]: exploratory laparotomy with washout, repair of
perforation in ileum, placement of vacuum-assisted closure
dressing.


history of present illness:
64-year-old man with a history of colonic polyps, who on
screening colonoscopy ([**2146-5-17**]) demonstrated an ulcerated,
clamshell, nonobstructing mass in the cecum.  the length was
approximately 3 cm.  biopsy confirmed invasive
adenocarcinoma grade ii.  otherwise, he has had no change in his
health. no blood per rectum, no weight loss, no abdominal pain.
he currently has [**12-24**] formed bowel movements per day.  he does
experience loose bowel movements if he eats fatty foods or
cheese.

past medical history:
past medical history:
1.  myocardial infarction, [**2143**].
2.  right-sided nephrolithiasis.
3.  morbid obesity (bmi 44.3 kg/m2).
4.  hypertension.
5.  history of colonic polyps.

past surgical history:
1.  jejunoileal bypass, [**2109**] (16 inches of jejunum anastomosis
    to the last 6 inches of ileum) appendectomy was performed at

    that time.
2.  open cholecystectomy with choledochostomy tube and
    gastrostomy tube for acute gallstone pancreatitis, [**2109**].
3.  ureteroscopy with stenting, 05/[**2144**].  this was complicated
    by bradycardia into the 20s.
4.  cardiac pacemaker placement, [**2145-4-6**].
5.  right flank incision with stone extraction, [**2145-5-5**].
6.  cystoscopic attempted stone extraction and stenting,
    [**2145-5-21**].
7.  surgical extraction of right renal stone, [**2145-6-4**].
8.  cardiac stents (drug-eluting), [**2143**].
9.  right shoulder surgery, [**2140**], no metallic implants.

social history:
he does not smoke, drink excessively or use
drugs.  he manages an insurance firm.  he is accompanied by his
wife and daughter today.


family history:
significant for mother with [**name (ni) 2481**] disease,
father with [**name (ni) 5895**] disease.


physical exam:
bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi:
44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99.

physical examination:  general:  he is alert, oriented, in no
acute distress.  heent:  pupils are equal, round and reactive to
light.  sclerae anicteric.  oropharynx is clear.  neck:  supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly or nodules.  trachea is midline.  lungs:  clear to
auscultation bilaterally.  heart:  regular.  abdomen:  obese.
he
has a right subcostal incision (cholecystectomy).  he has a
right
lower abdominal transverse incision (intestinal bypass).  he has
a right flank incision (renal surgery).  there are no obvious
hernias.  there is no tenderness.  genitourinary:  penis is
circumcised.  testicles are descended bilaterally.  extremities:

without edema.  neurologic:  grossly nonfocal.


pertinent results:
[**2146-6-15**] 04:50pm   glucose-187* urea n-12 creat-1.0 sodium-141
potassium-4.1 chloride-104 total co2-27 anion gap-14
[**2146-6-15**] 04:50pm   estgfr-using this
[**2146-6-15**] 04:50pm   calcium-9.2 phosphate-3.9 magnesium-1.4*
[**2146-6-15**] 04:50pm   wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6*
mcv-77* mch-23.8* mchc-30.8* rdw-15.5
[**2146-6-15**] 04:50pm   plt count-102*
[**2146-6-15**] 12:44pm   type-art rates-/12 tidal vol-700 po2-330*
pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 12:44pm   glucose-153* lactate-2.1* na+-135 k+-3.8
cl--101
[**2146-6-15**] 12:44pm   hgb-10.7* calchct-32 o2 sat-97
[**2146-6-15**] 12:44pm   freeca-1.19
[**2146-6-15**] 10:53am   type-art rates-/12 tidal vol-700 po2-84*
pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 10:53am   na+-135
[**2146-6-15**] 10:53am   hgb-10.3* calchct-31 o2 sat-94

brief hospital course:
the patient presented to pre-op on [**2146-6-15**]. pt was evaluated by
anaesthesia and taken to the operating room where a laparoscopic
adjustable gastric band placement was performed. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout the
hospitalization; until her was intubated and sedated. pain was
well controlled with iv pain medications.
cv: vital signs were routinely monitored. the patient remained
stable from a cardiovascular standpoint until he developed
tachycardia and hypotension on [**2146-6-27**]. following that the
patient was placed on multiple pressors by the icu team. cardiac
enzymes were initially negative, a tee revealed a hyperdynamic
myocardium.
pulmonary: vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. the patient remained
stable from a pulmonary standpoint until [**2146-6-27**] when he
developed shortness of breath, new and increasing oxygen
requirement and desaturation. cta of the chest revealed no
evidence of pe, but the patient had evidence of worsening
pulmonary function and ards. he was intubated and his peep was
optimized using an intraesophageal balloon. he remained
intubated until the decision of comfort measures only was
executed terminally extubating the patient.

gi/gu/fen: he was kept npo with ng tube to suction. the patient
was initially putting out about 7-8 liters of bilious fluid a
day. this was adequately replaced with iv fluids. the patient
was later decreasing his ng tube outputs to 4 liters by day 6
post-operatively. the patient passed gas on the 5th day
post-operatively, and bowel movements pod6. tpn was started due
to the elevated ng outputs (dark green bile). patient's intake
and output were closely monitored.
 pod#12, the patient decompensated with sudden onset chest and
shoulder pain, shortness of breath, tachypnea, new oxygen
requirement, ekg new right bundle branch block, and transient
abdominal pain.
the patient was taken to the or and exploration revealed a total
of 5 liters of fluid non bilious. he was found to have one small
hole at the proximal anastomosis and purulent pocket. 3 drains
were placed. subsequently the patient developed multiple organ
system failure, with acute renal failure requiring continuous
venovenous hemodialysis. worsening refractory metabolic acidosis
requiring multiple boluses and iv drip bicarbonate. acute liver
failure was also noted with inr>3 and liver transaminases >[**2133**].


id: the patient's fever curves were closely watched for signs of
infection. the
patient developed sepsis as discussed above with multiple
organisms (k. pneumonia, b. fragilis,...) the patient was placed
on broad spectrum iv antibiotics.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

 the patient was showing signs of multiple organ system collapse
with refractory hypotension and acidosis despite maximal medical
therapy. a family meeting was conducted with the family deciding
that the patient's wishes would be to withdraw care at that
point. the patient was extubated terminally and the patient
passed away shortly after on [**2146-6-28**] at 17:37.

medications on admission:
medications - prescription
atorvastatin -  (prescribed by other provider) - 40 mg tablet -
1
tablet(s) by mouth once a day
hydrochlorothiazide -  (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth once a day
sildenafil [viagra] -  (prescribed by other provider) - dosage
uncertain
valsartan [diovan] -  (prescribed by other provider) - 80 mg
tablet - 1 tablet(s) by mouth once a day

medications - otc
aspirin -  (prescribed by other provider) - 81 mg tablet,
chewable - 1 tablet(s) by mouth once a day
cholecalciferol (vitamin d3) [vitamin d] -  (prescribed by other
provider) - dosage uncertain


discharge medications:
none

discharge disposition:
expired

discharge diagnosis:
cecal cancer with positive lymph node
reversal of jejunoileal bypass
liver cirrhosis secondary to jejunoileal bypass
acute respiratory distress syndrome
acute liver failure
acute renal failure
intraabdominal severe septic shock

discharge condition:
dead

discharge instructions:
na

followup instructions:
na


completed by:[**2146-7-26**]"
155,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
156,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
   demographics
   attending md:
   [**location (un) **] [**doctor first name **] a.
   admit diagnosis:
   tongue swelling
   code status:
   full code
   height:
   admission weight:
   58.6 kg
   daily weight:
   allergies/reactions:
   nsaids
   please avoid du
   precautions:
   pmh:  anemia, diabetes - oral [**doctor last name **], gi bleed, hepatitis
   cv-pmh:  hypertension
   additional history: hep c cirrhosis, portal htn w/ grade i varices,
   ascites, encephalopathy, variceal bleeding, dm 2, right renal
   nephrectomy for renal cell ca (15 yrs ago), hypercholesterolemia,
   osteopenia, insomnia,
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:122
   d:54
   temperature:
   98.7
   arterial bp:
   s:
   d:
   respiratory rate:
   22 insp/min
   heart rate:
   85 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   nasal cannula
   o2 saturation:
   96% %
   o2 flow:
   3 l/min
   fio2 set:
   50% %
   24h total in:
   655 ml
   24h total out:
   415 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2150-4-17**] 05:15 am
   potassium:
   4.3 meq/l
   [**2150-4-17**] 05:15 am
   chloride:
   112 meq/l
   [**2150-4-17**] 05:15 am
   co2:
   24 meq/l
   [**2150-4-17**] 05:15 am
   bun:
   27 mg/dl
   [**2150-4-17**] 05:15 am
   creatinine:
   1.1 mg/dl
   [**2150-4-17**] 05:15 am
   glucose:
   132 mg/dl
   [**2150-4-17**] 05:15 am
   hematocrit:
   31.4 %
   [**2150-4-17**] 05:15 am
   finger stick glucose:
   159
   [**2150-4-17**] 06:00 pm
   valuables / signature
   patient valuables: none
   other valuables:
   clothes:  sent home with:
   wallet / money:
   no money / wallet
   cash / credit cards sent home with:
   jewelry:
   transferred from: micu-7
   transferred to: [**hospital ward name 4126**]
   date & time of transfer:  [**2150-4-17**] 1830
"
157,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension; one ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: ercp [**2179-2-13**]
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   90% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 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:
"
158,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   patient started on clear liquid diet this am [**2-14**], tol well. pt
   remains alert/ oriented, denies pain. vss. afebrile. ambulates in room,
   tol well, steady gait. wbc trending down, cont on ns at 100ml/hour per
   surgery. cont unasyn iv. voids per urinal , 1bm this am.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension, 1ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: [**2179-2-13**] ercp
   latest vital signs and i/o
   non-invasive bp:
   s:123
   d:53
   temperature:
   97
   arterial bp:
   s:
   d:
   respiratory rate:
   13 insp/min
   heart rate:
   66 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   96% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   2,520 ml
   24h total out:
   825 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2179-2-14**] 04:09 am
   potassium:
   3.5 meq/l
   [**2179-2-14**] 04:09 am
   chloride:
   113 meq/l
   [**2179-2-14**] 04:09 am
   co2:
   18 meq/l
   [**2179-2-14**] 04:09 am
   bun:
   23 mg/dl
   [**2179-2-14**] 04:09 am
   creatinine:
   0.8 mg/dl
   [**2179-2-14**] 04:09 am
   glucose:
   66 mg/dl
   [**2179-2-14**] 04:09 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 am
   valuables / signature [**2179-2-14**]
   patient valuables: wristwatch
   other valuables:
   clothes:  jacket, jeans, tshirt, underwear, hat, belt, boots,
   toiletries
   wallet / money:  brown leather wallet, no money, one bankcard
   cash / credit cards sent home with:
   jewelry:
   transferred from: [**hospital ward name **] 4
   transferred to: 917
   date & time of transfer:  [**2179-2-14**] 1300
"
159,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   patient started on clear liquid diet this am [**2-14**], tol well. pt
   remains alert/ oriented, denies pain. vss. afebrile. ambulates in room,
   tol well, steady gait. wbc trending down, cont on ns at 100ml/hour per
   surgery. cont unasyn iv. voids per urinal , 1bm this am.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension; one ppd smoker
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy, [**doctor first name **]-[**doctor last name **] 2 [**2140**],
   aorto-bifemoral bpg [**2172**]
   surgery / procedure and date: ercp [**2179-2-13**]
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   97
   o2 flow:
   ra
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 am
   valuables / signature
   patient valuables: wristwatch
   other valuables:
   clothes:  jacket, jeans, tshirt, underwear, hat, belt, boots,
   toiletries
   wallet / money:  brown leather wallet, no money, one bankcard
   cash / credit cards sent home with:
   jewelry:
   transferred from: [**hospital ward name **] 4
   transferred to: 917
   date & time of transfer:
"
160,"68 yr old man presented to [**hospital 1097**] hospital [**2179-2-12**] with ruq pain and
   2-3 episodes of emesis and poor appetite x several days. he reports a
   similar episode 2 weeks ago. a u/s of the ruq revealed a distended gb
   with stones, sludge and a positive [**doctor last name **] sign, likely cholangitis.
   pt was transferred to [**hospital1 1**] for evaluation / ercp.
   ercp was done on [**2179-2-13**]. during the procedure several gallstones and
   sludge removed, stent placed. patient returned from procedure at 10am
   with no adverse events noted.
   hypotension (not shock)
   assessment:
   patient
s initially presented to the ed with hypotension where he was
   treated with fluids. since admission to the unit his bp has remained
   within acceptable limits.
   action:
   continuous blood pressure monitoring. he was received on ivf at
   200cc/hr and same was decreased to 100cc/hr.
   response:
   sbp 90s-100s with no change in mental status or any other signs of
   hypotension. patient was offered a urinary catheter but refused and has
   been voiding without difficulty.
   plan:
   patient has verbalized an understanding of the importance of monitoring
   urinary output. continue to monitor vital signs and i&o
   cholangitis
   assessment:
   patient is now s/p ercp with stent placement.
   action:
   he continues on unasyn for antibiotic coverage. remains npo and is for
   re-evaluation this am.
   response:
   he has been afebrile throughout the shift with no complaints of
   discomfort. vital signs remain stable.
   plan:
   continue antibiotics as ordered.
   demographics
   attending md:
   [**doctor last name 46**] [**initials (namepattern4) 47**] [**last name (namepattern4) 48**]
   admit diagnosis:
   cholangitis
   code status:
   full code
   height:
   65 inch
   admission weight:
   74.3 kg
   daily weight:
   allergies/reactions:
   no known drug allergies
   precautions:
   pmh:
   cv-pmh:  hypertension
   additional history: pud, pvd, barrett's esophagus, htn,
   hypercholesterolemia, distal gastrectomy [**2140**], aorto-bifemoral bpg [**2172**]
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:102
   d:51
   temperature:
   98.4
   arterial bp:
   s:
   d:
   respiratory rate:
   17 insp/min
   heart rate:
   67 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   none
   o2 saturation:
   90% %
   o2 flow:
   2 l/min
   fio2 set:
   24h total in:
   583 ml
   24h total out:
   0 ml
   pertinent lab results:
   sodium:
   141 meq/l
   [**2179-2-13**] 04:46 am
   potassium:
   3.9 meq/l
   [**2179-2-13**] 04:46 am
   chloride:
   108 meq/l
   [**2179-2-13**] 04:46 am
   co2:
   21 meq/l
   [**2179-2-13**] 04:46 am
   bun:
   27 mg/dl
   [**2179-2-13**] 04:46 am
   creatinine:
   1.2 mg/dl
   [**2179-2-13**] 04:46 am
   glucose:
   123 mg/dl
   [**2179-2-13**] 04:46 am
   hematocrit:
   30.9 %
   [**2179-2-14**] 04:09 am
   finger stick glucose:
   177
   [**2179-2-13**] 10:00 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:
"
161,"admission date:  [**2108-6-26**]              discharge date:   [**2108-7-2**]

date of birth:  [**2049-2-6**]             sex:   f

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2108-6-26**]: laparascopic sleeve gastrectomy


history of present illness:
[**known firstname **] has class iii extreme morbid obesity with weight of
364.3 pounds as of [**2108-5-29**] (her initial screen weight on [**2108-5-22**]
was 368 pounds), height of 65 inches and bmi 60.6.  her previous
weight loss efforts have included hmr for one year in [**2104**]
losing 20 pounds, off-label prescription weight loss medication
combination of fenfluramine/phentermine (""fen/phen"") in [**2092**] for
one year losing 70 pounds and [**street address(1) 41635**] visits on/off over
the past 5 years with very little weight loss.  she has exercise
for two years at curves for women losing 50 pounds and one year
of [**location (un) 86**] sports club in [**2106**] to [**2107**] losing 20 pounds. in all
of her efforts whatever weight she loss she was unable to
maintain from no more than one year.  she denied taking
over-the-counter ephedra-containing appetite suppressant/herbal
supplements.  her weight at age 21 was 150 pounds with her
lowest adult weight 125 pounds and her highest weight being 377
pounds earlier this year (2/[**2108**]).  she weighed 192 pounds at
age 33, 200 pounds at age 38, 286 pounds at age 46 and 325
pounds at the age of 50.  she stated she developed a significant
[**last name 4977**] problem at the age of 35 and has been struggling with
weight since birth of her second child and quit  smoking in
[**2081**].  factors contributing to her excess weight include large
portions, genetics, too many carbohydrates and emotional eating.
 for exercise she does water aerobics 60 minutes 5 days per week
since [**month (only) 359**] and lap swimming 90 minutes 5 days per week.  she
denied history of eating disorders and does have depression but
has not been followed by a therapist nor has she been
hospitalized for mental health issues and she is on psychotropic
medication (sertraline).


past medical history:
past medical history:  notable for fatty liver, rotator cuff
tendinitis, right shoulder, obstructive sleep apnea, type 2
diabetes with a1c of 6%, dyslipidemia, gastroesophageal reflux,
osteoarthritis of the knees, aortic valve regurgitation, past
depression.

past surgical history:  c-section x 2, carpal tunnel, right hand

social history:
she smoked one to two packs a day for 25 years quit [**2091**], no
recreational drugs, has occasional alcohol, drinks caffeinated
beverages.  she is a retired teacher, is divorced and has two
adult children

family history:
her family history is noted for father deceased age 58 with
heart disease, hyperlipidemia and obesity; mother living with
hyperlipidemia; sister deceased at 36 years of age secondary to
bulimia; maternal and paternal grandparents with heart
disorders.

physical exam:
vs: t 98, hr 86, bp 149/65, rr 18, o2 97%ra

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd: soft, appropriate peri-incisional tenderness, no rebound
tenderness/guarding
wounds: abd lap sites with steri-strips cdi, no periwound
erythema, + periwound ecchymosis
ext: no edema

pertinent results:
labs:
[**2108-6-27**] 07:40am blood hct-36.2
[**2108-6-26**] 04:21pm blood hct-38.4
[**2108-6-28**] 09:38am blood type-art po2-70* pco2-47* ph-7.40
caltco2-30 base xs-2
[**2108-6-30**] 06:40am blood wbc-5.6 rbc-4.21 hgb-11.3* hct-36.6
mcv-87 mch-26.7* mchc-30.7* rdw-15.2 plt ct-184 neuts-81.0*
lymphs-12.6* monos-3.6 eos-2.7 baso-0.1

imaging:
[**2108-6-27**]:
ugi sgl contrast w/ kub:
impression:  no evidence of obstruction or leak.


brief hospital course:
the patient presented to pre-op on [**2108-6-26**]. pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparascopic sleeve gastrectomy. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout
hospitalization; pain was initially managed with a pca and then
transitioned to oral roxicet once tolerating a stage 2 diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient was triggered on pod2 for desaturations
with an increased oxygen requirement.  the patient was
subsequently transferred to the tsicu on pod2 where she was
weaned to 3l nasal cannula; vancomycin was initiated as empiric
therapy.  she was subsequently transferred back to the general
surgical [**hospital1 **] on pod3 and weaned completely from o2 on pod5.
good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization. the pt was
maintained on cpap overnight for known sleep apnea.
gi/gu/fen: the patient was initially kept npo.  on pod1, an
upper gi study, which was negative for a leak, therefore, the
diet was advanced sequentially to a bariatric stage 2 diet,
which was well tolerated. however, on pod2, during period of
acute oxygen desaturation, the pt was made npo.  a methylene
blue dye test was performed without change in character of drain
output which remained serosanguinous throughout the admission.
the patient's diet was resumed and she was able to tolerate a
stage 3 diet without incident. patient's intake and output were
closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none; empiric treatment with
vancomycin was administered from pod2 through pod5 as described
above.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
metformin 500 mg [**hospital1 **]
omeprazole 20 mg daily
sertraline 50 mg daily
simvastatin 20 mg daily
vitamin d3 5000 units daily
multivitamin with minerals 1 tablet daily

discharge medications:
1. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*
2. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day
for 1 months.
disp:*600 ml* refills:*0*
3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**6-21**] ml
po every four (4) hours as needed for pain.
disp:*250 ml* refills:*0*
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day.
disp:*250 ml* refills:*0*
5. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable/crushable; no gummy.
6. metformin 500 mg tablet sig: 0.5 tablet po twice a day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule;
sprinkle contents onto applesauce, swallow whole.
8. sertraline 50 mg tablet sig: one (1) tablet po once a day.
9. simvastatin 20 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
morbid obesity


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except:
1.  please decrease your metformin to 250 mg twice daily.
please continue to monitor blood sugars and report elevated or
low readings to your prescribing provider.

crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:15 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:30 am
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2108-7-2**]"
162,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
163,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
164,"admission date:  [**2130-4-26**]              discharge date:   [**2130-5-3**]

date of birth:  [**2048-7-7**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 3223**]
chief complaint:
incarcerated right inguinal hernia
left lower extremity cellulitis


major surgical or invasive procedure:
[**2130-4-26**]: right inguinal herniorraphy with mesh


history of present illness:
81m with right inguinal hernia with non-reducible bulge since
noon today.  pain in right groin since then. noted some
discomfort as early as this morning. has had some nausea
throughout day as well.  no vomiting or other abdominal pain.
has not noted a hernia before.  additionally left leg has been
red for a couple of weeks; has been using cream and has not seen
a physician for it.  did not notice that it was swolen.


past medical history:
past medical history: hearing impaired (fluent with sign
language), chronic 1st degree heart block, recurrent atrial
fibrillation/ atrial flutter, s/p dccv [**2120-1-24**], s/p dccv
[**2121-8-8**], bradycardia, elevated psa, htn, hyperlipidemia, m.r.,
basal cell ca s/p excision

past surgical history: none


social history:
lives alone. works for [**company 2318**], independent in adls. no tobacco,
rare etoh.


family history:
mother breast cancer, leg cancer, stomach cancer. father cva.
brother w/ cabg at 64yrs.


physical exam:
on admission:
vitals:97.2 95 182/91 16 100%
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: rrr, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds. right groin with palpable
non-reducible
large hernia, hernia contents extending into scrotum as well,
ttp.
dre: normal tone, no gross or occult blood
ext: no le edema, le warm and well perfused


pertinent results:
[**2130-4-29**]
labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3*
mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93
urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12
[**2130-4-29**] 05:30am blood calcium-8.5 phos-2.4* mg-2.0

[**2130-4-28**]:
chest (portable ap):
severe bilateral opacities appear to be unchanged with no change
in the element of pulmonary edema. cardiomegaly is severe. known
pericardial effusion is most likely present. consolidations in
the left lower lobe are slightly asymmetric and might represent
superimposed abnormality such as infectious process, please
correlate clinically.

[**2130-4-27**]:
echo: impression: mildly depressed left ventricular systolic
function. moderately dilated right ventricle. focal asymetric
hypertrophy of the basal antero-septum. heavily calcified aortic
valve. moderate amount of pericardial effusion with no evidence
of tamponade physiology.

ecg: atrial fibrillation with rapid ventricular response and
probable ventricular premature beats. slight intraventricular
conduction delay may be incomplete left bundle-branch block.
delayed r wave progression may be due to intraventricular
conduction delay, left ventricular hypertrophy or possible prior
septal myocardial infarction, although is non-diagnostic. st-t
wave abnormalities are non-specific but cannot exclude
myocardial ischemia. clinical correlation is suggested. since
the previous tracing of [**2130-4-26**] the rate is faster and lateral
lead st-t wave changes appear more prominent.

chest (portable ap): findings: as compared to the previous
radiograph, there is unchanged massive cardiomegaly. in
addition, there is evidence of mild to moderate pulmonary edema.
presence of co-existing pneumonia cannot be excluded. no
pneumothorax.

bilat lower ext veins port: impression: no dvt in the right or
left lower extremity.

labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30*
11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm
blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33*

[**2130-4-26**]:
ecg: atrial fibrillation. slight intraventricular conduction
delay may be incomplete left bundle-branch block. delayed r wave
progression with late precordial qrs transition may be due to
intraventricular conduction delay, left ventricular hypertrophy
or possible prior anterior wall myocardial infarction, although
is non-diagnostic. st-t wave abnormalities are non-specific.
since the previous tracing of [**2130-3-28**] the ventricular rate is
faster and the qtc interval is shorter.

labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1*
mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1
inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98
hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 [**2130-4-26**] 05:50pm
blood ctropnt-<0.01


brief hospital course:
the patient presented to the emergency department on [**2130-4-26**] due to a non-reducible right groin bulge with associated
pain and nausea.  additionally, the patient reported left leg
erythema which had been present for a few weeks without fevers.
given physical findings consistent with incarcerated hernia, the
patient was taken to the operating room where he underwent a
laparoscopic right inguinal hernia repair with mesh. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

shortly following transfer to the general surgical [**hospital1 **], the
patient was triggered for lethargy, hypoxia and atrial
fibrillation with rapid ventricular response.  intravenous
metoprolol and lasix were administered and the patient was
maintained on a non-rebreather with improved oxygenation.  he
was subsequently transferred to the trauma intensive care unit
for further management.

neuro: the patient was somnolent post-operatively, which was
deemed post-operative baseline by the als interpreter, who
reportedely knew patient well.  the somnolence resolved by pod1
and he remained alert and oriented throughout the remainder of
his hospitalization.  the patient is deaf at baseline and was
able to communicate via an als interpreter.  pain was well
controlled with oral tylenol and intermittent intravenous
hydromorphone.
cv: the patient has baseline rate controlled atrial fibrillation
on warfarin.    however, as described above, he developed a fib
with rvr on pod 0, which responsed to intravenous metoprolol
without recurrence.  additionally, an ekg obtained upon transfer
to the icu revealed st changes; cycled cardiac enzymes were
negative.  an echocardiogram was obtained and revealed mildly
depressed left ventricular systolic function, a moderately
dilated right ventricle, focal asymetric hypertrophy of the
basal antero-septum, heavily calcified aortic valve and a
moderate amount of pericardial effusion with no evidence of
tamponade physiology.  his home medication regimen was resumed
and the patient remained stable from a cardiovascular standpoint
for the remainder of his hospitalization; vital signs were
routinely monitored.
pulmonary: as described above, the patient experienced an
episode of hypoxia on pod 0, likely due to pulmonary edema.
intravenous lasix was administered with immediate effect.  upon
arrival to the icu, the patient was placed on bipap, which was
weaned to nasal cannula on pod 1.  the patient remained stable
from a pulmonary standpoint for the remainder of his
hospitalization and was weaned off supplemental oxygen entirely
on pod 3. good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
gi/gu/fen: the diet was advanced to regular on pod 1, which was
well tolerated.   patient's intake and output were closely
monitored; electrolytes were repleted routinely.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.  the left lower extremity
cellulitis improved on intravenous cefazolin and treatment was
transitioned to oral antibiotics on pod 4, which will continue
for an additional seven days.
skin: a deep tissue injury to the sacrum was identified while in
the icu.  aggressive skin care was provided via nursing without
evidence of further skin breakdown.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to
ambulate early and often.  additionally, given the events of
pod0, a lower extremity ultrasound was obtained and was negative
for a dvt.
rehab: the patient received physical therapy while hospitalized
due to deconditioning, but was deemed unsuitable for discharge
to home.  short term rehabilitation was recommended to maximize
independence and regain conditioning and independence.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating with a walker and physical therapy, voiding
without assistance, and pain was well controlled.  the patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
he will be discharged to a rehab facility for additional
physical therapy.


medications on admission:
atenolol 25mg daily
finasteride 5mg daily
simvastatin 20mg daily
verapamil er 240mg daily
coumadin 1mg daily
vitamin d2 1,000 units daily
vitamin e 400 units daily

discharge medications:
1. verapamil 240 mg tablet extended release sig: one (1) tablet
extended release po q24h (every 24 hours).
2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every
8 hours).
3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm.
4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five
(5) ml po q6h (every 6 hours) as needed for cough.
5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day): hold for loose stool.
6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily).

7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
8. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
9. bisacodyl 10 mg suppository sig: one (1) suppository rectal
hs (at bedtime) as needed for constipation.
10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).

11. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every
6 hours) for 7 days.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - [**location (un) 550**]

discharge diagnosis:
incarcerated right inguinal hernia
left lower extremity cellulitis


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 an incarcerated right
inguinal hernia and subsequently underwent surgical repair with
mesh.  additionally, you were noted to have cellulitis on the
lower aspect of your left leg, which was treated with
antibiotics.  during your stay, you also received treatment from
a physical therapist, who recommended discharge to a
rehabiliation facility to furhter improve your conditioning and
independence.  you are now preparing for disharge to a
rehabiliation facility with the following instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service at [**telephone/fax (1) 600**] to make a
follow-up appointment within 2 weeks.
please contact your primary care provider to make [**name initial (pre) **] follow-up
appointment within 1 week from discharge from the rehabilitation
facility.
provider: [**first name11 (name pattern1) 5445**] [**initial (namepattern1) **] [**last name (namepattern4) 5446**], dpm phone:[**telephone/fax (1) 543**]
date/time:[**2130-5-22**] 3:50
provider: [**first name8 (namepattern2) 6118**] [**last name (namepattern1) 6119**], rn,ms,[**md number(3) 1240**]:[**telephone/fax (1) 1971**]
date/time:[**2130-6-16**] 10:00


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

completed by:[**2130-5-3**]"
165,"admission date:  [**2146-6-15**]              discharge date:   [**2146-6-28**]

date of birth:  [**2081-10-25**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1556**]
chief complaint:
colon cancer
s/p jejunoileal bypass in [**2109**]

major surgical or invasive procedure:
[**2146-6-15**]: rt hemicolectomy, reversal of jejunoileal bypass, liver
biopsy (tru-cut needle).
[**2146-6-27**]: exploratory laparotomy with washout, repair of
perforation in ileum, placement of vacuum-assisted closure
dressing.


history of present illness:
64-year-old man with a history of colonic polyps, who on
screening colonoscopy ([**2146-5-17**]) demonstrated an ulcerated,
clamshell, nonobstructing mass in the cecum.  the length was
approximately 3 cm.  biopsy confirmed invasive
adenocarcinoma grade ii.  otherwise, he has had no change in his
health. no blood per rectum, no weight loss, no abdominal pain.
he currently has [**12-24**] formed bowel movements per day.  he does
experience loose bowel movements if he eats fatty foods or
cheese.

past medical history:
past medical history:
1.  myocardial infarction, [**2143**].
2.  right-sided nephrolithiasis.
3.  morbid obesity (bmi 44.3 kg/m2).
4.  hypertension.
5.  history of colonic polyps.

past surgical history:
1.  jejunoileal bypass, [**2109**] (16 inches of jejunum anastomosis
    to the last 6 inches of ileum) appendectomy was performed at

    that time.
2.  open cholecystectomy with choledochostomy tube and
    gastrostomy tube for acute gallstone pancreatitis, [**2109**].
3.  ureteroscopy with stenting, 05/[**2144**].  this was complicated
    by bradycardia into the 20s.
4.  cardiac pacemaker placement, [**2145-4-6**].
5.  right flank incision with stone extraction, [**2145-5-5**].
6.  cystoscopic attempted stone extraction and stenting,
    [**2145-5-21**].
7.  surgical extraction of right renal stone, [**2145-6-4**].
8.  cardiac stents (drug-eluting), [**2143**].
9.  right shoulder surgery, [**2140**], no metallic implants.

social history:
he does not smoke, drink excessively or use
drugs.  he manages an insurance firm.  he is accompanied by his
wife and daughter today.


family history:
significant for mother with [**name (ni) 2481**] disease,
father with [**name (ni) 5895**] disease.


physical exam:
bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi:
44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99.

physical examination:  general:  he is alert, oriented, in no
acute distress.  heent:  pupils are equal, round and reactive to
light.  sclerae anicteric.  oropharynx is clear.  neck:  supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly or nodules.  trachea is midline.  lungs:  clear to
auscultation bilaterally.  heart:  regular.  abdomen:  obese.
he
has a right subcostal incision (cholecystectomy).  he has a
right
lower abdominal transverse incision (intestinal bypass).  he has
a right flank incision (renal surgery).  there are no obvious
hernias.  there is no tenderness.  genitourinary:  penis is
circumcised.  testicles are descended bilaterally.  extremities:

without edema.  neurologic:  grossly nonfocal.


pertinent results:
[**2146-6-15**] 04:50pm   glucose-187* urea n-12 creat-1.0 sodium-141
potassium-4.1 chloride-104 total co2-27 anion gap-14
[**2146-6-15**] 04:50pm   estgfr-using this
[**2146-6-15**] 04:50pm   calcium-9.2 phosphate-3.9 magnesium-1.4*
[**2146-6-15**] 04:50pm   wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6*
mcv-77* mch-23.8* mchc-30.8* rdw-15.5
[**2146-6-15**] 04:50pm   plt count-102*
[**2146-6-15**] 12:44pm   type-art rates-/12 tidal vol-700 po2-330*
pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 12:44pm   glucose-153* lactate-2.1* na+-135 k+-3.8
cl--101
[**2146-6-15**] 12:44pm   hgb-10.7* calchct-32 o2 sat-97
[**2146-6-15**] 12:44pm   freeca-1.19
[**2146-6-15**] 10:53am   type-art rates-/12 tidal vol-700 po2-84*
pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 10:53am   na+-135
[**2146-6-15**] 10:53am   hgb-10.3* calchct-31 o2 sat-94

brief hospital course:
the patient presented to pre-op on [**2146-6-15**]. pt was evaluated by
anaesthesia and taken to the operating room where a laparoscopic
adjustable gastric band placement was performed. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout the
hospitalization; until her was intubated and sedated. pain was
well controlled with iv pain medications.
cv: vital signs were routinely monitored. the patient remained
stable from a cardiovascular standpoint until he developed
tachycardia and hypotension on [**2146-6-27**]. following that the
patient was placed on multiple pressors by the icu team. cardiac
enzymes were initially negative, a tee revealed a hyperdynamic
myocardium.
pulmonary: vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. the patient remained
stable from a pulmonary standpoint until [**2146-6-27**] when he
developed shortness of breath, new and increasing oxygen
requirement and desaturation. cta of the chest revealed no
evidence of pe, but the patient had evidence of worsening
pulmonary function and ards. he was intubated and his peep was
optimized using an intraesophageal balloon. he remained
intubated until the decision of comfort measures only was
executed terminally extubating the patient.

gi/gu/fen: he was kept npo with ng tube to suction. the patient
was initially putting out about 7-8 liters of bilious fluid a
day. this was adequately replaced with iv fluids. the patient
was later decreasing his ng tube outputs to 4 liters by day 6
post-operatively. the patient passed gas on the 5th day
post-operatively, and bowel movements pod6. tpn was started due
to the elevated ng outputs (dark green bile). patient's intake
and output were closely monitored.
 pod#12, the patient decompensated with sudden onset chest and
shoulder pain, shortness of breath, tachypnea, new oxygen
requirement, ekg new right bundle branch block, and transient
abdominal pain.
the patient was taken to the or and exploration revealed a total
of 5 liters of fluid non bilious. he was found to have one small
hole at the proximal anastomosis and purulent pocket. 3 drains
were placed. subsequently the patient developed multiple organ
system failure, with acute renal failure requiring continuous
venovenous hemodialysis. worsening refractory metabolic acidosis
requiring multiple boluses and iv drip bicarbonate. acute liver
failure was also noted with inr>3 and liver transaminases >[**2133**].


id: the patient's fever curves were closely watched for signs of
infection. the
patient developed sepsis as discussed above with multiple
organisms (k. pneumonia, b. fragilis,...) the patient was placed
on broad spectrum iv antibiotics.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

 the patient was showing signs of multiple organ system collapse
with refractory hypotension and acidosis despite maximal medical
therapy. a family meeting was conducted with the family deciding
that the patient's wishes would be to withdraw care at that
point. the patient was extubated terminally and the patient
passed away shortly after on [**2146-6-28**] at 17:37.

medications on admission:
medications - prescription
atorvastatin -  (prescribed by other provider) - 40 mg tablet -
1
tablet(s) by mouth once a day
hydrochlorothiazide -  (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth once a day
sildenafil [viagra] -  (prescribed by other provider) - dosage
uncertain
valsartan [diovan] -  (prescribed by other provider) - 80 mg
tablet - 1 tablet(s) by mouth once a day

medications - otc
aspirin -  (prescribed by other provider) - 81 mg tablet,
chewable - 1 tablet(s) by mouth once a day
cholecalciferol (vitamin d3) [vitamin d] -  (prescribed by other
provider) - dosage uncertain


discharge medications:
none

discharge disposition:
expired

discharge diagnosis:
cecal cancer with positive lymph node
reversal of jejunoileal bypass
liver cirrhosis secondary to jejunoileal bypass
acute respiratory distress syndrome
acute liver failure
acute renal failure
intraabdominal severe septic shock

discharge condition:
dead

discharge instructions:
na

followup instructions:
na


completed by:[**2146-7-26**]"
166,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
167,"admission date:  [**2198-6-19**]              discharge date:   [**2198-7-8**]

date of birth:  [**2120-8-11**]             sex:   m

service: urology

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1232**]
chief complaint:
angiosarcoma of bladder cancer

major surgical or invasive procedure:
radical cystoprostatectomy
ileal loop urinary diversion
regional node dissection
right internal jugular vein central line placement
swan-ganz catheter placement
arterial line placement
nasogastric tube placement

history of present illness:
mr. [**known lastname 19000**] is a 77-year-old male who was
diagnosed with prostate cancer in [**2189-11-8**] by abnormal dre.

he reports a psa of that time of 14. he received external beam
radiation therapy at [**hospital6 **]. he reports that his
psa post radiation was 0.3. he was followed periodically by psa
after radiation. his psa rise to about 11 in [**2193**]. he started
casodex and lupron [**4-8**]. he reports he was getting lupron every

other month. his lowest psa on hormonal treatment was 0.4 in
[**2197-2-6**]. his psa started to climb 1004 and reached 2.2 in 05/

05. he has been followed by dr. [**last name (stitle) 4749**] in [**hospital1 **].

the patient noted painless hematuria and clots beginning of
[**month (only) 958**]
he had a tur at [**hospital 1281**] hospital by dr. [**last name (stitle) **] where a bladder
tumor was noted. he has been seen by dr. [**last name (stitle) **] in evaluation
for a possible cystectomy and dr. [**last name (stitle) **] for medical oncologic

opinion of the angiosarcoma.
he reports he multiple negative ct scans and bone scans in the
past. most recently he had a bone scan in [**4-12**], which showed
increased tracer activity in l5-s1 region, likely representing
degenerative changes. ct chest, abdomen, and pelvis [**4-12**], shows

a infrarenal aortic aneurysm, measuring 4.2 x 4.8 cm, asymmetric

inferior bladder wall thickening, and multiple small bilateral
pulmonary nodules, the largest measuring 5 mm in the right
middle
lobe.
he presents for cystoprostatectomy.

past medical history:
prostate carcinoma
heartburn
asthma
appendectomy
no tuberculosis noted
copd: fev1 58%



social history:
mr. [**known lastname 19000**] is retired. he spent seven and a
half years in the russian army, then he went to college and was
an electrical engineer in a fairly high position. he lives in
[**location **]. he immigrated to the us about ten years ago. he has two
daughters and two grandsons who live in the area. he quit
smoking about 11 years ago. he smoked nonfiltered cigarettes for

a total of 100 pack years. he drinks vodka and bourbon once or
twice a week.


family history:
no family history of cancers. he has five
brothers, four of whom have died of heart attacks. his older
brother lives in [**name (ni) 6607**]. his mother died of a cva. his father
died at age 33 in [**2125**] from typhoid.


physical exam:
gen:  aaox3 nad
cv: s1 s2 rrr
chest: cta b/l
abd: pos bs soft nt/nd midline scar, uretostomy
extrem: no c/c/e

pertinent results:
[**2198-7-5**] 07:20am blood wbc-5.3 rbc-4.35* hgb-12.6* hct-39.1*
mcv-90 mch-29.0 mchc-32.2 rdw-15.6* plt ct-297
[**2198-7-4**] 07:00am blood wbc-4.0 rbc-4.21*# hgb-12.4*# hct-37.3*#
mcv-89 mch-29.4 mchc-33.1 rdw-15.1 plt ct-270
[**2198-7-3**] 07:25am blood wbc-3.8* rbc-3.24* hgb-9.8* hct-28.6*
mcv-88 mch-30.2 mchc-34.2 rdw-14.2 plt ct-211
[**2198-7-2**] 08:00am blood wbc-4.2 rbc-3.22* hgb-9.8* hct-29.0*
mcv-90 mch-30.3 mchc-33.6 rdw-14.2 plt ct-197
[**2198-7-1**] 03:23am blood wbc-3.3* rbc-3.15* hgb-9.4* hct-29.0*
mcv-92 mch-29.8 mchc-32.3 rdw-14.7 plt ct-170
[**2198-6-19**] 05:39pm blood wbc-6.8 rbc-3.27*# hgb-9.8*# hct-29.8*#
mcv-91 mch-29.8 mchc-32.8 rdw-14.1 plt ct-125*
[**2198-6-20**] 04:15am blood wbc-4.9 rbc-2.92* hgb-8.8* hct-26.1*
mcv-89 mch-30.3 mchc-33.9 rdw-14.1 plt ct-104*
[**2198-6-20**] 11:00am blood hct-31.6*
[**2198-6-20**] 03:57pm blood hct-31.3*
[**2198-6-21**] 03:45am blood wbc-7.4# rbc-3.47* hgb-10.7* hct-31.1*
mcv-90 mch-30.9 mchc-34.4 rdw-13.9 plt ct-104*
[**2198-6-21**] 08:29am blood wbc-6.7 rbc-3.48* hgb-10.8* hct-31.1*
mcv-89 mch-31.0 mchc-34.8 rdw-13.7 plt ct-105*
[**2198-6-21**] 04:21pm blood wbc-5.4 rbc-3.29* hgb-10.1* hct-29.4*
mcv-90 mch-30.8 mchc-34.4 rdw-13.9 plt ct-105*
[**2198-7-5**] 07:20am blood plt ct-297
[**2198-7-4**] 07:00am blood plt ct-270
[**2198-7-3**] 07:25am blood plt ct-211
[**2198-7-2**] 08:00am blood plt ct-197
[**2198-7-1**] 03:23am blood plt ct-170
[**2198-6-19**] 05:39pm blood pt-14.6* ptt-32.9 inr(pt)-1.4
[**2198-6-19**] 05:39pm blood plt ct-125*
[**2198-6-20**] 04:15am blood plt ct-104*
[**2198-6-21**] 03:45am blood plt ct-104*
[**2198-6-21**] 08:29am blood plt ct-105*
[**2198-7-6**] 09:00am blood glucose-97 urean-17 creat-1.3* na-142
k-3.7 cl-103 hco3-33* angap-10
[**2198-7-5**] 07:20am blood glucose-104 urean-14 creat-1.2 na-141
k-4.0 cl-102 hco3-32 angap-11
[**2198-7-4**] 07:00am blood glucose-105 urean-12 creat-1.0 na-144
k-3.6 cl-106 hco3-32 angap-10
[**2198-7-3**] 07:25am blood glucose-95 urean-14 creat-1.0 na-145
k-3.7 cl-108 hco3-29 angap-12
[**2198-6-19**] 05:39pm blood glucose-165* urean-17 creat-1.1 na-140
k-4.9 cl-112* hco3-23 angap-10
[**2198-6-20**] 04:15am blood glucose-133* urean-21* creat-1.6* na-135
k-4.4 cl-110* hco3-23 angap-6
[**2198-6-20**] 02:25pm blood glucose-124* urean-25* creat-2.8*# na-137
k-4.6 cl-110* hco3-21* angap-11
[**2198-6-20**] 08:00pm blood urean-28* creat-3.2* na-137 k-4.6 cl-111*
hco3-19* angap-12
[**2198-7-4**] 07:00am blood ck(cpk)-19*
[**2198-6-21**] 04:21pm blood alt-2 ast-24 alkphos-86 amylase-83
totbili-0.4
[**2198-6-21**] 03:45am blood alt-4 ast-28 ld(ldh)-208 ck(cpk)-619*
alkphos-59 totbili-0.5
[**2198-6-20**] 04:15am blood ck(cpk)-808*
[**2198-6-20**] 02:00am blood ck(cpk)-755*
[**2198-6-19**] 05:39pm blood ck(cpk)-160
[**2198-7-4**] 07:00am blood ck-mb-3 ctropnt-0.02*
[**2198-6-20**] 04:15am blood ck-mb-5 ctropnt-<0.01
[**2198-6-20**] 02:00am blood ck-mb-6
[**2198-6-19**] 05:39pm blood ck-mb-3 ctropnt-<0.01
[**2198-7-6**] 09:00am blood calcium-8.7 phos-3.4 mg-2.0
[**2198-7-5**] 07:20am blood phos-3.4 mg-1.9
[**2198-7-4**] 07:00am blood calcium-8.7 phos-3.3 mg-1.8
[**2198-7-3**] 07:25am blood calcium-8.4 phos-2.4* mg-1.7
[**2198-7-2**] 08:00am blood calcium-8.4 phos-2.0* mg-1.6
[**2198-6-19**] 05:39pm blood calcium-8.0* phos-4.9* mg-1.5*
[**2198-6-20**] 04:15am blood calcium-7.4* phos-2.9# mg-2.1
[**2198-6-20**] 02:25pm blood mg-2.1
[**2198-6-21**] 03:45am blood albumin-2.7* calcium-7.5* phos-5.3*#
mg-2.1
[**2198-6-21**] 08:29am blood calcium-7.4* phos-6.0* mg-2.2
[**2198-6-30**] 06:29pm blood type-art po2-122* pco2-35 ph-7.47*
calhco3-26 base xs-2
[**2198-6-30**] 03:38am blood type-art po2-75* pco2-43 ph-7.41
calhco3-28 base xs-1
[**2198-6-28**] 04:03am blood ph-7.42 comment-green top
[**2198-6-19**] 08:35am blood type-art po2-529* pco2-48* ph-7.39
calhco3-30 base xs-3
[**2198-6-19**] 10:19am blood type-art po2-212* pco2-45 ph-7.39
calhco3-28 base xs-2
[**2198-6-19**] 11:30am blood type-art po2-240* pco2-45 ph-7.38
calhco3-28 base xs-1
[**2198-6-19**] 12:30pm blood type-art rates-/10 tidal v-650 fio2-57
po2-239* pco2-41 ph-7.38 calhco3-25 base xs-0 intubat-intubated
vent-controlled
[**2198-6-19**] 02:11pm blood type-art po2-252* pco2-40 ph-7.41
calhco3-26 base xs-1
[**2198-6-19**] 03:54pm blood type-art ph-7.41
[**2198-6-30**] 06:29pm blood lactate-1.5
[**2198-6-30**] 03:38am blood glucose-108*
[**2198-6-27**] 05:12pm blood lactate-0.9
[**2198-6-27**] 03:31am blood glucose-152*
[**2198-6-25**] 03:18am blood glucose-86 lactate-1.2
[**2198-6-19**] 08:35am blood glucose-126* lactate-1.8 na-138 k-4.2
cl-104
[**2198-6-19**] 10:19am blood glucose-149* lactate-1.8 na-140 k-4.6
cl-105
[**2198-6-19**] 11:30am blood glucose-147* lactate-1.8 na-139 k-4.1
cl-109
[**2198-6-19**] 12:30pm blood glucose-153* lactate-2.4* na-137 k-4.6
cl-109
[**2198-6-19**] 02:11pm blood glucose-154* lactate-2.0
[**2198-6-30**] 03:38am blood o2 sat-96
[**2198-6-26**] 04:11pm blood o2 sat-90
[**2198-6-25**] 03:18am blood o2 sat-98
[**2198-6-22**] 11:27am blood o2 sat-97
[**2198-6-30**] 06:29pm blood freeca-1.20
[**2198-6-30**] 03:38am blood freeca-1.11*
[**2198-6-28**] 04:03am blood freeca-1.10*
[**2198-6-27**] 03:31am blood freeca-1.15

cxr - [**2198-7-5**]
indications: desaturation.

ap and lateral chest radiographs: comparison is made to [**2198-7-1**] and a
chest ct scan from [**2198-4-27**]. cardiac size is at the upper
limits of
normal. two rounded nodules are seen, one in each upper lobe.
the one in the
right measures 9 mm and the one in the left measures 13 mm.
these appear
different than on multiple prior studies. the patient has known
nodules on ct
scan. there are no consolidations. there is mild blunting of the
right cp
angle, likely reflecting a small effusion. overall, there is
improved
aeration of the left lower lobe.

impression: bilateral upper lobe nodules, more conspicuous than
on prior
studies. further evaluation with chest ct scanning is
recommended.

cxr - [**2198-7-1**]

there has been interval removal of the right ij line. there is
improved
aeration of both lower lobes. both cp angles are off the film.
there is no
focal infiltrate.

cxr - [**2198-6-22**]
findings: in comparison with the previous examination of the
same date, the
pulmonary artery catheter is again seen, now terminating within
the right
pulmonary artery and entering via a right internal jugular
approach. an
endotracheal tube terminates approximately 8.5 cm from the
carina. nasogastric
tube extends below the diaphragm and likely terminates in the
upper stomach.
there is interval improvement in pulmonary edema. probable small
bilateral
pleural effusions are incompletely evaluated due to exclusion of
the
costophrenic angles bilaterally. stable bibasilar atelectasis.

impression:

1. cardiomegaly and improving congestive heart failure.

2. bibasilar atelectasis and probable small bilateral pleural
effusions.


brief hospital course:
mr. [**known lastname 19000**] [**last name (titles) 1834**] a cystoprostatectomy on [**2198-6-19**] (please see
dictated operative report for details) without adverse events.
it was noted by surgeons that urine output was low throughout
the procedure. in the or he received 6,000cc of crystaloid, 2
units of packed red cells, 1000cc of hespan, and 750cc of 5%
albumin. estimated blood loss was 2,500cc.  given the large
fluid requirement and his history of copd, patient remained
intubated overnight.  he remained hemodynamically stable post
operatively. his urine output was variable with outputs 28-145cc
per hour and a total of 813 by midnight on operative day.  on
post-operative day 1 by 0600, his urine output progressively
decreased to a point where he was making < 5 cc per hour.  he
was given both normal saline and 2 units of prbcs with no kidney
response (24 hour total of 304 cc) and he remained in aneuric
failure despite receiving >5000cc of fluid over 24 hours.   he
was transferred to the intensive care unit from the
post-anesthesia care unit. his bun/cre also began to rise.
nephrology consult was obtained and the worry was that the
patient was in aneuric renal failure vs. outflow obstruction.
ct studies were obtained on [**6-21**] and revealed: 1. no evidence
for hydronephrosis or hydroureter. no evidence for urinoma. 2.
small amount of intraabdominal ascites as well as inflammatory
stranding along the pararenal fascia and within the right lower
quadrant at the site of the ureteroileal loop anastomosis. small
amount of intraabdominal free air. anasarca. these changes are
most likely secondary to recent postoperative state. 3. small
bilateral pleural effusions with bilateral lung base compressive
atelectasis. urinalysis was consistent with acute tubular
nephritis with aneuria, and creatinine continued to rise. he
remained intubated for ventilartory support.  he had minimal
response to lasix challanges. swan-ganz catheter was inserted
over existing right ij to monitor fluid status and cardiac
function. his creatinine and bun peaked at 6.4/49 respectively
on post operative day 2. he developed progressive non-anion gap
acidosis and bicarbonate infusion was started to control
acidemia.  at that point renal function began to return and
patient began to autodiurese with urine outputs in 3,000-4,000cc
range per 24 hours. he spiked fevers to 101.6 on post operative
day 6. blood, urine, sputum cultures were obtained and sputum
culture showed pseudomonas aureginosa presence. he was begun on
zosyn on [**2198-6-21**] and defervesced over the next 3 days. his bun
and creatinine progressively normalized, as did the acidemia. he
ramained intubated for ventilatory support.  with significan
autodiuresis, patient's sodium began to rise and free water
repletion was begun.  electrolytes were repleted as needed
throughout the stay.  propofol sedation was weaned and his
mental function slowly returned to [**location 213**].  he was extubated on
post-operative day 8. he continued to autodiurese. his mental
function slowly improved and he was transferred to the floor on
post-operative day 13.  after transfer to floor pulmonary was
consulted.  he was started on advair and standing
alb/ipratropium inhaler.  he was continued on zosyn.  he was
also diuresed with lasix which helped clear up his lungs.  his
pulmoary exam improved.  he was on 1:1 sitter which was stopped
and then started again and then stopped on [**7-5**].  he got
startled and slid back against the wall on [**7-4**] prompting the
sitter being restarted.  he made adequate urine output on the
floor and was seen and evaluated by pt who helped him ambulate.
his is/os were good on the floor and he tolerated his pos.  he
was screened for rehab and is in good condtion for discharge.


medications on admission:
advair
combivent
casodex 50 mg
protonix,
lupron every other month, last given [**2198-5-13**]


discharge medications:
1. albuterol sulfate 0.083 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for sob, wheezing.
disp:*30 inhalation* refills:*0*
2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every
4 to 6 hours) as needed.
disp:*30 tablet(s)* refills:*0*
3. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for wheezing, copd.
disp:*10 inhalation* refills:*0*
4. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times
a day).
disp:*60 tablet(s)* refills:*0*
5. fluticasone-salmeterol 500-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
disp:*60 disk with device(s)* refills:*0*
6. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
disp:*30 injection* refills:*0*
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:*0*
8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: one
(1) puff inhalation qid (4 times a day).
disp:*30 inhalation* refills:*2*
9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
disp:*60 capsule(s)* refills:*0*
10. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3
times a day).
disp:*135 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital 3915**] [**hospital **] rehab center

discharge diagnosis:
angiosarcoma of bladder


discharge condition:
good

discharge instructions:
discharge to rehab facility
need intructions and care for uroestomy
can shower
if have fever >101.4, intractable nausea, vomiting, severe pain
or trouble with your ostomy, please return.

followup instructions:
follow up with cardiology
follow up with pulmonology
follow up with dr. [**last name (stitle) **] (urology) - ([**telephone/fax (1) 4276**]



"
168,"admission date:  [**2104-3-29**]              discharge date:   [**2104-5-2**]

date of birth:  [**2043-11-1**]             sex:   f

service: medicine

allergies:
codeine / vicodin / percocet / compazine / percodan / tigan /
latex / betadine viscous gauze / protonix / surgical lubricant

attending:[**first name3 (lf) 943**]
chief complaint:
""severe all over body pain""


major surgical or invasive procedure:
- esophagogastroduodenoscopy


history of present illness:
60-year-old female with history of etoh/nash cirrhosis
complicated by ascites and encephalopathy (no known varices or
history of sbp) who presents with ""severe all over body pain"".
.
the patient was recently admitted for hypotension and
hyponatremia where she was found to have esbl uti and treated
with tobramycin/tetracycline. she was discharged to a nursing
home on [**2104-3-25**]. at the nursing home, the patient states that she
has not been taking her lactulose and has not had bowel
movements. she is confused and states she has ""all over body
pain"" although she is unable to describe it and unsure of if it
is different or more severe than her baseline chronic pain. she
presents to [**hospital1 18**] for further evaluation.
.
upon presentation to the ew, intial vitals were: t 98.2, hr 86,
bp 130/80, rr 18, sao2 97% ra. labs show inr 1.6, hct 27 (near
recent baseline), lfts okay. she is confused and has asterixis
on exam. she denies rectal. cxr with question of focal
infiltrate. kub with dilated loops of small bowel likely
secondary to ileus (although cannot rule out obstruction).
ultrasound with difficult anatomy and not enough ascites to
safely do diagnostic paracentesis at bedside. recommend
ultrasound guided paracentesis. she received lactulose and was
admitted for hepatic encephalopathy treatment.
.
currently, patient confused. yelling at nurses and very slow
with movement. she notes chills, nausea, right upper quadrant
discomfort and diffuse pain. she is unsure if this is different
than baseline. she is unsure of her last bowel movement and is
unsure if she is taking lactulose. she denies or does not know
about other ros.

past medical history:
1. cirrhosis: thought to be secondary to etoh use and fatty
liver disease
2. h/o pancreatitis
3. etoh abuse
4. cholelithiasis
5. obesity
6. hypothyroidism
7. venous insuffuciency
8. chronic lower extremity edema
9. spinal stenosis
10. reflex sympathetic dystrophy
11. hypokalemia
12. mitral regurgitation
13. neuropathy
14. bilateral hand weakness
15. osteoporosis
16. macrocytic anemia
17. thrombocytopenia
18. uterine fibroids
19. chronic renal insufficiency
20. ""tummy tuck""
21. chronic pain: on narcotics


social history:
lives with her roomate. is a former constable and volunteer
police officer. drinks 3-4 beers/day x 12 yrs. no h/o withdrawl
szs. no tobacco or illicit drug use. estranged from family. no
hcp, though patient believes that father or [**name2 (ni) 8317**] [**name (ni) **] could
be hcp.


family history:
aunt with cirrhosis. mother with alcoholism.

physical exam:
vs: t 98.2, bp 104/66, hr 86, rr 16, sao2 94% ra
general: yelling at nurses - ""no - i want to do it my own way"",
no apparent distress
heent: nc/at, perrl, eomi, sclerae anicteric, mmm, op clear
neck: supple
lungs: limited lung volumes, bibasilar crackles, no cough,
wheezes.
heart: rr, nl rate, i/vi murmur
abdomen: obese, soft, diffuse tenderness no rebound or guarding,
decreased bowel sounds
extremities: warm, le edema 2+
skin: stasis dermatitis bilateral lower extremities, multiple
ecchymotic lesions, rash right forearm
neuro - awake, a&ox2 (name and hospital, wrong day, month,
unsure of year) unwilling to participate in neuro examination,
very upset when asked to participate, emotionally labile. +
asterixis.

pertinent results:
labs on admission:
[**2104-3-29**] 06:54pm   comments-green top
[**2104-3-29**] 06:54pm   glucose-89 lactate-1.4 na+-131* k+-3.5
cl--97* tco2-26
[**2104-3-29**] 06:50pm   urea n-10 creat-1.0
[**2104-3-29**] 06:50pm   estgfr-using this
[**2104-3-29**] 06:50pm   alt(sgpt)-15 ast(sgot)-22 ld(ldh)-227 alk
phos-61 tot bili-1.9*
[**2104-3-29**] 06:50pm   lipase-14
[**2104-3-29**] 06:50pm   calcium-9.3 phosphate-3.9# magnesium-1.5*
[**2104-3-29**] 06:50pm   wbc-5.7 rbc-2.43* hgb-9.1* hct-27.0* mcv-111*
mch-37.7* mchc-33.9 rdw-16.1*
[**2104-3-29**] 06:50pm   neuts-62.6 lymphs-23.1 monos-8.5 eos-4.9*
basos-0.9
[**2104-3-29**] 06:50pm   plt count-148*
[**2104-3-29**] 06:50pm   pt-17.8* ptt-37.0* inr(pt)-1.6*

labs on discharge:
131  95  5
------------<98
3.1  31  0.8

microbiology:
[**2104-3-30**] 10:57 am urine      source: cvs.

                            **final report [**2104-3-31**]**

   urine culture (final [**2104-3-31**]):
      yeast.    >100,000 organisms/ml..

[**2104-4-3**] 3:23 pm urine      source: cvs.

                            **final report [**2104-4-6**]**

urine culture (final [**2104-4-6**]):
      enterococcus sp..    >100,000 organisms/ml..
      yeast.    >100,000 organisms/ml..

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             enterococcus sp.
                             |
ampicillin------------  =>32 r
linezolid-------------     1 s
nitrofurantoin--------    64 i
tetracycline----------  =>16 r
vancomycin------------  =>32 r

[**2104-4-17**] 11:03 am sputum      source: endotracheal.

                            **final report [**2104-4-22**]**

   gram stain (final [**2104-4-17**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2104-4-22**]):
      commensal respiratory flora absent.
      escherichia coli.    rare growth.
         warning! this isolate is an extended-spectrum
beta-lactamase
         (esbl) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. consider
infectious
         disease consultation for serious infections caused by
         esbl-producing species.
      yeast.    rare growth.

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             escherichia coli
                             |
amikacin--------------   <=2 s
ampicillin------------  =>32 r
ampicillin/sulbactam--  =>32 r
cefazolin-------------  =>64 r
cefepime--------------       r
ceftazidime-----------       r
ceftriaxone-----------       r
ciprofloxacin---------   =>4 r
gentamicin------------  =>16 r
meropenem-------------<=0.25 s
tobramycin------------     8 i
trimethoprim/sulfa----  =>16 r

[**2104-4-29**] 9:39 am urine     no growth.

imaging:
- chest (pa & lat)	study date of [**2104-3-29**] 7:11 pm
impression: markedly limited study. question increased density
at the medial right lung base. this could represent
superimposition of normal structures crowded by significant
volume loss, however focal infiltrates cannot be entirely
excluded.

- portable abdomen	study date of [**2104-3-30**] 9:07 am
impression: two frontal views of the supine abdomen show
disproportionate
dilatation of the stomach and proximal small bowel with respect
to relatively mild gaseous dilatation of the colon, probably the
transverse. appearance is similar to [**3-29**]; small-bowel
obstruction must still be considered. no nasogastric tube is
seen despite severe gaseous distention of the stomach.
right lung base is elevated, probably a combination of
subpulmonic pleural
effusion and upward displacement of the diaphragm.

- ct abd & pelvis with contrast	study date of [**2104-3-30**] 2:56 pm
impression:
1. proximal small bowel dilatation measuring up to 3.6 cm with a
point of transition in the right lower quadrant. imaging
findings are consistent with partial versus complete obstruction
likely on the basis of adhesions.
2. findings of hepatic cirrhosis as on prior exams.
3. anterior abdominal wall hernia containing mesenteric fat and
fluid.

- lung scan	study date of [**2104-3-31**]
impression: underventilated triple match v/q defect with low
probability of pe.

- unilat up ext veins us	study date of [**2104-4-3**] 9:53 am
impression: no evidence of deep vein thrombosis in the right
arm.

- ct abd & pelvis with contrast	study date of [**2104-4-5**] 2:58 pm
impression:
1. stable mild dilatation of the proximal small bowel loops,
maximally measuring 3.6 cm. distal loops appear less distended,
with possible transition point in the right lower quadrant,
likely representing mild/partial small-bowel obstruction.
2. cirrhosis with moderate amount of abdominal and pelvic
ascites.

- ct head w/o contrast	study date of [**2104-4-16**] 6:30 pm
impression:
1. no acute intracranial hemorrhage or mass effect. if there is
continued
concern for parenchymal abnormalities, consider mr head if not
contra-indicated.
2. mild diffuse volume loss increased from [**2096**] ct head study.

- portable abdomen	study date of [**2104-4-20**] 9:38 pm
impression:
in comparison to [**2104-4-17**] exam, there is mild improvement of
ileus without
complete resolution.

- chest (portable ap)	study date of [**2104-4-25**] 8:38 am
findings: in comparison with the study of [**4-23**], the degree of
pulmonary
vascular congestion may have slightly improved. extensive
bilateral
atelectatic changes are again seen with blunting of the
costophrenic angles
consistent with pleural fluid. area of increased opacification
in the right
mid zone may merely represent atelectasis, though in the
appropriate clinical setting the possibility of pneumonia would
have to be considered.

brief hospital course:
summary statement:

ms. [**known lastname 28445**] is a 60 year old female with a provisional diagnosis
of etoh cirrhosis who presented from rehab after a brief
hospitalization for an mdr e.coli uti, new diagnosis of
cirrhosis, and hyponatremia with chronic pain who was found to
have an narcotic ileus who required tpn and then was transferred
to the micu for concern for prolonged epistaxis from presumably
ngt trauma who has remained encephalopathic with decompensated
cirrhosis, persistent ileus from administration from narcotics,
volume overload and hypoxia secondary to pulmonary edema and
atelectasis

prior to transfer to the micu:

1) narcotic ilues: prior to admission she presented with diffuse
abdominal pain, and dilated small loops of bowl on kub.
subsequent abdominal ct scans reveal potential transistion
points and partial small bowel obstruction.  she also developed
non-bloody bilious emesis necessitating ngt placement and small
bowel decompression.  surgery was consulted and a small bowel
follow through revealed and an ileus that was secondary to
prolonged narcotic use for a presumed diagnosis of rsd.  her
narcotics were then stopped, but her ileus persisted which
necessitated starting tpn, and subsequently her ileus resolved
after  methalynaloxone was administered.  her pain from rsd was
subsequently controlled with non-opioid analgesia including
tramadol and lyrica.  radiographs of the abdomin showed passing
of contrast from the small bowel to the colon and her nutrition
was transitioned from tpn to po.  she was tolerating po prior to
her transfer to the micu for epistaxis

2) decompensated cirrhosis:  she presented with peripherial
edema ascities without evidence of encephalopathy.  however, she
became mildly encephalopathic (grade i) with mild asterixis and
disorientation (date) as her ileus persisted.  she was given
lactulose enemas which helped resolve her confusion.  there was
also concern that she may have sbp, although she was never
febrile, and a a diagnostic paracentesis was negative.
subsequently however, she underwent a therapeutic paracentesis
to help remove ascites (3l removed) to improve her respiratory
mechanics in addition to her ileus.  she remained mildly
encephalopathic until her transfer to the micu.

2) volume overload:  she developed volume overload secondary to
decompensated cirrhosis and portal hypertension, ascities, and
the administration tpn in addition to iv medications and
antibiotics.  she was given albumin and prbc to maintain her map
to help diuresis with aldactone and lasix.  due to her uti, and
concern for delerium, a foley was note placed to monitor uop.
her weights were followed to monitor her fluid balance.

3) nutrition: due to her inability to tolerate po and narcotic
ileus.  she was started on tpn for several days.  she also
required additional potassium repletion due to diuresis for
volume overload.

4) hyponatremia: she developed hypervolemic hyponatremia due to
decompensated cirrhosis.  her hyponatremia resolved after the
administration of diurectics and free water restriction.

5) enterococcus/yeast uti.  upon admission she was noted to have
inflammation on her ua in addition to persistent yeast in her
urine and vre.  she was treated empirically for seven days for a
complicated uti with linezolid and fluconazole.  subsequent
urine cultures were negative for persisent yeast or vre.

6) mdr e.coli uti: upon admission she was completing a course of
tobramycin for an esbl uti, please see previous discharge
summary for sensitivities.

7) anemia: the patient remained anemic on presentation and
required multiple prbc transfusions for volume due to
hypotension secondary to decreased intravascular volume.  prior
to her transfer to the micu she did not have evidence of active
bleeding.

micu course: patient transferred to micu given concern for
hematemesis and upper gi bleed.  was electively intubated for
egd on [**4-16**].  egd did not reveal presence of varices, but did
show barrett's and gastropathy.  patient continued on famotidine
for gi ppx.  there was no recurrence of hematemesis, and hct
remained stable.  patient did develop hypotension while
intubated, likely multifactorial secondary to her underlying
cirrhosis and to sedating medications.  was briefly on pressors,
but quickly weaned off once extubated.  was successfully
extubated [**2104-4-17**].  patient developed recurrent ileus while in
icu; ngt kept to continuous low wall suction and patient kept
npo.  course notable for persistent ams, and patient was given
lactulose enemas while npo.  no evidence of infection, as
patient afebrile without leukocytosis.  diagnostic para [**4-16**]
negative for sbp.

post micu course

# encephalopathy: the patient's encephalopathy continued after
she was transferred from the micu to the floor. she was aao x 1
with asterixis. she was treated heavily with lactulose po/pr,
and began to put out an appropriate amount of stool, but without
resolution of her encephalopathy. an infectious work-up with
blood, urine, and chest x-ray was negative. opioid medications,
which were given to her in the icu, were avoided on the floor.
the patient's encephalopathy cleared on [**2104-4-24**], when she was
aaox3, and was following commands, but with occasional
asterixis. she no longer required restraints, and had not been
using the olanzapine which was written for her prn for
agitation. her encephalopathy was felt likely secondary to
lingering opioid medication, and not to hepatic encephalopathy
given her appropriate output of stool.

# epistaxis: upon transfer back from the icu, the patient did
not have any signs of epistaxis, and did not require any
transfusion.

# ileus: the patient had an ileus that was noted on abdominal
x-ray upon return from the icu, which was felt likely secondary
to opioid medication. the patient was made npo, and started on
metoclopromide. a few days later the patient's gi motility
started to return, and her diet was gradually advanced, and her
medications were returned to po. opioid medication was again
thought to play the largest role in the patient's ileus.
metoclopromide was discontinued on patient's discharge.

# tachypnea: the patient was noted on the floor for tachypnea
during her stay, with a normal abg and normal o2 sats. her
tachypnea was felt to be secondary to abdominal ascities with
ateletasis and an element of volume overload. she was treated on
the floor with iv lasix, and ultimately her o2 requirements were
removed. the patient was started on a dose of 40 mg lasix po bid
and her home dose of spironolactone (50 mg daily). she was
discharged on her home dose of 40 mg lasix daily and a new dose
of 100 mg spironolactone daily without tachypnea.

# decompensated cirrhosis: underlying etoh cirrhosis. no history
of varices or sbp; egd from [**4-16**] confirmed patient does not have
varices, and diagnostic para [**4-16**] not suggestive of sbp. the
patient was continued on lactulose and rifaximin.

# hypernatremia/hyponatremia: the patient transiently became
hypernatemic with na of 154 after diuresis, which resolved with
free water administration. on discharge she was hyponatremic
without end organ signs likely secondary to diuresis.

# nutrition: given resolving ileus and multiple bm, the patient
was discharged on regular diet low salt/heart healthy diet

# pain: the patient's chronic leg and back pain had previously
been treated with opiod medication, but her hospital course was
complicated by several adverse events secondary to opioid
medication (ileus, encephalopathy). her morphine doses were
discontinued, and the patient was started in house on standing
tylenol for pain control.

# history of restless legs: the patient previously had been on
mirapex 1mg qhs for restless legs.  this was stopped while in
the hospital, but may be restarted as needed.

medications on admission:
1. alendronate 70 mg po qweekly
2. morphine 30 mg po q12h
3. morphine 15 mg po q6h prn
4. omeprazole 20 mg po daily
5. potassium chloride 20 meq po bid
6. mirapex 1 mg po qhs
7. trazodone 300 mg po qhs
8. hydroxyzine hcl 25 mg po q6h prn
9. lactulose 30ml po tid
10. phenazopyridine 100 mg po tid prn
11. triamcinolone acetonide 0.1 % cream topical [**hospital1 **]
12. lidocaine 5 %(700 mg/patch) adhesive patch daily
13. zofran 8 mg po qid prn
14. calcium citrate + d 630-400 mg-unit po bid
15. vitamin d-3 1,000 unit po daily
16. cyanocobalamin (vitamin b-12) 1,000 mcg po daily
17. docusate sodium 100 mg po bid
18. centrum silver po daily
19. furosemide 40 mg po daily
20. spironolactone 50 mg po daily
21. rifaximin 550 mg po bid
22. tetracycline 500 mg po qid last day [**2104-3-31**]
23. azithromycin 250mg daily (started at rehab)
24. albuterol nebulizer (started at rehab)

discharge medications:
1. alendronate 70 mg tablet sig: one (1) tablet po once a week.

2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
3. potassium chloride 10 meq capsule, extended release sig: two
(2) capsule, extended release po twice a day.
4. trazodone 300 mg tablet sig: one (1) tablet po at bedtime as
needed for insomnia.
5. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po every six
(6) hours as needed for itching.
6. lactulose 10 gram/15 ml solution sig: thirty (30) ml po three
times a day.
7. phenazopyridine 100 mg tablet sig: one (1) tablet po three
times a day as needed for pain.
8. triamcinolone acetonide 0.1 % cream sig: one (1) application
to affected areas topical twice a day.
9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) patch topical once a day.
10. zofran 8 mg tablet sig: one (1) tablet po four times a day
as needed for nausea.
11. calcium 600 with vitamin d3 600 mg(1,500mg) -400 unit
capsule sig: one (1) capsule po twice a day.
12. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet,
chewable po once a day.
13. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1)
tablet po once a day.
14. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day.
15. centrum silver     tablet sig: one (1) tablet po once a day.

16. furosemide 40 mg tablet sig: one (1) tablet po once a day.
17. rifaximin 550 mg tablet sig: one (1) tablet po twice a day.

18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1) puff inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
19. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler
sig: one (1) puff inhalation every four (4) hours as needed for
shortness of breath or wheezing.
disp:*1 inhaler* refills:*3*
20. acetaminophen 500 mg capsule sig: one (1) capsule po every
six (6) hours.
disp:*120 capsule(s)* refills:*0*
21. artificial tears(glycerin-peg) 1-0.3 % drops sig: one (1)
drop to both eyes ophthalmic prn as needed for dry eye.
disp:*1 tube* refills:*0*
22. spironolactone 100 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
primary diagnosis:
- [**female first name (un) 564**] and vre cystitis
- opioid-induced ileus
- hepatic encephalopathy
secondary diagnosis:
- etoh cirrhosis


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:
ms. [**known lastname 28445**], it was a pleasure taking care of you in the
hospital. you were admitted to the hospital with diffuse body
pain. you were found to have an infection in your bladder, and
we treated you with the appropriate antibiotics. however, your
hospital course was complicated by a slow moving gi tract that
likely happened because of the high dose of narcotics which you
normally take. we confirmed that you did not have an obstruction
in your abdomen, and gave you some medications to help your gut
move along. during that time when you were not eating, we were
giving your nutrition through your veins. also during your
hospital stay, you had started vomiting some blood; we took you
to the icu were we put a breathing tube down your throat and
also looked at your stomach lining, where we did not see any
bleeding. we believe that your vomiting of blood may have been
blood which dripped into your stomach from your nose.

unfortunately, when you were intubated, we needed to give you
more doses of narcotics, which caused your gi tract to slow down
again. your gut motility improved, but you still remained a
little bit confused, which improved once the narcotics had
worked their way out of your system.

when you leave the hospital:
- stop morphine 30 mg every 12 hours
- stop morphine 15 mg every 6 hours as needed for pain
- stop tetracycline 500 mg four times a day
- stop azithromycin 250 mg every day
- stop mirapex 1mg before bedtime
- start ipratropium bromide inhaler 1 puff inhalation every four
(4) hours as needed for shortness of breath or wheezing
- start acetaminophen 500 mg every 6 hours
- start artificial tears(glycerin-peg)  1-0.3 % drops: use one
(1) drop to both eyes as needed for dry eyes
- increase your dose of spironolactone to 100 mg daily
(previously you had been taking 50 mg daily)

we did not make any other changes to your medications, so please
continue to take them as you normally have been.

followup instructions:
when you leave the hospital, please have your rehab facility
make the following appointments for you:

- make an appointment to see your primary care doctor, dr. [**first name (stitle) 1022**],
one week after your discharge from rehab by calling [**telephone/fax (1) 250**]

department: liver center
when: wednesday [**2104-5-7**] at 10:00 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 7128**], md [**telephone/fax (1) 2422**]
building: lm [**hospital unit name **] [**location (un) 858**]
campus: west     best parking: [**hospital ward name **] garage



"
169,"unit no:  [**numeric identifier 44622**]
admission date: [**2113-4-17**]
discharge date: [**2113-4-24**]
date of birth:  [**2091-7-11**]
sex:  m
service:


history of present illness:  the patient is a 21-year-old
male with a history of end-stage renal disease (on
hemodialysis) secondary to reflux nephropathy, and focal
segmental glomerulosclerosis who presented with fevers to 102
and a facial rash.

initially, he had a temperature of 100.6 at [**location (un) 4265**]
hemodialysis unit on [**2113-3-27**].  there, he received
vancomycin which was complicated by red man syndrome.  this
consisted of a fever and rash from the forehead down to his
waistline.  he was given benadryl and tylenol and sent home.

he received hemodialysis on [**2113-4-12**] uneventfully.  at
hemodialysis on [**2113-4-14**] he had a temperature to 102.7.
blood cultures were taken from his hemodialysis line.  he was
given 1 gram of kefzol and referred to the emergency
department.

in the emergency department, a chest x-ray showed no
pneumonia.  laboratories with a white blood cell count of
5.4.  urinalysis had small leukocyte esterase, but no
nitrites.  therefore, he was started empirically on
ciprofloxacin 500 mg twice per day times seven days for a
possible urinary tract infection.  urine culture ultimately
returned negative.  he began taking ciprofloxacin in the
morning of [**2113-4-15**].  he woke up on [**2113-4-16**] with
""dots"" all over and pruritus.  he took his last dose of
ciprofloxacin on [**2113-4-16**] in the evening.  his rash was
not relieved with benadryl or tylenol, so he came to the
emergency department for further evaluation.

in the emergency department - on [**2113-4-17**] - he was
noted to have a temperature of 98.8, his blood pressure was
128/64, his pulse was 98, his respiratory rate was 16, and
his oxygen saturation was 100 percent on room air.  in the
emergency department, he was pan-cultured and given one dose
of vancomycin intravenously and ceftriaxone intravenously.
laboratories at that time showed a potassium of 6.3 with
questionable peaked t waves on his electrocardiogram.
therefore, he also received calcium gluconate 1 gram, 10
units of regular insulin, 1 ampule of dextrose, 1 ampule of
bicarbonate, and kayexalate 60 grams.  before leaving to the
emergency department, he spiked a temperature to 103.6.
therefore, tylenol was given.

of note,  he had a recent admission in [**month (only) 956**] after two
generalized tonic-clonic seizures.  at that time he was
started on dilantin.  also during that admission, he
completed a 3-day course of ciprofloxacin for a urine culture
that grew out acinetobacter.

during this admission, review of systems was significant for
fevers, sore throat, and generalized malaise.  he denied any
rigors, night sweats, or weight loss.  he denied chest pain,
shortness of breath, palpitations, orthopnea, or paroxysmal
nocturnal dyspnea.  there was no cough, wheezing, or
hemoptysis.  there was no dysuria, abdominal pain, or
suprapubic tenderness.  no nausea, vomiting, diarrhea, or
constipation.  no recent travel.  no recent medication
changes.  no outdoor activities or camping.  no recent
vaccinations.  no pets or tic exposures.  no recent sexual
contacts other than his longtime girlfriend with whom he is
in a monogamous relationship.

past medical history:  end-stage renal disease (on
hemodialysis) secondary reflux, nephropathy, and focal
segmental glomerulosclerosis.  he is dialyzed on monday,
wednesday, and friday.  he started hemodialysis on [**2113-3-1**].  reflux nephropathy resulted in recurrent ascending
escherichia coli infections.  he is status post placement of
a right subclavian perm-a-cath on [**2113-3-15**] and an
arteriovenous fistula was placed on [**2113-3-17**].

spina bifida; status post repair as an infant - complicated
by bowel and bladder incontinence, with a history of straight
catheterization three times daily - complicated by numbness
in the soles of the feet and backs of both thighs as well as
left foot weakness and hyperreflexive bilateral lower
extremities.

newly diagnosed seizure disorder on [**2113-3-14**] for two
generalized tonic-clonic seizures - started on dilantin on
[**2113-3-26**].  seizures characterized by initial head
deviation toward to the right followed by generalized tonic-
clonic movements.  his first seizure on [**2113-3-14**] was
felt to be secondary to hypercalcemia in the setting of a
calcium level of 6.  his second seizure took place on
[**2113-3-26**] and was felt to be idiopathic.  at that
time, he was loaded on dilatation 300 mg three times per day.
he erroneously continued on dilantin 300 mg three times per
day until a follow-up appointment on [**2113-4-6**].  at that
time, he was switched to a regimen of 300 mg in the morning
and 200 mg in the evening.

hypoparathyroidism.

history of multiple urinary tract infections; last diagnosed
in [**2113-2-26**] and treated with ciprofloxacin.

anemia of chronic disease.

allergies:  the patient reports no known drug allergies.

medications prior to admission:
1. dilantin 300 mg by mouth in the morning alternating with
   200 mg by mouth in the evening.
2. lisinopril 10 mg by mouth once per day.
3. epogen subcutaneously every week.
4. sodium bicarbonate tablets four tablets by mouth twice per
   day.
5. oxybutynin 5 mg by mouth twice per day.
6. tums 500 mg by mouth three times per day.
7. calcitriol at each hemodialysis session.
8. nephrocaps once per day.


social history:  the patient is a sophomore at [**university/college 5130**]
[**location (un) **].  he lives in a dormitory.  he is originally from
[**location (un) 17004**], [**state 531**].  he denies any tobacco or illicit drug use,
but he reports occasional social alcohol intake.  he is in a
monogamous sexual relationship with a longstanding
girlfriend.

family history:  the patient reports no family history of
seizures or kidney disease.

physical examination on presentation:  generally, this was
well-developed, well-nourished, thin, young male.  he was
uncomfortable and ill-appearing, but nontoxic.  vital signs
revealed his temperature was 99.8, his blood pressure was
128/64, his heart rate was 98, his respiratory rate was 16,
and his oxygen saturation was 100 percent on room air.  head
and neck examination was remarkable for normocephalic and
atraumatic.  the pupils were equal, round, and reactive to
light.  the mucous membranes were moist.  the posterior
oropharynx was erythematous, but there were no lesions
exudates.  the neck was supple with no masses or
lymphadenopathy.  the chest wall had hemodialysis catheter
site bandaged with no evidence of edema, fluctuance or
purulent discharge.  the lungs were clear to auscultation
bilaterally.  there were no rhonchi, rales, or wheezes.
cardiovascular examination revealed a regular rate and rhythm
with normal first and second heart sounds auscultated.  there
were no murmurs, rubs, or gallops.  the abdomen was soft,
nontender, and nondistended.  there were positive normal
active bowel sounds.  there was no hepatosplenomegaly.
examination of the back revealed no spinal or costovertebral
angle tenderness.  the extremities were warm and well
perfused.  there was no clubbing, cyanosis, or edema.  the
left forearm arteriovenous fistula had some serous drainage;
but no erythema, edema, or fluctuance.  a bruit was
auscultated over the arteriovenous fistula.  his skin
demonstrated erythematous, raised, maculopapular rash
diffusely, but concentrated mostly on the face, abdomen,
extremities, palms, and soles.  the lesions were
approximately 1 cm in diameter.  on the face, the eyelids
were spared.  otherwise, the rash was confluent, pruritic,
blanching, nonconfluent on the body with a questionable
appearance of wheels.  there were no bullae formation.  no
target lesions.  the skin examination was also remarkable for
a tuft of hair on his back and a scar overlying his previous
spina bifida surgery site.  neurologically, he was alert and
oriented times three with no tremor or asterixis.

pertinent laboratory values on presentation:  a complete
blood count on admission revealed his white blood cell count
was 5.1 (with 61 percent neutrophils, 26 percent lymphocytes,
5 percent monocytes, 7.2 percent eosinophils - 2.9 percent on
[**2113-3-26**] - and 0.5 percent basophils), his
hematocrit was 41.6, and his platelets were 194.  chemistries
showed his sodium was 138, potassium was 6.3, chloride was
95, bicarbonate was 27, blood urea nitrogen was 58,
creatinine was 13.5, and his blood glucose was 87.  his
calcium was 10.6, his phosphorous was 4.4, and his magnesium
was 2.5.  coagulation profile revealed his prothrombin time
was 12.7, his partial thromboplastin time was 26.4, and his
inr was 1.1.  hemolysis studies on [**2113-4-18**] showed a
haptoglobin of 87, his fibrinogen was 253, and his d-dimer
was elevated at 2274.  an additional workup for his rash and
fever revealed a throat swab with culture negative for beta
streptococcal infection.  stool culture was negative.  mono
spot was negative.  aso titer from [**4-19**] demonstrated a
positive aso screen with a titer positive to 200 to 400.
rapid plasma reagin nonreactive.  [**doctor last name 3271**]-[**doctor last name **] virus titer
showed the patient to be igg positive and igm negative.
urine culture from [**2113-4-14**] was also negative for
growth.

brief summary of hospital course:  fever issues:  a concern
over line source of fevers in the emergency department, the
patient received a vancomycin.  he was started on ceftriaxone
for gram-negative coverage given his history of multiple
urinary tract infections and a history of straight
catheterization use.  prior to antibiotic initiation, he was
pan-cultured.  on the night of admission, he spiked a
temperature to 103.7 which decreased to 101.5 with tylenol.

on the morning of [**2113-4-18**] he went to hemodialysis and
there spiked a temperature to 105.  he was cultured from his
hemodialysis line and sent back to the general medicine
floor.  as the fever started after hemodialysis sessions and
appeared to worsen with accessing his hemodialysis line, the
interventional radiology service was contact[**name (ni) **] for removal of
the patient's tunnel catheter.  initially, the interventional
radiology service did not feel the catheter needed to be
removed.  thereafter, the patient himself refused removal.
later on the day of [**2113-4-18**] he was dialyzed via his
arteriovenous fistula with no adverse events.

he was seen in consultation by the infectious disease service
who recommended holding vancomycin, ciprofloxacin, and
dilantin.  an exhaustive workup; including pan cultures,
liver function tests, mono spot, cytomegalovirus, [**doctor last name 3271**]-
[**doctor last name **] virus, mycoplasma, and titers, rapid plasma reagin, aso,
throat swab, antineutrophil cytoplasmic antibody, rheumatoid
factor, and sedimentation rate was initiated out of concern
for drug fevers, viral infection, line infection, vasculitis,
toxic shock syndrome, primary human immunodeficiency virus
infection.

the patient was covered initially with aztreonam after he
spiked a fever to 107.3 in the setting of a normal blood
pressure of 140/90 and a heart rate of 120.  in addition to
aztreonam during this temperature spike he also received 1
gram of tylenol and benadryl.  he was moved from the floor to
the medical intensive care unit for further monitoring.

out of continued concern for a line infection in spite of
negative culture data, the patient's tunneled port-a-cath was
removed on [**2113-4-19**].  he continued to have dialysis and
was dialyzed on [**2113-4-20**] through his arteriovenous
fistula.  about one hour into that hemodialysis session, he
had rigors.  there was some question of whether his fevers
and rigors could be secondary to a membrane issue.

as all of the patient's culture data was negative, and his
fevers subsided status post discontinuation of vancomycin and
dilantin, it was felt that his fevers were most likely
secondary to an acute drug reaction.  it is therefore
recommended that he avoid exposure to vancomycin and dilantin
in the future.

rash issues:  it was unclear whether the patient's rash was
drug related versus infectious in etiology.  the onset
occurred after therapy with ciprofloxacin and had an
urticaria appearance and peripheral eosinophilia which was
suggestive of a drug related process.  however, in light of
the high fevers ________ was maintained for infectious
sources as well.

an exhaustive workup (as outlined above) was undertaken in
order to help delineate the source of the patient's fevers.
an infectious workup was negative.  for symptoms, he was
continued on benadryl and an h2 blocker to decrease histamine
release.  he was not initially treated with steroids out of
concern for infection.

on [**2113-4-18**] he was noted to have cracking and peeling
as well as a edema of his lips and a question ulcerative
lesion in his oropharynx and conjunctivae.  this was
concerning for [**doctor last name **]-[**location (un) **] syndrome.  he was seen in
consultation by the dermatology, infectious disease, and
ophthalmology services.  ophthalmology saw only mild
conjunctivitis on their examination and recommended
artificial tears and lacri-lube.  per dermatology, the likely
culprits for the patient's rash included vancomycin and
dilantin.  however, there was really no way to delineate
which of these two agents were the cause of this.  with
conservative and symptomatic therapy, the patient's rash
improved.

end-stage renal disease issues:  on the day of his admission,
the patient had discontinuation of his tunneled port-a-cath.
he started hemodialysis via an arteriovenous fistula.  he
tolerated this well with the exception of intermittent fever
spikes.  he was continued on nephrocaps, calcium acetate,
epogen, and calcitriol per the renal team.

seizure disorder issues:  in light of the suspicion of
dilantin as an etiologic [**doctor last name 360**] for the patient's fevers and
rash, dilantin was discontinued.  he was monitored closely in
the setting of fevers due to the fact that fevers can
decrease seizure threshold.  he was started on gabapentin
after consultation with the neurology service.  outpatient
neurology followup was arranged as well.

code status issues:  the patient was a full code.

condition on discharge:  good - afebrile times 36 hours and
hemodynamically stable.  dilantin and vancomycin levels were
trending down.  skin rash was improving.  all culture data
was negative for acute infection.

discharge status:  the patient was discharged to home.

discharge diagnoses:  drug fever and reaction secondary to
vancomycin or dilantin.

end-stage renal disease (on hemodialysis).

history of recurrent urinary tract infections.

history of a seizure disorder.

history of spina bifida; status post surgical repair.

bowel and bladder incontinence.

anemia of chronic disease.

medications on discharge:
1. gabapentin 300 mg by mouth at hour of sleep.
2. lisinopril 20 mg by mouth once per day.
3. epogen injections subcutaneously at hemodialysis.
4. oxybutynin 5 mg by mouth twice per day.
5. calcium acetate 670 mg two tablets by mouth three times
   per day (with meals).
6. nephrocaps one capsule by mouth every day.
7. artificial tears 1 drop each eye q.2h.
8. lacri-lube one application each eye at hour of sleep.
9. benadryl 25 mg one capsule by mouth q.4-6h. as needed (for
   itching).
10.      calcitriol.


follow-up plans:  the patient was instructed to call his
primary care physician or visit [**name initial (pre) **] local emergency room if he
experienced recurrent fevers, shaking chills, headaches,
chest pain, confusion, recurrent skin rash, or any other
worrisome symptoms.  he was instructed if he feels fevers and
rash, the most likely reaction was medications; however, we
could not ascertain whether the reaction was due to dilantin
or vancomycin.  we strongly suggested that he absolutely
avoid both of these agents in the future.  he was instructed
to discontinue his dilantin and sodium bicarbonate.

additionally, he had follow-up appointments with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] in the neurology department on [**2113-6-6**].  he was
instructed to call both dr. [**last name (stitle) 44623**] and dr. [**last name (stitle) **] from the
renal division for follow-up appointments after discharge.


                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 20314**]

dictated by:[**last name (namepattern1) 14378**]
medquist36
d:  [**2113-7-6**] 16:30:22
t:  [**2113-7-6**] 22:13:09
job#:  [**job number 44624**]

cc:[**last name (namepattern1) 44625**]



"
170,"admission date:  [**2130-10-16**]       discharge date:  [**2130-10-24**]


service:  ccu

history of present illness:  this is an 83-year-old white
male with history of coronary artery disease status post
coronary artery bypass graft times three vessels in [**2121**], end
stage renal disease on hemodialysis three times a week,
diabetes mellitus and hypertension transferred from [**hospital 1474**]
hospital for cardiac catheterization.

the patient initially presented to [**hospital 1474**] hospital with
complaints of increased dyspnea on exertion, weakness and
dizziness.  in the emergency department their he was found to
have new ekg changes, new t wave depressions in v2 through v3
and more depressed t wave depressions in v4 through v6 and
atrial fibrillation.  the patient was ruled out for mi by
serial enzymes, although he did have an initial ck mb index
of 3.2 and had an echocardiogram which showed lv enlargement
with akinesis of the inferior and posterior walls.  also with
hypokinesis of other lv walls and ejection fraction of 30%,
mitral tricuspid regurgitation with a pulmonary artery
systolic pressure of 45 mg of mercury, mild mr with
significant left atrial enlargement.  patient then had a
persantine mibi which showed a small lateral wall ischemia
and small inferior wall infarct.

decision was then made to transfer to [**hospital1 190**] for cardiac catheterization.  cardiac
catheterization showed a pulmonary capillary wedge pressure
of 22 mg of mercury, right atrial pressure of 25 mg of
mercury, pa pressure of 46/17, right ventricular pressure
48/9.  a totally occluded lad with positive collateral flow,
70% stenosis of the left circumflex.  the svg to om graft was
totally occluded.  svg to dm graft was patent and lima to lad
graft was patent.  overall severe three vessel disease.  two
out three grafts had moderately decreased left ventricular
ejection fraction of 40%, moderate mitral regurgitation and
moderately diffuse hypokinesis.

during the procedure, the patient became hypertensive with a
210/110 and intravenous prior to nitroglycerin was started.
patient also had flash pulmonary edema after a
................. load of about 500 cc and was electively
intubated for increased shortness of breath and agitation.
the patient was then transferred to the ccu for nipride wean
and extubation.

medications on transfer:
1.  tylenol p.r.n.
2.  ambien p.r.n.
3.  metoprolol 25 mg p.o. b.i.d.
4.  captopril 6.25 mg p.o. t.i.d.
5.  ec-asa 325 mg p.o. q.d.
6.  coumadin 5 mg h.s. then 2 mg h.s.
7.  nitroglycerin drip 0.052.2 mcg per kilogram per minute.
8.  nephrocaps one cap p.o. q.d.
9.  regular insulin sliding scale.
10. glipizide xl 10 mg p.o. q.d.
11. propofol drip.

past medical history:
1.  coronary artery disease status post coronary artery
bypass graft for three vessels in [**2121**].
2.  end stage renal disease on hemodialysis on tuesday,
thursday and saturday.
3.  hypertension.
4.  diabetes mellitus.
5.  anemia.
6.  prostate ca.
7.  new onset atrial fibrillation.

social history:  not obtainable.

family history:  not obtainable.

initial ekg showed atrial fibrillation at 65 beats per
minute, normal axis, qrs mildly elongated, left ventricular
hypertrophy by voltage, t wave inversions in v2 through v5,
st depressions in i and l, unchanged from outside hospital
ekgs.

physical examination:  vital signs with a temperature of 97.6
f, blood pressure 106/45, heart rate 68.  pulmonary artery
pressure 37/11.  in general elderly, sedated, intubated male
lying still in bed.  head, eyes, ears, nose and throat:
normocephalic, atraumatic.  pupils are 2 mm bilaterally,
equal, round, reactive to light.  endotracheal tube in place.
neck:  no jugular venous distention.  cardiovascular:  iv/vi
systolic murmur loudest at the apex radiating to the axilla
into the back, irregular.  pulmonary:  loud bronchial sounds
bilaterally.  abdomen:  soft, nondistended with normal
abdominal bowel sounds, no hepatosplenomegaly.  positive
abdominal bruit.  extremities:  warm, no edema, no hematoma
at right groin.  neuro:  patient sedated.  withdraws from
touching of feet.

initial laboratory results:  white blood cell count of 5.7,
hematocrit 32.7, platelets 134.  differential was 72.4%
neutrophils, 18.2% lymphocytes, 8.2% monocytes, 1.0%
eosinophils, 0.2% basophil.  inr was 1.3. potassium 5.5,
calcium 8.3, magnesium 2.7, phosphorus was 9.7.

abg done was 7.45, 73 and 345 on 100% oxygen.

initial assessment:  this is an 83-year-old male with history
of coronary artery disease, diabetes mellitus, end stage
renal disease on hemodialysis transferred from outside
hospital for cardiac catheterization secondary to abnormal p
mibi with dyspnea and hypertension in cath lab.  started on
nipride and nitroglycerin drips, intubated and electively
transferred to ccu for extubation and drip weaning.

hospital course:
1.  cardiac:  patient is being kept on the nitroglycerin drip
throughout the entire course when he was on the ventilator
and it was discontinued once he had been weaned.  the patient
was started on imdur 50 mg p.o. q.d. for approximately six
hours prior to stopping the nitroglycerin drip with no ill
effects.

patient was noted to have a moderately decreased left
ventricular ejection fraction of 30 to 40%.  the patient was
started on an ace inhibitor and was gradually titrated up,
however two days into ace inhibitor therapy with captopril,
the patient developed an erythematous rash which was
pruritic.  at this point, it was assumed that the rash was
secondary to the sulfur group of the captopril and patient
was switched to lisinopril 40 p.o. q.d. with eventual
clearing of rash and no other ill effects.

the patient was switched over from nitroglycerin drip to
imdur with no ill effects.  patient remained moderately
hypertensive throughout the hospital course with blood
pressures up to 160 mg of mercury systolic were tolerated as
this patient is on hemodialysis.

2.  rhythm:  patient was noted to have new onset atrial
fibrillation.  patient was maintained on telemetry and had
frequent episodes of nonsustained ventricular tachycardia as
well as ventricular tachycardia throughout the first two days
of hospitalization with gradual clearing of these.  the
patient was tried on a beta blocker and pr prolongation was
noted.  at this point, the beta blocker was discontinued and
patient had a pacemaker placed so that he would be able to
tolerate amiodarone therapy.

patient had a dual chamber rate responsive pacemaker placed
and was started on amiodarone loading 400 mg p.o. b.i.d.  at
pacemaker placement, the patient received a dose of
vancomycin.  the patient tolerated the pacemaker placement
and was kept on telemetry for 24 hours after pacemaker was
placed with no adverse events noted.

the patient was also restarted on coumadin for
anticoagulation after pacemaker placement.  the decision of
how long to continue coumadin will be left up to the pcp.
[**name10 (nameis) **] patient's amiodarone loading should be 400 mg p.o. b.i.d.
times one week then 400 mg p.o. q.d. times one week and then
200 mg p.o. q.d.  the patient should be seen at [**hospital **]
clinic in one week.

3.  coronaries:  patient with status post coronary artery
bypass graft in [**2121**], lima to lad, svg to lpda, and svg to om
which is totally occluded, 70% stenotic lesion in mid
circumflex.  patient was started on lipitor 10 mg p.o. q.d.
and was kept on aspirin throughout hospital course.  the
patient should continue to take these two drugs indefinitely.


4.  pulmonary:  patient had an initial weaning trial
approximately 12 hours after admission to the ccu.  the
patient became tachypneic as he was initially weaned from the
ventilator and it was decided to rest him for another day.
the patient was switched over to pressure support and
successfully weaned on hospital day #2.  the patient
initially required oxygen, but soon was able to tolerate room
air with o2 saturations of 95% and above.  there were no
further pulmonary issues in the hospital course.

5.  renal:  patient was continued on hemodialysis throughout
hospital course and initially started on amphojel and phos-lo
as patient had increased phosphorus on presentation.
eventually, amphojel was able to be discontinued after four
hospital days as per renal's recommendation.  patient to
continue hemodialysis as an outpatient on tuesdays, thursdays
and sundays.

6.  endocrine:  the patient was noted to become hypoglycemic
with blood sugars as low as 48.  patient had his glipizide
discontinued and had some hypoglycemia for one day after
discontinuation and subsequently high blood sugars of 160s to
200s while continuing regular insulin sliding scale.  it was
decided to reinitiate glipizide at a lower dose of 2.5 mg
q.d. and further watch for hypoglycemia as an outpatient.

7.  dermatologic:  patient developed an erythematous
maculopapular and some areas ................ pruritic rash
over the trunk and upper thighs and back on day #2 of
captopril.  a dermatology consult was called and a skin
biopsy was performed.  the patient was switched from
captopril to lisinopril.  skin biopsy confirmed a lymphocytic
infiltrate with rare eosinophils, focal rbc extravasation
consistent with systemic hypersensitivity reaction, no
leukocytoclastic vasculitis was seen.

the patient's rash eventually cleared, although not
completely after lisinopril was initiated.  the patient was
given sarna lotion, [**doctor first name **] and benadryl p.r.n. for itching
with moderate effect.

8.  prophylaxis:  patient received aspirin, lipitor, coumadin
and protonix for gi prophylaxis during hospital course.

discharge diagnosis:
1.  new onset atrial fibrillation status post dual chamber
pacemaker placement, initiation of amiodarone therapy.
2.  coronary artery disease.
3.  end stage renal disease on hemodialysis tuesday, thursday
and saturday.
4.  hypertension.
5.  diabetes mellitus type 2.
6.  anemia.
7.  prostate ca.

discharge medications:
1.  warfarin 2 mg p.o. q.h.s.
2.  amiodarone 400 mg p.o. b.i.d. times seven days started
[**2130-10-23**] then 400 mg p.o. q.d. times seven days then
200 mg p.o. q.d.
3.  lisinopril 40 mg p.o. q.d.
4.  imdur 60 mg p.o. q.d.
5.  lipitor 10 mg p.o. q.h.s.
6.  enteric coated aspirin 325 mg p.o. q.d.
7.  benadryl 25 mg p.o. q. six hours p.r.n.
8.  docusate 100 mg p.o. b.i.d.
9.  [**doctor first name **] 60 mg p.o. b.i.d.
10. sarna tp p.r.n.
11. phos-lo three caps p.o. t.i.d.
12. [**doctor last name **] two tabs p.o. b.i.d. p.r.n.

condition on discharge:  good.

discharge status:  to short term rehab.  patient to follow up
with own cardiologist to arrange pulmonary function test as
patient is now being started on amiodarone and also to follow
up tsh and lfts.




                            [**first name11 (name pattern1) **] [**last name (namepattern4) 1008**], m.d.  [**md number(1) 1009**]

dictated by:[**name8 (md) 45172**]
medquist36

d:  [**2130-10-24**]  16:26
t:  [**2130-10-24**]  14:35
job#:  [**job number 45173**]
"
171,"admission date:  [**2125-2-9**]              discharge date:   [**2125-2-18**]

date of birth:  [**2058-2-22**]             sex:   f

service: medicine

allergies:
ace inhibitors

attending:[**first name3 (lf) 69838**]
chief complaint:
hematuria

major surgical or invasive procedure:
trans-urethral resection of bladder


history of present illness:
66 y.o. female with cad s/p mi and bm stent, chf, s/p mechanical
avr on coumadin and recently discovered bladder tumor who was
transferred from [**hospital 8125**] hospital with hematuria. patient developed
hematuria on [**1-17**], which prompted her to go to the
hospital. at that time, she was felt to have a uti and was
treated wtih tetracyclin. additionally a ct abdomen showed a
bladder tumor, that as of yet has not been biopsied. after
completing antibiotics, the hematuria cleared and the patient
was doing well, being followed by dr. [**last name (stitle) 770**] for eventual plans
to biopsy the tumor. on [**2-7**], patient noticed blood in her
urine, but says it was minimal. she spoke to her urologist who
reassured her but told her to continue to monitor the symptoms.
on the following day, she developed clots and by the day of
admission, [**2-9**], felt as though she was ""hemorrhaging"". prior to
this, she was asymptomatic, but on the day of presentation,
reports feeling dizzy without chest pain or palpitations. she
additionally denies f/c, n/v but does endorse some mild back
pain and dysuria.
.
patient initially presented to [**hospital 8125**] hospital with her
complaints, but was then transferred to [**hospital1 18**] because her
urologist was here. in the ed, labs revealed an inr of 4.3 and a
strongly positive ua and wbc of 21 with 84% neutrophils, no
bands. she was afebrile and hemodynamically stable. urology was
consulted and placed a 22 french foley and hand irrigated many
clots from the bladder, after which the urine remained pink.
patient's cardiologist, dr. [**last name (stitle) **], saw the patient in the ed and
recommended holding her asa and coumadin for now. patient was
given ceftriaxone empirically for the uti and was then admitted
to the medicine team for continued management of her hematuria.



past medical history:
bladder tumor
chf (ef 40-45% in 10/'[**23**])
cad s/p mi and stents to lcx [**8-5**]
carotid stenosis
hypertension
hypercholesterolemia
s/p hysterectomy


social history:
former smoker, but stopped in [**2124-7-29**]. denies alcohol
or illicit drug use. patient lives in [**hospital3 **] and works in real
estate.

family history:
non-contributory

physical exam:
physical exam:
t: 96.9, bp: 110/60, p: 83, rr: 18, o2 sats: 94% ra
gen: awake, alert, nad
heent: nc/at; perrla, eomi; op clear, nonerythematous
neck: supple, no lad, no jvd
cv: s1, s2 nl, no m/r/g appreciated, though valvular click was
ausculated
resp: ctab
abd: soft, tender to palpation in suprapubic area, nd, + bs
back: no flank tenderness
gu: normal female genitalia with foley in place, draining frank
blood
ext: no c/c/e
neuro: grossly intact


pertinent results:
=================
  admission labs
=================

wbc-21.3*# rbc-3.53* hgb-8.9*# hct-28.0* mcv-79*# mch-25.2*#
mchc-31.7 rdw-14.6 plt ct-458*
neuts-84.2* lymphs-10.8* monos-3.9 eos-1.0 baso-0.1
pt-39.4* ptt-37.2* inr(pt)-4.3*
glucose-114* urean-17 creat-0.7 na-136 k-4.6 cl-97 hco3-28
angap-16

===============
  radiology
===============

chest (pa & lat)  [**2125-2-10**] 3:07 pm
median sternotomy wire and mitral valve annuloplasty again
noted. the lungs are grossly clear. cardiac contour within
normal limits. aortic arch is calcified. aorta is ectatic.
impression:
1. no active disease in the chest.
2. ectatic aorta.

ct pelvis w&w/o c   [**2125-2-11**] 11:15 am
findings: there is a large intraluminal filling defect within
the urinary bladder, predominantly on the right, slightly
adherent to the wall, measuring 6 x 5.5 x 5.3 cm. this filling
defect is heterogeneous in appearance and has irregular margins.
it is also directly related to the right ureterovesical
junction. there is a foley catheter within the urinary bladder
as well as foci of air. there is no evidence of significant
retroperitoneal lymphadenopathy. there is no evidence of
hydronephrosis. multiple small foci of hypodensity within the
right renal parenchyma, most likely representing small cysts.
the bilateral adrenal glands are unremarkable. the spleen, the
liver and the pancreas are unremarkable. there is evidence of
cholelithiasis. there is no evidence of free fluid or free air.
the bowel appears unremarkable. there is a thoracoabdominal
aortic aneurysm, measuring 4.4 cm in maximum diameter at the
inlet to the abdomen, after which it tapers to 2.5 cm at the
level of the sma.
bilateral lung bases are unremarkable.
there are no suspicious bony lesions.
impression:
1. large filling defect within the urinary bladder, which is
heterogeneous, measuring 6 cm in maximal diameter. differential
diagnosis includes a bladder tumor versus a blood clot given
that the patient has been on coumadin

================
 microbiology
================

urine culture (final [**2125-2-14**]):    no growth.

=================
 discharge labs
=================

wbc-13.3* rbc-3.60* hgb-9.5* hct-29.8* mcv-83 mch-26.2*
mchc-31.8 rdw-16.4* plt ct-420
pt-17.9* ptt-125.2* inr(pt)-1.6*
glucose-102 urean-10 creat-0.8 na-139 k-4.3 cl-99 hco3-29
angap-15
calcium-8.8 phos-3.2 mg-2.0

brief hospital course:
66 y.o. female with known bladder tumor and mechanical mitral
valve, presenting with gross hematuria, now with stable hct, s/p
transurethral tumor resection
.
# hematuria / bladder tumor: although culprit for hematuria was
a known tumor, intervention was not possible upon admission
secondary to anticoagulation. patient has mechanical valve at
the mitral position, for which she is anticoagulated with
coumadin. patient required a single transfusion of 2 units of
pbrc after warfarin was stopped. continuous bladder irrigation
was initiated and inr was allowed to drift down without reversal
due to increased risk of adverse events in setting of mechanical
valve.
patient was started on heparin drip when inr reached 2.5 and
urology performed trans-urethral bladder tumor resection once
inr reached 1.5.
tissue sent to pathology, this however is pending at the time of
discharge. patient will follow up with dr [**last name (stitle) 770**] for further
management.

# mechanical mitral valve: as above, patient with ([**hospital3 **])
valve in place. after procedure was performed patient was
re-startedd on heparin drip and transitioned to lovenox. she was
discharged on a lovenox to coumadin drip and asked to have inr
checked at her primary care provider, [**name10 (nameis) **] request of her
cardiologist. patient given script for [**name10 (nameis) **] work. defer further
management to primary care physician.

# uti: history of vre uti in the past. this admission, patient
had infection with streptococcus species. she will complete 10
day course of [**last name (lf) **], [**first name3 (lf) **] require two more doses as outpatient.
.
# cad: patient is s/p mi with bare metal stent [**8-5**]. we
re-started aspirin at time of discharge, and continued beta
blocker and statin during entire admission.
.
# chronic systolic heart failure: ef 40-45% on [**9-4**], following
mvr. patient remained well compensated during this admission and
no changes in medication regimen were made.
.
# carotid artery stenosis: per ultrasound ([**2124-9-6**]) 80-99%
right ica stenosis, with no significant left ica stenosis. no
neurological symptoms during this presentation.
.
# fen: patient tolerated a cardiac/heart-healthy diet
.
# code: patient remained full code during this admission.


medications on admission:
lipitor 20 mg po qd
lasix 80 mg po bid
potassium
coumadin 5mg mwf, 2.5mg tuthsasu
asa 81 mg po qd
toprol xl 50 mg po qd
digoxin 125 mcg
advair


discharge medications:
1. atorvastatin 20 mg tablet sig: one (1) tablet po daily
(daily).
2. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a
day).
3. metoprolol succinate 50 mg tablet sustained release 24 hr
sig: one (1) tablet sustained release 24 hr po daily (daily).
4. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily).

5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
6. lovenox 80 mg/0.8 ml syringe sig: one (1) syringe (80 mg)
subcutaneous twice a day: until your doctor asks you to stop.
[**hospital1 **]:*28 syryinges* refills:*0*
7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
8. warfarin 5 mg tablet sig: one (1) tablet po at bedtime:
please note, dose will be modified by your primary care
physician.
[**name initial (nameis) **]:*30 tablet(s)* refills:*0*
9. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h
(every 12 hours) for 2 days.
[**name initial (nameis) **]:*4 tablet(s)* refills:*0*
10. percocet 5-325 mg tablet sig: one (1) tablet po every six
(6) hours as needed for pain for 7 days.
[**name initial (nameis) **]:*28 tablet(s)* refills:*0*
11. outpatient [**name initial (nameis) **] work
please have cbc and pt/ptt/inr drawn on [**2-21**]


discharge disposition:
home

discharge diagnosis:
primay:
mechanical mitral valve
hematuria
bladder tumor


discharge condition:
hemodynamically stable, afebrile


discharge instructions:
you were admitted to the hospital because you were having
bleeding from your bladder and required a different type of
anticoagulation that would allow for a surgery to find the cause
of your bleeding. you underwent the procedure and tolerated it
well. the results of the tissue analysis will not availabe for a
few days, your primary care doctor will need to follow this up.

you will need to follow up with your primary care doctor and
take all medications as prescribed. you will also need to give
yourself lovenox injections twice daily until your inr (level of
coumadin) is at a good range.

if you experience any chest pain, nausea, vomiting, diarrhea, or
any other symptom that concerns you, please seek medical
attention immediatly.

followup instructions:
please make schedule a follow up appointment with your primary
care physician [**name initial (pre) 176**] 1 week. you will need to have your
coumadin level checked in his office on [**2-21**].

[**last name (lf) **],[**first name3 (lf) **] h [**telephone/fax (1) 57926**]


                             [**first name4 (namepattern1) **] [**last name (namepattern1) **] md [**md number(2) 69841**]

"
172,"admission date:  [**2101-5-17**]              discharge date:   [**2101-5-22**]

date of birth:  [**2072-12-18**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2101-5-17**]
1. open cholecystectomy.
2. open roux-en-y gastric bypass.


history of present illness:
[**known firstname 87221**] has class iii extreme morbid obesity with bmi of 60.7.
previous weight loss efforts have included weight watchers,
slim-fast, prescription [**street address(1) 87222**]/pcp [**name initial (pre) 51433**]. she has
been struggling with weight her entire life and  cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
she denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse.  has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. she was once on psychotropic
medication (citalopram), but is no longer.


past medical history:
htn, migraine, osa(recommended cpap), fatty liver,
cholelithiasis


social history:
denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. works as a day care teacher and she is
single living with her mother age 62 and she has no children.

family history:
father deceased age 72 with cancer, diabetes and hyperlipidemia.
mother living age 62 with heart disease, hyperlipidemia, dm, oa
and obesity.  sister in her 40s also with obesity and underwent
roux-en-y gastric bypass.

physical exam:
admission physical exam:
bp 129/79, pulse 73, respirations 18 and o2 saturation 100% on
room air.
gen: casually dressed, pleasant and in no distress.
skin: warm, dry with no rashes.
heent: sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
chest: ctab, symmetric, good air movement
cv: distant but present s1 and s2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
abd: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. no spinal tenderness or flank pain.
ext: lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good.  there was no joint swelling or inflammation
of the joints.
neuro: there were no gross neurological deficits and gait was
normal.

pertinent results:
post-operative: [**2101-5-17**] 03:27pm
hct-45.7

discharge labs: [**2101-5-21**] 03:06am
wbc-7.2  hgb-11.4*  hct-34.1*  plt-210
na-136 k-3.6 cl-101 hco3-28 urean-8 creat-0.7 glucose-109*
calcium-8.3* phos-3.0 mg-2.0

[**2101-5-19**] - cta chest
no large central pe. evaluation of segmental and subsegmental
branches is limited.

[**2101-5-19**] - ct abdomen
the patient is status post recent gastric bypass surgery. no
contrast is noted in the peritoneal cavity. the liver, spleen,
both adrenals, both kidneys, pancreas are unremarkable. the
patient is status post cholecystectomy. a drain is noted in the
right upper quadrant appropriately. the small bowel loops are
mildly prominent, likely representing ileus. the large bowel is
unremarkable. no free fluid or air noted. no evidence of leak.

[**2101-5-19**] - ugi
approximately 20 cc of optiray contrast was administered orally
which passed freely into the gastric pouch and proximal loops of
bowel without evidence of a leak. subsequently, thin barium was
orally administered, which demonstrated no further evidence of a
leak.


brief hospital course:
ms [**known firstname 87221**] was evaluated by anaesthesia and taken to the
operating room for open cholecystectomy and roux-en-y gastric
bypass. there were no adverse events in the operating room;
please see dr[**name (ni) 78793**] operative note for details. she was
extubated in the or, taken to the pacu until stable, then
transferred to the [**hospital1 **] for observation. she remained on the
surgical [**hospital1 **] for 2 days then was transferred to the icu given
her persistent tachycardia and concern for anastamotic leak. she
was transferred back to the floor 2 days later and was
discharged on pod 5.

neuro: she was alert and oriented throughout her
hospitalization. her pain was initially managed with an epidural
which was removed on post-operative day 4. she was transitioned
to low dose oral roxicet but this appeared to make her
somnolent, so she was provided liquid acetaminophen as
monotherapy for pain relief.

cv: she was persistently hypertensive and tachycardic beginning
immediately post-operatively. this was felt to be due primarily
to fluid deficit, given her post-op hemoconcentration (hct 45).
she was refractory to hydralazine and metoprolol iv. she
responded partially to fluid boluses, but not until starting a
labetolol drip in the icu were we able to control her heartrate
and blood pressure. after weaning her off the drip, her
hemodynamics sustained in a normal range using only her home
dose of chlorthalidone. serial ekgs were performed for
intermittent dull epigastric pain; these showed no changes from
prior.

pulmonary: she was administered cpap during some of her nights
while admitted. she did not tolerate this well, and preferred to
sleep without it. she had mild oxygen demand pod [**3-17**] and given
persisent tachycardia, she was evaluated by cta chest to
rule-out pulmonary embolus. the study was negative albeit
limited by body habitus. good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.

gi/gu/fen: she was initially kept npo until an upper gi study,
methylene blue test, and ct abdomen were performed on
post-operative day 2. all were negative for leak, therefore, her
diet was advanced to a bariatric stage i. she tolerated this for
over 24 hours before being advanced to stage ii. after a day of
stage ii, she was put on stage iii which was well tolerated. her
intake and output were closely monitored.
the jp bulb was removed on post op day 5 immediately prior to
discharge.

id: her fever curves and wbc count were closely watched for
signs of infection. perioperative antibiotics were
adminitstered; none other were warranted.

heme: her blood counts were closely watched for signs of
bleeding, of which there were none. her hematocrit returned back
down to baseline following resuscitation.

prophylaxis: she received subcutaneous heparin and venodyne
boots were used during this stay; she was encouraged to ambulate
as early as possible. she was ambulating independently by pod 4.


at the time of discharge, she was doing well, afebrile with
stable vital signs. she was tolerating a stage 3 diet,
ambulating, voiding without assistance, and pain was well
controlled. she received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.

medications on admission:
chlorthalidone 25'

discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: 20-30 ml po q6h
(every 6 hours) as needed for pain / fever: maximum 120ml per
day.
disp:*1000 ml* refills:*0*
2. colace 60 mg/15 ml syrup sig: two (2) tsp po twice a day:
hold for loose stool.
disp:*600 ml* refills:*0*
3. pediatric multivitamin-iron     tablet, chewable sig: one (1)
tablet, chewable po once a day.
4. zantac 15 mg/ml syrup sig: ten (10) ml po twice a day.
disp:*600 ml* refills:*0*
5. chlorthalidone 25 mg tablet sig: one (1) tablet po once a
day: please crush and mix with liquid.


discharge disposition:
home

discharge diagnosis:
1. obesity, body mass index of 64, weight of 394 pounds.
2. obstructive sleep apnea.
3. fatty liver.
4. gallstones.
5. borderline type 2 diabetes.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
[**hospital 1560**] clinic, surgical subspecialties, [**hospital ward name 23**] building
[**hospital1 **] [**last name (titles) 516**]
[**2101-6-1**] 11:00   dr. [**last name (stitle) **],md  [**telephone/fax (1) 305**]
[**2101-6-1**] 11:30   [**first name8 (namepattern2) **] [**doctor last name **],rd,ldn  [**telephone/fax (1) 305**]



"
173,"admission date:  [**2150-4-16**]              discharge date:   [**2150-4-21**]


service: medicine

allergies:
nsaids / bactrim

attending:[**first name3 (lf) 358**]
chief complaint:
angioedema

major surgical or invasive procedure:
intubation

history of present illness:
pt is an 85 y/o f with a h/o gave s/p argon treatment last on
[**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc, portal
htn/grade 1 varices but no hx of bleeding varices, cri (baseline
cr = 1.2-1.5) who is transfered from [**hospital3 **] intubated
s/p angioedema. by report the pt has some mild abdominal pain
and some irritation in her throat a day prior to admission to
[**hospital3 **]. the following morning she called her son with
complaints of oral swelling; son states that her speach was
garbled. the son reports that the patient denies having had any
sob, no wheezing, no hives. he called an abmulance who
transported the pt to [**hospital3 **].
.
per omr, the patient present to [**hospital1 18**] pheresis unit on [**2150-4-10**]
for blood transfusion for chronic slow upper gi bleeding. she
had no pretreatment medications given and no adverse events;
vitals on leaving the unit were 97.4 - 67 - 119/55. she has also
been recently treated for a uti with bactrim started on [**2150-4-3**].

.
at st elizabeths', she was hd stable but had a large, edematous
tongue. she recevied decadron, epinephrine, benadryl, famotidine
and hydroxazine in the ed. the ed was unable to intubate and she
was taken to the or. laryngeal edema was noted, but the et tube
was passed successfully. she was then transfered to the ccu. she
received hydroxazine tid and her tongue swelling improved. sbt
was attempted early on but failed likely secondary to sedation.
per report, pt did have a cuff leak. family requested transfer
to [**hospital1 18**] as pt receives all her care here.
.
on arrival in the micu she passed an sbt and was successfully
extubated. she did well throughout the day but continued to have
an o2 requirement. by the time of transfer to the floor she was
on 2l of nc o2 satting 94%. on the floor she is alert and
oriented. she does not know what caused her swelling. she denies
new pills, new medications, or new foods. she feels well and has
no sob, itching, or complaints.
.


past medical history:
# gave - s/p argon treatment, last on last on [**2150-3-11**]
# hepatitis c
# cirrhosis
- child's class a, portal htn, grade 1 varices
- no h/o ascites, encephalopathy, variceal bleeding, synthetic
function intact
# dm type ii
# htn
# iron deficiency anemia
# s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
# hypercholesterolemia
# osteopenia
# insomnia
# angioedema [**3-26**] possibly due to bactrim but as yet not proven

social history:
lives alone in [**location (un) 583**] in [**hospital3 4634**] complex. is widowed.
has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
holidays). worked in food business in sales.


family history:
no family history of allergic diseases

physical exam:
gen: pleasant elderly lady in nad, speaking comfortably, no
cyanosis, jaundice, or dyspnea
vs: 99.4 124/58 82 18 94% on 2l nc
heent: mmm, no op lesions, tongue nl size, neck supple, no lad
or thyromegaly
cv: rr, nl s1 s2 no s3 s4 mrg
pulm: roncherous breath sounds with scattered wheezes and
crackles 1/4 up the lung fields
abd: bs+, nt, ventral hernia, gas on percussion, no masses or
hsm, no fluid wave, + collaterals and angiomata
limsb: no le edema, + clubbing
neuro: perrla, eomi, moving all limbs, reflexes 2+ of the biceps
and petellar tendons.


pertinent results:
admission labs:
[**2150-4-17**] 05:15am blood wbc-7.4 rbc-3.41* hgb-10.2* hct-31.4*
mcv-92 mch-29.9 mchc-32.5 rdw-16.7* plt ct-139*
[**2150-4-17**] 05:15am blood glucose-132* urean-27* creat-1.1 na-143
k-4.3 cl-112* hco3-24 angap-11
[**2150-4-18**] 08:30am blood alt-112* ast-59* ld(ldh)-203 alkphos-99
totbili-1.7*
[**2150-4-17**] 05:15am blood calcium-8.6 phos-2.8 mg-2.4
.
discharge labs:
[**2150-4-21**] 05:50am blood wbc-5.0 rbc-3.13* hgb-9.6* hct-28.4*
mcv-91 mch-30.7 mchc-33.8 rdw-16.9* plt ct-200
[**2150-4-21**] 05:50am blood glucose-91 urean-34* creat-1.4* na-137
k-3.9 cl-103 hco3-24 angap-14
[**2150-4-20**] 05:40am blood alt-55* ast-34 ld(ldh)-182 alkphos-83
totbili-1.3
[**2150-4-20**] 05:40am blood albumin-2.6* calcium-8.3* phos-3.5 mg-2.0

brief hospital course:
85f with a h/o gave s/p argon laser treatment last on [**2150-3-11**],
iron deficiency anemia due to chronic ugib, cirrhosis [**1-19**] hcv,
portal htn with grade 1 varices but no history variceal
bleeding, cri (baseline cr = 1.2-1.5) who is s/p prolonged
intubatation for angioedema of unknown etiology - possibly due
to bactrim. she is doing very well on s/p extubation at this
point. all antihistamines have been discontinued at this point.
she was progressively be restarted on her home meds.
.
# angioedema: resoved. lack of hives, bronchospasm or
hypotension suggests that this was not allergic angioedema but
rather bradykinin related. c3 and c4 were low. c1 esterase
inhibitor pending, [**doctor first name **] neg. per allergy consult at [**hospital 7302**] prior to transfer, non-allergic angioedema
is due to complement depletion (either hereditary or ca related)
or complement activation (infection or transfusion). the patient
did have a transfusion recently which may be related.
medications would also be high on the list of etiologies. common
offenders are nsaids and aceis, but arbs have also been
implicated.  it was discovered that the pt was taking bactrim
when the reaction leading to her admission. this is a possible
offender and has been added to her allergy list. restarted home
meds one by one. all but felodipine have been restarted. had
hives and itching the day prior to discharge which did not
generalize and seemed more of a contact dermatitis on the l arm.
no new medications were started so it is unclear what initiated
this. responded to hydroxyzine x1. also of note, the patient
refused to shower or be washed down this admission which may
contribute to her itchiness.
.
# chronic ugib: received regular blood transfusions as an
outpatient for any hct < 30. in the past she only needed them
infrequently but her transfusion requirements have increased
lately. transfused prior to discharge. [**month (only) 116**] need outpatient
follow up with gi (dr [**first name8 (namepattern2) 1158**] [**last name (namepattern1) 679**] has been recommended by her
outpatient gastroenterologist [**first name4 (namepattern1) 2127**] [**last name (namepattern1) 10113**]).
.
# wheezes and ronchi: related to angioedema and volume overload
most likely. resolved with diuresis and nebulizers.
.
# hx hcv complicated by cirrhosis. no evidence of encephalopathy
now, but is at risk. continued lactulose. continued
spironolactone [aldactone] - 50 mg daily. continue furosemide
[lasix] - 40 mg daily. continue nadolol - 80 mg daily as ppx
against variceal bleeding.
.
# htn: holding home ccb as normotensive. on nadolol as above.
.
# cri: baseline 1.5, was elevated on admission to [**hospital3 5097**] to
1.7. at baseline on discharge.
.
# diabetes: iss in house. discharged on metformin.

medications on admission:
home medications:
felodipine - 10 mg qam and 5 mg qpm
folic acid - 1 mg daily
furosemide [lasix] - 40 mg daily
hydrocortisone acetate [anusol-hc] - 25 mg daily
lactulose 10 gram/15 ml daily
metformin - 1000 mg qam and 500 mg qpm
mupirocin - 2 % ointment [**hospital1 **]
nadolol - 80 mg daily
pantoprazole - 40 mg [**hospital1 **]
spironolactone [aldactone] - 50 mg daily
sucralfate - 1 g tid
zolpidem - 5 mg tablet - [**12-21**] qhs prn
calcium carbonate-vitamin d2 - 500 mg-375 unit [**hospital1 **]
cyanocobalamin - 500 mcg daily
ferrous gluconate - 325 mg 5 times a day
sarna ultra [**hospital1 **]


discharge medications:
1. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one
(1) tablet po twice a day.
disp:*60 tablet(s)* refills:*11*
2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*11*
3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
4. anusol-hc 25 mg suppository sig: one (1) suppository rectal
once a day.
disp:*30 suppositories* refills:*6*
5. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po once a
day.
disp:*450 ml(s)* refills:*11*
6. metformin 500 mg tablet sig: two (2) tablet po qam.
disp:*60 tablet(s)* refills:*5*
7. metformin 500 mg tablet sig: one (1) tablet po qpm.
disp:*30 tablet(s)* refills:*5*
8. nadolol 80 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*5*
10. spironolactone 50 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*5*
11. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
disp:*30 tablet(s)* refills:*0*
12. b-12 dots 500 mcg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*11*
13. ferrous gluconate 325 mg tablet sig: one (1) tablet po five
times a day.
disp:*150 tablet(s)* refills:*11*


discharge disposition:
home

discharge diagnosis:
angioedema

discharge condition:
stable vital signs, at baseline

discharge instructions:
you were admitted at [**first name8 (namepattern2) 1495**] [**hospital **] hospital with angioedema,
or swelling in your mouth and throat. you had a breathing tube
placed for this. you were then transfered to [**hospital1 771**] where you had the breathing tube taken
out. you improved clinically and were discharged to home.
.
please continue to take your medications as ordered. because you
had a likely medication reaction that led to your angioedema you
should throw out your old medications. do not take any
supplements. here is your updated medication list list:
1. stop taking felodipine for now
2. calcium + vitamin d twice daily
3. vitamin b12 daily
4. folic acid daily
5. furosimide 40mg daily
6. anusol daily as needed for hemorrhoids
7. metformin 1000mg (2 pills) in the morining and 500mg (1 pill)
in the evening
8. lactulose 15ml daily to 3 bowel movements per day
9. nadolol 80mg daily
10. pantoprazole (protonix) 40mg twice daily
11. spironolactone 50mg daily
12. zolpidem (ambien) 5mg at night as needed for insomnia
13. iron 5 times daily
.
please attend your follow up appointments.
.
please call your doctor or come to the emergency room if you
experience swelling of you face or tongue, chest pain,
palpitations, shortness of breath, wheezing, bleeding, or other
concerning symptoms.

followup instructions:
md: [**name6 (md) 10160**] [**name8 (md) 10161**], np
specialty: priamry care
date and time: [**last name (lf) 766**], [**5-4**] at 4pm
location: [**hospital3 **]
phone number: [**telephone/fax (1) 250**]
special instructions if applicable: booked with russain
interpreter


completed by:[**2150-4-22**]"
174,"admission date:  [**2124-12-15**]     discharge date:  [**2124-12-16**]

date of birth:   [**2068-7-22**]     sex:  m

service:  micu

history of present illness:   this is a 56 year old man with
a history of lung cancer status post radiation therapy and
chemotherapy and chronic obstructive pulmonary disease, who
presents with acute dyspnea and oropharynx swelling.  the
patient states that he was in his usual state of health when
three hours after eating a dinner of shrimp and scallops,
began to develop burning and warmth of his posterior cervical
neck and forehead.  he went to cvs to get some benadryl and
on the way became progressively short of breath and
complained of upper and lower lip swelling.  the emergency
medical services was activated.  he was found to be
stridorous with a blood pressure of 60/palpation complaining
of his throat closing up.

the patient received epinephrine 0.3 subcutaneously and
benadryl 50 mg intravenous en route to the hospital and his
blood pressure normalized.  the patient was saturating at 98%
on room air.  he received intravenous solu-medrol and
intravenous cimetidine.

the patient reported a history of swelling after a bee sting
30 years ago for which he went to the emergency room and
received intravenous benadryl.  he consumes shellfish
regularly and has had no adverse events in the past.  the
patient is currently on chemotherapy, the cycle beginning in
[**month (only) 359**].  his last dosage of medication being approximately
two weeks prior to presentation.

past medical history:
1.  nonsmall cell lung cancer status post chemotherapy and
radiation therapy found to be non-surgical on thoracotomy.
evidence of metastases to the left adrenal gland.
2.  emphysema.
3.  depression.
4.  status post tonsillectomy.

medications:
1.  chemotherapy.
2.  combivent two puffs four times a day p.r.n.
3.  wellbutrin 150 mg twice a day.

allergies:   no known drug allergies.

physical examination:   vital signs were afebrile.  blood
pressure 94/48; pulse 109; respirations 20; saturation of 98%
on room air.  in general, in no apparent distress, alert and
oriented times three.  the patient is speaking in full
sentences.  no respiratory distress.  heent:  normocephalic,
atraumatic.  pupils are equal, round and reactive to light.
extraocular movements intact.  sclerae anicteric.  there is
swelling of the upper and lower lips and question of swelling
of the tongue; no airway compromise, no lymphadenopathy.
chest is clear to auscultation bilaterally.  cor:
tachycardia, normal s1, s2, no murmurs, rubs or gallops.
abdomen is soft, nontender, nondistended.  no
hepatosplenomegaly or masses.  positive bowel sounds.
extremities are warm and well perfused.  positive for
clubbing.  no cyanosis of edema.  neurological:  cranial
nerves ii through xii are intact.  he moves all extremities.
strength is five out of five.

laboratory:  white blood cell count 3.9, hematocrit 30.4,
platelets 494.  sodium 143, potassium 4.4, chloride 107,
bicarbonate 29, bun 13, creatinine 0.7, glucose 130.  serum
toxicology screen negative.

ekg with sinus tachycardia at the rate of 114.

chest x-ray with ill defined density overlying the right
superior hilum suggestive of a mass.  right lateral pleural
thickening, rib fractures and atelectatic changes consistent
with post surgical change.

hospital course:
1.  anaphylaxis:  the patient was started on intravenous
hydrocortisone, intravenous famotidine and intravenous
diphenhydramine,.  he was admitted and observed in the
medical intensive care unit given his history for previous
anaphylaxis in the setting of p.o. allergen.

the patient remained hemodynamically stable and his
angioedema resolved.  it seemed unusual that the patient
would develop an allergy to shellfish at the age of 56.  it
was suspected that the patient's history of chemotherapy may
have put him at risk for this allergic reaction.

the patient will be discharged with the plan to follow-up
with his primary care physician on [**name9 (pre) 766**], [**12-18**].  he
will be referred to an allergist and is instructed in the use
of an epinephrine pen which he will carry with him at all
times, keeping one in the glove compartment of his car and
one in his house.

the patient will complete a rapid steroid taper.

2.  lung cancer:  this is followed by the patient's
oncologist at the [**hospital3 328**].

3.  tachycardia:  the patient remained in sinus tachycardia
in the low 100s throughout his hospital course.  this was
felt to represent the physiologic response to the patient's
anemia.  this will be followed up at the patient's primary
care physician.

4.  the patient's anemia was felt to be secondary to
chemotherapy.  further evaluation is deferred to the
patient's primary care physician.

condition on discharge:   good.

discharge status:   to home.

discharge diagnoses:
1.  anaphylaxis to shellfish.
2.  nonsmall cell lung cancer.
3.  resting tachycardia.

discharge medications:
1.  prednisone taper, 40 mg times one day, then 20 mg times
one day.
2.  albuterol ipratropium mdi one to two puffs q. six hours
p.r.n.
3.  bupropion 150 mg p.o. twice a day.
4.  benadryl 50 mg p.o. q. six hours p.r.n.
5.  epinephrine pen 1/[**numeric identifier 4856**] syringe, one injection
intramuscular p.r.n. anaphylaxis.

discharge instructions:
1.  the patient will follow-up with his primary care
physician, [**last name (namepattern4) **]. [**last name (stitle) 6512**], at the southern [**hospital 12162**] health center on
[**12-18**], at 11:30 a.m.
2.  the patient will be referred to an allergist for further
evaluation.




dictated by:[**name8 (md) 96586**]

medquist36

d:  [**2124-12-16**]  12:15
t:  [**2124-12-16**]  19:17
job#:  [**job number 96587**]
"
175,"admission date:  [**2160-6-15**]     discharge date:  [**2160-6-22**]


service:

chief complaint:  ""i've been feeling bad for the last few
days and since yesterday i have been nauseous and vomiting.""

history of present illness:  the patient is a 77-year-old man
who presents with the above chief complaint and his past
medical history includes numerous medical problems including
non q wave mi times two, status post cabg in [**2139**],
hypertension, insulin dependent diabetes mellitus,
hypercholesterolemia, history of tias, history of lower gi
bleed and diverticulosis.  the patient was in his usual state
of health until approximately 4-5 weeks ago when his
degenerative joint disease and disc disease of his lumbar
spine began causing shooting right lower extremity pains.  at
that time the patient was treated with steroid injections and
po prednisone which caused an increase in his blood sugars.
for this increase in blood sugars he was started on humalog
approximately 3-5 days ago as his sugars have been in the
300-400's on his previous regimen.  approximately one week
ago the patient began feeling bad and run down.  the
patient's primary care doctor believed it was due to the high
blood sugars and started the humalog 3-5 days ago.  yesterday
the patient reports the onset of nausea and vomiting after
eating.  he tolerated lunch as his last meal and he has not
taken any po today.  also today he reports the onset of loose
stools times three.  he denied any fevers, abdominal pain,
weight change or urinary symptoms.  he does acknowledge night
sweats and chills at night over the last two days.  he has a
chronic cough secondary to post nasal drip which is
unproductive of sputum.  there is no erythema over the skin
where he injects his insulin.  his exercise tolerance is
approximately one flight of stairs and he is limited by right
lower leg pain.  he also denies any chest pain, shortness of
breath, palpitations or diaphoresis.  he has no pnd.  the
patient finally came to the er as he was not able to take
anything by mouth.

past medical history:  1) insulin dependent diabetes
mellitus.  2) hypertension, poorly controlled.  3) chronic
renal insufficiency.  4) status post non q wave mi times two.
5) status post cabg in [**2139**].  6) hypercholesterolemia.  7)
history of tia.  8) gout.  9) lower gi bleed status post
polyp removal.  10) diverticulosis.  11) allergies and post
nasal drip.

medications:  [**doctor first name **] 60 mg po q d, lopressor 20 mg po q d,
multivitamin, doxazosin 4 mg q h.s., lipitor 20 mg po q d,
allopurinol 300 mg po q d, ranitidine 150 mg po q h.s.,
glyburide 10 mg po bid, diovan 80 mg po q d, enteric coated
aspirin 325 mg po q d, quinine as needed, nph 20-30 units q
a.m., 10-15 units q p.m., humalog sliding scale started three
days ago.

social history:  the patient lives with his wife.  [**name (ni) **] denies
any tobacco or alcohol use.

family history:  noncontributory.

allergies:  morphine makes him nauseous.

physical examination:  vital signs, temperature 99.5, heart
rate 83, blood pressure 170/125, respiratory rate 18, satting
100% on two liters nasal cannula.  in general he is an
elderly man lying in bed in no acute distress.  heent:  he
has alopecia, pupils are equal, round and reactive to light
from 3 to 2 mm, sclera are anicteric.  mucus membranes are
moist.  neck supple, no jugulovenous distension, no
lymphadenopathy, no bruits.  cardiac exam, irregularly
irregular, s1 and s2 normal, no murmurs, gallops or rubs.
lungs are clear to auscultation bilaterally. abdomen, mild
tenderness to deep palpation of the left lower quadrant.  he
is non distended, bowel sounds present and normal.  abdomen
is soft.  gu, normal male genitalia, trace guaiac positive on
exam.  prostate without any nodules, regular and smooth.
extremities, no clubbing, cyanosis or edema. neuro, he is
alert and oriented times three, cranial nerves ii through xii
normal.  reflexes 2+ bilaterally biceps and achilles
strength, [**3-29**] upper extremities bilaterally, in the left
lower extremity is 4+/5 strength in his right big toe and
plantar and dorsiflexion of his foot.  gait and coordination
were not tested.

laboratory data:  white count 14.6, differential with 84
neutrophils, 1 band, 10 lymphs, hematocrit 44.4, platelet
count 134,000, pt 11.7, ptt 21.4, inr 0.9.  sma 7, 137, 5.2
which was hemolyzed, 100, 21, 40, 1.4, glucose 297.  calcium
8.4, phosphorus 4.7, magnesium 2.1, ast 24, alt 28, total
bilirubin 0.9, ck 54, troponin 0.3, alkaline phosphatase 59,
amylase 114, lipase 41, albumin 3.3, uric acid 4.3, tsh is
pending at this time.  chest x-ray showed no signs of
pulmonary edema and no infiltrate.  ekg was irregularly
irregular at 92, axis -30, occasional p waves, looking like
flutter but there are also absent p waves.  intervals are
normal.  there is a q in 3 and f, no st changes, poor r wave
progression.  an echocardiogram from [**2160-4-25**] showed mild
left atrial dilatation, non obstructive focal septal
hypertrophy, depressed lv function 1+ aortic regurg, mild mr
[**first name (titles) **] [**last name (titles) **] fraction could not be estimated at that time.

impression:  this is a 77-year-old man with multiple ongoing
medical problems who presents with generalized complaints of
the last week and a [**11-27**] day history of nausea and vomiting
and loose stool.  he was found to be in new onset atrial
fibrillation in the er.  physical exam was remarkable for the
atrial fibrillation with guaiac positive stool and mild left
lower quadrant tenderness.  labs revealed an increased white
blood cell count with left shift and low albumin.  chest
x-ray and ekg are normal and unchanged respectively.

plan:
cardiac:  the patient has known cad.  his aspirin, beta
blocker, lipitor and [**last name (un) **] will be continued.  his hypertension
will be aggressively controlled.  although ischemia is
unlikely without any changes in ekg, cks will be followed.
the patient is in new onset atrial fibrillation but lopressor
will be increased to 50 mg [**hospital1 **] for rate control.  tsh is
pending after weighing the risks and benefits of heparin.
given the patient's trace guaiac positive stool, history of
lower gi bleed, the decision was made to start the patient on
heparin as he had multiple risk factors for stroke elevating
him into a higher level of category including his past
history of tias.

infectious disease:  he has an elevated white count with a
left shift.  he has night sweats, chills times two days.
cultures of urine, stool and blood will be sent.  blood
cultures will be obtained when the patient's fever curve is
greater than 101.  no empiric antibiotics will be started at
this time.

endocrine:  the patient has poor glucose control.  he will be
written for an insulin sliding scale while in the hospital
and fingersticks will be checked qid.  his oral hypoglycemics
will be held for now.

gi:  he is trace guaiac positive with left lower quadrant
tenderness and a history of diverticulosis.  diverticulitis
is certainly a possibility although given the benign
presentation of his abdomen on exam, it is unlikely.
however, we will continue to follow his abdominal exam.  we
will guaiac all stools and we will follow hematocrit q d on
heparin.  the patient will be given antiemetics as needed to
control the nausea and vomiting.

renal:  the patient has a creatinine of 1.4 with an elevated
bun to creatinine ratio.  he is most likely dehydrated given
his nausea and vomiting and slightly prerenal and will be
hydrated.

musculoskeletal and neuro:  he has decreased strength in his
right lower leg consistent with his past medical history of
djd and disc disease of his lumbar spine.  his pain will be
controlled with non opioids as much as possible as opioids
have given him bad reactions in the past.  the patient was
admitted and this plan was pursued.

hospital course:  on hospital day #2 the patient had no
adverse events overnight.  the stool samples and the tsh are
still pending.  the patient is maintained on heparin and the
plan will be to transition him to coumadin, then to discharge
the patient and bring him back at 1-2 months for tee and
cardioversion at that time after anticoagulation, as it is
unknown how long patient has been in atrial fibrillation.
also on this admission the plan is to control his blood
sugars, hopefully the combined approach will lead to a
resolution of his nausea and vomiting and he can go home.  on
hospital day #3 the patient complained of some right thigh
swelling.  he was neurovascularly intact and this was thought
to be secondary to a muscle pull the patient experienced
approximately five days prior to admission.  there was a
small hematoma.  this is most likely exacerbated because of
the heparin the patient has been on, but the team was not so
concerned about this.  also on the third hospital day the
patient became tachycardic and hypotensive with blood
pressure in the 60's/30's.  the patient was somnolent at this
time.  exam was unchanged from prior.  iv fluids were given
and ekg was done that was unchanged.  the heparin was
discontinued and an ng lavage was performed that showed dark
brown fluid in the stomach with occasional clots which were
gastroccult positive.  with the lavage, the red fluid did not
clear.  a stat hematocrit came back at 26 which was down from
44 on admission, although this is partly due to rehydration,
this is significantly due to an upper gi bleed.  the patient
was transferred to the ccu at that time and transfused two
units of packed red blood cells.  the patient underwent
emergent egd that showed clotted blood in the lower third of
the esophagus and multiple non bleeding diffuse erosions in
the lower third of the esophagus.  the stomach was normal.
in the duodenum there were multiple acute crater ulcers in
the bulb and in the second part of the duodenum.  pigmented
material coating these ulcers suggested recent bleeding in
one of the ulcers.  the patient was treated with proton pump
inhibitor [**hospital1 **], discontinuation of all nsaids and
anticoagulation.  hematocrits were continually followed and
an h. pylori antibody was checked.  the tsh level came back
as normal at this time.  on the fourth hospital day the
patient was transferred back to the floor from the unit after
the egd and the 2 units of packed cells when patient was
stabilized.  on hospital day #5 the patient's main complaint
was his right thigh swelling leading to right thigh weakness
when he stood up.  he denied anymore episodes of
lightheadedness, dizziness, chest pain, shortness of breath,
bright red blood per rectum, melena or vomiting of blood.  at
this time his aspirin was changed to 81 mg from 325 mg and
the patient was not on either heparin or coumadin.  the
patient's hematocrit post transfusion rose to 31 and has
continued to rise since then.  his creatinine and bun bumped
transiently during the patient's hypovolemia episodes.  they
are now trending down.  the nph and regular insulin sliding
scale is controlling the patient's blood sugars.  [**initials (namepattern4) **] [**last name (namepattern4) **]
consult was obtained because the patient is usually followed
in [**last name (un) **], to further optimize the patient's insulin regimen.
the plan is to treat the patient for one month with proton
pump inhibitors, to follow-up the results of the h. pylori,
treat that if positive and to allow the ulcers one month to
heal.  the patient will return for a repeat upper endoscopy
in one month.  at that time if the ulcers are healed,
anticoagulation will be pursued with the eventual goal of
performing a tee and cardioversion either chemical or
electrical, once the patient has been on stable
anticoagulation for one month.  hospital day #6 the patient's
diet was advanced as tolerated.  physical therapy saw the
patient who agreed he was safe for discharge home.  on
hospital day #7 the patient slowly was regaining his strength
in his right leg and mobility.  he was starting to ask to go
home.  on hospital day #8 he was discharged home.  he will
follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 1313**], dr. [**last name (stitle) 19862**] from endocrine
and dr. [**first name (stitle) 1104**] from cardiology.  all of those attendings are
aware of the [**hospital 228**] hospital course.  the patient's
lopressor dose at the time of discharge is 37.5 mg po tid.
the h. pylori result came back positive.  he will be treated
for h. pylori infection.  he will follow-up with gi in [**2-29**]
weeks for repeat upper endoscopy.




                          [**first name11 (name pattern1) **] [**last name (namepattern4) 31943**], m.d.  [**md number(1) 31944**]

dictated by:[**last name (namepattern1) 8228**]

medquist36

d:  [**2161-1-28**]  12:05
t:  [**2161-1-28**]  14:07
job#:  [**job number **]
"
176,"admission date:  [**2125-10-8**]              discharge date:   [**2125-10-19**]

date of birth:  [**2055-7-28**]             sex:   f

service: omed

allergies:
codeine / carboplatin / cisplatin

attending:[**last name (namepattern1) 5062**]
chief complaint:
fatigue, acute hematocrit drop

major surgical or invasive procedure:
none

history of present illness:
initial hx prior to icu admission:
this is a 70 yo f w/ h/o relapsing papillary serous ovarian
cancer last first diagnosed in [**2117**].  she was last admitted to
this hospital for her 7th cycle of cisplatin.  she was given
[**doctor last name **]/taxol once in [**2117**], and was changed to [**doctor last name **]-cytoxan for
low counts in 01/[**2118**].  she tne received six cycles of cisplatin
started in [**1-/2125**] and administered in the hospital because of
the questionable history of allergic reaction to carboplatin.
-
since that admission, she showed signs of fluid retention, both
in her legs and in her ascites but she did not have any evidence
of congestive heart failure based on exam with normal lungs and
flat jvd. there was concern that perhaps her cancer was
progressing and that is the reason for her tense ascites, but
consideration was also given to worsening renal failure as
explanation for increased ascites.  ct scan taken [**2125-9-21**] showed increased ascites, but otherwise stable exam with
mesenteric masses and evidence of peritoneal carcinomatosis that
appear unchanged when compared to [**2125-7-25**].
-
her husband reported some recent confusion during their clinic
visit on [**9-26**].  due to her creatinine clearance of about
20ml/min, the decision was made during this visit to switch the
patient to weekly gemzar despite the stability of dz achieved
w/cisplatin.  due to her decreased creatinine clearance, a
reduced dose of 500 mg per meters squared was chosen.  she was
started on this dose on [**10-3**] and acutely tolerated it well.  the
plan was for weekly gemzar, three weeks on and one week off.
-
the patient first felt different from her normal self on
saturday, when she ""started to feel lousy.""  she saw an
accupuncturist on sat. for posterior neck pain; needles were
inserted into her head, back and ankles.  on sunday, her
weakness progressed to the point that she could no longer stand.
 her husband noted a bloodshot left eye ealier today, now
resolved.  she recently fell on her left buttock.
-
on ros, the patient notes moderate to severe abdominal pain for
the past several days, especially before meals and sometimes
resolved with food.  she sleeps with three pillows.
-
today, the patient's fellow contact[**name (ni) **] her.  she reported the
above symptoms and was told to come to clinic.  her hematocrit
has decreased from 33 to 17 and so she was admitted to omed and
immediately transferred to icu as inr>60.

on transfer back to omed from icu:

mrs. [**known lastname 1661**] is a 70 y/o f with recurrent ovarian ca, s/p cabg,
s/p mv repair, and hypothyroid, presented from onc clinic on
[**2125-10-8**] with weakness, nausea, and decreased po intake since
gemcitabine tx on [**2125-10-3**] and on clinic visit [**10-8**] was found to
be hyptotensive, decrease hct (from 33.0 to 17.1), and inr>60.
patient was initially admitted to omed service, but transferred
to micu for further evaluation. please see micu admit note for
more information on past medical hx and course during stay. in
brief, patient was admitted for hemodynamic stability and work
up of coagulopathic state. mrs. [**known lastname 1661**] denied diarrhea,
hematuria but did report very slight brbpr on toilet paper. she
was trace guiac positive on admission. she had diffuse
ecchymosis over lower extremities, back, and buttocks. she
received 6 units of prbc's with appropriate bump in hct to 34.1
on [**10-16**].  in terms of her coagulopathy, it is thought that a
combination of coumadin (for h/o dvt), decrease po intake, and
recent administration of gemcitabine were instigating factors.
coumadin held on admission. she received 1 unit ffp and was
initially treated with po vitamin k while in micu, with decrease
in inr to 3.0 on morning of [**10-17**]. on [**10-17**] she received 1 mg iv
vitamin k. her initial mixing studies were negative for
inhibitors. shortly after receiving the 6 units of blood,
patient became sob secondary to fluid overloaded state. she was
diuresed and responded well to lasix; however, creatinine began
rising (above baseline of ~2.6) likely because of hypovolumia
and decrease blood flow to kidneys. patient was subsequently
gently hydrated, with impoved renal status.  creatinine 2.8 on
[**10-16**]. during fluid overloaded state, mrs. [**known lastname 1661**] also developed
afib, which per family was new onset. after cardiology consult
and discussion with primary oncology team, it was decided to
cardiovert patient. she tolerated well and is now in nsr.
nutrition is still an issue for patient, as she has decrease
appetite. also, she was seen by pt for gait instability/[**month (only) **]
balance. mrs [**known lastname 1661**] appears well and states that she is feeling
good. she is anxious to get up and walk around the floor.
patient currently denies and n/v/dizziness. no f/c/ns/sob/cp.
she has not urinated since foley d/c'ed this morning but feels
that she might be able to go soon. urinary retention was not a
problem for her prior to admission.


past medical history:
1.relapsing papillary serous ovarian ca as above--hx onc
therapy:
she was diagnosed in [**2117**].

she is status post carboplatin and taxol times one in [**2117**],
changed to [**doctor last name **]- cytoxan because of low counts in 01/[**2118**].

status post cytoxan and cisplatin times two and then cytoxan and

carboplatin times four from [**6-/2119**] to 09/[**2119**].
status post [**doctor last name **] times six until 05/[**2121**].
status post taxol times eight from [**3-/2123**] to 10/[**2123**].
status post oral etoposide times one, discontinued because of
mouth sores in 11/[**2123**].
status post carboplatin times two, discontinued because of an
allergic reaction that occurred in 12/[**2123**].
status post cisplatin times three from [**1-/2124**] to [**4-/2124**],
discontinued because of rising creatinine.
status post weekly taxol but discontinued because of disease
progression.
started on cisplatin 50 mg/m2 in [**9-/2124**] status post two cycles
at that time, discontinued because of rising creatinine.
status post two cycles with navelbine, discontinued because of
disease progression.
status post seven cycles of cisplatin started in [**1-/2125**] and
administered in the hospital because of the questionable history

of allergic reaction to this medication given the fact that she
had an allergic reaction to carboplatin in the past. cisplatin
was discontinued due to rising cr.
status post gemzar treatment last wednesday, [**2125-10-3**]
-
2. yeast infection [**2125-8-29**]
-
3.cad s/p cabg and mvr
-
4. h/o le dvt
-
5.cri
-
6. hyperchol.
-
7. gout
-
8. hypothyroidism


social history:
married, 30 pack yr tob, quitx20 years, no etoh, no ivda.

family history:
mother=[**name (ni) **]
father:prostate ca
brother:pd
m aunt=ovarian ca
cousin=ovarian ca


physical exam:
[**10-8**]:
vitals: 99.4  76-80 (76)  94/42
gen: pale woman relaxing in bed in nad, brighter appearing than
yesterday evening or this morning
neck: supple, perrl, eomi, conjunctivae remain pale, mouth and
oropharynx clear
lungs: ctab
heart: rrr
abd: soft, distended, nt
ext: warm x 4 with pulses x 4
skin: left large ecchymosis on buttocks slighly increased in
size and color since yesterday, bil hands, abdomen

[**10-16**]:
pe:t:98.0  p: 68-75   bp: 86-128/44-99   rr:24 o2:93-98%
gen: patient is pleasant, pale appearing elderly female, nad
heent: perrl - consenusally, eomi, sclerae anicteric; supericial
ulcer on r side of tongue, blood blister on back l tongue; neck:
supple, from, no lad
lungs: cta with bibasilar crackles
cardiac: rrr, no m/g/r
abd: moderate distention-but not firm, no peritoneal signs,
nontender, no masses appreaciated, +bs, resolving ecchymosis on
luq of abd.
ext: 2+ pitting edema of le bilat. diffuse ecchymosis of b/l
buttocks r>l, and upper thighs, mostly resolved on l left
extremity; few small ecchymosis on l wrist. resolving per micu
notes.
neuro: a&ox3; responding appropriately, very talkative, cn2-12
intact with no focal deficit. strength 5/5 throughout.


pertinent results:
crit: baseline mid 20s; [**10-3**] 33  [**10-5**] 17.1  9/21@1430 following
3u 28.6
pt: [**9-5**] 13.7  [**10-8**] >100  [**10-9**] following 1u ffp 24.8, 32.6
ptt: [**9-5**] 23.6  [**10-8**]  150, 143 [**10-9**] following 1u ffp 61.7, 48.8
platelets: [**10-8**] 263 [**10-9**] 162

ct of the chest without iv contrast: there are minor dependent
atelectatic
changes. extensive atherosclerotic changes of the aorta and
coronary arteries
are evident. multiple prominent but nonpathologically enlarged
mediastinal
lymph nodes are identified. there is a large hiatal hernia. no
pleural or
pericardial effusions are present.

ct of the abdomen without iv contrast: there is a
moderate-to-large amount of
ascites within the abdomen, but no evidence of an intra- or
retroperitoneal
hematoma. allowing for the limitations of a noncontrast exam,
the liver,
gallbladder, spleen, pancreas, adrenal glands, and kidneys are
within normal
limits. extensive aortic calcifications are again noted. no
pathologically
enlarged retroperitoneal or mesenteric lymph nodes are
identified in this
limited study. there is no free air.

ct of the pelvis without iv contrast: a large volume of ascites
is present
within the pelvis. the urinary bladder is unremarkable. there is
sigmoid
diverticulosis without diverticulitis.

bone windows: no suspicious lytic or blastic leions are
identified.

impression: moderate-to-large volume of ascites, but no evidence
of intra- or
retroperitoneal hemorrhage.

[**10-9**] chest ap:
portable ap chest: comparison is made with a chest ct scan from
[**2125-10-8**]. again seen is a left subclavian port with the tip in the
svc, in
satisfactory position. there is no pneumothorax. there are
multiple
mediastinal clips and a prosthetic mitral valve. there is stable
cardiomegaly
with mild upper lung zone redistribution. there is a large
hiatal hernia with
associated atelectasis in the left lower lobe. there is
worsening right lower
lobe atelectasis.


brief hospital course:
a/p: mrs. [**known lastname 1661**] is a 70 yo female with h/o recurrent ovarian
cancer who recieved first dose of gemcitabine on [**2125-10-3**] and
presented to clinic on [**10-8**] with hypotension, drop in hct
(33-->17), and inr>30, admitted to icu. icu course c/b fluid
overload, acute on chronic renal fl., and afib. transferred to
omed on [**10-16**] hemodynamically stable, inr 3.0 and 34.1.

1. coagulopathy - patient admitted with an inr >60, 3.0 on [**10-16**].
thought to be [**2-19**] combination of decrease po intake, coumadin,
and gemcatabine.  continue to hold coumadin. as per hpi, treated
with ffp and vitamin k in icu with inr decrease to 3.0. given
1gm vitamin k iv [**10-16**] prior to transfer to floor. inr 2.1 day
prior to discharge and 2.9 on day of discharge. per primary
oncology team, she was given 10mg po vitamin k prior to
discharge and will f/u in clinic in 3 days to have inr
rechecked. coumadin was held on discharge.
2. anemia - patient with chronic anemia, but acute blood loss
internally to buttocks thighs in setting of coagulopathic state.
responded appropriately to 6 units prbc's in icu with hct
remained stabe once transferred to oncology service. she was
receiving procrit about once a week prior to admission to
hospital and received injection 3x/week during admisison. she is
to f/u with primary team on monday to discuss continuation of
procrit.
3. htn: blood pressures had been fluctuating while in icu and
initially holding of metoprolol. outpatient dose of metoprolol
25mg [**hospital1 **] and was restarted and switched to 12.5mg tid for while
in the icu. her blood pressures were well controlled on this
dose and she was discharged on 12.5 mg tid.
4. acute on chronic renal insufficiency - patient with baseline
creatinine of 2.4-2.7. creatinine had increased [**2-19**] to prerenal
azotemia while being diuresed in icu. trending to baseline on
transfer to floor. creatinine was 2.7 on day of discharge.
nephrotoxic medications were avoided during admission.
5. ovarian cancer -  s/p gemcitabine treatment [**10-3**], preceeding
admission and onset of previoulsy discussed adverse events. will
discuss with primary oncologist future treatment plans.
6. nutrition - mrs [**known lastname 1661**] has had poor appetite for some time,
which may have attributed to coagulopathic state.  seen and
evaluated by nutrition service. patient notes that her appetite
is slowly increasing and appeared to be eating about [**date range (1) 5082**] of
food on tray. discussed importance of eating green vegetables -
ie broccoli- but encouraged any po intake for now.
7. constipation - mrs. [**known lastname 1661**] has had difficulty moving bowels
x 1 week despite aggressive treatment. she was managed on senna
and colace and responded well to .5l of golytely to get bowels
started and then occassional miralax.
8. pt: physical therapy evaluated patient today and suggested
3-5 visits/wk to help with balance, gait, and transfers.
suggested possible rehab on discharge, but patient refused and
stated that she preferred home pt. also with ot evaluation with
suggestion of home aide to supervise shower transfers and home
safety evaluations.
9. cad/hyperlipidemia - continue atorvastatin during admission
and on dsicharge.
10. hypothyroid - continued outpatient dose of levothyroxil
during admission and on discharge.
11. episode of afib - patient was noted to be in afib during icu
stay (as per hpi). because of the desire to avoid need for
anticoagulation (if need for cardioversion if in afib >48 hours)
she was successfully  cardioverted on [**10-12**]. nsr throughout rest
of hospitalization.
12. fen: continue protonix, phosphagel, tums, and pneumoboots.
13. code: dnr/dni


medications on admission:
levoxyl 75 mcg p.o. daily, prilosec, coumadin 1mg qd,
lipitor, atenolol, anzemet, celexa, oxycontin b.i.d., iron,
procrit, renagel 40mg qd and ativan daily.

discharge medications:
1. levothyroxine sodium 75 mcg tablet sig: one (1) tablet po qd
(once a day).
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 q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*2*
3. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po
qd (once a day).
disp:*30 tablet(s)* refills:*2*
4. sevelamer hcl 400 mg tablet sig: one (1) tablet po tid (3
times a day).
disp:*90 tablet(s)* refills:*2*
5. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2
times a day).
disp:*120 capsule(s)* refills:*2*
6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day).
disp:*60 tablet(s)* refills:*2*
7. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
8. calcium carbonate 500 mg tablet, chewable sig: one (1)
tablet, chewable po tid w/meals (3 times a day with meals).
disp:*30 tablet, chewable(s)* refills:*2*
9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3
times a day).
10. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as
needed for anxiety.


discharge disposition:
home with service

facility:
[**hospital 119**] homecare

discharge diagnosis:
primary diagnosis:
1. coagulopathy
secondary diagnosis
1. ovarian cancer
2. malignant ascities
3. chronic renal insufficiency
4. congestive heart failure
5. h/o dvt
6. s/p mvr


discharge condition:
stable.

discharge instructions:
please call your pcp or come to the ed if you have notice
worsening bruising, bloody stools, shortness of breath, chest
pain, feves/chills, or other worrisome symptoms.
please follow up on monday in the [**hospital **] clinic to have your
labs drawn.
do not restart coumadin on discharge. please discuss restarting
this medication with your doctor when you return to the [**hospital **]
clinic on [**10-22**].


followup instructions:
1. please return to the oncology clinic on monday, [**2125-10-22**] to have your labs drawn.
2. please call your oncologist for an appointment in [**1-19**] weeks.
3. please call your pcp, [**last name (namepattern4) **]. [**first name (stitle) **] at ([**telephone/fax (1) 95873**] for an
appointment in [**1-19**] weeks.



"
177,"admission date:  [**2133-5-18**]              discharge date:   [**2133-6-1**]

date of birth:  [**2107-3-17**]             sex:   f

service: surgery

allergies:
penicillins / shellfish

attending:[**first name3 (lf) 301**]
chief complaint:
1. obesity with body mass index of 52.
2. fatty liver.
3. gallstones.
4. sleep apnea.
5. gastroesophageal reflux.
6. polycystic ovary syndrome.


major surgical or invasive procedure:
1.laparoscopic cholecystectomy converted to open; open roux-en-y
gastric bypass.

2.exploratory laparotomy for removal of foreign body.


history of present illness:
[**known firstname 4890**] has class iii morbid obesity with weight of 303.7 pounds
as of [**2133-4-29**] with her initial screen weight on [**2133-4-7**] as 304.6
pounds, height 64 inches and bmi of 52.1.  her previous weight
loss efforts have included 3 months of prescription weight loss
medication orlistat (xenical) in [**2131**] losing 10 pounds that she
gained back in two months, 4 months of slim-fast in [**2131**] without
results and she also took over-the-counter herbal preparation
green tea for weight loss in [**2132**] but achieved no results.  she
has not taken over-the-counter ephedra-containing appetite
suppressants.  her weight at age 21 was 260 pounds her lowest
adult weight with her highest weight being 307.8 pounds on
[**2133-4-21**].  she weighed 220 pounds one year ago.  she states she
developed a significant weight problems since her teenage years
and cites as factors contributing to her excess weight genetics,
late night eating, large portions, too many carbohydrates in
saturated fats as well as lack of exercise.  she denies history
of eating disorders or depression.  she has not been seen by a
therapist nor has she been hospitalized for mental health issues
and she is not on any psychotropic medications.


past medical history:
gastroesophageal reflux, hyperlipidemia with elevated
triglycerides, obstructive sleep apnea testing use cpap, vitamin
d deficiency, polycystic ovary syndrome, fatty liver and
cholelithiasis

social history:
she has been smoking two cigarettes a day for 6 years and quit
one month ago and has been using chantix for smoking cessation.
she denied recreational
drug usage and has alcoholic beverage on rare occasion, does
drink both caffeinated and carbonated beverages. she is a
student at [**location (un) 6188**]
community college studying hospitality.  she is single and has
no children.  she lives with her sister at age 34 and 3 nieces.


family history:
father living age 54 with obesity and sister living age 27 with
asthma.

physical exam:
vitals on discharge: temp-97.8 bp-120/77 p-104 rr-20 o2 100%
room air

constitutional: no acute distress; comfortable appearing
neuro: alert and oriented to person, place and time
cardiac: regular, rate and rhythm, nl s1,s2
lungs: cta bilaterally, no respiratory distress
abd: soft, nd, + peri-incisional tenderness, no rebound
tenderness/ guarding
wounds: abdominal midline incision superior aspect intact.
inferior aspect open: wound bed- 100% red granulation tissue,
drainage- serosanguinous, periwound edges- no erythema, no
edema.
ext: no edema

pertinent results:
laboratory results:
[**2133-5-18**] 06:32pm blood hct-33.6*
[**2133-5-19**] 09:05am blood wbc-12.4* rbc-4.34 hgb-11.8* hct-34.3*
mcv-79* mch-27.2 mchc-34.5 rdw-15.0 plt ct-338 neuts-88.7*
lymphs-6.9* monos-4.2 eos-0.1 baso-0.1 glucose-125* urean-7
creat-0.7 na-139 k-4.1 cl-105 hco3-27 angap-11 alt-141* ast-122*
alkphos-44 amylase-27 totbili-0.9 albumin-3.5 calcium-8.3*
phos-2.7 mg-1.5*
[**2133-5-19**] 08:00pm blood type-art po2-74* pco2-46* ph-7.40
caltco2-30 base xs-2
[**2133-5-20**] 03:30am blood wbc-13.0* rbc-3.81* hgb-10.5* hct-30.2*
mcv-79* mch-27.5 mchc-34.7 rdw-14.9 plt ct-329 glucose-105*
urean-6 creat-0.7 na-137 k-4.1 cl-103 hco3-29 angap-9 alt-119*
ast-103* alkphos-41 amylase-23 [**2133-5-20**] 02:06pm blood
calcium-8.6 phos-1.8* mg-1.9
[**2133-5-20**] 03:09pm blood type-art rates-/20 peep-5 po2-81*
pco2-54* ph-7.38 caltco2-33* base xs-4 intubat-not intuba
[**2133-5-21**] 01:59am blood wbc-11.5* rbc-3.50* hgb-9.7* hct-28.4*
mcv-81* mch-27.7 mchc-34.2 rdw-14.8 plt ct-298 glucose-78
urean-7 creat-0.6 na-139 k-3.8 cl-100 hco3-31 angap-12
calcium-7.9* phos-2.6* mg-1.9
[**2133-5-22**] 01:46am blood wbc-11.4* rbc-3.40* hgb-9.4* hct-27.1*
mcv-80* mch-27.8 mchc-34.8 rdw-15.0 plt ct-347 glucose-81
urean-6 creat-0.5 na-134 k-3.5 cl-95* hco3-28 angap-15
calcium-8.2* phos-2.5* mg-1.8
[**2133-5-23**] 06:40am blood wbc-13.7* rbc-3.49* hgb-9.7* hct-28.2*
mcv-81* mch-27.9 mchc-34.5 rdw-14.8 plt ct-365

[**2133-5-19**] chest (portable ap):
impression: findings concerning for retained sponge within the
right upper quadrant of the abdomen

[**2133-5-19**] abdomen (supine & erect):
impression: apparent interval removal of a retained sponge

[**2133-5-20**] chest (portable ap):
the lung volumes are low. the heart size is top normal, probably
exaggerated  by the presence of low lung volumes and portable
character of the study. there is a right perihilar opacity that
might represent infectious process or may be a combination of
infection and asymmetric pulmonary edema. left lung demonstrates
mild interstitial pulmonary edema. bilateral pleural effusions
cannot be excluded. no appreciable pneumothorax is seen.

[**2133-5-20**] cta chest w&w/o c&recon:
impression:
1. no evidence of pulmonary emboli. bilateral moderate
atelectasis.
2. no evidence of intra-abdominal fluid collection with close
attention paid to the region of the hepatic fossa of the
gallbladder as well as at the jejunostomy and gastrojejunostomy
site.

[**2133-5-21**] chest (portable ap):
impression:
1. stable bibasilar atelectasis and right upper lung zone linear
atelectasis.
2. no focal consolidation, pneumothorax or pulmonary edema.

[**2133-5-23**] chest (pa & lat):
impression:
findings concerning for developing pneumonia and possibly mild
fluid overload.

[**2133-5-24**] abdomen (supine & erect):
air in the colon and scattered small bowel segments, nonspecific
bowel gas pattern. no frank obstruction.no radiopaque foreign
body is identified.
clips are present in the right upper quadrant.

[**2133-5-24**] chest (pa & lat):
impression: developing pneumonia.

[**2133-5-25**] [**last name (un) **] dup extext bil (map/dvt): no evidence of deep vein
thrombosis either right or left lower extremity

microbilogy results:
[**2133-5-20**] urine culture (final [**2133-5-22**]): escherichia
coli.>100,000 org/ml
[**2133-5-20**] blood culture, routine (final [**2133-5-26**]): no growth.
[**2133-5-20**] mrsa screen (final [**2133-5-23**]):    no mrsa isolated.
[**2133-5-24**] blood culture:
[**2133-5-24**] urine culture: no growth
[**2133-5-26**] sputum gram stain (final [**2133-5-26**]): [**12-1**] pmns and >10
epithelial cells/100x field. gram stain indicates extensive
contamination with upper respiratory secretions. bacterial
culture results are invalid.
[**2133-5-26**] abdominal wound: no growth


brief hospital course:
pt was evaluated by anaesthesia and taken to the operating room
for laparoscopoic converted to open cholecystectomy and
roux-en-y gastric bypass. there were no adverse events in the
operating room; please see the operative note for details.
pt was extubated, taken to the pacu until stable, then
transferred to the [**hospital1 **] for observation.

pod 0 ([**2133-5-18**]): the patient was tachycardic (hr 120-130's)and
was given a bolus of 1 litre of intravenous fluids.

pod 1 ([**2133-5-19**]): the patient continued to be tachycardic during
the early morning hours. she was afebrile and had no pain. she
was scheduled for an urgent ugi of the abdomen to rule out any
leak. an abdominal film done at this time showed evidence of a
retained foreign body possibly a sponge in the right upper
quadrant of the abdomen.
she was then taken to the or for an emergent exploratory
laparotomy to remove the sponge. please see the operative note
for details. she was not extubated and transferred to the pacu
where she was extubated after a few hours. she was kept on bipap
overnight on which she stayed very stable.

pod 2 ([**2133-5-20**]): she was transferred to the trauma icu where
she had a brief episode of desaturation to 80% on 4 l of o2. she
was tachycardic and hemodynamically stable through out this
period. a ct angiogram of the chest was performed and ruled out
any pulmonary embolism. she required  15 l of o2/min during the
day and this was further weaned down to 10 l/min overnight. her
diet was advanced to stage 1 which was tolerated very well. she
also recieved intravenous lasix 20 mg twice since she was
thought to be fluid overloaded.

pod 3 ([**2133-5-21**]): she continued to do well on the 10l/min  of o2
which was further weaned down to 4l/min. she had a fever spike
to 102 f when she was pan cultured. her urine culture grew
e.coli and she was then started on ciprofloxacin. she recieved a
few hous of cpap overnight.

pod 4 ([**2133-5-22**]): she was transferred to the floor and her diet
was advanced to stage ii. this was tolerated well.

pod 5 ([**2133-5-23**]): diet was advanced to stage iii which was
tolerated well. there was an increase in the wbc count from 11.4
to 13.7. a chest x-ray was done given her persistent o2
requirement, which was concerning for a possible developing
pneumonia.

pod 6 ([**2133-5-24**]): she had a fever spike to 101.9f when she was
pan cultured again. a chest x-ray was done that showed
developing pneumonia. also there was an increase in the wbc
count noted.

pod 7 ([**2133-5-25**]): she did well during the day except for being
tachycardic to 130's & occasionally 140's with activity. she
stayed completely asymptomatic throught this period. in view of
her rising white count and recent chest x-ray, intavenous
vancomycin and cefepime were started empirically.

pod 8([**2133-5-26**]): the lower part of abdominal wound appeared
erythematous and was hence opened. wound swabs were sent for
gram stain & culture. the gram stain did not show any organisms.
she had a fever spike to 101.7f during the day. otherwise, she
conitnued to do well on stage iii. her tachycardia was better
than the day before and her hr stayed in the 120's and
occasionally in 130's with activity.

pod 9([**2133-5-27**]): the jp was removed and an infectious disease
consult was sought. a repeat chest x-ray was done and blood and
urine cultures were sent following their recommendations. she
stayed afebrile through out the day.

pod 10 ([**2133-5-28**]): the abdominal wound was examined and a wound
vac dressing was placed. her white cell count was down from 14.7
to 11.7.

pod 11 ([**2133-5-29**]): she remained afebrile with continued
intravenous antibiotics; a wound vac remained in place; her
tachycardia had resolved and vital signs remained stable.

pod 12 ([**2133-5-30**]): no new events

pod 13 ([**2133-5-31**]): no new events

pod 14 ([**2133-6-1**]): antibiotics were discontinued with completion
of a 7 day course.  the vac was removed and the wound was
dressed with dry, sterile gauze. the patient's sister was given
instruction and demonstrated efficiency in performing the
dressing changes.  the patient did not have a cpap machine at
home, therefore, it was arranged to have one delivered to her
home.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.  a cpap machine will be
delivered to her home with mask fitting and instruction for
machine operation.


medications on admission:
omeprazole 20mg od, mvi 1 tab od, vitd 5000u od

discharge medications:
1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2
times a day) as needed for constipation for 10 days.
disp:*200 ml* refills:*0*
2. oxycodone 5 mg/5 ml solution sig: one (1)  po every 4-6 hours
as needed for pain for 10 days: please do not drive or operate
heavy machinery while taking this medication.
disp:*100 ml* refills:*0*
3. multivitamin,tx-minerals     tablet sig: one (1) tablet po
bid (2 times a day): chewable.
4. vitamin d 5,000 unit tablet sig: one (1) tablet po once a
day: please crush.
5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule; do
not chew beads.


discharge disposition:
home with service

facility:
caregroup vna

discharge diagnosis:
1. obesity with body mass index of 52.
2. fatty liver.
3. gallstones.
4. sleep apnea.
5. gastroesophageal reflux.
6. polycystic ovary syndrome.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-21**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
please perform dressing changes with dry, sterile gauze twice
daily as instructed or more frequently as needed.  please
contact dr. [**last name (stitle) 15645**] office if you have increased drainage from
the wound requiring more frequent changes.  also, please call
dr. [**last name (stitle) **] if you develop redness surrounding the wound and/ or
fevers greater than 101f.


followup instructions:
provider: [**first name8 (namepattern2) **] [**doctor last name **], rd,ldn phone:[**telephone/fax (1) 305**]
date/time:[**2133-6-3**] 11:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2133-6-3**] 12:00



completed by:[**2133-6-8**]"
178,"admission date:  [**2127-12-7**]              discharge date:   [**2127-12-17**]

date of birth:  [**2063-4-18**]             sex:   f

service: surgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1556**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
1. exploratory laparotomy.
2. lysis of adhesions.
3. oversew of colonic deserosalization.


history of present illness:
64 year old female who presents with sudden onset of
periumbilical pain that started early this morning at around
5am. abdominal pain is mid abdomen with no radiation; relieved
by pain meds and no definite aggravating factors. associated
nausea and vomiting ~6 times. bilious; no blood. denies any
fevers, chills. bowel movements this morning; flatus last night.


past medical history:
- ovarian cancer, diagnosed in [**2109**] and treated with tah bso and
6 runs of chemotherapy complicated by deep vein thrombosis in
left lower extremity and was on coumadin briefly
- bladder cancer, diagnosed in [**2114**] and treated with cystecomy
and ileal conduit and stoma
- documented to have chronic anemia of unknown etiology
- pt. reported last colonoscopy 5 years ago with no abnormal,
she did have polyp removed during colonoscopy 10 years ago but
was not sure if malignancy was found.
-osteoporosis

psychiatric history:
patient has a diagnosis of ""psychotic disorder"" and has been
treated by her primary care provider successfully with
thorazine. she does not see any therapists or psychiatrists at
this time. she saw dr. [**last name (stitle) 100898**] in therapy 1x/mo for 6yrs
until she changed her insurance in [**month (only) 547**]. she reports trying
zoloft for a short time in [**2111**] but did not mention results.

hospitalizations: [**2111**] - ""[**first name4 (namepattern1) **] [**last name (namepattern1) **] accomodations""
                  [**2110**] - [**hospital1 336**]
                  [**2092**] - [**hospital1 **] [**hospital1 **] 4

patient reports 1 prior suicide attempt in [**2084**] when she
""stopped eating and wearing warm clothes and stayed out all
night, everything to excess."" she was then hospitalized for
pneumonia, no history of hurting herself.

social history:
born in mission [**doctor last name **] and raised in [**location (un) 669**], one of 11 children
(10 per omr). she reports 7 living (omr notes say 6) and all
except two sisters are in the [**name (ni) 86**] area.  lives alone. remote
smoker, no drugs/etoh


family history:
she had ten siblings. malignancy in the family: deceased sister:
ovarian ca
sister: breast cancer brother : ca brain brother: liver cancer
father: prostate cancer; mother's sister had schizophrenia.

physical exam:
constitutional: comfortable
chest: clear to auscultation
cardiovascular: regular rate and rhythm, normal first and second
heart sounds
abdominal: diffuse tenderness to palpation. no guarding or
rebound tenderness to palpation. abdomen nondistended, soft.
extr/back: no cyanosis, clubbing or edema
skin: no rash, warm and dry
neuro: speech fluent
psych: normal mood, normal mentation


pertinent results:
[**2127-12-7**] 02:45pm urine  hours-random
[**2127-12-7**] 02:45pm urine  gr hold-hold
[**2127-12-7**] 02:45pm urine  color-yellow appear-clear sp [**last name (un) 155**]-1.016
[**2127-12-7**] 02:45pm urine  blood-tr nitrite-neg protein-25
glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-7.0 leuk-sm
[**2127-12-7**] 02:45pm urine  rbc-0-2 wbc-[**4-18**] bacteria-many yeast-none
epi-0-2
[**2127-12-7**] 02:11pm   k+-4.1
[**2127-12-7**] 02:02pm   glucose-129* urea n-28* creat-1.4* sodium-144
potassium-4.1 chloride-108 total co2-26 anion gap-14
[**2127-12-7**] 12:30pm   glucose-137* urea n-31* creat-1.4* sodium-143
potassium-5.1 chloride-104 total co2-28 anion gap-16
[**2127-12-7**] 12:30pm   alt(sgpt)-13 ast(sgot)-32 alk phos-75 tot
bili-0.3
[**2127-12-7**] 12:30pm   lipase-55
[**2127-12-7**] 12:30pm   calcium-9.6
[**2127-12-7**] 12:30pm   wbc-6.3# rbc-3.65* hgb-10.6* hct-32.6* mcv-89
mch-29.2 mchc-32.7 rdw-13.9
[**2127-12-7**] 12:30pm   neuts-87.4* lymphs-9.4* monos-2.4 eos-0.5
basos-0.3
[**2127-12-7**] 12:30pm   plt count-190

[**2127-12-8**] abdominal ct w/ contrast: 1. high-grade small-bowel
obstruction, with dilation of the mid small bowel up to 3.4 cm.
the proximal and distal small bowel are decompressed and two
closely approximated transition points are seen in the
mid-abdomen, concerning for a closed loop obtruction, possibly
secondary to either internal hernia or
adhesion. while there is associated wall edema, mesenteric
fluid, and
adjacent ascites, there is no pneumatosis or portal venous air
identified to definitively suggest ischemia.
2. status post right nephroureterectomy and radical cystectomy,
with
unremarkable appearance of urostomy in the right lower quadrant.
no definite evidence of metastatic disease. small nodular
density at the left lung base is stable, though attention on
followup is warranted.
3. stable 4 mm hypodensity within the body of the pancreas,
unchanged.
4. ivc filter in standard position.

[**2127-12-12**] ekg: sinus rhythm with sinus arrhythmia. borderline low
limb lead voltage. diffuse non-specific st-t wave abnormalities.
compared to the previous tracing of [**2127-12-8**] findings are
similar.



brief hospital course:
ms. [**known lastname 20400**] presented to the emergency department on [**2127-12-7**] with complaints of sudden onset abdominal pain at the
umbilical level associated with nausea and vomiting and not
relieved with over the counter pain medication.  an abdominal
x-ray was obtained, which indicated a small bowel obstruction.
therefore, [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube was placed and the patient was
transferred to the general surgical [**hospital1 **] for management.

on hospital day #1 the patient developed worsening abdominal
pain.  additionally, an abdominal ct scan had beeb obtained,
which revealed a high grade small bowel obstruction.  given the
worsening abdominal exam and the results of the ct scan, the
patient was brought to the operating room, where an exploratory
laparotomy, lysis of adhesions and oversew of colonic
deserosaliazation was performed.  there were no adverse events
in the operating room; please see the operative note for
details. pt was extubated, taken to the pacu until stable, then
transferred to the surgical intensive care unit for close
observation.

on hosptial day #2 the patient remained stable, was weaned from
the ventilator and extubated.  she was subsequently transferred
to the general surgical [**hospital1 **] for further management.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially controlled with intravenous
dilaudid.  the patient reported complete resolution of pain by
post-operative day #5 and did not require pain medication for
the remainder of her hospitalization.

cv: the patients vital signs were routinely monitored. she
became hypertensive in the intensive care unit with a systolic
blood pressure in the 160s.  additionally, she had 8 beats of
non-sustained ventricular tachycardia on post-operative day #4.
she was maintained on intravenous metoprolol which was initiated
in the intensive care unit and continued until post-operative
day #8; her blood pressure and heart rate remained within
acceptable limits without metoprolol administration.

pulmonary: the patient tolerated extubation postoperatively
without difficulty and maintained appropriate oxygen saturation
levels throughout her admission.

gi/gu/fen: she was initially npo with iv fluids and a
[**last name (un) **]-gastric tube, which was removed on post-operative day #4.
diet was advanced sequentially, which was well tolerated,
however, oral liquid and solid intake was initially suboptimal.
nutritional supplements were then provided with each meal with
improved overall oral intake; she will continue this regimen at
home to optimize her nutritional status  patient's intake and
output were closely monitored, and iv fluid was adjusted when
necessary; electrolytes were routinely monitored and repleted as
necessary.

id: the patient's white blood cell counts and fever curves were
monitored routinely throughout her admission and did not show
any signs of intrabdominal or wound infections.

hematology: the patient's complete blood count was examined
routinely; no transfusions were required.

prophylaxis: the patient received subcutaneous heparin and
venodyne boots were used during this stay; she was encouraged to
get up and ambulate as early as possible.

rehab: given her prolonged hospital course and operation, a
physical therapy consult was requested.  she was evaluted on
post-operative day #8 and deemed safe for discharge home without
additional physical therapy requirements.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding via her urostomy tube, and pain was
well controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
risperidone 1 mg tab qpm
vitamin d 800 unit tab daily
calcium 1200 mg chewable tab daily

discharge medications:
1. risperidone 0.5 mg tablet sig: two (2) tablet po hs (at
bedtime).
2. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2)
tablet po daily (daily).
3. calcium 500 mg tablet sig: 2.5 tablets po once a day.


discharge disposition:
home

discharge diagnosis:
small bowel obstruction


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-23**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.


followup instructions:
please call dr. [**last name (stitle) **] at [**telephone/fax (1) 3201**] to make a follow-up
appointment for friday, [**2127-12-26**].
provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 6198**], md phone:[**telephone/fax (1) 22**]
date/time:[**2127-12-12**] 3:30



completed by:[**2127-12-18**]"
179,"chief complaint:  angioedema
   hpi:
   pt is an 85 y/o f with a h/o gave s/p argon treatment last on [**2150-3-11**],
   iron deficiency anemia, cirrhosis [**1-19**] hepc, portal htn/grade 1 varices
   but no hx of bleeding varices, cri (baseline cr = 1.2-1.5) who is
   transfered from [**hospital3 2546**] intubated s/p angioedema. the following
   history is obtained from her son as the patient is intubated. he states
   that she reported some mild abdominal pain and some irritation in her
   throat a day prior to admission to [**hospital3 2546**]. the following
   morning she called her son with complaints of oral swelling; son states
   that her speach was garbled. the son reports that the patient denies
   having had any sob, no wheezing, no hives. he called an abmulance who
   transported the pt to [**hospital3 2546**].
   .
   per omr, the patient present to [**hospital1 1**] pheresis unit on [**2150-4-10**] for
   blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications given and no adverse events; vitals on leaving
   the unit were 97.4 - 67 - 119/55. she has also been recently treated
   for a uti with bactrim started on [**2150-4-3**].
   .
   at st elizabeths', she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate in the ed and she
   was taken to the or. laryngeal edema was noted, but the et tube was
   passed successfully. she was then transfered to the ccu. she received
   hydroxyzine tid and her tongue swelling improved. sbt was attempted
   early on but failed likely secondary to sedation. per report, pt did
   have a cuff leak. family requested transfer to [**hospital1 1**] as pt receives all
   her care here.
   patient admitted from: transfer from other hospital
   history obtained from family / [**hospital 380**] medical records
   patient unable to provide history: language barrier
   allergies:
   nsaids
   please avoid du
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   home medications:
   felodipine - 5 mg tablet sustained release 24 hr - 3 tablet(s) by mouth
   once a day (2 tabs in a.m. and 1 tab in the p.m
   folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day
   furosemide [lasix] - 40 mg tablet - 1 tablet(s) by mouth once a day
   hydrocortisone acetate [anusol-hc] - 25 mg suppository - one rectally
   daily
   lactulose -  (prescribed by other provider) - 10 gram/15 ml solution -
   15 ml by mouth once a day for encephalopathy; goal of [**2-18**] bms qd
   metformin - 500 mg tablet - 2 (two) tablet(s) by mouth every morning
   and one tablet every evening.
   mupirocin - 2 % ointment - topical twice a day as needed for lesion or
   rash
   nadolol - 80 mg tablet - 1 (one) tablet(s) by mouth qam
   pantoprazole - 40 mg tablet, delayed release (e.c.) - one tablet(s) by
   mouth twice daily
   spironolactone [aldactone] - 50 mg tablet - one tablet(s) by mouth
   daily
   sucralfate - 1 gram tablet - 1 tablet(s) by mouth thre times per day
   zolpidem [ambien] - 5 mg tablet - 1/4-1 tablet(s) by mouth at bedtime
   as needed for insomnia
   calcium carbonate-vitamin d2 [oyster shell calcium-vit d3] - 500 mg-375
   unit tablet - 1 (one) tablet(s) by mouth twice a day
   cyanocobalamin - 500 mcg tablet - 1 tablet(s) by mouth once a day
   ferrous gluconate - 325 mg tablet - 1 tablet(s) by mouth 5 times a day
   pramoxine-menthol-petrolatum [sarna ultra] - 1 %-0.5 %-30 % cream -
   apply to affected areas one to two times per day
   past medical history:
   family history:
   social history:
   # gave - s/p argon treatment, last on last on [**2150-3-11**]
   # hepatitis c
   # cirrhosis
   - child's class a, portal htn, grade 1 varices
   - no h/o ascites, encephalopathy, variceal bleeding, synthetic
   function intact
   # dm type ii
   # htn
   # iron deficiency anemia
   # s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
   # hypercholesterolemia
   # osteopenia
   # insomnia
   no hx angioedema
   occupation:
   drugs:
   tobacco:
   alcohol:
   other: lives alone in [**location (un) 2471**] in [**hospital3 718**] complex. is widowed.
   has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
   holidays). worked in food business in sales.
   review of systems:
   flowsheet data as of [**2150-4-16**] 08:21 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 35.8
c (96.4
   tcurrent: 35.8
c (96.4
   hr: 84 (84 - 95) bpm
   bp: 119/53(69) {119/53(69) - 127/56(74)} mmhg
   rr: 19 (19 - 26) insp/min
   spo2: 96%
   heart rhythm: sr (sinus rhythm)
                  total in:
                  po:
                  tf:
   ivf:
   blood products:
   total out:
                                                                      0 ml
                                                                     50 ml
   urine:
   50 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    -50 ml
   respiratory
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (spontaneous): 398 (398 - 398) ml
   ps : 10 cmh2o
   rr (spontaneous): 25
   peep: 5 cmh2o
   fio2: 50%
   pip: 16 cmh2o
   spo2: 96%
   ve: 11.5 l/min
   physical examination
   gen: intubated awake alert with tube in place
   heent: ncat,oropharynx clear and without erythema or exudate, tongue is
   normal sized w/o any edema
   neck: supple, no lad, no appreciable jvd
   cv: rrr, normal s1s2, [**12-23**] holosystolic blowing murmur at apex.
   pulm: ctab, no w/r/r, good air movement bilaterally
   abd: soft, obese, ntnd, easily reduced umbilical hernia,
   normoactive bowel sounds, no organomegaly
   ext: warm and well perfused, full and symmetric distal pulses,
   no pedal edema
   neuro: awake, alert
   skin; no hives
   labs / radiology
   140
   1.1
   47
   22
   107
   5.5
   135
   32.5
   7.8
        [image002.jpg]
   assessment and plan:
   assessment and plan:  pt is an 85 y/o f with a h/o gave s/p argon
   treatment last on [**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc,
   portal htn/grade 1 varices but no hx of bleeding varices, cri (baseline
   cr = 1.2-1.5) who is transfered from [**hospital3 2546**] intubated s/p
   angioedema.
   .
   # angioedema: resoved. lack of hives, bronchospasm or hypotension
   suggests that this was not allergic angioedema but rather bradykinin
   related. c3 and c4 were low. c1 esterase inh pending, [**doctor first name **] neg per
   allergy consult at [**hospital3 5692**], non-allergic angioedema is due to
   completment depletion ([**1-19**] hereditary or carelated) or complement
   activation (infection or transfusion). the patient did have a
   transfusion recently which may be related. medications would also be
   high on the list of etiologies.  nsaids? [**last name (un) 284**]?
   - cont hydroxyzine from one more day
   - check cuff leak and extubate in am
   - hold all non-essential possible culprit meds: [**last name (un) 284**], felodipine, lasix,
   nadolol, bactrim
   - f/u complement studies at [**hospital3 2546**]
   - consider allergy consult
   - contact blood bank re risk of angioedema with transfusion as pt will
   need future transfuse and may be at risk for recurrent episode
   .
   # hx  cirrhosis:
   - cont lactulose
   .
   #cri: baseline 1.5, was elevated on admission to [**hospital3 5692**] to 1.7 now
   down to 1.1
   - monitor.
   icu care
   nutrition:
   glycemic control:
   lines:
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
   ------ protected section ------
   i have seen and examined the patient with the resident and agree with
   the assessment and plan with the following modifications/changes:
   85 year old with resolving angioedema transferred from osh.  remains
   intubated at this time and is hemodynamically stable.
   per son, swelling of tongue much improved.
   a:
   1)       angioedema
   2)       respiratory failure secondary to angioedema
   p:
   1)       review med records for report of grade view of airway
   2)       extubation in the am
   critically ill
   time spent: 30 minutes
   ------ protected section addendum entered by:[**name (ni) **] [**last name (namepattern1) 402**], md
   on:[**2150-4-17**] 10:40 am ------
"
180,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   angioedema
   assessment:
   action:
   response:
   plan:
"
181,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
   demographics
   attending md:
   [**location (un) **] [**doctor first name **] a.
   admit diagnosis:
   tongue swelling
   code status:
   full code
   height:
   admission weight:
   58.6 kg
   daily weight:
   allergies/reactions:
   nsaids
   please avoid du
   precautions:
   pmh:  anemia, diabetes - oral [**doctor last name **], gi bleed, hepatitis
   cv-pmh:  hypertension
   additional history: hep c cirrhosis, portal htn w/ grade i varices,
   ascites, encephalopathy, variceal bleeding, dm 2, right renal
   nephrectomy for renal cell ca (15 yrs ago), hypercholesterolemia,
   osteopenia, insomnia,
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:122
   d:54
   temperature:
   98.7
   arterial bp:
   s:
   d:
   respiratory rate:
   22 insp/min
   heart rate:
   85 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   nasal cannula
   o2 saturation:
   96% %
   o2 flow:
   3 l/min
   fio2 set:
   50% %
   24h total in:
   655 ml
   24h total out:
   415 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2150-4-17**] 05:15 am
   potassium:
   4.3 meq/l
   [**2150-4-17**] 05:15 am
   chloride:
   112 meq/l
   [**2150-4-17**] 05:15 am
   co2:
   24 meq/l
   [**2150-4-17**] 05:15 am
   bun:
   27 mg/dl
   [**2150-4-17**] 05:15 am
   creatinine:
   1.1 mg/dl
   [**2150-4-17**] 05:15 am
   glucose:
   132 mg/dl
   [**2150-4-17**] 05:15 am
   hematocrit:
   31.4 %
   [**2150-4-17**] 05:15 am
   finger stick glucose:
   159
   [**2150-4-17**] 06:00 pm
   valuables / signature
   patient valuables: none
   other valuables:
   clothes:  sent home with:
   wallet / money:
   no money / wallet
   cash / credit cards sent home with:
   jewelry:
   transferred from: micu-7
   transferred to: [**hospital ward name 4126**]
   date & time of transfer:  [**2150-4-17**] 1830
"
182,"chief complaint:  angioedema
   hpi:
   pt is an 85 y/o f with a h/o gave s/p argon treatment last on [**2150-3-11**],
   iron deficiency anemia, cirrhosis [**1-19**] hepc, portal htn/grade 1 varices
   but no hx of bleeding varices, cri (baseline cr = 1.2-1.5) who is
   transfered from [**hospital3 2546**] intubated s/p angioedema. the following
   history is obtained from her son as the patient is intubated. he states
   that she reported some mild abdominal pain and some irritation in her
   throat a day prior to admission to [**hospital3 2546**]. the following
   morning she called her son with complaints of oral swelling; son states
   that her speach was garbled. the son reports that the patient denies
   having had any sob, no wheezing, no hives. he called an abmulance who
   transported the pt to [**hospital3 2546**].
   .
   per omr, the patient present to [**hospital1 1**] pheresis unit on [**2150-4-10**] for
   blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications given and no adverse events; vitals on leaving
   the unit were 97.4 - 67 - 119/55. she has also been recently treated
   for a uti with bactrim started on [**2150-4-3**].
   .
   at st elizabeths', she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate in the ed and she
   was taken to the or. laryngeal edema was noted, but the et tube was
   passed successfully. she was then transfered to the ccu. she received
   hydroxyzine tid and her tongue swelling improved. sbt was attempted
   early on but failed likely secondary to sedation. per report, pt did
   have a cuff leak. family requested transfer to [**hospital1 1**] as pt receives all
   her care here.
   patient admitted from: transfer from other hospital
   history obtained from family / [**hospital 380**] medical records
   patient unable to provide history: language barrier
   allergies:
   nsaids
   please avoid du
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   home medications:
   felodipine - 5 mg tablet sustained release 24 hr - 3 tablet(s) by mouth
   once a day (2 tabs in a.m. and 1 tab in the p.m
   folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day
   furosemide [lasix] - 40 mg tablet - 1 tablet(s) by mouth once a day
   hydrocortisone acetate [anusol-hc] - 25 mg suppository - one rectally
   daily
   lactulose -  (prescribed by other provider) - 10 gram/15 ml solution -
   15 ml by mouth once a day for encephalopathy; goal of [**2-18**] bms qd
   metformin - 500 mg tablet - 2 (two) tablet(s) by mouth every morning
   and one tablet every evening.
   mupirocin - 2 % ointment - topical twice a day as needed for lesion or
   rash
   nadolol - 80 mg tablet - 1 (one) tablet(s) by mouth qam
   pantoprazole - 40 mg tablet, delayed release (e.c.) - one tablet(s) by
   mouth twice daily
   spironolactone [aldactone] - 50 mg tablet - one tablet(s) by mouth
   daily
   sucralfate - 1 gram tablet - 1 tablet(s) by mouth thre times per day
   zolpidem [ambien] - 5 mg tablet - 1/4-1 tablet(s) by mouth at bedtime
   as needed for insomnia
   calcium carbonate-vitamin d2 [oyster shell calcium-vit d3] - 500 mg-375
   unit tablet - 1 (one) tablet(s) by mouth twice a day
   cyanocobalamin - 500 mcg tablet - 1 tablet(s) by mouth once a day
   ferrous gluconate - 325 mg tablet - 1 tablet(s) by mouth 5 times a day
   pramoxine-menthol-petrolatum [sarna ultra] - 1 %-0.5 %-30 % cream -
   apply to affected areas one to two times per day
   past medical history:
   family history:
   social history:
   # gave - s/p argon treatment, last on last on [**2150-3-11**]
   # hepatitis c
   # cirrhosis
   - child's class a, portal htn, grade 1 varices
   - no h/o ascites, encephalopathy, variceal bleeding, synthetic
   function intact
   # dm type ii
   # htn
   # iron deficiency anemia
   # s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
   # hypercholesterolemia
   # osteopenia
   # insomnia
   no hx angioedema
   occupation:
   drugs:
   tobacco:
   alcohol:
   other: lives alone in [**location (un) 2471**] in [**hospital3 718**] complex. is widowed.
   has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
   holidays). worked in food business in sales.
   review of systems:
   flowsheet data as of [**2150-4-16**] 08:21 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 35.8
c (96.4
   tcurrent: 35.8
c (96.4
   hr: 84 (84 - 95) bpm
   bp: 119/53(69) {119/53(69) - 127/56(74)} mmhg
   rr: 19 (19 - 26) insp/min
   spo2: 96%
   heart rhythm: sr (sinus rhythm)
                  total in:
                  po:
                  tf:
   ivf:
   blood products:
   total out:
                                                                      0 ml
                                                                     50 ml
   urine:
   50 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    -50 ml
   respiratory
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (spontaneous): 398 (398 - 398) ml
   ps : 10 cmh2o
   rr (spontaneous): 25
   peep: 5 cmh2o
   fio2: 50%
   pip: 16 cmh2o
   spo2: 96%
   ve: 11.5 l/min
   physical examination
   gen: intubated awake alert with tube in place
   heent: ncat,oropharynx clear and without erythema or exudate, tongue is
   normal sized w/o any edema
   neck: supple, no lad, no appreciable jvd
   cv: rrr, normal s1s2, [**12-23**] holosystolic blowing murmur at apex.
   pulm: ctab, no w/r/r, good air movement bilaterally
   abd: soft, obese, ntnd, easily reduced umbilical hernia,
   normoactive bowel sounds, no organomegaly
   ext: warm and well perfused, full and symmetric distal pulses,
   no pedal edema
   neuro: awake, alert
   skin; no hives
   labs / radiology
   140
   1.1
   47
   22
   107
   5.5
   135
   32.5
   7.8
        [image002.jpg]
   assessment and plan:
   assessment and plan:  pt is an 85 y/o f with a h/o gave s/p argon
   treatment last on [**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc,
   portal htn/grade 1 varices but no hx of bleeding varices, cri (baseline
   cr = 1.2-1.5) who is transfered from [**hospital3 2546**] intubated s/p
   angioedema.
   .
   # angioedema: resoved. lack of hives, bronchospasm or hypotension
   suggests that this was not allergic angioedema but rather bradykinin
   related. c3 and c4 were low. c1 esterase inh pending, [**doctor first name **] neg per
   allergy consult at [**hospital3 5692**], non-allergic angioedema is due to
   completment depletion ([**1-19**] hereditary or carelated) or complement
   activation (infection or transfusion). the patient did have a
   transfusion recently which may be related. medications would also be
   high on the list of etiologies.  nsaids? [**last name (un) 284**]?
   - cont hydroxyzine from one more day
   - check cuff leak and extubate in am
   - hold all non-essential possible culprit meds: [**last name (un) 284**], felodipine, lasix,
   nadolol, bactrim
   - f/u complement studies at [**hospital3 2546**]
   - consider allergy consult
   - contact blood bank re risk of angioedema with transfusion as pt will
   need future transfuse and may be at risk for recurrent episode
   .
   # hx  cirrhosis:
   - cont lactulose
   .
   #cri: baseline 1.5, was elevated on admission to [**hospital3 5692**] to 1.7 now
   down to 1.1
   - monitor.
   icu care
   nutrition:
   glycemic control:
   lines:
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
"
183,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
"
184,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   angioedema
   assessment:
   pt arrived to micu 7 in nad. denies cp/sob or any difficulty breathing.
   psv 50% 10/5. ls cta. tongue slightly protruding/deviating to left side
   of mouth. pt suctioned for significant amt of thick blood tinged oral
   secretions. rr teens -20
s. afebrile.
   action:
   cxr o/n to assess ett/ogt placement (wnl) frequent mouth care o/n. sbt
   in place @ 0600 & doing well.
   response:
   tolerating sbt @ this time. oral secretions have decreased. tongue
   swelling appears to have also decreased.
   plan:
   extubation this am. pt is a known difficult intubation per transfer
   note from st. e
s. cont to monitor resp. status.
          pt
s son [**doctor first name 4215**] at bedside and spoke w/ this rn and micu
   team. pt is [**name (ni) **] speaking only but follows gestures/commands very
   well.
"
185,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   action:
   response:
   plan:
"
186,"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
"
187,"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
"
188,"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
"
189,"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
"
190,"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
"
191,"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
"
192,"ccu nursing progress note
please see nursing admission summary

s:  denies c/o itching.  asking many questions re: asa desensitization therapy

o:  see flow sheet for objective data.

pt. premedicated with 25 mg po benadryl 45 minutes prior to start of asa desensitization. patient received progressively increasing doses of asa according to protocol.  rn in room continuously throughout protocol and for 45 minutes after the last dose.  patient without vs changes, no wheezing, no edema, no rash.  patient instructed to immediately notify nurse of any itching, or change in sensation through the night.

pt. given info and explained the purpose of health care proxy.    [**name (ni) **] does not wish to complete the form this evening, but says that he might be willing to do it tomorrow (""doesn't want to jinx himself."")  does state that he would designate his wife as proxy anyways, so legally, he's not sure if it makes any difference.  have explained that not all patients designate their spouse to be proxy, and it gives the health care providers a more clear indication of his wishes.

pt is pre-cath for tomorrow.  pt. does not have any further questions re:  cath procedure.

a:  s/p successful completion of asa desensitization protocol without adverse events.

p:  monitor for delayed allergic reaction. follow pre cath orders.  re-assess wishes regarding health care proxy tomorrow.
"
193,"micu npn 7p-7a
this is a 55 y/o female with hx cervical ca with xrt and htn. presented to osh, after neighbor found her confused, with rhabdo, leukocytosis, hypotension, arf (resolved with flds), and uti. found to have mssa bacteremia that seeded to left hip (confirmed by tap)and left knee. ct with multi infarcts (septic emboli). also noted to have nstemi and question abscess vs tumor to spine. transferred to [**hospital1 10**] for further w/u on [**3-27**].

since admit pt had left knne tapped that was mssa. went to or on [**3-28**] for i&d of left hip and knee. then started on pca dilaudid. [**3-29**] tee confirmed vegetation on aortic valve. [**3-31**] mri of c-spine was neagtyive and started on decadron. [**4-1**] left knee washout. [**4-2**] thoracic and lumbar mri. hospital course shows that she has had 3units of prbc's for hct trending down. hemodynamics and resp status have been stable. has been aaox3 with no adverse events. pain controlled with pca and prns. mssa treated with nafcillin and has been afebrile with wbc wnl. surveillance bls cx's ngtd.

neuro: patient has had a rough night. at beginning of shift with daughter in room she was aaox3 and cooperative. was weepy when daughter left. as shift has progressed patient has become more delirious. she remains oriented but has increasingly become more anxious, frustrated, agitated, and paranoid. has been found several times pulling off gown, leads, and cuff. when asked what is wrong or what she is doing she will say she is frustrated or doesn't know what to do next and begin to cry. ?steroid induced psychosis. ativan 2mg x2 as well as ambien for sleep has not helped. md aware. she is moving all extremities much more easily with less pain. has decreased the use of her pca and has been seen pulling herself on her side. will follow commands appropiately. mri pending from yesterday. soft wrist restraints placed this morning as she continously interferes with proper monitoring and care needed.

cardiac: hr 101-120 st with no ectopy. ^hr [**2-10**] anxiety. bp 125-155/66-87, on lopressor and lisinopril. pp by doppler. hct continues to trend down, 22.6 from 25.3. no signs of bleeding other than blood collecting in the drains.

resp: remains on room air with rr 14-30 and sats 95-100%. ls clear with diminished bases. no cough/cong/sob.

gi/gu: abd soft and obese with +bs. mushroom cath removed as stool becoming to thick. is brown. uop 40-60cc/hr amber/yellow with sediment. creat rising to 1.3 from 1.1.

fen: cvp 6-11, anasarca. +12l los. lytes per carevue. house diet but poor intake. needs encouragement. albumin low.

id: tmax 99.1 with wbc 8 down from 11. continues on nafcillin. cx's ngtd.

skin: rash to back improved, sarna lotion apllied. dsg changed to left hip, weeping lge amount of serous fld. staples intact. dsd and ace wrap to left knee, small amount of blood oozing through. jp drains intact. groins with yeast rash, mycostatin powder applied.

access: rij cvl.

social/dispo: full code. husband and daughter visiting last noc. awaiting read of yesterday's m
"
194,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
195,"varizig consent note
i met with [**doctor last name **] and [**known firstname 613**] [**known lastname 4366**] to discusse the risk/benfits of varizig because of her exposure to varicella.  we discussed circumstances of her exposure to her brother in very close proximity during the period of his highest viral shedding.  we discussed the incubation period of varicella.  we discussed the complications associated with varicella in an immunocompromised host.

i explained to the family that i had spoken with one of the research scientist who worked on varizig for cangene.  they explained to me the potential side effect and the adverse events reported.  there have been some who have developed fever and muscle ache at the injection site. there have not been any cases of death associated with the varizig. we discussed in detail the dosing and timing of dose related to exposure.  i talked to the fff enteprises the distributors of the varizig.  i also had an in depth discussion with the [**hospital1 187**] pharmacy.

i explained the the family the experimental nature of varizig. i explained that there was very little experience with giving the varizig in an infant as small as [**known lastname 4367**].  i also explained  that we had very limited other options.

i talked to the family with nurse [**first name8 (namepattern2) 2660**] [**last name (namepattern1) 2502**] present. the family agreed that the varizig should be given.  i wanted the family to take a little more time to think about it.  i let them take the hour long drive home.

an hour later, i called  the family at home.  i spoke with [**doctor last name **].  i reviewed the information we had previously discussed. i reviewed the irb informed consent with the family.  they continued to agree that [**known lastname 4367**] should be given the varizig.  they agreed to sign the consent form when they returned to the hospital.
"
196,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
197,"admission date:  [**2170-5-17**]     discharge date:  [**2170-5-22**]

date of birth:   [**2112-6-10**]     sex:  m

service:

chief complaint:  shortness of breath.

history of present illness:  this is a 57-year-old male with
a history of pe in [**2156**], obstructive sleep apnea and prostate
cancer, who presented with shortness of breath starting four
days prior to admission, but becoming acutely worse on the
morning of admission.  the patient went to his primary care
physician and was sent to the emergency department.  he had
no chest pain, no pleuritic chest pain, no new lower
extremity edema, although the patient does have chronic
stable lower extremity edema bilaterally.  the patient had
recently flown to [**location (un) **] and returned five days ago.  no
fevers or chills were noted, no recent illnesses, no melena,
no hematochezia.

past medical history:  1. pe in [**2156**].  2. status post
orthopedic surgery.  3. obstructive sleep apnea with cpap at
12 mm of water.  4. hyperglycemia history without a diagnosis
of diabetes mellitus, last a1c 6.5 in [**2167**].  5. obesity.  6.
prostate cancer status post prostatectomy.  7. ankle
fracture.  8. glaucoma.  9. hypertension.  10.
diverticulosis.  11. chronic lower extremity edema.

allergies:  sulfa give the patient a rash.

medications:  1. aspirin.  2. multivitamin.  3. timolol.  4.
hydrochlorothiazide started three days prior to admission.

social history:  the patient is the chief of anesthesiology
at [**hospital6 1708**].  he does not smoke, drinks
occasional alcohol.

family history:  mother died of pe.

physical examination:  temperature was 97.2, blood pressure
135/93, pulse 85, respirations 16, saturating 98% on five
liters, 88% on room air.  general:  obese male, mildly
tachypneic with nasal cannula on.  alert and oriented x 3 in
no acute distress.  heent:  pupils were equal, round, and
reactive to light and accommodation.  mucous membranes were
moist.  extraocular movements intact, anicteric sclerae,
benign oropharynx.  neck:  no lymphadenopathy, no jugular
venous distension appreciated.  chest:  clear to auscultation
bilaterally.  cardiac:  regular rate and rhythm, split s2, no
rubs, gallops or murmurs, no heave.  abdomen:  obese,
nontender, nondistended, normal active bowel sounds, no
organomegaly.  extremities:  2+ pitting edema bilaterally and
equal.  neurologic:  no focal neurologic deficits.  the
patient reports a rectal examination was done in the primary
care physician's office and was negative.

laboratory data:  white blood cell count 8.5, 69% polys, 21%
lymphocytes, hematocrit 42.9, platelet count 203, mcv 87,
sodium 136, potassium 4.4, chloride 93, bicarbonate 23, bun
17, creatinine 0.9, glucose 141, inr 1.2.

spiral cta showed large left main pulmonary artery embolus
and large right pulmonary embolus slightly smaller than left;
both are in the main pulmonary arteries.

ekg:  normal sinus rhythm at 90, question of right atrial
abnormality, otherwise normal axis, no s1, q3, t3, no st
changes, no old ekg for comparison.

echocardiogram done in the emergency department showed an
ejection fraction of greater than 60% but increased pulmonary
artery pressures 48-56 mmhg.  he has a dilated right
ventricle with decreased right ventricular function, abnormal
septal motion consistent with right ventricular volume
overload and left apical sparing consistent with [**last name (un) **]
sign.  there was mild symmetric left ventricular hypertrophy.

hospital course:  this is a 57-year-old male with past pe
presenting with massive bilateral pulmonary emboli and
hemodynamically stable.  the echocardiogram does show signs
of right ventricular strain.

1. pulmonary emboli:  massive bilateral pes with right
ventricular strain but hemodynamic stability.  the patient
was initially admitted to the intensive care unit after being
started on heparin in the emergency department.  he was
observed in the intensive care unit for two days without
adverse events.  he was then called out to the floor and
continued on his heparin gtt with coumadin dosing.  he was
then switched from heparin to lovenox in anticipation for
discharge.  he gradually was weaned from his nasal cannula
and the patient was saturating 98% on room air with
ambulation upon discharge.

lower extremity duplex was performed to look for potential
source of his pe.  this examination showed a nonobstructive
left popliteal dvt.  because the patient was hemodynamically
stable throughout his hospitalization and improving on
anticoagulation, he was not given thrombolysis treatment for
his massive pe.  his anticoagulation will be managed by his
primary care physician, [**first name8 (namepattern2) **] [**last name (namepattern1) 3306**], [**name initial (nameis) **].d.

2. diabetes mellitus:  the patient was hyperglycemic
throughout his hospital admission.  his fasting blood sugars
were repeatedly greater than 126 and he was diagnosed with
type 2 diabetes mellitus.  he was started on glucophage 500
mg p.o. q.d.  a hemoglobin a1c level was drawn which was 7.8
consistent with his suspected diabetes mellitus.

3. gout:  the patient had a flare of gout in his left great
toe, podagra.  he was treated with indomethacin 50 mg p.o.
t.i.d. with mild improvement upon discharge.

4. obstructive sleep apnea:  the patient was continued on his
cpap of 13 mm of water at night.

the patient was discharged home stable on room air with
coumadin and lovenox bridging.  he will follow up at the
office of dr. [**last name (stitle) 3306**] on friday [**2170-5-25**] for an inr draw
and follow-up appointment.

discharge diagnoses:
1. massive pulmonary embolism.
2. diabetes mellitus.
3. gout.
4. obstructive sleep apnea.

discharge medications:
1. lovenox 120 mg subcutaneous b.i.d. until therapeutic inr
as instructed by dr. [**last name (stitle) 3306**].
2. coumadin 10 mg p.o. q.d. until appointment with dr.
[**last name (stitle) 3306**] and then doses according to her instructions.
3. timolol eyedrops 0.25% b.i.d. bilaterally.
4. latanoprost 0.005% drops bilateral eyes q.h.s.
5. indomethacin 50 mg p.o. t.i.d. until gout relieved.
6. glucophage 500 mg p.o. q.d.
7. multivitamin one p.o. q.d.





                          [**name6 (md) 251**] [**name8 (md) **], m.d.  [**md number(1) 1197**]

dictated by:[**dictator info **]

medquist36

d:  [**2170-5-31**]  14:50
t:  [**2170-6-6**]  08:03
job#:  [**job number 14081**]
"
198,"admission date:  [**2164-7-13**]              discharge date:   [**2164-7-16**]

date of birth:  [**2089-3-5**]             sex:   f

service: medicine

allergies:
atenolol / diltiazem / lisinopril / verapamil

attending:[**first name3 (lf) 443**]
chief complaint:
sob, chest pain

major surgical or invasive procedure:
cardiac catherization


history of present illness:
ms. [**known lastname 18582**] is a 75 [**last name (un) **] with htn, hyperlipidemia, depression,
gerd, hypothyroidism and osetoporosis who was admitted today for
an elective cath.  she had been complaining of one year of
fatigue and sob.
.
she was taken to the cath lab where she had lad with 40%
stenosis after the diagonal. the proximal d1 had a 90% stenosis
in which a bms was placed. the pt had some cp on leaving the
cath lab which persisted and then worstened on [**hospital ward name 121**] 3. pt with
st elevations in i, avl and was sent for rpt cath
.
on repeat cath, she had restenosed the stent placed earlier in
the day so it was restented proximally and distally with 2 more
bms's. of note, she recieved a total of 465cc iv contrast.
.
on arrival in the icu, she has no complaints initially but then
c/o mild headache.
.
on ros, she denies any fevers, nausea, vomitting, pain, sob,
lightheadedness or any other sx.


past medical history:
gerd
h pylori [**2156**]
lower gi bleed r/t diverticulitis
polyps removed
chronic headaches
hypertension
osteoporosis
depression
intermittent blurry vision-unclear etiology
pneumonia
ep study [**2161**] d/t bradycardia
eye surgery for growth
hypothyroid
pernicious anemia


social history:
retired [**hospital1 18**] ekg tech. widow. lives alone. has
5 daughters. denies tobacco and etoh.

family history:
father died of an mi at age 52. mother died at age [**age over 90 **]


physical exam:
general: nad
heart: rrr, no m/r/g
pulm: ctab, no w/r/r
ext: no edema
neuro: grossly intact

pertinent results:
admission labs:
[**2164-7-13**] 04:06pm blood wbc-13.1* rbc-4.68 hgb-13.1 hct-38.8
mcv-83 mch-28.0 mchc-33.7 rdw-13.8 plt ct-308
[**2164-7-13**] 04:06pm blood pt-15.4* ptt-47.6* inr(pt)-1.4*
[**2164-7-13**] 04:06pm blood glucose-165* urean-12 creat-0.6 na-137
k-3.4 cl-99 hco3-25 angap-16
[**2164-7-13**] 04:06pm blood calcium-8.3* phos-4.9* mg-1.7
[**2164-7-14**] 06:04am blood triglyc-97 hdl-49 chol/hd-3.8 ldlcalc-120
.
cardiac enzymes:
[**2164-7-13**] 07:12pm blood ck-mb-33* mb indx-14.5*
[**2164-7-13**] 07:12pm blood ck(cpk)-228*
[**2164-7-14**] 06:04am blood ck-mb-42* mb indx-11.0*
[**2164-7-14**] 06:04am blood ck(cpk)-383*
[**2164-7-14**] 02:35pm blood ck-mb-24* mb indx-8.0* ctropnt-0.66*
[**2164-7-14**] 02:35pm blood ck(cpk)-300*
[**2164-7-15**] 05:35am blood ck-mb-8 ctropnt-0.53*
[**2164-7-15**] 05:35am blood ck(cpk)-118
[**2164-7-16**] 06:05am blood ck-mb-3 ctropnt-0.72*
[**2164-7-16**] 06:05am blood ck(cpk)-49
.
discharge labs:
[**2164-7-16**] 06:05am blood glucose-97 urean-12 creat-0.8 na-140
k-4.9 cl-102 hco3-30 angap-13
[**2164-7-16**] 06:05am blood calcium-9.3 phos-4.3 mg-2.1
.
[**2164-7-14**] echo:
the left atrium is dilated. there is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
distal septal, anterior and apical hypokinesis. the remaining
segments contract normally (lvef = 45%). 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 (1+) aortic regurgitation is seen. mild (1+)
mitral regurgitation is seen. there is mild pulmonary artery
systolic hypertension. there is no pericardial effusion.
impression: mild regional left ventricular systolic dysfunction,
c/w cad. mild mitral and aortic regurgitation.
compared with the prior study (images reviewed) of [**2164-7-13**],
the findings are similar.
.
[**2164-7-13**] echo:
there is mild symmetric left ventricular hypertrophy with normal
cavity size. there is regional left ventricular systolic
dysfunction. there is no pericardial effusion.
impression: no pericardial effusion identied.
.
[**2164-7-13**] 2nd cath:
comments:
1- limited selective coronary angiography of the lmca sysrtem
showed
acute occlusion of the entire d1 system. this vessel underwent
ptca and
stening with a 2.25x12 mm minivision bms 2 hours prior. the
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- the lmca, lad (known mid vessel lesion that was negative by
ffr
earlier), and lcx were unchanged.
3- successful emergent ptca and stenting of the d1 with two
additional
stents: a 2.0x8 mm distally overlapping and a 2.25x12 proximally

overlapping with the old (placed this am) 2.25x12 mm minivision
bms.
final angiography showed timi 3 flow thrroughout the d1 system
without
vresidual stenosis, dissection or distal emboli.
4- resting hemodynamic assessment showed stable hemodynamics
compared to
earlied rhc except for severe systemic arterial hypertension
(required
ntg gtt at doses as high as 200 mcg per min). the left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- bedside echocardiography showed absence of pericardial
effusion

final diagnosis:
1. acute closure of the d1, two hours after pci and stenting
2. [**name (ni) 18583**] ptca and stenting of the d1 with two additional
bms (one
distal and the second proximal to the earlier placed bms, all
overlapping).
3. ccu admission for observation
4. continue integrilin gtt for 18 hours
5. plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. asa 325 mg po indefinitely
7. 2d echocardiogram
8. global cardiovascular risk reduction strategies
.
[**2164-7-13**] 1st cath:
comments:
1- limited selective coronary angiography of the lmca sysrtem
showed
acute occlusion of the entire d1 system. this vessel underwent
ptca and
stening with a 2.25x12 mm minivision bms 2 hours prior. the
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- the lmca, lad (known mid vessel lesion that was negative by
ffr
earlier), and lcx were unchanged.
3- successful emergent ptca and stenting of the d1 with two
additional
stents: a 2.0x8 mm distally overlapping and a 2.25x12 proximally

overlapping with the old (placed this am) 2.25x12 mm minivision
bms.
final angiography showed timi 3 flow thrroughout the d1 system
without
vresidual stenosis, dissection or distal emboli.
4- resting hemodynamic assessment showed stable hemodynamics
compared to
earlied rhc except for severe systemic arterial hypertension
(required
ntg gtt at doses as high as 200 mcg per min). the left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- bedside echocardiography showed absence of pericardial
effusion

final diagnosis:
1. acute closure of the d1, two hours after pci and stenting
2. [**name (ni) 18583**] ptca and stenting of the d1 with two additional
bms (one
distal and the second proximal to the earlier placed bms, all
overlapping).
3. ccu admission for observation
4. continue integrilin gtt for 18 hours
5. plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. asa 325 mg po indefinitely
7. 2d echocardiogram
8. global cardiovascular risk reduction strategies


brief hospital course:
ms. [**known lastname 18582**] is a 75 [**last name (un) **] with htn, hyperlipidemia, depression,
gerd, hypothyroidism and osetoporosis who was admitted today for
an elective cath, had bms to 1st diag which thrombosed acutely
on the floor and had rpt stent x2
.
# cad: patient was chest pain free after 2nd catherization. she
was started on aspirin 235, plavix 75, and pravastatin 40mg po
qday. patient was hesitant to start new medications but was
counseled extensively that especially stopping aspirin and
plavix could lead to another mi. she was not started on a
beta-blocker given her history of complete heart block on
beta-blocker. she was not started on ace-i or [**last name (un) **] [**3-6**] h/o
adverse events and patient refusal to start those medications.
echo showed ef of 45% and regional systolic dysfunction c/w cad.
she will follow up with dr. [**last name (stitle) **].
.
# rhythm- patient was in sinus rhythm throughout
hospitalization.
.
# osteoporosis- cont home ca, vit d



medications on admission:
asa 81mg daily
calcium/ vit d 600/400 [**hospital1 **]
mvt daily


discharge medications:
1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
disp:*30 tablet, delayed release (e.c.)(s)* refills:*2*
2. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
3. multivitamin     tablet sig: one (1) tablet po daily (daily).

4. pravastatin 20 mg tablet sig: two (2) tablet po daily
(daily).
disp:*60 tablet(s)* refills:*2*
5. calcium 600 + d(3) 600-400 mg-unit tablet sig: one (1) tablet
po twice a day.


discharge disposition:
home

discharge diagnosis:
primary diagnosis:
stemi
.
secondary diagnosis:
gerd
osteoperosis


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
you were admitted for a cardiac catherization. after the
catherization you had a heart attack and you had additional
stents placed in your coronary arteries. we have started you on
several medications that you must take every day otherwise you
could have another heart attack. please follow up with your
cardiologist.
.
we have started you on the following medications:
1. aspirin 325mg by mouth every day
2. plavix 75mg by mouth every day
3. pravastatin 40mg by mouth every day

followup instructions:
provider: [**first name4 (namepattern1) **] [**last name (namepattern1) **] phone: [**telephone/fax (1) 7960**] date/time: [**2164-8-1**]
1:45pm



completed by:[**2164-7-17**]"
199,"admission date: [**2175-11-5**]        discharge date: [**2175-12-27**]

date of birth:  [**2147-8-13**]        sex:  f

service:  [**last name (un) **]


admission diagnosis:  respiratory distress.

history of present illness:  the patient is a 28-year-old
female with sle/lupus, nephritis, end-stage renal disease
status post cadaveric renal transplant [**2175-9-1**],
complicated by delayed graft function/atn, biopsy done
intraoperatively during reexploration post transplant for
bleeding requiring multiple transfusions. the patient has had
multiple admissions in the past since her transplant for
abdominal pain and dehydration. on [**2175-11-5**], the
patient was admitted for respiratory distress.

the patient was found to have agonal
breathing/unresponsiveness. at that time, fingersticks were
less than 20. the patient was treated with 1.5 amps of d50
but still not adequately awake. the patient was intubated in
the emergency room for airway protection. at that time, her
heart rate was in the 100s. systolic blood pressure was 90-
100.

the patient was transferred to the icu, and labs demonstrated
that the patient had a hematocrit of 14, sodium of 125,
potassium 8.3, chloride 95, bicarb 11, bun and creatinine of
37 and 6.6.

in the icu a line was placed, and a central line was placed.
the patient was transfused with 2 units of packed red blood
cells, 2 units of ffp, 1 unit of platelets and bicarb in the
setting of severe acidosis. the patient remained
hemodynamically stable.

past medical history:
1.  sle diagnosed in [**2166**] complicated by lupus/nephritis,
    anemia, serositis and ascites, currently in remission.
2.  end-stage renal disease on hemodialysis monday, wednesday
    and friday secondary to lupus.
3.  history of vsd status post corrective surgery at age 13.
4.  hypertension.
5.  itp.
6.  mssa endocarditis.
7.  [**year (4 digits) **] cell trait.
8.  status post left oophorectomy related to iud-associated
    infection.
9.  restrictive lung disease noted on pfts from [**2166**]. in [**2173**]
    chest ct was with diffuse ground glass opacities.
10. gerd in [**2172**].
11. history of domestic violence.
12. most recently is status post cadaveric renal on [**8-31**], [**2174**], complicated by delayed graft function.

allergies:  levaquin, cephalosporin, unasyn, vancomycin and
derivative, demerol and meperidine.

medications on admission:  prednisone 5 mg daily, bactrim ss
1 tablet daily, valcyte 450 mg every other day, __________
2.5 mg daily, nifedipine 90 mg sustained release daily,
protonix 40 mg daily, dronabinol 2.5 b.i.d., mirtazapine 15
mg q.h.s., mmf 500 mg b.i.d., nystatin suspension 5 ml
q.i.d., epogen injection 3000 units monday, wednesday and
friday, percocet [**12-11**] 5/325 mg tablets 1 tablet q.4-6 hours
p.r.n., labetalol 400 t.i.d., linezolid 600 q.12 for a total
of 7 days, reglan 5 mg q.i.d., sodium bicarb 650 mg tablets 4
tablets t.i.d., coumadin 5 mg 1 p.o. daily for a left
axillary thrombus, rapamune 6 mg once a day, the patient at
that time was on linezolid because of a gram-negative staph
urinary tract infection, and on coumadin for a non-occlusive
thrombus of left axillary vein that was documented on
[**2175-10-24**].

in the emergency room was intubated and sedation. ct of the
abdomen was performed demonstrating a large right-sided
hematoma displacing the transplanted kidney anteromedially
and inferiorly. the hematoma is larger compared to the cat
scan that was performed on [**2175-6-29**], but appears smaller
compared to the cat scan on [**2175-9-11**].

the transplanted kidney is barely discernable. the uv
catheter is noted in situ. a 3.8 cm heterogenous lesion,
likely arising from the uterus and probably a fibroid was
noted. there was also diffuse thickening of small bowel wall
with a differential of wide and intramural hemorrhage, and
there was massive ascites.

preoperative diagnosis:
1.  anemia.
2.  acute renal failure.
3.  hyperkalemia.
4.  metabolic acidosis.
5.  coagulopathy.
6.  sepsis.

the patient was rushed to the or where surgery was performed
on the morning of [**2175-11-6**], performed by dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **]. exploratory laparotomy and transplant nephrectomy
was performed due to a ruptured kidney.

a french [**doctor last name 406**] drain was brought out through a separate
incision and sutured in place with 3-0 nylon.

the patient remained intubated and was taken to the icu in
stable and satisfactory condition.

postoperatively the patient was febrile. the patient had a
right femoral arterial line and left triple lumen. cultures
were obtained on [**2175-11-7**], because the patient
became febrile which grew out pseudomonas.

the renal consulting team followed the patient closely.

the patient continued with hemodialysis monday, wednesday and
friday. cat scan was obtained postoperatively on [**2175-11-8**], to evaluate the abdomen and hematoma which demonstrated
interval removal of the transplant kidney with extravasation
of right extraperitoneal __________ . at the surgical site
remains an ill-defined collection consisting of residual
hemorrhage and gas and hyperdense perihepatic fluid probably
hemoperitoneum. there was free air present which may be
related to surgery. according to the radiologist, there was
nonspecific cecal thickening, new bibasilar consolidations
and new gallbladder distention.

the patient continued to be intubated. he was placed for tube
feeds, and tube feeds were started for nutrition. the patient
remained intubated. tube feeds were continued. the patient
was continued on antibiotics, linezolid day 16, zosyn day 13.

the patient was also continued on a fentanyl patch for pain
control.

at that time, [**2175-11-20**], she was assist control 40%,
peep of 10, 45 x 25.

infectious disease was consulted for ongoing fever despite
being on multiple antibiotics. the patient had a radial
peroneal abscess that was drained. infectious disease closely
followed the patient and made recommendations without
switching antibiotics.

on [**2175-11-14**], central line change was performed
complicated by a large left apical and basilar hemothorax.
chest tube was placed that evening. another chest x-ray was
performed demonstrating marked decrease of left-sided
pneumothorax, residual small left apical and basilar
pneumothorax.

the patient had another cat scan on [**2175-11-16**], because
of ongoing abdominal pain. the patient required another
catheter for drainage of collection. cat scan demonstrated 1)
interval improvement in bilateral basal consolidations, 2)
there was a collection along the right flank, decreased in
size compared to the prior study with catheter in adequate
position, 3) there was reduction of gallbladder distention,
4) stable small collection to the right of the uterus
consistent with resolving hematoma, 5) stable splenic
infarcts.

the patient hemodynamically stable. the patient did complete
a 7-day course for a possible mucocutaneous hsv. antibiotics
were changed to meropenem. linezolid and gentamicin were
discontinued.

tpn was discontinued. nepro tube feeds were started per
recommendations from nutrition.

the patient was slowly weaning from the vent. tube feeds were
advanced.

on [**2175-11-20**], the patient needed central venous
access, and there was successful placement of an 8.5 french
16 cm long four-lumen catheter via the left common femoral
vein. also the venogram demonstrated occlusion of the left ij
and the left subclavian vein with multiple collaterals, and
also the right ij was shown to be occluded on ultrasound
scan. therefore the left femoral line was in place and ready
to use for central access.

on [**2175-11-24**], the patient had a bronchoscopy to
evaluate and assess airway patency. using an endotracheal
tube, which was flexible, it was documented that her airway
was clear. there were no complications.

the patient continued with the dialysis 3 days a week. renal
continued to follow the patient.

on [**2175-11-30**], the patient had an open tracheostomy
performed by dr. [**last name (stitle) **] because of respiratory failure and
failure to wean off the ventilator status post tracheostomy
tube with a 7 french non-fenestrated tracheostomy tube. the
patient ventilated well, and the patient was transferred back
to the recovery room in stable condition.

on [**2175-12-2**], the patient had another cat scan
because of abdominal pain and persistent fever. the case was
discussed with dr. [**last name (stitle) 816**] who requested drainage of subhepatic
fluid collection.
1.  the size of the subhepatic fluid collection within an
    enhancing wall has decreased slightly since the prior
    study. this was drained with an 8 french pigtail catheter
    which was left in place.
2.  there was a jp drain in the right pericolic fluid
    collection which was in good position. the size of the
    fluid collection was essentially [**last name (stitle) 1506**] from the prior
    study of [**2175-11-23**].
3.  there was a stable appearance of a cystic collection deep
    within the pelvis to the right of the uterus not easily
    amendable to percutaneous drainage.
4.  there was anasarca with ascites.
5.  there was bilateral lower lobe consolidation which was
    [**year (4 digits) 1506**].
6.  there were splenic infarcts, which was [**year (4 digits) 1506**].

we continued to check her labs which included cbc,
electrolytes daily and were replaced as needed.

the patient was evaluated for rehab.

another cat scan was performed on [**12-22**] at 1 a.m.
because of abdominal pain, and was documented:
1.  persistent, although smaller multiloculated fluid
    collection along the right flank, status post removal of
    drainage catheter. the presence of infection cannot be
    excluded.
2.  there was a similar uterine mass.
3.  there was ascites and edema.
4.  improving bilateral lower lobe consolidations.
5.  continued splenic infarcts, not well appreciated on that
    particular study.

the patient continued on antibiotics for pseudomonas coverage
and vre bacteremia related to lines and questionable
abdominal fluid collections.

later that day on [**2175-12-22**], the patient had a ct-
guided abdominal drainage using ct fluoroscopic guidance. [**initials (namepattern4) **]
[**last name (namepattern4) 4300**] needle was advanced to the right flank collection.
approximately 40-50 ml of blood-tinged fluid was aspirated.
postprocedural films demonstrated that the right flank
collection appears in good position. the patient tolerated
the procedure well. there were no immediate complications.
the 8 french catheter remained in place after the ct was
completed.

on [**2175-12-12**], the patient was evaluated for a passy-
muir valve evaluation, and it was observed that she did
tolerate wearing the pmv for 20 minutes with no oxygen
desaturation and was able to speak with a clear voice and
intelligible speech; however, she then began to cough at the
end of the evaluator's exam suggesting either
dryness/irritation or possibility of aspiration secretions.

physical therapy and occupational therapy met with the
patient for evaluation and treatment and definitely felt that
the patient needed to go to rehab. the patient continued with
hemodialysis.

on [**2175-12-21**], the patient had a chest x-ray because of
ongoing fevers, and the radiologist documented the chest x-
ray report as a long-standing interstitial abnormality in the
right lower lobe present since [**5-19**]. this probably
represents irreversible changes of previous edema, pulmonary
hemorrhage, vascular congestion or interstitial lung disease,
not an acute process. top-normal heart size and dilatation of
pulmonary arteries and left atrium are long standing. there
are no findings to suggest further cardiovascular
decompensation or current enterothoracic infection. feeding
tube ends at the pylorus. tracheostomy tube in standard
placement. no pleural effusion.

pigtail catheter was removed on [**2174-12-21**], and
tracheostomy was downsized, and there were no adverse events
over night. she was afebrile with vital signs stable. p.o.
intake 640, tube feeds 710; does not void. the patient had jp
drainage of 35 cc.

infectious disease had recommended to continue tobramycin,
p.o. vancomycin and cipro until her follow-up appointment
with infectious disease on [**2176-1-9**]. at that time,
abdominal/pelvic ct will be obtained to assess fluid
collections to help define further duration of antibiotics.

on [**2175-12-22**], another cat scan was performed to
evaluate the abdominal collections after the drains have been
removed.

on [**2175-12-23**], pain service was consulted requires
multiple narcotics. the pain service had stated to continue
the fentanyl patch, to change her p.o. dilaudid regimen and
to discontinue her iv dilaudid.

currently the patient is on cipro for pseudomonas. the
patient is also on linezolid for enterococcus and history of
vre. the patient continues on vancomycin for prior c-diff.
she is also receiving tobramycin.

she has 2 pending cultures from blood cultures that were
obtained on [**2175-12-24**].

her labs on [**2175-12-26**], revealed the following: wbc
9.4, hematocrit 26.8, platelets 111; ptt 30.5, inr 1.1;
sodium 131, 3.6, 95, 28, bun and creatinine of 20 and 3.5,
glucose 88, calcium 9.6, phos 2.5, magnesium 0.7, albumin
2.6. the patient had a tobramycin level of 1.1 on [**2175-12-26**].

when the patient goes to rehab, the patient will need daily
cbc, chem10 at least once-a-week. the patient will need to
have a cbc with diff and a post dialysis tobramycin level.
those results need to be faxed to infectious disease [**telephone/fax (1) 18624**].

the patient has a follow-up appointment with dr. [**first name (stitle) 2505**] on
[**2176-1-9**], from infectious disease, [**telephone/fax (1) 457**]. this
appointment is for [**2176-1-9**], at 9 a.m. if you have
any questions or problems with the appointment please dr.[**name (ni) 18625**] office immediately. also the facility should make an
appointment with transplant surgery potentially on the same
day; please call [**telephone/fax (1) 673**].

discharge medications:  prednisone 5 mg daily, mucomyst
solution q.4-6 hours as needed, heparin 5000 units subcu
b.i.d., vancomycin 125, which is the oral liquid, q.6 hours,
prevacid 30 mg suspension 1 tablet daily, albuterol aerosol
puff inhalation 1-2 puffs q.6 hours, lopressor 4.5 b.i.d.,
fentanyl patch 100 mcg, please change every 72 hours,
__________  750 q.24 hours, colace 100 mg b.i.d., dilaudid 2
mg tablets 1-3 tablets q.2 hours p.r.n., linezolid 600 mg
q.12 hours, ativan 1 mg iv q.6 hours, tobramycin as needed,
the last dose was 140 mg, but please check level prior to
giving dose. if there are any questions in regards to the
tobramycin, call infectious disease at [**telephone/fax (1) 457**].

the patient is on tube feeds, nepro 3/4 strength, goal rate
of 40 cc/hr. please check residuals q.4 hours and hold tube
feeds for residuals greater than 100 ml. please flush with 50
cc of water q.8 hours. the patient should also receive
calorie counts and have a dietician following the patient.
the patient could be possibly transitioned from tube feeds to
a regular diet.

final diagnosis:  this is a 28-year-old woman with lupus
nephritis status post renal transplant on [**2175-9-1**],
with acute rejection and subsequent graft rupture.

secondary diagnosis:
1.  pseudomonas bacteremia.
2.  peritoneal abscess/necrotizing fascitis.
3.  left ij and left subclavian vein occlusion.
4.  left pneumothorax requiring chest tube placement.
5.
    respiratory failure requiring tracheostomy.
6.  intra-abdominal fluid collection status post drainage.



                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 3432**]

dictated by:[**last name (namepattern1) 4835**]
medquist36
d:  [**2175-12-27**] 12:32:23
t:  [**2175-12-27**] 14:04:32
job#:  [**job number 18626**]
"
200,"admission date:  [**2198-6-19**]              discharge date:   [**2198-7-8**]

date of birth:  [**2120-8-11**]             sex:   m

service: urology

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1232**]
chief complaint:
angiosarcoma of bladder cancer

major surgical or invasive procedure:
radical cystoprostatectomy
ileal loop urinary diversion
regional node dissection
right internal jugular vein central line placement
swan-ganz catheter placement
arterial line placement
nasogastric tube placement

history of present illness:
mr. [**known lastname 19000**] is a 77-year-old male who was
diagnosed with prostate cancer in [**2189-11-8**] by abnormal dre.

he reports a psa of that time of 14. he received external beam
radiation therapy at [**hospital6 **]. he reports that his
psa post radiation was 0.3. he was followed periodically by psa
after radiation. his psa rise to about 11 in [**2193**]. he started
casodex and lupron [**4-8**]. he reports he was getting lupron every

other month. his lowest psa on hormonal treatment was 0.4 in
[**2197-2-6**]. his psa started to climb 1004 and reached 2.2 in 05/

05. he has been followed by dr. [**last name (stitle) 4749**] in [**hospital1 **].

the patient noted painless hematuria and clots beginning of
[**month (only) 958**]
he had a tur at [**hospital 1281**] hospital by dr. [**last name (stitle) **] where a bladder
tumor was noted. he has been seen by dr. [**last name (stitle) **] in evaluation
for a possible cystectomy and dr. [**last name (stitle) **] for medical oncologic

opinion of the angiosarcoma.
he reports he multiple negative ct scans and bone scans in the
past. most recently he had a bone scan in [**4-12**], which showed
increased tracer activity in l5-s1 region, likely representing
degenerative changes. ct chest, abdomen, and pelvis [**4-12**], shows

a infrarenal aortic aneurysm, measuring 4.2 x 4.8 cm, asymmetric

inferior bladder wall thickening, and multiple small bilateral
pulmonary nodules, the largest measuring 5 mm in the right
middle
lobe.
he presents for cystoprostatectomy.

past medical history:
prostate carcinoma
heartburn
asthma
appendectomy
no tuberculosis noted
copd: fev1 58%



social history:
mr. [**known lastname 19000**] is retired. he spent seven and a
half years in the russian army, then he went to college and was
an electrical engineer in a fairly high position. he lives in
[**location **]. he immigrated to the us about ten years ago. he has two
daughters and two grandsons who live in the area. he quit
smoking about 11 years ago. he smoked nonfiltered cigarettes for

a total of 100 pack years. he drinks vodka and bourbon once or
twice a week.


family history:
no family history of cancers. he has five
brothers, four of whom have died of heart attacks. his older
brother lives in [**name (ni) 6607**]. his mother died of a cva. his father
died at age 33 in [**2125**] from typhoid.


physical exam:
gen:  aaox3 nad
cv: s1 s2 rrr
chest: cta b/l
abd: pos bs soft nt/nd midline scar, uretostomy
extrem: no c/c/e

pertinent results:
[**2198-7-5**] 07:20am blood wbc-5.3 rbc-4.35* hgb-12.6* hct-39.1*
mcv-90 mch-29.0 mchc-32.2 rdw-15.6* plt ct-297
[**2198-7-4**] 07:00am blood wbc-4.0 rbc-4.21*# hgb-12.4*# hct-37.3*#
mcv-89 mch-29.4 mchc-33.1 rdw-15.1 plt ct-270
[**2198-7-3**] 07:25am blood wbc-3.8* rbc-3.24* hgb-9.8* hct-28.6*
mcv-88 mch-30.2 mchc-34.2 rdw-14.2 plt ct-211
[**2198-7-2**] 08:00am blood wbc-4.2 rbc-3.22* hgb-9.8* hct-29.0*
mcv-90 mch-30.3 mchc-33.6 rdw-14.2 plt ct-197
[**2198-7-1**] 03:23am blood wbc-3.3* rbc-3.15* hgb-9.4* hct-29.0*
mcv-92 mch-29.8 mchc-32.3 rdw-14.7 plt ct-170
[**2198-6-19**] 05:39pm blood wbc-6.8 rbc-3.27*# hgb-9.8*# hct-29.8*#
mcv-91 mch-29.8 mchc-32.8 rdw-14.1 plt ct-125*
[**2198-6-20**] 04:15am blood wbc-4.9 rbc-2.92* hgb-8.8* hct-26.1*
mcv-89 mch-30.3 mchc-33.9 rdw-14.1 plt ct-104*
[**2198-6-20**] 11:00am blood hct-31.6*
[**2198-6-20**] 03:57pm blood hct-31.3*
[**2198-6-21**] 03:45am blood wbc-7.4# rbc-3.47* hgb-10.7* hct-31.1*
mcv-90 mch-30.9 mchc-34.4 rdw-13.9 plt ct-104*
[**2198-6-21**] 08:29am blood wbc-6.7 rbc-3.48* hgb-10.8* hct-31.1*
mcv-89 mch-31.0 mchc-34.8 rdw-13.7 plt ct-105*
[**2198-6-21**] 04:21pm blood wbc-5.4 rbc-3.29* hgb-10.1* hct-29.4*
mcv-90 mch-30.8 mchc-34.4 rdw-13.9 plt ct-105*
[**2198-7-5**] 07:20am blood plt ct-297
[**2198-7-4**] 07:00am blood plt ct-270
[**2198-7-3**] 07:25am blood plt ct-211
[**2198-7-2**] 08:00am blood plt ct-197
[**2198-7-1**] 03:23am blood plt ct-170
[**2198-6-19**] 05:39pm blood pt-14.6* ptt-32.9 inr(pt)-1.4
[**2198-6-19**] 05:39pm blood plt ct-125*
[**2198-6-20**] 04:15am blood plt ct-104*
[**2198-6-21**] 03:45am blood plt ct-104*
[**2198-6-21**] 08:29am blood plt ct-105*
[**2198-7-6**] 09:00am blood glucose-97 urean-17 creat-1.3* na-142
k-3.7 cl-103 hco3-33* angap-10
[**2198-7-5**] 07:20am blood glucose-104 urean-14 creat-1.2 na-141
k-4.0 cl-102 hco3-32 angap-11
[**2198-7-4**] 07:00am blood glucose-105 urean-12 creat-1.0 na-144
k-3.6 cl-106 hco3-32 angap-10
[**2198-7-3**] 07:25am blood glucose-95 urean-14 creat-1.0 na-145
k-3.7 cl-108 hco3-29 angap-12
[**2198-6-19**] 05:39pm blood glucose-165* urean-17 creat-1.1 na-140
k-4.9 cl-112* hco3-23 angap-10
[**2198-6-20**] 04:15am blood glucose-133* urean-21* creat-1.6* na-135
k-4.4 cl-110* hco3-23 angap-6
[**2198-6-20**] 02:25pm blood glucose-124* urean-25* creat-2.8*# na-137
k-4.6 cl-110* hco3-21* angap-11
[**2198-6-20**] 08:00pm blood urean-28* creat-3.2* na-137 k-4.6 cl-111*
hco3-19* angap-12
[**2198-7-4**] 07:00am blood ck(cpk)-19*
[**2198-6-21**] 04:21pm blood alt-2 ast-24 alkphos-86 amylase-83
totbili-0.4
[**2198-6-21**] 03:45am blood alt-4 ast-28 ld(ldh)-208 ck(cpk)-619*
alkphos-59 totbili-0.5
[**2198-6-20**] 04:15am blood ck(cpk)-808*
[**2198-6-20**] 02:00am blood ck(cpk)-755*
[**2198-6-19**] 05:39pm blood ck(cpk)-160
[**2198-7-4**] 07:00am blood ck-mb-3 ctropnt-0.02*
[**2198-6-20**] 04:15am blood ck-mb-5 ctropnt-<0.01
[**2198-6-20**] 02:00am blood ck-mb-6
[**2198-6-19**] 05:39pm blood ck-mb-3 ctropnt-<0.01
[**2198-7-6**] 09:00am blood calcium-8.7 phos-3.4 mg-2.0
[**2198-7-5**] 07:20am blood phos-3.4 mg-1.9
[**2198-7-4**] 07:00am blood calcium-8.7 phos-3.3 mg-1.8
[**2198-7-3**] 07:25am blood calcium-8.4 phos-2.4* mg-1.7
[**2198-7-2**] 08:00am blood calcium-8.4 phos-2.0* mg-1.6
[**2198-6-19**] 05:39pm blood calcium-8.0* phos-4.9* mg-1.5*
[**2198-6-20**] 04:15am blood calcium-7.4* phos-2.9# mg-2.1
[**2198-6-20**] 02:25pm blood mg-2.1
[**2198-6-21**] 03:45am blood albumin-2.7* calcium-7.5* phos-5.3*#
mg-2.1
[**2198-6-21**] 08:29am blood calcium-7.4* phos-6.0* mg-2.2
[**2198-6-30**] 06:29pm blood type-art po2-122* pco2-35 ph-7.47*
calhco3-26 base xs-2
[**2198-6-30**] 03:38am blood type-art po2-75* pco2-43 ph-7.41
calhco3-28 base xs-1
[**2198-6-28**] 04:03am blood ph-7.42 comment-green top
[**2198-6-19**] 08:35am blood type-art po2-529* pco2-48* ph-7.39
calhco3-30 base xs-3
[**2198-6-19**] 10:19am blood type-art po2-212* pco2-45 ph-7.39
calhco3-28 base xs-2
[**2198-6-19**] 11:30am blood type-art po2-240* pco2-45 ph-7.38
calhco3-28 base xs-1
[**2198-6-19**] 12:30pm blood type-art rates-/10 tidal v-650 fio2-57
po2-239* pco2-41 ph-7.38 calhco3-25 base xs-0 intubat-intubated
vent-controlled
[**2198-6-19**] 02:11pm blood type-art po2-252* pco2-40 ph-7.41
calhco3-26 base xs-1
[**2198-6-19**] 03:54pm blood type-art ph-7.41
[**2198-6-30**] 06:29pm blood lactate-1.5
[**2198-6-30**] 03:38am blood glucose-108*
[**2198-6-27**] 05:12pm blood lactate-0.9
[**2198-6-27**] 03:31am blood glucose-152*
[**2198-6-25**] 03:18am blood glucose-86 lactate-1.2
[**2198-6-19**] 08:35am blood glucose-126* lactate-1.8 na-138 k-4.2
cl-104
[**2198-6-19**] 10:19am blood glucose-149* lactate-1.8 na-140 k-4.6
cl-105
[**2198-6-19**] 11:30am blood glucose-147* lactate-1.8 na-139 k-4.1
cl-109
[**2198-6-19**] 12:30pm blood glucose-153* lactate-2.4* na-137 k-4.6
cl-109
[**2198-6-19**] 02:11pm blood glucose-154* lactate-2.0
[**2198-6-30**] 03:38am blood o2 sat-96
[**2198-6-26**] 04:11pm blood o2 sat-90
[**2198-6-25**] 03:18am blood o2 sat-98
[**2198-6-22**] 11:27am blood o2 sat-97
[**2198-6-30**] 06:29pm blood freeca-1.20
[**2198-6-30**] 03:38am blood freeca-1.11*
[**2198-6-28**] 04:03am blood freeca-1.10*
[**2198-6-27**] 03:31am blood freeca-1.15

cxr - [**2198-7-5**]
indications: desaturation.

ap and lateral chest radiographs: comparison is made to [**2198-7-1**] and a
chest ct scan from [**2198-4-27**]. cardiac size is at the upper
limits of
normal. two rounded nodules are seen, one in each upper lobe.
the one in the
right measures 9 mm and the one in the left measures 13 mm.
these appear
different than on multiple prior studies. the patient has known
nodules on ct
scan. there are no consolidations. there is mild blunting of the
right cp
angle, likely reflecting a small effusion. overall, there is
improved
aeration of the left lower lobe.

impression: bilateral upper lobe nodules, more conspicuous than
on prior
studies. further evaluation with chest ct scanning is
recommended.

cxr - [**2198-7-1**]

there has been interval removal of the right ij line. there is
improved
aeration of both lower lobes. both cp angles are off the film.
there is no
focal infiltrate.

cxr - [**2198-6-22**]
findings: in comparison with the previous examination of the
same date, the
pulmonary artery catheter is again seen, now terminating within
the right
pulmonary artery and entering via a right internal jugular
approach. an
endotracheal tube terminates approximately 8.5 cm from the
carina. nasogastric
tube extends below the diaphragm and likely terminates in the
upper stomach.
there is interval improvement in pulmonary edema. probable small
bilateral
pleural effusions are incompletely evaluated due to exclusion of
the
costophrenic angles bilaterally. stable bibasilar atelectasis.

impression:

1. cardiomegaly and improving congestive heart failure.

2. bibasilar atelectasis and probable small bilateral pleural
effusions.


brief hospital course:
mr. [**known lastname 19000**] [**last name (titles) 1834**] a cystoprostatectomy on [**2198-6-19**] (please see
dictated operative report for details) without adverse events.
it was noted by surgeons that urine output was low throughout
the procedure. in the or he received 6,000cc of crystaloid, 2
units of packed red cells, 1000cc of hespan, and 750cc of 5%
albumin. estimated blood loss was 2,500cc.  given the large
fluid requirement and his history of copd, patient remained
intubated overnight.  he remained hemodynamically stable post
operatively. his urine output was variable with outputs 28-145cc
per hour and a total of 813 by midnight on operative day.  on
post-operative day 1 by 0600, his urine output progressively
decreased to a point where he was making < 5 cc per hour.  he
was given both normal saline and 2 units of prbcs with no kidney
response (24 hour total of 304 cc) and he remained in aneuric
failure despite receiving >5000cc of fluid over 24 hours.   he
was transferred to the intensive care unit from the
post-anesthesia care unit. his bun/cre also began to rise.
nephrology consult was obtained and the worry was that the
patient was in aneuric renal failure vs. outflow obstruction.
ct studies were obtained on [**6-21**] and revealed: 1. no evidence
for hydronephrosis or hydroureter. no evidence for urinoma. 2.
small amount of intraabdominal ascites as well as inflammatory
stranding along the pararenal fascia and within the right lower
quadrant at the site of the ureteroileal loop anastomosis. small
amount of intraabdominal free air. anasarca. these changes are
most likely secondary to recent postoperative state. 3. small
bilateral pleural effusions with bilateral lung base compressive
atelectasis. urinalysis was consistent with acute tubular
nephritis with aneuria, and creatinine continued to rise. he
remained intubated for ventilartory support.  he had minimal
response to lasix challanges. swan-ganz catheter was inserted
over existing right ij to monitor fluid status and cardiac
function. his creatinine and bun peaked at 6.4/49 respectively
on post operative day 2. he developed progressive non-anion gap
acidosis and bicarbonate infusion was started to control
acidemia.  at that point renal function began to return and
patient began to autodiurese with urine outputs in 3,000-4,000cc
range per 24 hours. he spiked fevers to 101.6 on post operative
day 6. blood, urine, sputum cultures were obtained and sputum
culture showed pseudomonas aureginosa presence. he was begun on
zosyn on [**2198-6-21**] and defervesced over the next 3 days. his bun
and creatinine progressively normalized, as did the acidemia. he
ramained intubated for ventilatory support.  with significan
autodiuresis, patient's sodium began to rise and free water
repletion was begun.  electrolytes were repleted as needed
throughout the stay.  propofol sedation was weaned and his
mental function slowly returned to [**location 213**].  he was extubated on
post-operative day 8. he continued to autodiurese. his mental
function slowly improved and he was transferred to the floor on
post-operative day 13.  after transfer to floor pulmonary was
consulted.  he was started on advair and standing
alb/ipratropium inhaler.  he was continued on zosyn.  he was
also diuresed with lasix which helped clear up his lungs.  his
pulmoary exam improved.  he was on 1:1 sitter which was stopped
and then started again and then stopped on [**7-5**].  he got
startled and slid back against the wall on [**7-4**] prompting the
sitter being restarted.  he made adequate urine output on the
floor and was seen and evaluated by pt who helped him ambulate.
his is/os were good on the floor and he tolerated his pos.  he
was screened for rehab and is in good condtion for discharge.


medications on admission:
advair
combivent
casodex 50 mg
protonix,
lupron every other month, last given [**2198-5-13**]


discharge medications:
1. albuterol sulfate 0.083 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for sob, wheezing.
disp:*30 inhalation* refills:*0*
2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every
4 to 6 hours) as needed.
disp:*30 tablet(s)* refills:*0*
3. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for wheezing, copd.
disp:*10 inhalation* refills:*0*
4. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times
a day).
disp:*60 tablet(s)* refills:*0*
5. fluticasone-salmeterol 500-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
disp:*60 disk with device(s)* refills:*0*
6. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
disp:*30 injection* refills:*0*
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:*0*
8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: one
(1) puff inhalation qid (4 times a day).
disp:*30 inhalation* refills:*2*
9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
disp:*60 capsule(s)* refills:*0*
10. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3
times a day).
disp:*135 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital 3915**] [**hospital **] rehab center

discharge diagnosis:
angiosarcoma of bladder


discharge condition:
good

discharge instructions:
discharge to rehab facility
need intructions and care for uroestomy
can shower
if have fever >101.4, intractable nausea, vomiting, severe pain
or trouble with your ostomy, please return.

followup instructions:
follow up with cardiology
follow up with pulmonology
follow up with dr. [**last name (stitle) **] (urology) - ([**telephone/fax (1) 4276**]



"
201,"admission date:  [**2192-8-19**]              discharge date:   [**2192-9-4**]

date of birth:  [**2111-4-12**]             sex:   f

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1042**]
chief complaint:
coffee-ground emesis

major surgical or invasive procedure:
upper endoscopy


history of present illness:
hpi: the patient is an 81 year old female who presented from a
nursing home with coffee ground emesis on [**2192-8-19**]. the patient
was unable to provide a history due to dementia but the micu
admitting team was able to speak to her nursing home who
provided the following history. per her nurse she had several
episodes of dark, coffee-ground emesis on the day prior to
admission. she did not complain of abdominal pain. per report
from her nursing home she also fell two days prior to admission
and hit her forehead (no further history on her fall available).
per the patient's daughter at baseline, pt is minimally verbal,
able to answer simple questions and interject into conversation
but does not speak spontaneously and has significant word
finding difficulties. she adds that the pt has been less active
in the few days preceeding admission.
.
in ed her vitals were bp 132/50, hr 76, o2 sat 95% on ra. she
was found to have a hematocrit of 37. she received 1l of ns and
iv protonix. an ng lavage per report was not performed because
there was no evidence of active vomiting. ct of the head
revealed no evidence of acute bleed.
.
while in the micu her vital signs have been stable. her
hematocrit on admission to the er was 37 on [**8-19**] at 12 am. this
decreased to 29.8 at 6 am, 27.6 at 12 pm and 30.8 at 12 am on
[**8-20**]. at no time did she require transfusion. bilateral lower
extremity ultrasounds were performed given assymetric lower
extremity edema which were negative for clots. she was started
on high dose iv ppi for her presumed gi bleed. she underwent ct
of the abdomen which showed a large hiatal hernia with a
thoracic stomach and no evidence of pancreatitis despite
incidentally noted elevated pancreatic enzymes. she was
evaluated by gastroenterology who plan for her to under upper
endoscopy tomorrow am.
.


past medical history:
# [**first name8 (namepattern2) **] [**male first name (un) 923**] aortic valve, not currently anticoagulated at
rehab/nursing home
# atrial fibrillation
# hiatal hernia with esophagitis
# hypoxic brain injury
# dementia
# breast ca s/p lumpectomy
# osteoporosis
# chf, ef unknown
# cad s/p cabg


social history:
 has been living at [**hospital 19453**] nursing home & rehab for past
month.


family history:
noncontributory

physical exam:
vitals: 95.5 133/56 72 19 99% 3l nc
gen: lying in bed, oriented to person, ""hospital,"" and ""saturday
in [**month (only) 205**].""
heent: ecchymosis over l lower eyelid, perrl, eomi, op clear
neck: jugular veins difficult to assess [**2-24**] body habitus
cv: mechanical valve sounds
chest: cta ant and lateral fields
abd: soft, nontender, nabs
ext: no c/c/e
skin: no rashes


pertinent results:
admission labs [**2192-8-19**]:
hematology:
cbc: wbc-13.0*# rbc-4.38 hgb-12.5 hct-37.2 mcv-85 mch-28.4
mchc-33.5 rdw-21.9* plt count-421#
differential: neuts-80.7* lymphs-14.7* monos-3.4 eos-0.9
basos-0.2
pt-11.6 ptt-21.6* inr(pt)-1.0
chemistries:
glucose-146* urean-30* creat-0.9 na-145 k-3.9 cl-99 hco3-37*
angap-13
calcium-8.9 phos-3.5 mg-2.1
alt-27 ast-37 alkphos-174* amylase-326* totbili-0.4 lipase-276*
albumin-4.1
.
others [**2192-8-21**]:
alt-17 ast-23 ld(ldh)-279* alkphos-149* amylase-62 totbili-1.0
lipase-22 ggt-25
triglyc-70 hdl-51 chol/hd-3.9 ldlcalc-133*
b12: 631 folate: 9.0
tsh: 0.66
.
discharge laboratories:
[**2192-8-31**] cbc: wbc: 9.4 hgb: 10.6* hct: 31.6* plts: 400
[**2192-9-3**] [**name (ni) 2591**]  pt: 21.2* ptt: 28.2 inr: 2.1*
.
imaging:
.
ct head [**2192-8-19**]:
despite repetition, some of the posterior fossa scans are
degraded by patient motion. within this limitation, there is no
significant interval change seen compared to the prior
examination. specifically, there has been no interval
development of an intracranial hemorrhage or overt area of acute
brain ischemia. however, if the latter diagnostic consideration
is a possibility, an mri scan would be a more sensitive means
for detecting an area of acute infarction. the multiple areas of
chronic small-vessel infarctions previously described are
re-demonstrated. no other new extracranial abnormalities are
discerned, either.
.
ct abd [**2192-8-19**]:
1. intrathoracic stomach which may represent gastric volvulus.
if the patient is not symptomatic these findings may be related
to chronic volvulus.
2. no ct evidence of pancreatitis
.
bilateral le us [**2192-8-19**]:
grayscale and doppler examination of bilateral common femoral,
superficial femoral, and popliteal veins were performed. normal
compressibility, augmentation, waveforms, and doppler flow is
demonstrated. there is no evidence of intraluminal clot.
.
upper endoscopy [**2192-8-21**]:
findings: normal esophagus, large hiatal hernia with [**location (un) 3825**]
lesions, normal duodenum.
.
upper gi with small bowel follow through [**2192-8-21**]:
1. intrathoracic stomach with the pyloric at the level of the
diaphragmatic hiatus. no evidence of gastric outlet obstruction
or volvulus.
2. small amount of barium aspiration noted in the central
airways. followup chest x- ray is recommended if there is
concern for development of pneumonia.
.
echocardiogram [**2192-8-22**]:
conclusions: the left atrium is moderately dilated. no atrial
septal defect is seen by 2d or color doppler. 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 ascending aorta is moderately
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 mitral valve leaflets are mildly
thickened. there is no mitral valve prolapse. trivial mitral
regurgitation is seen. the tricuspid valve leaflets are mildly
thickened. there is no pericardial effusion.
.
ct head [**2192-8-24**]:
1.  no significant interval change to brain parenchyma without
acute
hemorrhage identified.
2.  slight decrease to predominantly left supraorbital subgaleal
hematoma.

brief hospital course:
mrs. [**known lastname 24831**] is an 81 year old female with a history of cad,
atrial fibrillation, aortic valve replacement and dementia who
presents with evidence of an upper gastrointestinal bleed.
.
# upper gi bleed: on presentation the patient had experienced
two episodes of coffee ground emesis at her nursing home.  she
has a history of esophagitis but otherwise no history of
gastrointestinal disorders or bleeding events.  in the emergency
room two large bore ivs were placed and she received iv fluids.
her hematocrit on admission was 37.2.  this fell over the course
of the following day decreased to 27.1 but the patient did not
require transfusion.  she was hemodynamically stable and
asymptomatic throughout.  she was started on high dose
intravenous ppi therapy.  a ct scan of the abdomen was performed
in the emergency room which revealed the presence of a large
hiatal hernia with a complete intrathoracic stomach.  the
patient underwent upper endoscopy on [**2192-8-21**] which revealed no
obvious bleeding sources but confirmed the presence of the large
hiatal hernia with the presence of [**location (un) 3825**] lesions.  given that
her hematocrit had stabilized and there was no obvious bleeding
source on endoscopy no further workup was initiated.  she was
discharged on an oral proton pump inhibitor.  no further
episodes of bleeding were observed throughout this
hospitalization.
.
# hiatal hernia: the patient was noted to have a large hiatal
hernia on ct scan.  the presence of an intrathoracic stomach was
confirmed on upper endoscopy.  an upper gi with small bowel
follow through was obtained to further clarify her anatomy.
this again showed the hiatal hernia, but showed no evidence of
volvulus or gastric outlet obstruction.  the possibility of
surgical intervention to prevent strangulation was discussed
with the patient's daughter.  [**name (ni) 227**] the patient's age and
comorbities and relatively low lifetime risk of adverse events
secondary to her hernia, surgical correction was not pursued
further.  she should continue to take a proton pump inhibitor to
protect against future bleeding events.
.
# dementia: the patient has a history of traumatic brain injury
as well as senile dementia.  on admission she was taking
aricept, seroquel and namenda.  while in house she was observed
to have reversal of her sleep/wake cycles with frequent episodes
of calling out at night.  psychiatry was consulted to assist
with her medication regimen.  her aricept and standing seroquel
were discontinued.  she was started on haldol 0.25 mg po tid
with good effect. behavioral interventions particularly
effective included allowing patient to sit in public areas where
she was able to interact with other people.
.
# mechanical aortic valve: the patient has a st. [**male first name (un) 1525**]
mechanical aortic valve.  she was not on anticoagulation on
admission.  her primary care physician was [**name (ni) 653**] who
confirmed that anticoagulation was appropriate.  she was started
on a heparin drip for anticoagulation which was quickly switched
to lovenox.  she was also started on coumadin.  her lovenox was
discontinued when her inr was within therapeutic range.  over
the remainder of her hospitalization her coumadin was titrated
to a goal inr between 2.5 to 3.5 for patients with a mechanical
valve and atrial fibrillation.  she was discharged on coumadin
1.5 mg t,th,[**last name (lf) **],[**first name3 (lf) **] and 2 mg m,w,f.  she will need to have her inr
monitored every other day at her nursing home until her inr is
stable.
.
# atrial fibrillation: currently well-rate controlled with
metoprolol. she was started on anticoaglation with coumadin as
described above.
.
# chf: patient has a past medical history of chf but the details
of this diagnosis are unclear.  as an outpatient she takes
toprol xl and lasix.  on admission her antihypertensive
medications were held in the setting of acute bleeding but were
restarted once serial hematocrits were stable.  an
echocardiogram was performed during this admission which
revealed mild symmetric lvh, no regional wall motion
abnormalities, lvef of > 55%, and a well-seated aortic valve
prosthesis with normal disc motion and transvalvular gradients.
she was started on lisinopril 5 mg daily during this admission
and this can further managed in the outpatient setting.
.
# cad - the patient has an unclear cardiac history but on ct
scan she has evidence of cabg and takes a beta blocker as an
outpatient.  a lipid profile was obtained to further assess her
cardiac risk.  her ldl was elevated at 133 and given her history
of cad she was started on simvastatin 10 mg daily.  she was also
started on lisinopril 5 mg daily.  she was continued on her beta
blocker.  she was not started on an aspirin on this admission
given her presentation with a gi bleed but this can be
considered as an outpatient.
.
# htn: the patient has a history of hypertension treated with
metoprolol as an outpatient.  on admission her antihypertensive
medications were held in the setting of acute bleeding but were
promptly restarted.  given that her blood pressures continued to
be elevated in the 140s on her outpatient regimen she was
started on lisinopril 5 mg daily during this admission with good
blood pressure control.
.
# paget's disease: patient was incidentally noted to have
evidence of paget's disease in the right hemipelvis and l1
vertebral body on ct.  she also has a mildly elevated alkaline
phosphatase and normal ggt consistent with this disorder.  this
issue may be followed as an outpatient.
.
# urinary tract infection: patient was noted to have klebsiella
uti during this admission.  she was asymptomatic but we opted to
treat with a three day course of ciprofloxacin given her waxing
and [**doctor last name 688**] mental status.
.
# osteoporosis: patient has a history of osteoporosis.  she
takes vitamin d and calcium as an outpatient and these were
continued during this admission.
.
# anemia: patient has a history of iron deficiency anemia.
baseline hematocrit is unknown.  further workup was not pursued
during this admission given her acute bleeding episode.  she was
continued on her home iron supplementation.
.
# prophylaxis: she was treated with subcutaneous heparin for dvt
prophylaxis.
.
# code status: dnr/dni

medications on admission:
namenda 10mg [**hospital1 **]
seroquel 12.5mg [**hospital1 **]
trazodone 50mg prn
aricept 10mg daily
calcium with d 600/200 [**hospital1 **]
iron 325mg daily
vit c 500mg daily
mvi
lasix 40mg daily
kcl 20meq [**hospital1 **]
toprol xl 25mg


discharge medications:
1. namenda 10 mg tablet [**hospital1 **]: one (1) tablet po twice a day.
2. ferrous sulfate 325 (65) mg tablet [**hospital1 **]: one (1) tablet po
daily (daily).
3. ascorbic acid 500 mg tablet [**hospital1 **]: one (1) tablet po daily
(daily).
4. acetaminophen 325 mg tablet [**hospital1 **]: 1-2 tablets po q6h (every 6
hours) as needed.
5. furosemide 40 mg tablet [**hospital1 **]: one (1) tablet po daily (daily).

6. simvastatin 10 mg tablet [**hospital1 **]: one (1) tablet po daily
(daily).
7. lisinopril 5 mg tablet [**hospital1 **]: one (1) tablet po daily (daily).

8. melatonin 3 mg tablet [**hospital1 **]: one (1) tablet po at bedtime.
9. docusate sodium 50 mg/5 ml liquid [**hospital1 **]: one (1)  po bid (2
times a day).
10. warfarin 1 mg tablet [**hospital1 **]: 1.5 tablets po hs (at bedtime):
please take tuesday, thursday, saturday and sunday.
11. warfarin 1 mg tablet [**hospital1 **]: two (2) tablet po at bedtime:
please take monday, wednesday and friday.
12. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1)
tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily).
13. haloperidol 0.5 mg tablet [**last name (stitle) **]: 0.5 tablet po tid (3 times a
day).
14. haloperidol 0.5 mg tablet [**last name (stitle) **]: 0.5 tablet po every eight (8)
hours as needed for aggitation .
15. calcium 600 with vitamin d3  oral
16. toprol xl 25 mg tablet sustained release 24 hr [**last name (stitle) **]: one (1)
tablet sustained release 24 hr po once a day.


discharge disposition:
extended care

facility:
armenian nursing & rehabilitation center - [**location (un) 538**]

discharge diagnosis:
primary:
upper gi bleed
dementia
urinary tract infection
.
secondary
atrial fibrillation
mechanical aortic valve
hypertension
chf
cad


discharge condition:
stable


discharge instructions:
you were seen and evaluated because you were vomiting blood.
you were given intravenous fluids and medication to decrease the
acid in your stomach.  you underwent upper endoscopy which did
not identify a clear source of bleeding.  you had a ct scan of
your head which showed no evidence of bleeding in the brain  you
had a ct of your chest which showed that your stomach is located
above your diaphragm.  you also had an upper gi study. you were
found to have a urinary tract infection which was treated with
antibiotics.  you were started on coumadin for your mechanical
heart valve.
.
please take all your medications as prescribed.  the following
changes were made to your medications.
1. your seroquel was discontinued
2 your aricept was discontinued
3 your trazadone was discontinued
4. you were started on haldol 0.25 mg by mouth three times a day
5. you were started on lisinopril 5 mg daily
6. you were started on lansoprazole 30 mg daily
7.  you were started on coumadin for your mechanical aortic
valve.  you will have to have your inr checked daily until your
levels have stabilized.
8.  you were started on simvastatin for your cholesterol
9. you were started on melatonin
.
you should been seen by your new primary doctor at your new
facility within one week
.
please seek immediate medical attention if you experience any
chest pain, shortness of breath, vomiting blood, blood in your
stool or darkness of your stool, fevers, numbness, inability to
move your arms or legs, or any other concerning symptoms.

followup instructions:
you should seen by your new primary care physician at your new
nursing home within one week.



"
202,"admission date:  [**2113-9-23**]              discharge date:   [**2113-9-28**]


service: med

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 2972**]
chief complaint:
nausea/vomiting, s/p fall

major surgical or invasive procedure:
none


history of present illness:
89 yo f with alzheimer's and recent admit for gi bleed from
gastritis and metaplastic pyloric mass presented with an episode
of nausea / vomiting / and a fall from her bed. she is a poor
historian, but records from [**location (un) **] indicate that she had
vomited w/o blood x 1 around 2 pm on [**2113-9-23**], and possibly
fell/slid from bed. pt denies f/c/abd pain/diarrhea/melena /
brbpr. in ed, she had episode of vomiting with sbp 60's,
bradycardia to 30's --> given atropine.she was transferred to
the micu for further mgmt.


past medical history:
alzheimer's dementia
htn
ocd
h/o recent gib w/ egd revealing
high grade duodenal dysplasia and intestinal metaplasia ([**8-9**])
egd [**9-9**] with ulcerating pyloric mass increased in size.


social history:
she lives at [**hospital3 **] facility). has a
remote history of tobacco use, quit 40 years ago. no etoh.

family history:
nc

physical exam:
o: v: t96.4 bp 114/84 p74 r20 94% 2l
gen: nad
heent: op clear, ng tube in place
resp: lungs coarse bilaterally
cv: distant, rrr
abd: soft ntnd +bs
ext: no edema
neuro: a+ox1 (to person), oriented to season and general place


pertinent results:
[**2113-9-23**] 03:45pm blood wbc-7.7 rbc-2.07*# hgb-6.4*# hct-20.5*#
mcv-99*# mch-31.1 mchc-31.4 rdw-18.9* plt ct-371#

[**2113-9-24**] 01:16am blood wbc-12.4*# rbc-3.01*# hgb-9.5*#
hct-28.7*# mcv-95 mch-31.4 mchc-33.0 rdw-18.7* plt ct-318
[**2113-9-24**] 05:59am blood hct-29.0*
[**2113-9-24**] 02:54pm blood hct-31.7*
[**2113-9-24**] 09:05pm blood hct-35.9*
[**2113-9-25**] 05:35am blood wbc-14.7* rbc-3.63* hgb-11.2* hct-34.1*
mcv-94 mch-30.8 mchc-32.9 rdw-19.5* plt ct-264
[**2113-9-25**] 03:15pm blood hct-35.2*
[**2113-9-26**] 06:00am blood hct-33.8*
[**2113-9-27**] 05:30am blood hct-33.3*
[**2113-9-24**] 01:16am blood ck-mb-86* mb indx-18.5* ctropnt-1.62*
[**2113-9-24**] 02:54pm blood ck-mb-135* mb indx-16.2* ctropnt-3.06*
[**2113-9-24**] 09:05pm blood ck-mb-97* mb indx-13.3*

[**9-23**] ct head - negative
[**9-23**] cxr - unremarkable


brief hospital course:
1. anemia - on admission her hct was 20.3 so she received total
of 3 units prbcs with an appropriate hct bump to around 33-35.
she was given 2 l ns in ed. this was felt to be secondary to
bleeding from the pre-pyloric mass. gi was consulted and felt
that she would benefit from stent placement only if she was
nauseated/vomiting, but that it would not control the bleeding,
so she was tried on food and tolerated all foods well. her ppi
was continued twice a day. it was discussed with her family that
a conservative/palliative approach will be pursued, with
symptomatic control with ppi twice a day, biweekly hct checks,
and likely no readmission if she has a massive gi bleed. this
will be conveyed to her [**hospital3 **] facility, where she is
to return.

2. cardiac ischemia: her troponins/ck were elevated during
admission, likely secondary to ischemia from low hematocrit. as
pt has history of bleeding, anticoagulation with heparing was
contraindicated anyway. a betal blocker was added to her regimen
instead of her calcium channel blocker. she was monitored on
telemetry without any adverse events. as she is dnr/dni, no
further enzymes will be drawn.

3. htn: a beta blocker was substituted for her calcium channnel
blocker for its cardioprotective effects. her bp was stable.

4. s/p fall: she was noted to have had a fall at the outside
hospital, but her head ct was negative for bleed and her mental
statyus

5. nausea/vomiting: she tolerated clears then solid food in the
hospital without aspiration or vomiting. she did not need
antiemetics.

6. code status: dnr/dni - this was discussed with the family and
palliative care. also no invasive procedures (i.e. cath, egd for
massive gi bleed) should be done but will consider egd/stent as
outpatient if gastric outlet obstruction develops. the family
will clarify her status further, with possible cmo, as an
outpatient, and may fill out a do not hospitalize plan.


medications on admission:
home meds:pantoprazole 40 mg po bid, b-12 1000 mcg po qd,
ferrous sulfate 5 g po tid, folic acid 0.4 mg po bid, diltiazem
(tiazac) 240

discharge medications:
1. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2
times a day).
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 q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*2*
3. fluoxetine hcl 10 mg capsule sig: one (1) capsule po once a
day.
disp:*30 capsule(s)* refills:*2*
4. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po
once a day.
disp:*30 tablet(s)* refills:*2*
5. b complex-c     tablet sustained release sig: one (1) tablet
sustained release po once a day.
6. multi-vit 55 plus     tablet sig: one (1) tablet po once a
day.
7. outpatient lab work
please draw hct every monday and thursday and send results to
dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]. [**0-0-**]
8. colace 100 mg capsule sig: one (1) capsule po twice a day.
disp:*60 capsule(s)* refills:*2*
9. senna 8.6 mg tablet sig: one (1) tablet po twice a day as
needed for constipation.
disp:*30 tablet(s)* refills:*0*


discharge disposition:
home with service

facility:
homecare  solutions

discharge diagnosis:
pyloric mass with subacute bleeding
dementia
cardiac ischemia


discharge condition:
pt was eating and drinking well. she was ambulating, and had no
complaints of pain.

discharge instructions:
please administer her current medications, and give colace and
senna if constipated.

she may resume a normal diet.

please have the nurse or laboratory draw her blood monday [**10-2**], and each thursday and monday after that, with results sent
to dr. [**last name (stitle) **].

if she has vomiting, nausea, bleeding or dark stools, please
contact dr. [**last name (stitle) **]. please do not hospitalize without contacting
her daughter first.

followup instructions:
follow up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] early next week for check of
your blood count ([**0-0-**]).

follow up with [**first name4 (namepattern1) **] [**last name (namepattern1) 3815**] (gi) as needed, ([**telephone/fax (1) 8892**].



"
203,"admission date:  [**2104-3-29**]              discharge date:   [**2104-5-2**]

date of birth:  [**2043-11-1**]             sex:   f

service: medicine

allergies:
codeine / vicodin / percocet / compazine / percodan / tigan /
latex / betadine viscous gauze / protonix / surgical lubricant

attending:[**first name3 (lf) 943**]
chief complaint:
""severe all over body pain""


major surgical or invasive procedure:
- esophagogastroduodenoscopy


history of present illness:
60-year-old female with history of etoh/nash cirrhosis
complicated by ascites and encephalopathy (no known varices or
history of sbp) who presents with ""severe all over body pain"".
.
the patient was recently admitted for hypotension and
hyponatremia where she was found to have esbl uti and treated
with tobramycin/tetracycline. she was discharged to a nursing
home on [**2104-3-25**]. at the nursing home, the patient states that she
has not been taking her lactulose and has not had bowel
movements. she is confused and states she has ""all over body
pain"" although she is unable to describe it and unsure of if it
is different or more severe than her baseline chronic pain. she
presents to [**hospital1 18**] for further evaluation.
.
upon presentation to the ew, intial vitals were: t 98.2, hr 86,
bp 130/80, rr 18, sao2 97% ra. labs show inr 1.6, hct 27 (near
recent baseline), lfts okay. she is confused and has asterixis
on exam. she denies rectal. cxr with question of focal
infiltrate. kub with dilated loops of small bowel likely
secondary to ileus (although cannot rule out obstruction).
ultrasound with difficult anatomy and not enough ascites to
safely do diagnostic paracentesis at bedside. recommend
ultrasound guided paracentesis. she received lactulose and was
admitted for hepatic encephalopathy treatment.
.
currently, patient confused. yelling at nurses and very slow
with movement. she notes chills, nausea, right upper quadrant
discomfort and diffuse pain. she is unsure if this is different
than baseline. she is unsure of her last bowel movement and is
unsure if she is taking lactulose. she denies or does not know
about other ros.

past medical history:
1. cirrhosis: thought to be secondary to etoh use and fatty
liver disease
2. h/o pancreatitis
3. etoh abuse
4. cholelithiasis
5. obesity
6. hypothyroidism
7. venous insuffuciency
8. chronic lower extremity edema
9. spinal stenosis
10. reflex sympathetic dystrophy
11. hypokalemia
12. mitral regurgitation
13. neuropathy
14. bilateral hand weakness
15. osteoporosis
16. macrocytic anemia
17. thrombocytopenia
18. uterine fibroids
19. chronic renal insufficiency
20. ""tummy tuck""
21. chronic pain: on narcotics


social history:
lives with her roomate. is a former constable and volunteer
police officer. drinks 3-4 beers/day x 12 yrs. no h/o withdrawl
szs. no tobacco or illicit drug use. estranged from family. no
hcp, though patient believes that father or [**name2 (ni) 8317**] [**name (ni) **] could
be hcp.


family history:
aunt with cirrhosis. mother with alcoholism.

physical exam:
vs: t 98.2, bp 104/66, hr 86, rr 16, sao2 94% ra
general: yelling at nurses - ""no - i want to do it my own way"",
no apparent distress
heent: nc/at, perrl, eomi, sclerae anicteric, mmm, op clear
neck: supple
lungs: limited lung volumes, bibasilar crackles, no cough,
wheezes.
heart: rr, nl rate, i/vi murmur
abdomen: obese, soft, diffuse tenderness no rebound or guarding,
decreased bowel sounds
extremities: warm, le edema 2+
skin: stasis dermatitis bilateral lower extremities, multiple
ecchymotic lesions, rash right forearm
neuro - awake, a&ox2 (name and hospital, wrong day, month,
unsure of year) unwilling to participate in neuro examination,
very upset when asked to participate, emotionally labile. +
asterixis.

pertinent results:
labs on admission:
[**2104-3-29**] 06:54pm   comments-green top
[**2104-3-29**] 06:54pm   glucose-89 lactate-1.4 na+-131* k+-3.5
cl--97* tco2-26
[**2104-3-29**] 06:50pm   urea n-10 creat-1.0
[**2104-3-29**] 06:50pm   estgfr-using this
[**2104-3-29**] 06:50pm   alt(sgpt)-15 ast(sgot)-22 ld(ldh)-227 alk
phos-61 tot bili-1.9*
[**2104-3-29**] 06:50pm   lipase-14
[**2104-3-29**] 06:50pm   calcium-9.3 phosphate-3.9# magnesium-1.5*
[**2104-3-29**] 06:50pm   wbc-5.7 rbc-2.43* hgb-9.1* hct-27.0* mcv-111*
mch-37.7* mchc-33.9 rdw-16.1*
[**2104-3-29**] 06:50pm   neuts-62.6 lymphs-23.1 monos-8.5 eos-4.9*
basos-0.9
[**2104-3-29**] 06:50pm   plt count-148*
[**2104-3-29**] 06:50pm   pt-17.8* ptt-37.0* inr(pt)-1.6*

labs on discharge:
131  95  5
------------<98
3.1  31  0.8

microbiology:
[**2104-3-30**] 10:57 am urine      source: cvs.

                            **final report [**2104-3-31**]**

   urine culture (final [**2104-3-31**]):
      yeast.    >100,000 organisms/ml..

[**2104-4-3**] 3:23 pm urine      source: cvs.

                            **final report [**2104-4-6**]**

urine culture (final [**2104-4-6**]):
      enterococcus sp..    >100,000 organisms/ml..
      yeast.    >100,000 organisms/ml..

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             enterococcus sp.
                             |
ampicillin------------  =>32 r
linezolid-------------     1 s
nitrofurantoin--------    64 i
tetracycline----------  =>16 r
vancomycin------------  =>32 r

[**2104-4-17**] 11:03 am sputum      source: endotracheal.

                            **final report [**2104-4-22**]**

   gram stain (final [**2104-4-17**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2104-4-22**]):
      commensal respiratory flora absent.
      escherichia coli.    rare growth.
         warning! this isolate is an extended-spectrum
beta-lactamase
         (esbl) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. consider
infectious
         disease consultation for serious infections caused by
         esbl-producing species.
      yeast.    rare growth.

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             escherichia coli
                             |
amikacin--------------   <=2 s
ampicillin------------  =>32 r
ampicillin/sulbactam--  =>32 r
cefazolin-------------  =>64 r
cefepime--------------       r
ceftazidime-----------       r
ceftriaxone-----------       r
ciprofloxacin---------   =>4 r
gentamicin------------  =>16 r
meropenem-------------<=0.25 s
tobramycin------------     8 i
trimethoprim/sulfa----  =>16 r

[**2104-4-29**] 9:39 am urine     no growth.

imaging:
- chest (pa & lat)	study date of [**2104-3-29**] 7:11 pm
impression: markedly limited study. question increased density
at the medial right lung base. this could represent
superimposition of normal structures crowded by significant
volume loss, however focal infiltrates cannot be entirely
excluded.

- portable abdomen	study date of [**2104-3-30**] 9:07 am
impression: two frontal views of the supine abdomen show
disproportionate
dilatation of the stomach and proximal small bowel with respect
to relatively mild gaseous dilatation of the colon, probably the
transverse. appearance is similar to [**3-29**]; small-bowel
obstruction must still be considered. no nasogastric tube is
seen despite severe gaseous distention of the stomach.
right lung base is elevated, probably a combination of
subpulmonic pleural
effusion and upward displacement of the diaphragm.

- ct abd & pelvis with contrast	study date of [**2104-3-30**] 2:56 pm
impression:
1. proximal small bowel dilatation measuring up to 3.6 cm with a
point of transition in the right lower quadrant. imaging
findings are consistent with partial versus complete obstruction
likely on the basis of adhesions.
2. findings of hepatic cirrhosis as on prior exams.
3. anterior abdominal wall hernia containing mesenteric fat and
fluid.

- lung scan	study date of [**2104-3-31**]
impression: underventilated triple match v/q defect with low
probability of pe.

- unilat up ext veins us	study date of [**2104-4-3**] 9:53 am
impression: no evidence of deep vein thrombosis in the right
arm.

- ct abd & pelvis with contrast	study date of [**2104-4-5**] 2:58 pm
impression:
1. stable mild dilatation of the proximal small bowel loops,
maximally measuring 3.6 cm. distal loops appear less distended,
with possible transition point in the right lower quadrant,
likely representing mild/partial small-bowel obstruction.
2. cirrhosis with moderate amount of abdominal and pelvic
ascites.

- ct head w/o contrast	study date of [**2104-4-16**] 6:30 pm
impression:
1. no acute intracranial hemorrhage or mass effect. if there is
continued
concern for parenchymal abnormalities, consider mr head if not
contra-indicated.
2. mild diffuse volume loss increased from [**2096**] ct head study.

- portable abdomen	study date of [**2104-4-20**] 9:38 pm
impression:
in comparison to [**2104-4-17**] exam, there is mild improvement of
ileus without
complete resolution.

- chest (portable ap)	study date of [**2104-4-25**] 8:38 am
findings: in comparison with the study of [**4-23**], the degree of
pulmonary
vascular congestion may have slightly improved. extensive
bilateral
atelectatic changes are again seen with blunting of the
costophrenic angles
consistent with pleural fluid. area of increased opacification
in the right
mid zone may merely represent atelectasis, though in the
appropriate clinical setting the possibility of pneumonia would
have to be considered.

brief hospital course:
summary statement:

ms. [**known lastname 28445**] is a 60 year old female with a provisional diagnosis
of etoh cirrhosis who presented from rehab after a brief
hospitalization for an mdr e.coli uti, new diagnosis of
cirrhosis, and hyponatremia with chronic pain who was found to
have an narcotic ileus who required tpn and then was transferred
to the micu for concern for prolonged epistaxis from presumably
ngt trauma who has remained encephalopathic with decompensated
cirrhosis, persistent ileus from administration from narcotics,
volume overload and hypoxia secondary to pulmonary edema and
atelectasis

prior to transfer to the micu:

1) narcotic ilues: prior to admission she presented with diffuse
abdominal pain, and dilated small loops of bowl on kub.
subsequent abdominal ct scans reveal potential transistion
points and partial small bowel obstruction.  she also developed
non-bloody bilious emesis necessitating ngt placement and small
bowel decompression.  surgery was consulted and a small bowel
follow through revealed and an ileus that was secondary to
prolonged narcotic use for a presumed diagnosis of rsd.  her
narcotics were then stopped, but her ileus persisted which
necessitated starting tpn, and subsequently her ileus resolved
after  methalynaloxone was administered.  her pain from rsd was
subsequently controlled with non-opioid analgesia including
tramadol and lyrica.  radiographs of the abdomin showed passing
of contrast from the small bowel to the colon and her nutrition
was transitioned from tpn to po.  she was tolerating po prior to
her transfer to the micu for epistaxis

2) decompensated cirrhosis:  she presented with peripherial
edema ascities without evidence of encephalopathy.  however, she
became mildly encephalopathic (grade i) with mild asterixis and
disorientation (date) as her ileus persisted.  she was given
lactulose enemas which helped resolve her confusion.  there was
also concern that she may have sbp, although she was never
febrile, and a a diagnostic paracentesis was negative.
subsequently however, she underwent a therapeutic paracentesis
to help remove ascites (3l removed) to improve her respiratory
mechanics in addition to her ileus.  she remained mildly
encephalopathic until her transfer to the micu.

2) volume overload:  she developed volume overload secondary to
decompensated cirrhosis and portal hypertension, ascities, and
the administration tpn in addition to iv medications and
antibiotics.  she was given albumin and prbc to maintain her map
to help diuresis with aldactone and lasix.  due to her uti, and
concern for delerium, a foley was note placed to monitor uop.
her weights were followed to monitor her fluid balance.

3) nutrition: due to her inability to tolerate po and narcotic
ileus.  she was started on tpn for several days.  she also
required additional potassium repletion due to diuresis for
volume overload.

4) hyponatremia: she developed hypervolemic hyponatremia due to
decompensated cirrhosis.  her hyponatremia resolved after the
administration of diurectics and free water restriction.

5) enterococcus/yeast uti.  upon admission she was noted to have
inflammation on her ua in addition to persistent yeast in her
urine and vre.  she was treated empirically for seven days for a
complicated uti with linezolid and fluconazole.  subsequent
urine cultures were negative for persisent yeast or vre.

6) mdr e.coli uti: upon admission she was completing a course of
tobramycin for an esbl uti, please see previous discharge
summary for sensitivities.

7) anemia: the patient remained anemic on presentation and
required multiple prbc transfusions for volume due to
hypotension secondary to decreased intravascular volume.  prior
to her transfer to the micu she did not have evidence of active
bleeding.

micu course: patient transferred to micu given concern for
hematemesis and upper gi bleed.  was electively intubated for
egd on [**4-16**].  egd did not reveal presence of varices, but did
show barrett's and gastropathy.  patient continued on famotidine
for gi ppx.  there was no recurrence of hematemesis, and hct
remained stable.  patient did develop hypotension while
intubated, likely multifactorial secondary to her underlying
cirrhosis and to sedating medications.  was briefly on pressors,
but quickly weaned off once extubated.  was successfully
extubated [**2104-4-17**].  patient developed recurrent ileus while in
icu; ngt kept to continuous low wall suction and patient kept
npo.  course notable for persistent ams, and patient was given
lactulose enemas while npo.  no evidence of infection, as
patient afebrile without leukocytosis.  diagnostic para [**4-16**]
negative for sbp.

post micu course

# encephalopathy: the patient's encephalopathy continued after
she was transferred from the micu to the floor. she was aao x 1
with asterixis. she was treated heavily with lactulose po/pr,
and began to put out an appropriate amount of stool, but without
resolution of her encephalopathy. an infectious work-up with
blood, urine, and chest x-ray was negative. opioid medications,
which were given to her in the icu, were avoided on the floor.
the patient's encephalopathy cleared on [**2104-4-24**], when she was
aaox3, and was following commands, but with occasional
asterixis. she no longer required restraints, and had not been
using the olanzapine which was written for her prn for
agitation. her encephalopathy was felt likely secondary to
lingering opioid medication, and not to hepatic encephalopathy
given her appropriate output of stool.

# epistaxis: upon transfer back from the icu, the patient did
not have any signs of epistaxis, and did not require any
transfusion.

# ileus: the patient had an ileus that was noted on abdominal
x-ray upon return from the icu, which was felt likely secondary
to opioid medication. the patient was made npo, and started on
metoclopromide. a few days later the patient's gi motility
started to return, and her diet was gradually advanced, and her
medications were returned to po. opioid medication was again
thought to play the largest role in the patient's ileus.
metoclopromide was discontinued on patient's discharge.

# tachypnea: the patient was noted on the floor for tachypnea
during her stay, with a normal abg and normal o2 sats. her
tachypnea was felt to be secondary to abdominal ascities with
ateletasis and an element of volume overload. she was treated on
the floor with iv lasix, and ultimately her o2 requirements were
removed. the patient was started on a dose of 40 mg lasix po bid
and her home dose of spironolactone (50 mg daily). she was
discharged on her home dose of 40 mg lasix daily and a new dose
of 100 mg spironolactone daily without tachypnea.

# decompensated cirrhosis: underlying etoh cirrhosis. no history
of varices or sbp; egd from [**4-16**] confirmed patient does not have
varices, and diagnostic para [**4-16**] not suggestive of sbp. the
patient was continued on lactulose and rifaximin.

# hypernatremia/hyponatremia: the patient transiently became
hypernatemic with na of 154 after diuresis, which resolved with
free water administration. on discharge she was hyponatremic
without end organ signs likely secondary to diuresis.

# nutrition: given resolving ileus and multiple bm, the patient
was discharged on regular diet low salt/heart healthy diet

# pain: the patient's chronic leg and back pain had previously
been treated with opiod medication, but her hospital course was
complicated by several adverse events secondary to opioid
medication (ileus, encephalopathy). her morphine doses were
discontinued, and the patient was started in house on standing
tylenol for pain control.

# history of restless legs: the patient previously had been on
mirapex 1mg qhs for restless legs.  this was stopped while in
the hospital, but may be restarted as needed.

medications on admission:
1. alendronate 70 mg po qweekly
2. morphine 30 mg po q12h
3. morphine 15 mg po q6h prn
4. omeprazole 20 mg po daily
5. potassium chloride 20 meq po bid
6. mirapex 1 mg po qhs
7. trazodone 300 mg po qhs
8. hydroxyzine hcl 25 mg po q6h prn
9. lactulose 30ml po tid
10. phenazopyridine 100 mg po tid prn
11. triamcinolone acetonide 0.1 % cream topical [**hospital1 **]
12. lidocaine 5 %(700 mg/patch) adhesive patch daily
13. zofran 8 mg po qid prn
14. calcium citrate + d 630-400 mg-unit po bid
15. vitamin d-3 1,000 unit po daily
16. cyanocobalamin (vitamin b-12) 1,000 mcg po daily
17. docusate sodium 100 mg po bid
18. centrum silver po daily
19. furosemide 40 mg po daily
20. spironolactone 50 mg po daily
21. rifaximin 550 mg po bid
22. tetracycline 500 mg po qid last day [**2104-3-31**]
23. azithromycin 250mg daily (started at rehab)
24. albuterol nebulizer (started at rehab)

discharge medications:
1. alendronate 70 mg tablet sig: one (1) tablet po once a week.

2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
3. potassium chloride 10 meq capsule, extended release sig: two
(2) capsule, extended release po twice a day.
4. trazodone 300 mg tablet sig: one (1) tablet po at bedtime as
needed for insomnia.
5. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po every six
(6) hours as needed for itching.
6. lactulose 10 gram/15 ml solution sig: thirty (30) ml po three
times a day.
7. phenazopyridine 100 mg tablet sig: one (1) tablet po three
times a day as needed for pain.
8. triamcinolone acetonide 0.1 % cream sig: one (1) application
to affected areas topical twice a day.
9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) patch topical once a day.
10. zofran 8 mg tablet sig: one (1) tablet po four times a day
as needed for nausea.
11. calcium 600 with vitamin d3 600 mg(1,500mg) -400 unit
capsule sig: one (1) capsule po twice a day.
12. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet,
chewable po once a day.
13. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1)
tablet po once a day.
14. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day.
15. centrum silver     tablet sig: one (1) tablet po once a day.

16. furosemide 40 mg tablet sig: one (1) tablet po once a day.
17. rifaximin 550 mg tablet sig: one (1) tablet po twice a day.

18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1) puff inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
19. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler
sig: one (1) puff inhalation every four (4) hours as needed for
shortness of breath or wheezing.
disp:*1 inhaler* refills:*3*
20. acetaminophen 500 mg capsule sig: one (1) capsule po every
six (6) hours.
disp:*120 capsule(s)* refills:*0*
21. artificial tears(glycerin-peg) 1-0.3 % drops sig: one (1)
drop to both eyes ophthalmic prn as needed for dry eye.
disp:*1 tube* refills:*0*
22. spironolactone 100 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
primary diagnosis:
- [**female first name (un) 564**] and vre cystitis
- opioid-induced ileus
- hepatic encephalopathy
secondary diagnosis:
- etoh cirrhosis


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:
ms. [**known lastname 28445**], it was a pleasure taking care of you in the
hospital. you were admitted to the hospital with diffuse body
pain. you were found to have an infection in your bladder, and
we treated you with the appropriate antibiotics. however, your
hospital course was complicated by a slow moving gi tract that
likely happened because of the high dose of narcotics which you
normally take. we confirmed that you did not have an obstruction
in your abdomen, and gave you some medications to help your gut
move along. during that time when you were not eating, we were
giving your nutrition through your veins. also during your
hospital stay, you had started vomiting some blood; we took you
to the icu were we put a breathing tube down your throat and
also looked at your stomach lining, where we did not see any
bleeding. we believe that your vomiting of blood may have been
blood which dripped into your stomach from your nose.

unfortunately, when you were intubated, we needed to give you
more doses of narcotics, which caused your gi tract to slow down
again. your gut motility improved, but you still remained a
little bit confused, which improved once the narcotics had
worked their way out of your system.

when you leave the hospital:
- stop morphine 30 mg every 12 hours
- stop morphine 15 mg every 6 hours as needed for pain
- stop tetracycline 500 mg four times a day
- stop azithromycin 250 mg every day
- stop mirapex 1mg before bedtime
- start ipratropium bromide inhaler 1 puff inhalation every four
(4) hours as needed for shortness of breath or wheezing
- start acetaminophen 500 mg every 6 hours
- start artificial tears(glycerin-peg)  1-0.3 % drops: use one
(1) drop to both eyes as needed for dry eyes
- increase your dose of spironolactone to 100 mg daily
(previously you had been taking 50 mg daily)

we did not make any other changes to your medications, so please
continue to take them as you normally have been.

followup instructions:
when you leave the hospital, please have your rehab facility
make the following appointments for you:

- make an appointment to see your primary care doctor, dr. [**first name (stitle) 1022**],
one week after your discharge from rehab by calling [**telephone/fax (1) 250**]

department: liver center
when: wednesday [**2104-5-7**] at 10:00 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 7128**], md [**telephone/fax (1) 2422**]
building: lm [**hospital unit name **] [**location (un) 858**]
campus: west     best parking: [**hospital ward name **] garage



"
204,"admission date:  [**2170-6-12**]              discharge date:   [**2170-6-15**]

date of birth:  [**2105-8-24**]             sex:   m

service: medicine

allergies:
penicillins

attending:[**first name3 (lf) 2901**]
chief complaint:
chest pain

major surgical or invasive procedure:
left heart catheterization


history of present illness:
mr. [**known lastname 5066**] is a 54 y/o m with a history of cad s/p bms to
lad in [**2158**], htn, dm2 who presented with sudden onset chest
pain/indigestion approximately 1 hour prior to presentation to
the ed. patient reports burning chest pain that felt like
indigestion radiating to his left arm and up his neck. he was
watching television during the onset of his symptoms. he took
his home omeprazole with no relief. he called ems and who noted
ste in anterolateral leads. he was brought to the ambulance and
had an episode of v-fib, which responded to one shock. he
reverted to nsr after and was loaded with 150mg of amiodarone.
he was also given a aspirin 81mg.
.
when he arrived to the ed initial vitals were  pulse: 106 rr:
25, bp: 130/76, o2sat: 95%, o2flow: ra. a code stemi was called
and he was taken to the cath lab which revealed significant lad
disease primarily in-stent restenosis of his previous bms and a
more distal occlusion that was felt to be the culprit lesion. in
the ed he was given aspirin 325mg, plavix 600mg, and started on
a heparin and amiodarone drip. ekg showed ste in v1-v4 and
pathological q waves in ii, iii and avf.
.
on arrival to the floor, patient the patient was comfortable and
in no acute distress. he did note having continued indigestion
however he states that the sensation was different than what he
was experiencing previously. 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:
1. cardiac risk factors: + diabetes, + dyslipidemia, +
hypertension
2. cardiac history:
-cabg: n/a
-percutaneous coronary interventions: bms to lad [**2158**]
-pacing/icd: n/a
3. other past medical history:
ulcerative colitis
pud
osa not on cpap
asthma


social history:
he is a retired navy consultant.
-tobacco history: denies
-etoh: denies
-illicit drugs: denies

family history:
he states that his mother has angina but had never had an
intervention. his sister has struggled with arthritis and
multiple cancers.
no family history of early mi, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

physical exam:
admission exam:
general: comfortbale and 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.
cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3
or s4.
lungs: ctab, no crackles, wheezes or rhonchi.
abdomen: soft, ntnd. no hsm or tenderness.
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:
98-99.5 74-98 109-162/57-82 rr 18 93-98% ra
gen: comfortable, nad, nt/nd
heent: sclera anicteric, perrla. conjunctive pink without
cyanosis or pallor. no xanthelasma.
neck: supple, jvp of 7
cardiac: normal s1, s2. no murmurs, rubs, or gallops, difficult
due to adiposity.
lungs: good air entry bilaterally, no rales, rhonchi, or
wheezes.
abdomen: soft, non-tender, non-distended, normal bowel sounds.
no organomegaly.
extremities: edema present to one hands-breadth below knee
skin: no stasis ulcers, dermatitis, scars. abundant skin lesions
on back.
pulses: right and left dps and pts 2+

pertinent results:
[**2170-6-15**] 06:57am blood wbc-7.5 rbc-3.39* hgb-9.9* hct-30.4*
mcv-90 mch-29.2 mchc-32.6 rdw-14.8 plt ct-244
[**2170-6-12**] 03:30am blood wbc-12.4* rbc-4.10* hgb-11.9* hct-36.6*
mcv-89 mch-29.0 mchc-32.4 rdw-15.1 plt ct-225
[**2170-6-15**] 06:57am blood plt ct-244
[**2170-6-15**] 06:57am blood pt-14.3* ptt-73.5* inr(pt)-1.3*
[**2170-6-12**] 03:30am blood pt-12.2 ptt-150* inr(pt)-1.1
[**2170-6-12**] 03:30am blood plt ct-225
[**2170-6-12**] 03:30am blood fibrino-426*
[**2170-6-15**] 06:57am blood glucose-166* urean-10 creat-0.7 na-142
k-4.1 cl-105 hco3-28 angap-13
[**2170-6-12**] 09:08am blood glucose-221* urean-18 creat-0.8 na-139
k-3.5 cl-99 hco3-28 angap-16
[**2170-6-13**] 02:45am blood alt-28 ast-59* ld(ldh)-472* alkphos-79
totbili-0.2
[**2170-6-14**] 06:59am blood alt-22 ast-29
[**2170-6-14**] 09:24pm blood ck(cpk)-172
[**2170-6-14**] 09:24pm blood ck-mb-3 ctropnt-1.32*
[**2170-6-12**] 09:08am blood ck-mb-53*
[**2170-6-12**] 03:30am blood ck-mb-11* mb indx-2.9 ctropnt-0.90*
[**2170-6-15**] 06:57am blood calcium-8.3* phos-2.0* mg-2.2
[**2170-6-12**] 09:08am blood calcium-7.6* phos-2.0* mg-1.1*
[**2170-6-12**] 03:30am blood %hba1c-7.1* eag-157*
[**2170-6-12**] 03:30am blood triglyc-102 hdl-35 chol/hd-2.8 ldlcalc-44
[**2170-6-12**] 03:30am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2170-6-12**] 03:46am blood glucose-246* lactate-4.2* na-140 k-2.9*
cl-99 calhco3-27
[**2170-6-12**] 03:46am blood hgb-11.6* calchct-35 o2 sat-94 cohgb-2
methgb-0
[**2170-6-12**] 03:21pm blood freeca-1.03*
[**2170-6-13**] 02:09pm blood aldosterone-pnd
[**2170-6-13**] 02:09pm blood renin-pnd
indications for catheterization:
coronary artery disease, canadian heart class iv,  unstable.
prior ptca
[**2158-12-4**].

procedure:
percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

hemodynamics results body surface area:  2.58 m2
  hemoglobin: 11.9 gms %
  entry
**pressures
aorta {s/d/m} 112/74/86
**cardiac output
heart rate {beats/min} 103
rhythm sinus




**ptca results
  lad

ptca comments:
primary pci was delayed because of severe torutosity in the
right upper
extremity and inability to seat the guide appropriately. we
initially
gained access via the right radial artery. however, because of
severe
tortuosity in the right axilla and because of a short ascending
aorta,
we were unable to engage the left main coronary artery. because
of this,
we then gained access in the right femoral artery. a 6f sheath
was
inserted. initial angiography revealed a 70% stenosis in the
proximal
lad, a 70% stenosis in the proximal portion of the prior mid lad
stents
and a 95% stenosis in the mid to distal edge of the prior mid
lad
stents. we planned to treat all of these lesions with ptca and
stenting.
bivalirudin was administered for anticoagulation, and a
therapeutic act
was confirmed. a 6f xblad 3.5 guide provided adequate support. a

prowater wire crossed the lesions with mdoerate difficulty.  we
then
predilated the distal lesion with a 2.25 x 12 mm sprinter legend
rx
balloon at 10 atm three times. this led to a short dissection
and no
reflow in the distal lad. we therefore attempted to rapidly
deliver a
2.25 x 18 mm resolute rx stent, but we were not able to deliver
due to
tortuosity. we therefore elected to change for a stiffer wire. a
2.25 x
15 mm sprinter balloon was advanced to the distal lad, and the
prowater
wire was removed. a choice pt extra support wire was advanced to
the
distal lad, and the distal lad was again predilated with the
2.25 x 15
mm sprinter balloon at 12 atm. we were then able to deliver a
2.25 x 14
mm resolute stent to the distal lesion and deployed it at 13
atm. we
then delivered a 2.75 x 22 mm resolute to the more proximal
portion of
the prior stents and deployed it at 16 atm. the proximal portion
of
the new stents was postdilated with a 3.0 x 15 mm nc quantum
apex mr
balloon at 16 atm. the mid portion of the newly deployed stents
was
postdilated with a 2.75 x 12 mm nc quantum apex balloon at 18
atm. we
then direct stented the more proximal lad lesion with a 3.5 x 15
mm
resolute stent at 16 atm. final angiography revealed no residual

stenosis, no evidence of dissection and timi 3 flow. right
femoral
angigoraphy revealed an arteriotomy site appropriate for
closure, and a
6f perclose was deployed with adequate hemostasis.


technical factors:
total time (lidocaine to test complete) = 1 hour 54 minutes.
arterial time = 1 hour 53 minutes.
fluoro time = 35 minutes.
effective equivalent dose index (mgy) = 6634 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 440 ml

premedications:
          midazolam 0.5 mg iv
          fentanyl 25 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          diltiazem (ia) 500mcg
          nitroglycerine (ia) 200mcg
           potassium 40meq
          amiodarone (iv) 1mg/min
          bivalrudin 100mg ivb f/b 238mg/hr
          fentanyl 100mcg
          midazolam 1.5mg
          nicardipine 1000mcg
cardiac cath supplies used:
          - [**doctor last name **], prowater 300cm
          - [**company **], magic torque 260cm
          - [**company **], choice pt extra support 300cm
          2.25mm [**company **], sprinter 12mm
          2.25mm [**company **], sprinter 15mm
          - [**company **], nc apex 15/3.0
          - [**company **], nc apex 12/2.75
          6fr cordis, xblad 3.5
          6fr [**doctor last name **], perclose proglide
          - [**company **], resolute 15/3.5
          - [**company **], resolute 15/3.5
          - allegiance, custom sterile pack
          - merit, left heart kit
          6fr terumo, glidesheath
          - [**doctor last name **], priority pack 20/30
          - terumo, tr band large


comments:
1. selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel cad. the lmca had no
angiographically-apparent disease. the lad had 70% proximal
stenosis
prior to the old mid-lad stent. there was also 95% stenosis at
the
distal end of the old mid-lad stent. the lcx had 80% stenosis in
the om1
branch. the dominant rca had no angiographically apparent
disease.
2. limited resting hemodynamics revealed normal systemic
arterial
pressures with a measured central aortic pressure of 112/67/84.
3. left ventriculography was deferred.
4. successful ptca and stenting of the mid to distal lad with
overlapping 2.25 x 14 mm (distal) and 2.75 x 22 mm resolute dess

postdilated to 2.75 mm in the mid portion and 3.0 mm proximally
(see
ptca comments).
5. successful direct stenting of the more proximal lad with a
3.5 x 15
mm resolute des (see ptca comments).
6. successful rfa perclose (see ptca comments).

final diagnosis:
1. two vessel cad with lad stenosis (culprit).
2. successful pci of the mid to distal lad with overlapping 2.25
x 14 mm
(distal) and 2.75 x 22 mm (proximal) resolute dess postdilated
to 2.75
mm in the overlapping segment and 3.0 mm in the proximal
segment.
3. successful pci of the proximal lad with a 3.5 x 15 mm
resolute des.
4. successful rfa perclose.
.
i, dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **],
was physically present during the entire procedure and in
compliance with the cms regulations.
.
[**hospital1 18**] attending of record: [**last name (lf) **],[**first name3 (lf) **] e.
referring physician: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].
fellow: [**last name (lf) **],[**first name3 (lf) **]
[**last name (lf) **],[**first name3 (lf) **] b.
invasive attending staff: [**last name (lf) **],[**first name3 (lf) **] e.
electronically signed by: [**last name (lf) **],[**first name3 (lf) **] on fri [**2170-6-15**] 10:23
am
[**medical record number 28546**] m  64  [**2105-8-24**]
.
cardiovascular report ecg study date of [**2170-6-12**]  3:14:42 am
.
sinus tachycardia. left axis deviation. acute anterolateral wall
myocardial infarction. possible inferior wall myocardial
infarction. compared to the previous tracing of [**2159-6-21**] the
acute infarction is new.
.
echo [**2170-6-12**]
conclusions
the left atrium is mildly dilated. left ventricular wall
thicknesses and cavity size are normal. there is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior wall, septum and apex. the remaining segments contract
normally (lvef = 25%). no masses or thrombi are seen in the left
ventricle. right ventricular chamber size is normal with focal
hypokinesis of the apical free wall. the aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. no
aortic regurgitation is seen. the mitral valve leaflets are
mildly thickened. trivial mitral regurgitation is seen. 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.
.
impression: extensive regional left ventricular systolic
dysfunction, c/w proximal lad disease. no lv thrombus seen.
.
compared with the report of the resting portion of the prior
stress study (images unavailable for review) of [**2162-11-16**],
regional lv wall motion abnormalities are new.
.
findings were discussed with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] at 1120 hours
on the day of the study.
  electronically signed by [**first name8 (namepattern2) **] [**last name (namepattern1) 171**], md, interpreting
physician [**last name (namepattern4) **] [**2170-6-12**] 11:22
.
.
ekg study date of [**2170-6-12**]  7:54:28 pm
.
sinus rhythm. left axis deviation. there are q waves in the
anterior leads
with st segment elevation and terminal t wave inversion
extending into the
anterolateral leads. there are tiny r waves in the inferior
leads consistent
with probable infarction. there are additional non-specific st-t
wave changes.
compared to the previous tracing of the same day st segment
elevation in the
anterior leads has increased. clinical correlation is suggested.

tracing #3



brief hospital course:
active issues:
# stemi with reduced ef:
mr. [**known lastname 5066**] presented to the ed one hour after the onset of
sudden, severe, burning chest pain that radiated up his neck and
to his left arm. he perceived the chest pain to be indigestion
and took an antacid to no relief. he called ems, who documented
st elevation inthe anterolateral leads. during transport, mr.
[**known lastname 5066**] had an episode of ventricular fibrillation, which
responded to one shock. he reverted to normal sinus rhythm and
was administered amiodarone and aspirin.

in the ed, ecg demonstrated ste in v1-v4 and pathological q
waves in ii, iii and avf. mr. [**known lastname 5066**] was taken straight for
cardiac catheterization, which revealed significant lad disease
- primarily in-stent restenosis of his in situ bare metal stent
and a more distal 95% stenosis. three drug-eluting stents were
placed in the proximal and distal lad with good angiographic
results.

post-stemi echocardiography demonstrated an ejection fraction of
25%, which is a marked deterioration from previous studies
(ef=60%). moreover, there was newly diagnosed apical, anterior,
and septal akinesis. based on these findings, the team decided
that mr. [**known lastname 5066**] would benefit from the initiation of
coumadin therapy for thrombus prevention.

during mr. [**known lastname 28547**] stay, an electrophysiology consult
advised us to schedule mr. [**known lastname 5066**] for electrophysiology
follow-up as an outpatient in 40 days' time to assess his need
for an icd. they felt that he would not benefit from
anti-arrhythmic therapy or an external defibrillating device in
the interim.

recovery, first in the ccu and subsequently on the cardiology
[**hospital1 **], was speedy. mr. [**known lastname 5066**] required some potassium
supplementation, and several changes were made to his
medications. during his hospitalization, mr. [**known lastname 5066**] [**last name (titles) 28548**]d nifedipine 30mg once daily, irbesartan 150mg once
daily, metoprolol tartrate 100mg twice daily, and
hydrochlorothiazide 25mg once daily, and was commenced on
coumadin 3mg once daily, clopidogrel 75mg once daily, losartan
25mg once daily, metoprolol succinate 200mg once daily,
eplerenone 25mg once daily. his other medications remain
unchanged.

#inactive issues
1. ulcerative colitis: appears to be doing well with no recent
flares. continue dicyclomine as needed and sulfazaline 1000mg
tid

2. diabetes mellitus: the patient was switched from his oral
medications to insulin while in house with good results.

#transitional issues
1. mr. [**known lastname 5066**] has commenced coumadin prophylaxis. he
received his first dose (5mg) on [**2170-6-13**], and was discharged on
3mg once daily. his inr is to be checked by a visiting nurse on
[**2170-6-16**], and he is scheduled to attend your clinic on [**2170-6-19**].
he has been instructed to take 3mg once daily at 4pm until he
attends your clinic or is linked in with your coumadin service.
we defer any dose adjustments that he may require to you. i have
already contact[**name (ni) **] a nurse in your office with this information.

(2) given the fact that mr. [**known lastname 5066**] required potassium
supplementation a few times during his hospital stay, we
recommend that his serum electrolytes be checked in the short
term, possibly alongside his inr. we commenced him on
eplerenone, which may help in avoiding hypokalemia.

(3) outpatient appointments have been arranged with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] (cardiac services [**2170-6-18**]) and dr. [**last name (stitle) **] [**name (stitle) 1911**]
(cardiac services, electrophysiology [**2170-7-26**]).

(4) mr. [**known lastname 5066**] has expressed interest in cardiac rehab
services in [**location (un) 745**]. i informed him that he should contact the
center of his choice, which would correspond with your office to
arrange for an official referral. he also expressed concern at
having missed a recent appointment with a dietician, which he
would like to have rescheduled through your office.


medications on admission:
1. omeprazole 20 mg oral capsule, delayed release(e.c.) take 1
capsule 30 min before first meal of day
2. sitagliptin (januvia) 100 mg oral tablet take one tablet
daily
3. metformin 750 mg oral tablet extended release 24 hr take 1
tablet three times a day
4. sitagliptin (januvia) 100 mg oral tablet 1 tab po qd
5. fluticasone (flonase) 50 mcg/actuation nasal spray,
suspension 1 spray in each nostril twice a day
6. glipizide 10 mg oral tablet extended rel 24 hr take 1 tablet
twice daily
7. sulfasalazine 500 mg oral tablet 2 tablets (1000mg) three
times daily
8. atorvastatin 80 mg oral tablet take one tablet daily
9. irbesartan (avapro) 150 mg oral tablet take 1 tablet daily
10. loratadine 10 mg oral tablet 1 tablet daily as needed.
11. epinephrine (epipen) 0.3 mg/0.3 ml intramuscular pen
injector use as needed and seek medical advice
12. hydrochlorothiazide 25 mg oral tablet 1 tablet daily
13. nifedipine er 30 mg 24 hr tab 30 mg oral tr24 take 1 tablet
daily
14. dicyclomine 20 mg tab take 1 tablet by mouth 4 times a day
as needed
15. one touch ultra test strips (blood sugar diagnostic) use as
directed 2 times daily
16. lancets use [**hospital1 **] prn
17. metoprolol 100 mg tab (metoprolol tartrate) 1 tablet twice
daily
18. baby aspirin oral (aspirin) none entered

discharge medications:
1. omeprazole 20 mg po daily
2. losartan potassium 25 mg po daily
please hold for sbp<100
please start [**2170-6-15**]
rx *losartan 25 mg 1 tablet(s) by mouth daily disp #*30 tablet
refills:*3
3. nitroglycerin sl 0.3 mg sl prn chest pain
rx *nitrostat 0.3 mg 1 tablet sublingually every 15 minutes as
needed for chest pain not to exceed three pills disp #*30 tablet
refills:*3
4. eplerenone 25 mg po daily
rx *eplerenone 25 mg 1 tablet(s) by mouth daily disp #*30 tablet
refills:*3
5. metoprolol succinate xl 200 mg po daily
start in am on [**6-15**]
rx *metoprolol succinate 200 mg 1 tablet(s) by mouth daily disp
#*30 tablet refills:*3
6. clopidogrel 75 mg po daily
rx *clopidogrel 75 mg 1 tablet(s) by mouth daily disp #*30
tablet refills:*3
7. atorvastatin 80 mg po daily
please stop this drug if you develop muscle weakness or pain or
if your urine gets very dark.
8. aspirin 81 mg po daily
9. sulfasalazine_ 1000 mg po tid
10. januvia *nf* (sitagliptin) 100 mg oral daily
11. metformin xr (glucophage xr) 750 mg po tid
do not crush
12. fluticasone *nf* 50 mcg/actuation nu [**hospital1 **]
1 spray each nostril twice daily
13. glipizide xl 10 mg po bid
14. loratadine *nf* 10 mg oral qday:prn asthma
15. epipen *nf* (epinephrine) 0.3 mg/0.3 ml injection once:prn
anaphylaxis
use as needed and seek medical advice immediately
16. dicyclomine 20 mg po tid:prn bowel irritation
please do not take this medication until you see your physician,
[**last name (namepattern4) **]. [**last name (stitle) 28549**], on [**6-19**].
17. one touch ultra test *nf* (blood sugar diagnostic)
miscellaneous [**hospital1 **]
use as directed two times daily
18. lancets *nf*    miscellaneous [**hospital1 **]
use as directed twice daily
19. warfarin 3 mg po daily16
rx *warfarin 1 mg 3 tablet(s) by mouth daily disp #*30 tablet
refills:*3
20. outpatient lab work
please draw blood for an inr on [**2170-6-16**] and fax the result to
dr. [**last name (stitle) 28549**] at [**telephone/fax (1) 6808**]
21. outpatient lab work
please draw blood on [**2170-6-22**] and send it for serum sodium,
potassium, chloride, bicarbonate/co2, bun, creatinine, calcium,
magnesium, and phosphate. please fax the results to dr. [**last name (stitle) 28549**]
at [**telephone/fax (1) 6808**]


discharge disposition:
home with service

facility:
[**company 1519**]

discharge diagnosis:
primary diagnosis: anterolateral st segment myocardial
infarction (heart attack to the front wall of your heart)
secondary diagnosis: apical akinesis of the left ventricle


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
dear mr. [**known lastname 5066**],

it was a pleasure taking care of you while you were hospitalized
at the [**hospital1 **]. as you know, you were admitted to
the hospital because of your chest pain. on the way, the
emergency medical technicians had to shock you because of an
irregular heart rhythm, which reverted to normal subsequently.
when you got to the hospital, we confirmed that you indeed had a
heart attack and performed a procedure called a left heart
catheterization where a wire was threaded into the arteries that
supply your heart. we found that the area where you already had
a stent placed in [**2158**] was narrowed and there was a very severe
narrowing farther along the artery. the newly diagnosed
narrowing was fixed with a drug-eluting stent. this should help
prevent the re-narrowing that occurred at the site of the bare
metal stent you received in [**2158**].

please keep in mind two important points:
1. you must take plavix for at least 6 months to one year based
on the placement of your drug-eluting stent. you must not miss
any doses because if you do, you will run the risk of having a
sudden and severe blockage of the new stent that could give you
another severe heart attack.

2. because of the location of your heart attack, part of your
heart is not moving properly. this can cause blood to be
stagnant inside of the heart and clot, which can lead to strokes
or other adverse events. as a result, you will need to start a
blood thinner called coumadin for at least a few months. if your
heart regains some of its lost function, you may be able to stop
blood thinners, but this is a discussion that needs to be
undertaken in several months in conjunction with your
cardiologist. until you see dr. [**last name (stitle) 28549**], you should take 3mg of
coumadin by mouth each afternoon at 4pm.

you were brought to the cardiac care unit after your procedure
where you did well. you were transferred to the non-intensive
care cardiology floor shortly thereafter where your course
continued to be unremarkable.

you have several follow-up appointments listed below. please
keep all of them; each is extremely important. also, please
discuss cardiac rehabilitation with your cardiologist and
primary care provider next [**name9 (pre) 766**] and tuesday, respectively.

start:
coumadin 3mg by mouth once daily (on [**8-16**], and [**6-17**]). you
will have blood tests drawn on the 14th and 15th that will
dictate your dose on [**6-18**] and thereafter. you must go to [**hospital1 2292**] in [**location (un) **], [**university/college **], or [**location (un) 38**] to have these labs
drawn. they will be submitted electronically to dr.[**name (ni) 28550**]
office, where he and his team can decide the appropriate
coumadin dose.
plavix 75mg by mouth once daily
losartan 25mg by mouth once daily
metoprolol succinate (xl) 200mg by mouth once daily
eplerenone 25mg by mouth once daily

stop:
nifedipine er 30 daily
irbesartan 150 daily
metoprolol tartrate 100mg twice daily
hydrochlorothiazide 25mg daily


followup instructions:
department: cardiac services
when: monday [**2170-6-18**] at 4:20 pm
with: [**first name11 (name pattern1) **] [**last name (namepattern4) 1523**], md [**telephone/fax (1) 62**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

name: [**last name (lf) **],[**first name3 (lf) **] j
location: [**location (un) 2274**]-[**location **]
address: 291 independence dr, [**location **],[**numeric identifier 1700**]
phone: [**telephone/fax (1) 28551**]
appt:  [**6-19**] at 2:20pm

department: cardiac services
when: friday [**2170-7-13**] at 10:00 am
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

department: cardiac services
when: thursday [**2170-7-26**] at 1 pm
with: [**name6 (md) 1918**] [**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


                             [**first name11 (name pattern1) **] [**last name (namepattern1) 2908**] md, [**md number(3) 2909**]

"
205,"admission date:  [**2180-6-3**]              discharge date:   [**2180-6-12**]

date of birth:  [**2134-3-21**]             sex:   f

service: medicine

allergies:
vancomycin

attending:[**first name3 (lf) 759**]
chief complaint:
fever, sputum production, shortness of breath, stomach pain

major surgical or invasive procedure:
none

history of present illness:
mrs. [**known lastname **] is a 46-year-old with a history of intracranial
hemorrhage secondary to avm s/p evacuation in [**2179-8-27**],
complicated by hydrocephalus requiring vp shunt, brought in from
[**hospital3 2558**] nursing home. she has a tracheostomy and peg. she
has undergone rehabilitation at [**hospital3 **] [**hospital1 8**] and
[**location (un) 1036**] [**location (un) 620**]. during her time at [**location (un) 1036**], she was
hospitalized at [**hospital1 18**] [**location (un) 620**] and found to have a mucous plug
with sputum culture positive for mrsa, as well as e. faecalis
urinary tract infection (sensitive to linezolid, vancomycin, and
furantoin) treated with nitrofurantoin x 6 days. she was
transferred from [**location (un) 1036**] to [**hospital3 2558**] on [**2180-5-30**]. per a
[**hospital3 2558**] employee who spoke with the patient's respiratory
therapist, the patient was noted to have increasingly voluminous
secretions requiring increasingly frequent sunctioning (every
four hours -> every two hours -> every hour -> every 30
minutes). she was febrile to 101.2 with a heart rate in the
120s.
.
in the [**hospital1 18**] ed, vs were hr 126, bp 90/68, rr 26, o2 99% on ?
o2. she was thought to have suprapubic tenderness on exam. chest
x-ray revealed no acute intrathoracic process. urinalysis was
leukocyte- and nitrite-positive with many bacteria. sputum
gram-stain and culture, blood culture, and urine culture went
sent. she received cefepime 2g iv x 1 and linezolid 600mg iv x 1
for possible healthcare-associated pneumonia and urinary tract
infection, plus acetaminophen and fluids.
.
on the floor she is noted to be hypotensive to 82/palp and is
triggered in the setting of losing her iv access. she is
admitted to the micu for closer monitoring. in the micu she
denies complaints.
.
 in the micu pt received fluid boluses (6.5l total) to treat
hypotension, but did not receive pressors. linezolid and
cefepime were continued [**12-29**] vanc allergy. cxr revealed
questionable pneumonia with retrocardiac opacity vs atelectasis,
and current abx should treat for any hap as well. on hospital
day 3, pt's hypotension stabilized, with sbps in the 100s. at
time of txfr, sputum culture taken is growing gnr, which will
need to be followed. urine cx revealed e. coli sensitive to
cefepime. pt's lactate trended down with condition improvement.
pt was transferred to the floor.
.
on the floor, pt remained stable, with sbps in the 100s.
midodrine was added to pt's regimen, with resumption of normal
blood pressures in the 110s to 120s. pt remained afebrile on the
floor, with no adverse events. cefepime and linezolid were
continued. pt was restarted on her normal cycled tube feeding
regimen from continuous feeds, which she tolerated well.
.
review of systems:
(+) per hpi; she has had ongoing hyperthermia thought to a
""central fever""/reset thermostat, though she was afebrile on
discharge from [**location (un) 1036**] (t 98.0); husband also notes that she
has complained of intermittent headache recently; she is
constipated at baseline
(-) denies sinus tenderness, rhinorrhea or congestion. denied
chest pain or tightness, palpitations. denied arthralgias or
myalgias

past medical history:
intracranial hemorrhage in [**2179-8-27**]
s/p vp shunt
enterococcus faecalis uti ([**2-4**])
mucous plug ([**2-4**])
mrsa colonized
situational depression

social history:
cared for by husband, who is her guardian. currently [**name2 (ni) 546**] at
[**hospital3 2558**] ([**location (un) **]), a nursing facility, but has spent
the last ~9 months at [**hospital3 **] [**hospital1 8**] and [**location (un) 1036**]
[**location (un) 620**]. [**university/college **] grad [**first name8 (namepattern2) **] [**doctor first name **] note.


family history:
non-contributory

physical exam:
on admission:
vs: t 97.3, bp 95/60, hr 79, rr 24, spo2 100% on 50%
ga: somnolent and uncommunicative
heent: perrl. eyes with strabismus. oropharynx exam limited but
there are visible secretions. no lad. trach with visible
secretions.
cards: faint s1 and s2, no mrg, pulses full but faint
pulm: diffusely rhonchorous breath sounds with scattered
background wheezes
abd: soft, deep palpation did not elicit grimace
extremities: wwp
skin: warm with no rashes, peg site clean and non-draining
neuro/psych: strabisus as above. cn iv-xii, ue/le strength,
coordination, reflexes, and gait not assessed.

on discharge:
vs: t 98.8, bp 116/75, hr 82, rr 24, spo2 99% on 35% humidified
through trach mask
ga: alert and responsive.
heent: eyes with strabismus, left anisocoria. oropharynx without
lesions. no lad. trach clean and well-cushined with no leaking
secretions.
cards: normal s1 and s2, no mrg, pulses 2+
pulm: good air entry b/l throughout. transmitted upper airway
sounds from trach heard throughout.
abd: soft, non-tender, non-distended.
extremities: wwp 2+ pt/dp pulses
skin: warm with no rashes, peg site clean and non-draining
neuro/psych: strabisus as above, left anisocoria unchanged
during course on floors.


pertinent results:
admission labs:

discharge labs:

studies:
cxr [**2180-6-3**]:
impression: no acute intrathoracic process.

ct abd/pelvis:
impression:
mild amount of subcutaneous air in the anterior abdominal wall
inferiorly is likely related to injections.
trace pelvic free fluid, could be physiologic (if patient
pre-menopausal), or could relate to vp shunt.

micro:
blood cx [**2180-6-3**]: pending
urine cx [**2180-6-3**]: pending
sputum cx [**2180-6-3**]:
[**2180-6-3**] 11:45 am sputum

   gram stain (final [**2180-6-3**]):
      >25 pmns and <10 epithelial cells/100x field.
      3+  (5-10 per 1000x field):   gram negative diplococci.
      2+   (1-5 per 1000x field):   gram negative rod(s).
      1+    (<1 per 1000x field):   gram positive cocci.
                                    in pairs and in short
chains.
      1+    (<1 per 1000x field):   gram positive rod(s).

   respiratory culture (preliminary):

[**2180-6-8**] 06:15am blood wbc-8.8 rbc-3.24* hgb-10.0* hct-30.7*
mcv-95 mch-30.9 mchc-32.6 rdw-14.9 plt ct-378
[**2180-6-7**] 05:55am blood wbc-7.5 rbc-3.19* hgb-9.8* hct-30.3*
mcv-95 mch-30.8 mchc-32.4 rdw-14.6 plt ct-333
[**2180-6-6**] 06:14am blood hct-30.9*
[**2180-6-6**] 04:02am blood wbc-7.4 rbc-2.68* hgb-8.2* hct-24.9*
mcv-93 mch-30.8 mchc-33.1 rdw-14.5 plt ct-322
[**2180-6-5**] 05:46am blood wbc-8.0 rbc-3.20* hgb-9.9* hct-29.8*
mcv-93 mch-30.8 mchc-33.1 rdw-14.4 plt ct-264
[**2180-6-4**] 04:25am blood wbc-7.1# rbc-2.98*# hgb-9.2*# hct-28.0*#
mcv-94 mch-30.9 mchc-32.9 rdw-14.4 plt ct-280
[**2180-6-3**] 11:12am blood wbc-16.8* rbc-4.34 hgb-13.3 hct-39.0
mcv-90 mch-30.6 mchc-34.0 rdw-14.5 plt ct-421
[**2180-6-3**] 11:12am blood neuts-82.2* lymphs-10.4* monos-5.8
eos-0.7 baso-0.8
[**2180-6-8**] 06:15am blood plt ct-378
[**2180-6-5**] 05:46am blood pt-11.1 ptt-26.3 inr(pt)-0.9
[**2180-6-8**] 06:15am blood glucose-117* urean-6 creat-0.4 na-137
k-4.0 cl-98 hco3-32 angap-11
[**2180-6-7**] 05:55am blood glucose-103* urean-4* creat-0.3* na-138
k-3.9 cl-101 hco3-30 angap-11
[**2180-6-6**] 04:02am blood glucose-87 urean-6 creat-0.4 na-141 k-3.8
cl-107 hco3-27 angap-11
[**2180-6-5**] 05:46am blood glucose-139* urean-6 creat-0.4 na-136
k-4.0 cl-105 hco3-24 angap-11
[**2180-6-4**] 04:25am blood glucose-117* urean-11 creat-0.4 na-137
k-3.9 cl-108 hco3-22 angap-11
[**2180-6-3**] 11:12am blood glucose-128* urean-19 creat-0.7 na-132*
k-5.1 cl-95* hco3-20* angap-22*
[**2180-6-7**] 05:55am blood alt-74* ast-50* alkphos-78 totbili-0.1
[**2180-6-5**] 05:46am blood alt-33 ast-22 ld(ldh)-242 alkphos-69
totbili-0.1
[**2180-6-3**] 11:12am blood alt-53* ast-38 ld(ldh)-309* alkphos-98
amylase-47 totbili-0.2
[**2180-6-7**] 05:55am blood lipase-24
[**2180-6-5**] 05:46am blood lipase-29
[**2180-6-3**] 11:12am blood lipase-42
[**2180-6-8**] 06:15am blood calcium-9.0 phos-3.2 mg-2.4
[**2180-6-7**] 05:55am blood albumin-3.2* calcium-8.7 phos-3.6 mg-2.4
[**2180-6-6**] 04:02am blood calcium-8.5 phos-3.4 mg-2.3
[**2180-6-5**] 05:46am blood calcium-8.4 phos-2.8 mg-2.2 iron-20*
[**2180-6-4**] 04:25am blood calcium-7.9* phos-3.1 mg-2.2
[**2180-6-3**] 11:12am blood albumin-4.3 calcium-9.5 phos-3.1 mg-2.8*
[**2180-6-5**] 05:46am blood caltibc-218* ferritn-290* trf-168*
[**2180-6-4**] 04:56am blood type-[**last name (un) **] po2-76* pco2-43 ph-7.37
caltco2-26 base xs-0
[**2180-6-4**] 04:56am blood lactate-1.2
[**2180-6-3**] 11:21am blood lactate-2.3*

brief hospital course:
pt is a 46 yo f w pmh of avm intracerebral bleed c/b cerebral
edema in [**2178**] requiring a trach and peg who presents with
increased respiratory secretions, increased lethargy,
hypotension and fever concerning for severe sepsis. she was
transferred to the micu for hypotension and closer monitoring.
she was treated with linezolid and cefepime. cultures were sent
and showed e coli in the urine sensitive to cefepime.

# severe sepsis: patient's vitals in the ed were temp 102, hr
126, rr 26, with a wbc count of [**numeric identifier 2686**]. patient met all 4
criteria for sirs. patient also has a ua concerning for uti. pt
also has a trach aspirate growing moraxella from an osh and a
sputum culture pending here; however, clear lungs, lack of
increased sputum or o2 requirement here, lack of infiltrate
makes hap unlikely. ct abdomen unrevealing. pt was bolused with
ivf's and hypotension resolved. she would become intermittently
hypotensive 1-2x/day throughout her micu course thought to be
secondary to autonomic dysfunction secondary to her stroke.
sepsis was thought to be resolved, and the hypotension would
quickly recover on its own or with small fluid bolus. she was
started on linezolid given history of vanc allergy & vre
positive per report, in addition to cefepime to cover for gnr's
on [**2180-6-3**] for day 1. c. diff was ordered; however, pt was not
stooling while in the micu. kub was sent and revealed
constipation. she remained hemodynamically stable with no
pressor requirement while in the micu. cultures were sent and
showed e coli in the urine sensitive to cefepime.
outpatient issues:
-- continue cefepime next 4 days to complete 14d course,
midodrine

# abdominal pain: unclear origin but most likely [**12-29**] uti,
possible pyelonephritis. lfts showed only mildly elevated alt.
ct abd unrevealing. abdomen remained soft. vp peritonitis
considered, but only minimal ascites on imaging in addition to
benign abdomen on exam. kub revealed constipation and she
improved with suppositories and laxatives. once on floor s/p
micu stay, pt no longer complained of abdominal pain.

# anion gap acidosis: likely [**12-29**] lacate. lactate downtrended and
acidosis resolved.

# anemia: normocytic, previous baseline ~ 30-32. likely dry on
admission, and hct fell to 28, likely dilutional in setting of
volume resuscitation. patients hematocrit monitored daily. hcts
remained stable.
 .
# hypotension. per report patient with baseline sbps in
90s-100s. in micu patient received a total of 6.5l in 500cc
boluses to maintain pressures. with treatment of infection sbps
stabilized to 100s. decision made to start patient on standing
midodrine to treat possible component of autonimic dysfunction
secondary to known intracranial pathology.

# s/p intracerebral bleed: baseline neuro status according to
husband. on trach and peg. has [**2-29**] r sided strength, left sided
weakness. no acute issues.

# depression: wellbutrin held on linezolid due to initial
concern for serotonin syndrome. patient continued on ambien.


medications on admission:
-jevity tube feeds @ 85 cc/hr via ng tube at 8pm off at 6am
-azocranberry 150 mg ng [**hospital1 **]
-lactulose 15 ml ng [**hospital1 **]
-ritalin 2.5 mg ng daily
-clonidine 0.1 mg ng [**hospital1 **]
-vitamin b complex 1 tab ng daily
-lovanox 40 mg subq daily
-zantac 150 mg/10 ml syrup ng daily
-senna 2 tabs ng daily
-wellbutrin 100 mg ng daily
-ambien 5 mg ng qhs
-tylenol 650 mg ng q4h prn:pain, fever
-simethicone 80 mg ng qid prn:gas pain
-acetylcysteine [mucomyst] 600 mg neb [**hospital1 **]

discharge medications:
1. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2
times a day): [**month (only) 116**] decrease by half if pt has more than 2 bowel
movements per day.
2. b complex vitamins capsule sig: one (1) cap po daily (daily).

3. ranitidine hcl 15 mg/ml syrup sig: one [**age over 90 1230**]y (150) mg
po daily (daily).
4. senna 8.6 mg tablet sig: two (2) tablet po daily (daily).
5. acetaminophen 500 mg tablet sig: one (1) tablet po q4h (every
4 hours) as needed for pain.
6. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
7. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
8. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid
(4 times a day) as needed for thrush.
9. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1)
tablet, sublingual sublingual qid (4 times a day).
10. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2
times a day).
11. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po
daily (daily) as needed for constipation.
12. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a
day). disp:*180 tablet(s)* refills:*2*
13. cefepime 2 gram recon soln sig: one (1) recon soln injection
q12h (every 12 hours): for the next four days through [**2180-6-16**].
14. lovenox 40 mg/0.4 ml syringe sig: one (1) subcutaneous once
a day.
15. bisacodyl 5 mg tablet sig: 1-2 tablets po once a day as
needed: for constipation. tablet(s)
16. mucomyst neb sig: 600mg twice a day: give acetylcysteine
600mg neb [**hospital1 **].


discharge disposition:
extended care

facility:
[**hospital3 2558**] - [**location (un) **]

discharge diagnosis:
urosepsis

discharge condition:
level of consciousness: alert and interactive, though
neurologically limited.
activity status: bedbound.
mental status: confused - sometimes.


discharge instructions:
dear ms. [**known lastname **]: it was a pleasure participating in your care at
[**hospital1 69**]. you were treated here for
urosepsis, which is a severe infection of the bladder. you need
4 more days of antibiotics through your veins. you were also
treated for a likely infection of your lungs, you already
completed antibiotics for that. you should continue your
medications as you had previously, and take the antibiotics as
prescribed in the medicine list.
.
changes to your medication:
start: to treat infection, please take your cefepime twice per
day for the next 4 days.
start: please continue your bowel regimen (laxatives) as
prescribed on the medication sheet to avoid constipation and
belly pain.
start: to treat low blood pressure please take the midodrine as
prescribed on your medication sheet.

stop: ritalin 2.5mg daily, you did not seem to need this. you
are now getting midodrine.
stop: clonidine, your blood pressures were low during this
admission.
hold: wellbutrin 100mg daily. you can discuss with your rehab
doctor when you resume this medication.
to avoid future urinary tract infections, you should have your
diapers changed very regularly. your institution may want to
straight-cath collect urine every 4 hours if diaper changes are
not frequent enough.

followup instructions:
please follow up with the doctors at rehab this week.



completed by:[**2180-6-12**]"
206,"admission date:  [**2108-6-26**]              discharge date:   [**2108-7-2**]

date of birth:  [**2049-2-6**]             sex:   f

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2108-6-26**]: laparascopic sleeve gastrectomy


history of present illness:
[**known firstname **] has class iii extreme morbid obesity with weight of
364.3 pounds as of [**2108-5-29**] (her initial screen weight on [**2108-5-22**]
was 368 pounds), height of 65 inches and bmi 60.6.  her previous
weight loss efforts have included hmr for one year in [**2104**]
losing 20 pounds, off-label prescription weight loss medication
combination of fenfluramine/phentermine (""fen/phen"") in [**2092**] for
one year losing 70 pounds and [**street address(1) 41635**] visits on/off over
the past 5 years with very little weight loss.  she has exercise
for two years at curves for women losing 50 pounds and one year
of [**location (un) 86**] sports club in [**2106**] to [**2107**] losing 20 pounds. in all
of her efforts whatever weight she loss she was unable to
maintain from no more than one year.  she denied taking
over-the-counter ephedra-containing appetite suppressant/herbal
supplements.  her weight at age 21 was 150 pounds with her
lowest adult weight 125 pounds and her highest weight being 377
pounds earlier this year (2/[**2108**]).  she weighed 192 pounds at
age 33, 200 pounds at age 38, 286 pounds at age 46 and 325
pounds at the age of 50.  she stated she developed a significant
[**last name 4977**] problem at the age of 35 and has been struggling with
weight since birth of her second child and quit  smoking in
[**2081**].  factors contributing to her excess weight include large
portions, genetics, too many carbohydrates and emotional eating.
 for exercise she does water aerobics 60 minutes 5 days per week
since [**month (only) 359**] and lap swimming 90 minutes 5 days per week.  she
denied history of eating disorders and does have depression but
has not been followed by a therapist nor has she been
hospitalized for mental health issues and she is on psychotropic
medication (sertraline).


past medical history:
past medical history:  notable for fatty liver, rotator cuff
tendinitis, right shoulder, obstructive sleep apnea, type 2
diabetes with a1c of 6%, dyslipidemia, gastroesophageal reflux,
osteoarthritis of the knees, aortic valve regurgitation, past
depression.

past surgical history:  c-section x 2, carpal tunnel, right hand

social history:
she smoked one to two packs a day for 25 years quit [**2091**], no
recreational drugs, has occasional alcohol, drinks caffeinated
beverages.  she is a retired teacher, is divorced and has two
adult children

family history:
her family history is noted for father deceased age 58 with
heart disease, hyperlipidemia and obesity; mother living with
hyperlipidemia; sister deceased at 36 years of age secondary to
bulimia; maternal and paternal grandparents with heart
disorders.

physical exam:
vs: t 98, hr 86, bp 149/65, rr 18, o2 97%ra

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd: soft, appropriate peri-incisional tenderness, no rebound
tenderness/guarding
wounds: abd lap sites with steri-strips cdi, no periwound
erythema, + periwound ecchymosis
ext: no edema

pertinent results:
labs:
[**2108-6-27**] 07:40am blood hct-36.2
[**2108-6-26**] 04:21pm blood hct-38.4
[**2108-6-28**] 09:38am blood type-art po2-70* pco2-47* ph-7.40
caltco2-30 base xs-2
[**2108-6-30**] 06:40am blood wbc-5.6 rbc-4.21 hgb-11.3* hct-36.6
mcv-87 mch-26.7* mchc-30.7* rdw-15.2 plt ct-184 neuts-81.0*
lymphs-12.6* monos-3.6 eos-2.7 baso-0.1

imaging:
[**2108-6-27**]:
ugi sgl contrast w/ kub:
impression:  no evidence of obstruction or leak.


brief hospital course:
the patient presented to pre-op on [**2108-6-26**]. pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparascopic sleeve gastrectomy. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout
hospitalization; pain was initially managed with a pca and then
transitioned to oral roxicet once tolerating a stage 2 diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient was triggered on pod2 for desaturations
with an increased oxygen requirement.  the patient was
subsequently transferred to the tsicu on pod2 where she was
weaned to 3l nasal cannula; vancomycin was initiated as empiric
therapy.  she was subsequently transferred back to the general
surgical [**hospital1 **] on pod3 and weaned completely from o2 on pod5.
good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization. the pt was
maintained on cpap overnight for known sleep apnea.
gi/gu/fen: the patient was initially kept npo.  on pod1, an
upper gi study, which was negative for a leak, therefore, the
diet was advanced sequentially to a bariatric stage 2 diet,
which was well tolerated. however, on pod2, during period of
acute oxygen desaturation, the pt was made npo.  a methylene
blue dye test was performed without change in character of drain
output which remained serosanguinous throughout the admission.
the patient's diet was resumed and she was able to tolerate a
stage 3 diet without incident. patient's intake and output were
closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none; empiric treatment with
vancomycin was administered from pod2 through pod5 as described
above.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
metformin 500 mg [**hospital1 **]
omeprazole 20 mg daily
sertraline 50 mg daily
simvastatin 20 mg daily
vitamin d3 5000 units daily
multivitamin with minerals 1 tablet daily

discharge medications:
1. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*
2. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a day
for 1 months.
disp:*600 ml* refills:*0*
3. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**6-21**] ml
po every four (4) hours as needed for pain.
disp:*250 ml* refills:*0*
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day.
disp:*250 ml* refills:*0*
5. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable/crushable; no gummy.
6. metformin 500 mg tablet sig: 0.5 tablet po twice a day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule;
sprinkle contents onto applesauce, swallow whole.
8. sertraline 50 mg tablet sig: one (1) tablet po once a day.
9. simvastatin 20 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
morbid obesity


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except:
1.  please decrease your metformin to 250 mg twice daily.
please continue to monitor blood sugars and report elevated or
low readings to your prescribing provider.

crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:15 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2108-7-11**] at 11:30 am
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2108-7-2**]"
207,"admission date:  [**2118-10-14**]              discharge date:   [**2118-10-25**]

date of birth:  [**2068-6-1**]             sex:   m

service: [**hospital unit name 196**]

allergies:
vancomycin

attending:[**first name3 (lf) 4765**]
chief complaint:
dizziness

major surgical or invasive procedure:
cardiac catheterization with stent placement
intubation
urinary tract infection


history of present illness:
50yo man with h/o cad s/p imi and rca stent in [**2-13**], also with
h/o hypercholesterol, [**date range **], etoh, who p/t an osh hospital with
nstemi (st depressions in ii, iii, avf), bradycardic and
nauseated. he was transferred to [**hospital1 18**] emergently for cardiac
cath.

past medical history:
cad s/p imi and rca stent in [**2-13**]
hypercholesterol
[**date range **]
etoh

social history:
lives with his wife and daughter in [**name (ni) 28117**], ma, though wife
has avoided him recently because of his etoh use and depression.

etoh: significant increase in use x 6mths since his mother died
[**name2 (ni) **]: none
drugs: none

family history:
cad, with mi <55 in several relatives

physical exam:
vitals: t100.3, hr 100(paced), rr24 (vent), o2 sat 100% on 50%
fio2
gen: middle-aged man lying in bed, sleeping, awoken to voice
skin: warm and dry; no perspiration, no groin hematoma, no flank
hematoma; right groin with no bleeding
heent: normal size pupils, perrl, mmm, no oral bleeding, poor
dentition with missing teeth
cv: normal s1 s2, no g/r/m
lungs: bibasilar rales, no w/r, no egoph, no tact frem
abd: +bowel sounds, soft, nt/nd, no hsm, no masses palpated
ext: 2+ dp pulses b/l, feet warm and well perfused; no le edema
neuro: a+ox3

pertinent results:
[**2118-10-14**] 10:00pm blood wbc-16.4*# rbc-3.20* hgb-11.4* hct-33.0*
mcv-103*# mch-35.4* mchc-34.5 rdw-11.6 plt ct-221
[**2118-10-15**] 12:30am blood wbc-25.8*# rbc-3.83* hgb-13.3* hct-37.6*
mcv-98 mch-34.7* mchc-35.4* rdw-12.0 plt ct-362#
[**2118-10-23**] 12:15pm blood wbc-13.6* rbc-4.08* hgb-13.3* hct-38.2*
mcv-94 mch-32.5* mchc-34.8 rdw-13.8 plt ct-442*
[**2118-10-25**] 11:24am blood wbc-14.8* rbc-4.01* hgb-13.1* hct-37.1*
mcv-93 mch-32.7* mchc-35.3* rdw-14.0 plt ct-616*
[**2118-10-18**] 11:09pm blood neuts-77.8* lymphs-10.3* monos-5.2
eos-6.2* baso-0.5
[**2118-10-14**] 10:00pm blood pt-18.2* ptt-150.0* inr(pt)-2.1
[**2118-10-14**] 10:00pm blood plt ct-221
[**2118-10-15**] 12:30am blood pt-15.8* ptt-138.5* inr(pt)-1.6
[**2118-10-15**] 12:30am blood plt ct-362#
[**2118-10-22**] 06:01am blood plt ct-319
[**2118-10-23**] 12:15pm blood pt-13.9* ptt-25.4 inr(pt)-1.2
[**2118-10-23**] 12:15pm blood plt ct-442*
[**2118-10-25**] 11:24am blood plt ct-616*
[**2118-10-17**] 12:08pm blood fibrino-567* d-dimer-1370*
[**2118-10-17**] 12:08pm blood fdp-0-10
[**2118-10-14**] 10:00pm blood glucose-406* urean-8 creat-0.7 na-133
k-3.5 cl-104 hco3-13* angap-20
[**2118-10-15**] 12:30am blood glucose-229* urean-8 creat-0.9 na-135
k-4.1 cl-106 hco3-14* angap-19
[**2118-10-22**] 06:01am blood glucose-96 urean-11 creat-0.7 na-141
k-3.7 cl-101 hco3-31* angap-13
[**2118-10-23**] 12:15pm blood glucose-83 urean-11 creat-0.8 na-145
k-3.6 cl-107 hco3-24 angap-18
[**2118-10-24**] 06:45am blood glucose-95 urean-18 creat-0.8 na-145
k-4.7 cl-109* hco3-28 angap-13
[**2118-10-14**] 10:00pm blood ck(cpk)-69
[**2118-10-15**] 12:30am blood ck(cpk)-512*
[**2118-10-15**] 03:56am blood alt-33 ast-150* ld(ldh)-506* alkphos-82
totbili-0.6
[**2118-10-15**] 04:17am blood alt-25 ast-53* ld(ldh)-259* ck(cpk)-1355*
alkphos-85 totbili-0.6
[**2118-10-15**] 04:55pm blood ck(cpk)-6653*
[**2118-10-16**] 12:10am blood ck(cpk)-6893*
[**2118-10-16**] 07:27am blood alt-35 ast-144* ld(ldh)-428*
ck(cpk)-6313* alkphos-73 totbili-0.6
[**2118-10-19**] 04:24am blood ck(cpk)-3207*
[**2118-10-22**] 06:01am blood alt-50* ast-48* ck(cpk)-581* alkphos-167*
totbili-0.5
[**2118-10-23**] 12:15pm blood ggt-227*
[**2118-10-14**] 10:00pm blood ck-mb-5
[**2118-10-15**] 12:30am blood ck-mb-19* mb indx-3.7 ctropnt-0.28*
[**2118-10-15**] 04:17am blood ck-mb-44* mb indx-3.2 ctropnt-1.19*
[**2118-10-15**] 04:55pm blood ck-mb-45* mb indx-0.7 ctropnt-1.17*
[**2118-10-14**] 10:00pm blood calcium-3.5* phos-2.5* mg-1.7
[**2118-10-15**] 12:30am blood calcium-6.1* phos-1.8* mg-1.9
[**2118-10-15**] 03:56am blood calcium-8.1* phos-3.3 mg-1.9
[**2118-10-15**] 04:17am blood albumin-3.3* calcium-8.1* phos-1.9*
mg-2.5
[**2118-10-23**] 12:15pm blood calcium-8.7 phos-3.8 mg-2.3
[**2118-10-24**] 06:45am blood calcium-8.8 phos-3.7 mg-2.3
[**2118-10-17**] 04:35pm blood hapto-53
[**2118-10-15**] 08:35am blood %hba1c-5.0
[**2118-10-17**] 12:08pm blood triglyc-99
[**2118-10-16**] 07:27am blood tsh-0.090*
[**2118-10-16**] 07:27am blood free t4-1.0
[**2118-10-16**] 07:27am blood cortsol-29.8*
[**2118-10-14**] 10:13pm blood type-art tidal v-700 peep-5 o2-100
po2-304* pco2-41 ph-7.19* calhco3-16* base xs--11 aado2-390 req
o2-67 -assist/con intubat-intubated
[**2118-10-15**] 12:51am blood type-art temp-34.4 tidal v-600 o2-100
po2-191* pco2-31* ph-7.25* calhco3-14* base xs--12 aado2-509 req
o2-83 intubat-intubated vent-imv
[**2118-10-15**] 04:19am blood type-art po2-280* pco2-34* ph-7.46*
calhco3-25 base xs-1
[**2118-10-15**] 06:51am blood type-art o2-80 po2-291* pco2-30* ph-7.48*
calhco3-23 base xs-0 aado2-264 req o2-50 intubat-intubated
[**2118-10-15**] 01:45pm blood type-art temp-39.3 rates-22/ tidal v-650
peep-5 o2-50 po2-168* pco2-37 ph-7.46* calhco3-27 base xs-3
intubat-intubated
[**2118-10-17**] 04:13pm blood type-art temp-36.8 rates-/24 tidal v-430
peep-5 o2-40 po2-132* pco2-43 ph-7.45 calhco3-31* base xs-5
intubat-intubated vent-spontaneou
[**2118-10-20**] 06:03am blood type-art po2-142* pco2-44 ph-7.45
calhco3-32* base xs-6
[**2118-10-20**] 01:05pm blood type-art temp-36.8 po2-104 pco2-39
ph-7.46* calhco3-29 base xs-3
[**2118-10-15**] 12:51am blood lactate-7.3*
[**2118-10-15**] 12:51am blood freeca-0.83*
[**2118-10-19**] 09:19pm blood freeca-1.13

brief hospital course:
upon arrival to the cath lab the pt was slurring his speech,
nauseated and smelled of etoh. while his disorientation
prohibited the pt from making an informed decision about the
cath, the concern for acute mi and the apparent life threatening
nature of the event compelled the cardiac team to proceed with
the cath.

during the cath, the pt was found to be in bradycardic afib with
[**last name (lf) 46360**], [**first name3 (lf) **] two attempts at cardioversion were attempted without
success.  the pt was intubated at this time for airway
protection in the setting of repetitive vomitting. an attempt
was made to cross a lesion in the patient's om1 branch with a
graphix wire, at which time the patient went into vfib. over the
next 30-40 minutes, the pt received cpr intermittently, iv
lidocaine, amiodarone bolus x 300mg and iv drip, iv epinephrine,
defribrillation at 360j x 20 attempts. because of severe
bradycardia after cardioversion, a temporary pacing cath was
placed, with initial rate set at 100bpm. after stabilized in
this manner, the om1 branch was stented open. an attempt
thereafter to decrease his pacer rate to 60bpm resulted in
recurrent vfib. a second pacer wire was placed to reposition,
and then first pacer wire removed. finally, an iabp was placed
with sbp around 130mmhg thereafter, and the patient was
transferred to the ccu for further care.

1. cardio
a. coronaries: as above, pt had stent placed to his om1 branch
in the cath lab, with good post-cath flow and no evid of
dissection. pt was cont on asa, plavix, lipitor. also given
aggrastat x 2d post cath. was on heparin for iabp, which was
stopped after the iabp was removed.
b. pump: pt was transferred to the unit on pressors and iabp on
am on [**2118-10-15**]. iabp was d/c on pm of [**2118-10-16**].  dopamine was
titrated off over the course of several days as his blood
pressure tolerated.  tte revealed lvef 40%; hk of the inferior
free wall. started on metoprolol and captopril, switched over to
lisinopril prior to d/c.
c. rhythm: as noted, pt had recurrent vfib in cath lab, then had
5 episodes of vfib overnight while in the ccu during his first
night, all reverted to paced rhythm at 100bpm once shocked with
pacing pads at 360j x once.  pt was felt to be moving and
dislodging the pacing wires, leading to his vfib, so his
sedation was increased and thereafter he did not have any
further vfib. was initially on an amio drip and a lido drip from
cath lab. lido was weaned off on [**10-16**], with amio weaned off [**10-17**].
pt had his pm turned off, with normal sinus at 70bpm but
occassional drops to 35bpm with no [**month/day (4) 46360**].  pacer was d/c'd after
several days with no adverse events, no requirement for external
pacing. ep felt that pt's arrythmias were [**3-14**] acute ischemia now
resolved and that he would not benefit from an aicd.

2. pulm: pt extubated from cath lab, extubated on [**10-21**]; pt was
given a course of flagyl and levaquin x 10d for possible asp
pna.

3. renal: lytes were repleted qd

4. id: pt had rll atelectasis vs pna on initial cxr, was started
on abx; blood cultures with 1/2 anaerobic bottles growing gpc in
pairs/chains; started on abx on [**10-16**] -- was on vanc for 3d, zosyn
for 7d, ceftriaxone, ceftaz and flagyl; continued flagyl and
levaquin x 10d for possible asp pna.

5. gi: pt had sanguinous heme+ ogt drainage initially, gi
consult was sought. gi advised to follow hct, protonix [**hospital1 **] and
conservative management given the patient's anticoagulated
state. pt's ogt drainage resolved spontaneously after several
days.

6. heme: pt had platelet and hct drop initially, both of unclear
etiologies, which resolved; hit ab test was negative, plt drop
may have been related to prbc transfusions; hemolysis and dic
w/u negative, no source of bleeding other than initial ugib
found. pt received a total of 6 units over the course of this
hospitalization. hct was trending up and greater than 30 upon
discharge.

7. neuro/psych: pt was thought to be likely to have anoxic brain
injury vs. etoh dementia initially, though this did not seem to
be the case. he had no gross neuro deficits, was briefly on a
ciwa scale but did not show signs of etoh withdrawal. psych
evaluated, recommended outpatient f/u for patient's depression
and etoh use, which was set up for the pt prior to his d/c.

medications on admission:
asa
plavix
enalapril
lopressor
lipitor
ativan
paxil

discharge medications:
1. metoprolol succinate 50 mg tablet sustained release 24hr sig:
one (1) tablet sustained release 24hr po qd (once a day).
disp:*30 tablet sustained release 24hr(s)* refills:*2*
2. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every
24 hours) for 7 days.
disp:*7 tablet(s)* refills:*0*
3. multivitamin     capsule sig: one (1) cap po qd (once a day).
disp:*30 cap(s)* refills:*2*
4. lisinopril 5 mg tablet sig: 0.5 tablet po qd (once a day).
disp:*15 tablet(s)* refills:*2*
5. thiamine hcl 100 mg tablet sig: one (1) tablet po qd (once a
day).
disp:*30 tablet(s)* refills:*2*
6. folic acid 1 mg tablet sig: one (1) tablet po qd (once a
day).
disp:*30 tablet(s)* refills:*2*
7. atorvastatin calcium 80 mg tablet sig: one (1) tablet po once
a day.
disp:*30 tablet(s)* refills:*2*
8. aspirin, buffered 325 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
9. pantoprazole sodium 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*
10. docusate sodium 100 mg capsule sig: one (1) capsule po once
a day as needed for constipation.
disp:*30 capsule(s)* refills:*0*
11. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*


discharge disposition:
home

discharge diagnosis:
myocardial infarction (nstemi)
ventricular fibrillation
urinary tract infection


discharge condition:
stable

discharge instructions:
please take all medications as prescribed and attend all
appointments made for you. you will also need to schedule an
appointment with your primary care doctor, dr. [**last name (stitle) 27542**], by
calling ([**telephone/fax (1) 29515**] and with your cardiologist, dr. [**last name (stitle) 11493**], by
calling ([**telephone/fax (1) 29810**]. you should ask for appointments within
the next two weeks if at all possible.  you should mention to
the secretaries that you have just been discharged from the
hospital after having a myocardial infarction (heart attack)
that was complicated by ventricular fibrillation (a dangerous
disorganized electrical activity in the heart).  you should
mention that your doctor in the hospital wanted you to be seen
as soon as possible as an outpatient to follow up on the
medications that you were started on during your admission.

you have been set up for an appointment at [**hospital1 **], [**last name (namepattern1) 46361**] in [**hospital1 1559**], [**numeric identifier 46362**] this thursday, [**10-27**] at 1pm for
assistance in avoiding the health problems associated with
alcohol use.  while this is voluntary, we feel that it is very
important to your well being and the best way you can stay
healthy in the weeks and months ahead.  drinking for you is
particularly risky given your heart condition, and may have been
a factor in your recent heart attack.

you were admitted to this hospital on [**2118-10-14**] with a myocardial
infarction and are being discharged on [**2118-10-25**] having been
treated for this health problem as well as several complications
that have arrisen during the course of your hospitalization.
while you do not require physical therapy at this time, it is
important that you return to work only once you feel comfortable
to do so.  this may take up to a week depending on how quickly
your body recovers.

if you have any symptoms of chest pain, shortness of breath, or
any other complaints that concern you please return the er for
evaluation.

followup instructions:
please make appointments to see your primary care doctor as well
as your cardiologist:
dr. [**last name (stitle) 27542**] ([**telephone/fax (1) 29515**]
dr. [**last name (stitle) 11493**] ([**telephone/fax (1) 29810**]



"
208,"admission date:  [**2179-2-8**]     discharge date:  [**2179-2-12**]

date of birth:   [**2125-1-21**]     sex:  f

service:  ccu

history of present illness:  the patient is a 54 year old
white female with a history of hypertension,
hypercholesterolemia, and smoking history, who was
transferred to [**hospital1 69**] with
acute anterior myocardial infarction, status post failed
thrombolysis at outside hospital.

the patient reports onset of symptoms on the morning of
admission of acute midback pain with eventual radiation to
the chest, seven out of ten, with radiation to her left upper
extremity with associated shortness of breath, nausea and
diaphoresis.

she called ems within five minutes and was brought to [**hospital3 6454**] emergency department where she was found to have
anterior st elevations in v1 through v4.  she was given
morphine 2 mg intravenously times two, sublingual
nitroglycerin and nitroglycerin drip, heparin and reteplase
times two.

per records, she arrived at the [**hospital3 1280**] emergency
department at 10:40 a.m.  symptom onset was approximated to
be at 10:00 a.m.  she received her first dose of reteplase at
10:53 a.m. and her second dose at 11:23 a.m.  her symptoms
did not improved and her st elevation persisted and she was
transferred to [**hospital1 69**] for
emergent catheterization.

she arrived at the catheterization laboratory at 1:30 p.m.
at cardiac catheterization, she was found to have a tortuous
coronary circulation with a totally occluded distal left
anterior descending which was stented with timi two flow post
and complicated by grade b dissection distally.  she was
given intracoronary vasodilators and no further intervention
was pursued.  her left circumflex, right coronary artery and
left main coronary artery were without significant disease.

a left ventriculogram was performed and notable for
anteroapical and inferoapical akinesis with an ejection
fraction of 40%.

right heart cardiac catheterization revealed pulmonary
capillary wedge pressure of 18 and right atrial pressure of
13.  postprocedure, she was given full dose integrilin for 18
hours.

upon arrival to the ccu, she had the chief complaint of
nausea but denied shortness of breath or chest pain.

past medical history:
1.  hypertension.
2.  hypercholesterolemia.
3.  osteoporosis.
4.  history of atypical colitis, steroid dependent since
[**9-4**].  history of diagnosis of collagenous colitis in the past.
6.  status post tubal ligation.

medications on admission:
1.  zestril 2.5 mg p.o. once daily.
2.  prednisone 20 mg p.o. once daily.
3.  asacol 1600 mg p.o. three times a day.
4.  rowasa enemas pr once daily.
5.  fosamax 10 mg p.o. once daily.
6.  prempro p.o. once daily.
7.  serax p.r.n.
8.  zomig p.r.n.

allergies:  no known drug allergies.

family history:  no history of early coronary artery disease
or myocardial infarction.

social history:  the patient lives in [**location 38080**] with
husband.  she has two children.  she has smoked one pack per
day since college.  she has one to two cocktails per night.
recently laid off.

physical examination:  on examination, temperature is
afebrile, blood pressure 135/74, heart rate 90, respiratory
rate 16, oxygen saturation 98% on two liters.  in general,
the patient is somnolent in no apparent distress.  head,
eyes, ears, nose and throat - the pupils are equal, round,
and reactive to light and accommodation.  extraocular
movements are intact.  mucous membranes are mildly dry.  the
neck is soft, supple, no lymphadenopathy, jugular venous
distention, thyromegaly or masses.  cardiac examination -
regular rate and rhythm, no murmurs, s4 gallop.  the lungs
are clear to auscultation bilaterally.  the abdomen is soft,
nondistended, nontender, no organomegaly or masses,
normoactive bowel sounds.  extremities - right groin with
small hematoma.  extremities without edema, warm and with
good distal pulses.  neurologically, the patient is alert and
oriented times three, grossly nonfocal.

laboratory data:  white count 15.8, hematocrit 36.5,
platelets 238,000.  inr 1.1.  sodium 137, potassium 4.7,
blood urea nitrogen 7, creatinine 0.6, glucose 150.  ck peak
1148, ck mb peak 150.

initial electrocardiogram normal sinus rhythm, normal axis,
intervals, 2.[**street address(2) 2811**] elevations in v2 through v4 with
peaked t waves, 1.[**street address(2) 2811**] elevations in i and ii, 0.[**street address(2) 38081**] elevations in v5 and v6.

hospital course:
1.  coronary artery disease - status post acute anterior
myocardial infarction, total occlusion of the distal left
anterior descending, status post left anterior descending
stent, complicated by distal dissection and with timi two
flow post intervention.  the patient was hemodynamically
stable throughout her hospitalization.  her ck peaked at 1148
and then trended down.  she was treated with integrilin for
18 hours postcatheterization and then received aspirin,
plavix, beta blocker and ace inhibitor.  she was also started
on lipitor for a lipid panel with total cholesterol of 249,
and ldl of 143.  she will be discharged on aspirin, plavix to
finish one month course, atenolol, zestril and lipitor.

2.  pump - left ventriculogram during cardiac catheterization
was notable for apical akinesis and ejection fraction of 40%.
she had no signs or symptoms of congestive heart failure
during her hospitalization.  she was started on beta blocker
and ace inhibitor as above.  given her apical akinesis, she
was started on anticoagulation initially with heparin drip
and then with low molecular weight heparin as well as
coumadin.  she will be discharged on lovenox and coumadin, to
have inr followed up as an outpatient.

3.  electrophysiology - the patient with no adverse events on
telemetry during her hospitalization except for rare
premature ventricular contractions.

4.  hematology - the patient with right groin hematoma,
status post cardiac catheterization.  she was also noted on
the following evening to have a bruit over that area.  an
ultrasound revealed 1.7 by 2.0 centimeter pseudoaneurysm
which was treated with thrombin injection with good result.
her anticoagulation was held temporarily during these events
and then restarted without complications.  at the time of
discharge, the patient still has residual ecchymosis over her
right lower extremity as well as a small but stable hematoma.

5.  gastrointestinal - the patient had no gastrointestinal
symptoms during her hospitalization and was continued on her
outpatient regimen of asacol and rowasa enemas.  she received
stress dose steroids pericatheterization and then was
switched to a p.o. prednisone taper starting at 60 mg to be
tapered down to her baseline of 20 mg.

6.  endocrine - the patient has been on prempro as an
outpatient.  this was held in the setting of her acute
myocardial infarction but she will be able to restart this as
an outpatient.

medications on discharge:
1.  enteric coated aspirin 325 mg p.o. once daily.
2.  plavix 75 mg p.o. once daily, to continue one month
course.
3.  coumadin 5 mg p.o. once daily.
4.  lovenox 60 mg subcutaneous times three more doses.
5.  zestril 2.5 mg p.o. once daily.
6.  atenolol 25 mg p.o. once daily.
7.  prednisone taper down to 20 mg once daily.
8.  asacol 1600 mg p.o. three times a day.
9.  rowasa enema once a day.
10. fosamax 10 mg p.o. once daily.
11. prempro p.o. once daily.
12. serax p.r.n.

the patient has been ask to discontinue zomig in the setting
of coronary artery disease.

discharge follow-up:  with primary care physician, [**last name (namepattern4) **]. [**first name (stitle) 9959**]
[**name (stitle) 9960**], telephone [**2179**].




                          [**first name8 (namepattern2) 870**] [**last name (namepattern1) **], m.d.  [**md number(1) 5219**]

dictated by:[**name8 (md) 4925**]

medquist36

d:  [**2179-2-12**]  13:01
t:  [**2179-2-15**]  17:11
job#:  [**job number **]
"
209,"admission date:  [**2154-3-6**]     discharge date:  [**2154-3-10**]

date of birth:   [**2092-4-14**]     sex:  m

service:

history of present illness:  the patient has a long standing
history of hearing loss in the right side.  evaluation of
this hearing loss by his primary care physician led to an
mri, which revealed a right sided 1.6 cm acoustic neuroma.
he was evaluated by dr. [**last name (stitle) 3878**] in [**hospital **] clinic and the choice
of management was reviewed with the patient.  it was decided
that he would undergo a trans-labyrinthine excision of the
acoustic neuroma.

past medical history:  significant for hypertension and
hypercholesterolemia.

past surgical history:  he is status post left herniorrhaphy.

medications:  cardizem cd 360 mg po q.d., lipitor 5 mg po
q.d., hydrochlorothiazide 25 po q.d.

allergies:  no known drug allergies.

hospital course:  the patient was admitted on [**3-6**] and
underwent an uncomplicated right sided trans-labyrinthine
excision of his right acoustic neuroma.  preservation of the
facial nerve was verified with the use of nerve stimulation
at the end of the case.  the patient tolerated the procedure
well and was recovered in the intensive care unit overnight
without any adverse events.

on postop day one the patient was transferred to the floor.
the remainder of his hospital course was uneventful.
initially he had a mild nystagmus, as well as sensation of
dizziness and mild nausea.  after the ensuing couple of days
the patient's symptoms diminished.  the neurosurgery service
continued to follow the patient.  physical therapy was
consulted to assist the patient with ambulation.

on the day of discharge the patient was doing well, remained
afebrile.  he had adequate oral intake and no dizziness.  he
was discharged to home in stable condition with instructions
to contact dr.[**name2 (ni) 37129**] office to make his follow up
appointments.

discharge medications:  percocet one to two tabs po q 3 to 4
hours prn pain.  colace 100 mg po b.i.d., cardizem cd 360 mg
po q.d., lipitor 5 mg po q.d., hydrochlorothiazide 25 mg po
q.d.

discharge diagnosis:
right acoustic neuroma status post trans-labyrinthine
resection.

condition at discharge:  stable.






                          [**first name11 (name pattern1) **] [**last name (namepattern4) **], m.d.  [**md number(1) 37130**]

dictated by:[**last name (namepattern1) 3801**]

medquist36

d:  [**2154-3-9**]  15:42
t:  [**2154-3-13**]  05:56
job#:  [**job number **]
"
210,"admission date:  [**2109-4-21**]       discharge date:  [**2109-5-3**]

date of birth:   [**2046-6-13**]       sex:  f

service:  acove
history of present illness:  the patient is a 62 year-old
female admitted to the acove service on [**2109-4-21**] after transfer
from the medical intensive care unit.  the patient was initially
admitted to an outside hospital on [**4-16**] for a right total hip
replacement.  postoperatively, the patient was anticoagulated
with lovenox and coumadin secondary to thromboembolic concerns
given her history of deep venous thrombosis, pulmonary embolus
and known anticardiolipin antibody positive.  on postop day
number two several adverse events occurred including the patient
spiking a temperature to greater then 101, having an elevated
white blood cell and an inr, which was noted to be
supratherapeutic.  her creatinine also increased from a baseline
of 1.4 to 3.8 and the patient had become anuric and acidotic.  on
postoperative day number three the patient became transiently
hypotensive and an infection workup was instituted.  at that time
she was given stress dose steroids.  further anticoagulation was
held and the renal team was consulted.  subsequently the patient
was transferred to the [**hospital1 69**] on
postoperative day number four for further management.  prior
to transfer she was given bicarbonate and transfused 3 units
of packed red blood cells.

on the 30th the patient was directly admitted to the intensive
care unit.  at that time she was evaluated by the renal service
who felt that her physiology, urine and phena represented acute
atn and as such hemodialysis was not indicated.  the patient also
had antibiotics tapered to levaquin for treatment of an e-coli
urinary tract infection.  on the 27th the patient was noted to
have a hematocrit drop from 28 to 22 and abdominal pelvic ct
demonstrated a right hip thigh hematoma.  as such the patient was
taken to the operating room by orthopedics dr. [**first name8 (namepattern2) **] [**name (stitle) 1022**] for
exploration and evacuation of the expanding hematoma.  the
patient was transfused 5 units of packed red cells at that time.
she was also noted to hve neurological deficits in the right leg.
it is not clear as to the timing of these deficits.

past medical history:  1.  right hip avascular necrosis
diagnosed by mri with subsequent total hip replacement as
described in the history of present illness.  2.  history of
prior deep venous thrombosis and pulmonary embolism last
approximately five years prior to admission.  3.  systemic
lupus erythematosus.  4.  sjogren.  5.  chronic renal
insufficiency.  6.  peripheral vascular disease.  7.
coronary artery disease status post myocardial infarction,
status post percutaneous transluminal coronary angioplasty.
8.  known anticardiolipin antibody positive.  9.  anemia
thought secondary to chronic renal insufficiency.  10.  total
abdominal hysterectomy.  11.  history of benign prostatic
biopsy.

medications on transfer:  1.  synthroid .125.  2.  protonix
40 mg po q day.  3.  prednisone 60 mg po q day.  4.  sodium
bicarb [**2056**] mg t.i.d.  5.  amphojel 30 cc q.d.  6.  zocor 5
mg po q day.  7.  epogen 3000 units one time per week.  8.
colace 100 mg po b.i.d.  9.  percocet prn.  10.  iron sulfate
325 mg po b.i.d.  11. levaquin 250 mg po q.o.d.  12.  lovenox
30 mg subq b.i.d.  13.  regular insulin sliding scale.  14.
lactulose prn.

allergies:  the patient has reported allergies to penicillin,
sulfa, codeine and imuran.

social history:  the patient lives with her husband.  she has
a remote history of both tobacco and ethanol use
unquantitative.

hospital course on the acove service:  given the patient's renal
failure the decision was made in consultation with the renal
service to hold her lovenox and change over to heparin as there
is little data as to the clearance of lovenox in acute renal
failure and as such could not be appropriately dosed.  during the
transition period to heparin, which was done without a bolus the
patient was again noted to have increasing girth of her right
thigh and an 8 point hematocrit drop.  as such repeat ct scan of
the thigh was done, which showed reaccumulation of the hematoma.
the patient was again evaluated by orthopedics in this setting,
however, since there was no progression of her neurologic
deficits and there was no neurovascular compromise of the leg the
decision was made not to intervene at this time.  instead
anticoagulation was held until the patient was stabilized and the
patient was transfused a total of 3 units of packed red blood
cells.  during this time the patient was also evaluated by the
neurology service for her right sided deficits.  on further
evaluation it was determined that the patient that the patient
has a history of spondylolithiasis. however, this could not
account for all of her symptoms.

consultation with both orthopedics and neurology suggests the
possibility of damage of the nerve at time of initial surgery, as
her nerve was noted to be very superficial in the operative
report during the second operation at the [**hospital1 190**] for evacuation.  it also possible that some
compression of the nerve occurred with her initial hematoma.
after the patient was hemodynamically stable her renal function
was noted to return to baseline and her creatinine fell to 1.1.
as such it was felt that it was safe to reinstitute lovenox in
this patient and to slowly load coumadin.  it was verified with
her primary care physician that indeed the patient is
anticardiolipin antibody positive and as such will require
long term anticoagulation with a goal inr of approximately 3.5.
in this setting coumadin was again started.  on both lovenox and
coumadin the patient was hemodynamically stable with no further
evidence of bleeding for greater then 48 hours.  given the
patient's neurologic deficits evaluation by physical therapy
revealed that the patient would benefit from a rehab facility and
the patient was discharged on hip precautions for three months to
rehab.

discharge medications:  1.  synthroid 0.125 mg po q day.  2.
zocor 5 mg po q.d.  3.  iron sulfate 325 mg po b.i.d.  4.
colace 100 mg po b.i.d.  5.  tylenol 500 mg po q 6.  6.
oxycontin 10 mg po q 12.  7.  aspirin 81 mg po q day.  8.
prednisone 5 mg po q day, which is her baseline dose.  9.
metoprolol 75 mg po t.i.d.  10.  captopril 25 mg po t.i.d.
11.  oxycodone 5 mg po q 6 prn.  12.  lovenox 30 mg subq q 12
until therapeutic inr is met.  13.  coumadin 5 mg po q.h.s.
with goal inr of approximately 3.5.  14.  multivitamin one
tab po q day.

the patient is to be on hip precautions for three months
including no hip flexion with internal rotation.  the patient
is to follow up with dr. [**first name8 (namepattern2) **] [**name (stitle) 1022**] of [**location (un) 86**] orthopedics,
[**telephone/fax (1) 36310**].  at this time emg will be deferred as the patient
is to be anticoagulated and as such the risk of the procedure
would out weigh the benefits of the information gained.  the
patient was discharged to rehab in stable condition.

discharge diagnoses:
1.  status post right total hip replacement with subsequent
hematoma and evacuation with reaccumulation.
2.  anticardiolipin antibody positive.
3.  atn now resolved.

secondary diagnoses:
1.  hypothyroidism.
2.  sjogren.
3.  systemic lupus erythematosus.
4.  right avn.






                            [**name6 (md) **] [**name8 (md) **], m.d.  [**md number(1) 4446**]

dictated by:[**last name (namepattern1) 9348**]
medquist36

d:  [**2109-5-3**]  07:28
t:  [**2109-5-3**]  08:25
job#:  [**job number 42109**]
"
211,"admission date:  [**2124-3-19**]              discharge date:   [**2124-4-4**]


service: medicine

allergies:
penicillins

attending:[**first name3 (lf) 30**]
chief complaint:
s/p fall

major surgical or invasive procedure:
orif l hip
ivc filter placed


history of present illness:
ms. [**known lastname 39618**] is an 82 year old female with history of htn,
melanoma, paf, and nph s/p vp shunt admitted after a fall [**2124-3-19**]
with l hip fracture and bilateral subdural hematomas. no loc,
but did feel dizzy prior to fall. she was admitted to the
neurosurgical icu.
.
incidentally, on cspine and follow up ct scan she was found to
have extensive pleuroparenchymal scarring and traction
bronchiectasis with calcification involving r>l apex which
raised the question of tb, though the patient denied any
shortness of breath, cough, or fever, she did report chills at
night and a 35 lb weight over last year. she noted that she has
had ppds placed in the past and believes that one may have been
positive, however she had never received any treatment. id was
consulted.


past medical history:
nph s/p vp shunt
htn
hypercholesterolemia
osteoporosis
h/o amaurosis fugax
paf
melanoma, on face s/p excision
bilateral sdh hematoma
left hip fracture


social history:
lives at home alone in a retirement community. no alcohol,
tobacco or drug use. she is a retired social worker for
psychiatric patients.

family history:
father has a history of tb.

physical exam:
vs t99.8, bp 112-152/50-60, hr 80-90, rr18-22, o2sat 100% on 2l

gen: elderly appearing female in nad, lying still in bed.
heent: constricted but reactive pupils, dry mm. eomi - but did
not comply entirely with exam.
cv: regular rhythm, nl s1 s2, [**1-25**] holosystolic murmur best heard
at apex.
chest: lungs clear to auscultation bilaterally, no w/r/r
abd: soft, nt, nd, +bs, no hsm appreciated
ext: pneumoboots in place, no c/c/e appreciated. no tenderness
to palpation of bilateral hips.
neuro: a&o x 2. lle with good sensation. both le well perfused.
did not assess strength given recent or and mental status.


pertinent results:
[**2124-3-19**] 09:19am   pt-11.3 ptt-23.9 inr(pt)-1.0
[**2124-3-19**] 09:19am   plt smr-normal plt count-156
[**2124-3-19**] 09:19am   hypochrom-1+ anisocyt-normal poikilocy-normal
macrocyt-normal microcyt-normal polychrom-normal
[**2124-3-19**] 09:19am   neuts-87.1* bands-0 lymphs-9.6* monos-2.9
eos-0.3 basos-0.1
[**2124-3-19**] 09:19am   wbc-12.5* rbc-3.62* hgb-12.1 hct-35.8*
mcv-99* mch-33.3* mchc-33.7 rdw-12.8
[**2124-3-19**] 09:19am   ck-mb-notdone ctropnt-0.07*
[**2124-3-19**] 09:19am   ck(cpk)-53
[**2124-3-19**] 09:19am   estgfr-using this
[**2124-3-19**] 09:19am   glucose-133* urea n-21* creat-0.8 sodium-142
potassium-3.4 chloride-104 total co2-29 anion gap-12
[**2124-3-19**] 09:40am urine  blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0
leuk-neg
[**2124-3-19**] 09:40am urine  color-yellow appear-hazy sp [**last name (un) 155**]-1.019
[**2124-3-19**] 04:45pm   ctropnt-0.04*
.

.
[**3-19**] chest ct: impression:
1) biapical pleural parenchymal scarring, r>l. on the right,
there is traction bronchiectasis but no true cavitation. this
finding remains nonspecific, and could relate to a number of
chronic infectious and inflammatory causes ([**initials (namepattern4) **] [**doctor first name **] or other
granulomatous disease); correlation with clinical picture and
any prior chest cts is recommended, as tb is not excluded.
2) diffuse, peripheral peribronchiolar nodules consistent with
small airways inflammation; this is also very nonspecific
finding with a broad differential including infectious and
inflammatory etiologies
.
[**3-19**] hip film: impression: comminuted intertrochanteric fracture
left hip, with varus and anterior apex angulation.
.

[**3-20**] ct head w/o contrast: impression:
1. thin ""balanced"" bilateral subdural hematomas with minimal
mass effect on the subjacent gyri, and no significant shift of
midline structures. these may be acute-on-chronic.
2. questionable small subarachnoid hemorrhagic component in the
left parietal sulci.
3. ventriculoperitoneal shunt catheter in place.

[**3-20**] echo: the left atrium is elongated. no atrial septal defect
is seen by 2d or color  doppler. there is mild symmetric left
ventricular hypertrophy with normal  cavity size and systolic
function (lvef>55%). regional left ventricular wall  motion is
normal. tissue doppler imaging suggests an increased left
ventricular filling pressure (pcwp>18mmhg). there is no
ventricular septal  defect. right ventricular chamber size and
free wall motion are normal. the  aortic valve leaflets (3) are
mildly thickened. 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 (1+) mitral
regurgitation is seen. the left  ventricular inflow pattern
suggests impaired relaxation. the tricuspid valve  leaflets are
mildly thickened. there is mild pulmonary artery systolic
hypertension. there is no pericardial effusion.

[**3-23**] head ct
1. bilateral acute on chronic subdural convexity hematomas,
moderately increased compared to before; displacement of the
cerebral parenchyma on the left side with partial effacement of
the left lateral ventricle.
2. new subfalcine subdural hematoma - mild to moderate.
3. atherosclerotic disease with calcification involving
bilateral ica with 30-40% stenosis of the origin of the left
ica; moderate stenosis of the right vertebral artery origin;
moderate stenosis of left vertebral artery with no
calcification.
4. decreased blood volume in the left temporal lobe, unclear if
this is due to more proximal cervical ica stenosis. no increase
in mtt to suggest acute infarct.
5. no obvious evidence of cerebral infarct on the present study.
.
[**3-24**] ct head- impression:
1. unchanged mild to moderate acute on chronic subdural
hematomas, left more than right, with mass effect on the left
cerebral hemisphere.
2. marginal increase in the subfalcine hematoma.
3. unchanged 1.1 cm left temporal intraparenchymal hematoma.
4. study moderately limited due to motion artifacts
increasing bilateral subdural hematomas per neuro and neurosurg.
awaiting official rads read.
.

[**3-27**] cxr: ap semi-upright portable chest x-ray: the patient is
status post ventriculoperitoneal placement. the cardiac
silhouette, mediastinal and hilar contours are stable. pulmonary
vascular redistribution and prominence has increased slightly
from prior exam. small bilateral pleural effusions are also
increased. there are no new consolidations. no pneumothorax is
identified. there is a 6mm rounded opacity in the soft tissues
of the right arm which was not previously imaged and is likley
related to the skin.


brief hospital course:
82f with h/o nph s/p vp shunt, paroxysmal afib, htn who was
admitted s/p fall with b/l sdh and l hip fracture.  the patient
was initially observed overnight in the neuro-icu; her sdh was
stable overnight.  ortho performed orif of her l hip fracture on
[**3-21**].  she was transferred to medicine [**2124-3-22**].
.
on [**2124-3-23**] the patient was found to have noted to have new
neurological changes with right sided facial droop and new right
sided weakness. noted to have a 10 point hct drop since her
surgery. developed new rapid afib with hr in the 130's, and bp's
in the 120 range. given lopressor 5mg iv x 2 (no change in hr,
[**month (only) **] sbp). then given dilt 10mg iv with drop in hr to 90's but
also drop in sbp to 90's. stat head ct at that time showed
increase size in the sdh. skull films were taken to evaluate her
vp shunt. she was transferred to the micu.
.
in the micu the patient was tranfused 3 units prbc's.  repeat
head ct [**3-24**] showed a stable sdh since [**3-23**].  she had an ivc
filter placed on [**3-25**] for pe prophylaxis. induced sputum was
negative x1 for afb; the patient was unable to provide further
sputum samples. ms [**first name (titles) 4245**] [**last name (titles) 39619**], however, r sided weakness
and facial droop resolved.  a uti was diagnosed on [**3-24**] and
treatment was instituted with ciprofloxacin. sensitivities
returned on [**3-27**] and antibiotics were changed to bactrim as the e
coli infection was resistant to cipro. she was called out to the
floor on [**2124-3-27**].
.
on the floor, the following issues were addressed:
.
#uti- the patient was found to have a uti.  she was initially
treated with cipro, however, culture revealed growth of e coli,
resistant to cipro but sensitive to bactrim. therefore, her
antibiotics were changed to bactrim.  she was treated with
bactrim ds [**hospital1 **] from [**date range (1) 39620**].  a repeat ua was wnl.  her mental
status markedly improved with treatment of her uti.
.
# ms changes/delerium- the patient was delerious through much of
her hospitalization.  this was thought to be toxic metabolic in
the setting of infection, icu setting, sdh and hip fracture.
she required prn haldoperidol and restraints for safety while in
the icu, these measures were discontinued by the time of her
transfer to the floor.  her mental status markedly improved with
treatment of above, and returned to near her baseline per her
family members at the time of discharge, though she still had
some mild waxing and [**doctor last name 688**] (especially in the early mornings).
her home psychiatrist, dr [**first name8 (namepattern2) **] [**last name (namepattern1) **], was contact[**name (ni) **] and
updated throughout her stay.  her remeron dose was decreased per
dr [**last name (stitle) **] suggestion from 7.5 mg qhs to 3.75 mg qhs.

#sdh- presented with small b/l sdh on [**3-19**], found to have
increased sdh on [**3-23**].  treated with dilantin for seizure
prophylaxis x 1 week after enlargement.  eeg revealed no
evidence of seizures.  followed by neurosurgery and neurology
without intervention. stable at discharge.  she will follow up
with her outpatient neurologist, dr [**last name (stitle) 4887**] ([**hospital1 112**]) after discharge.

.
# [**name (ni) 39621**] pt with history of paf.  she initially had an episode of
afib with rvr in the setting of hct drop from 30 to 20 ([**3-23**]),
but this resolved after resuscitation with blood products.
received total of 3 u prbcs. from [**3-27**] until [**3-31**] the patient had
several episodes of sustained rvr to the 140s (without symptoms,
change in bp or ekg changes).  diltiazem was started and
titrated up; a beta blocker was also added with good control.
tsh was normal. she was not anticoagulated given her recent sdh.
 we did not do a cta to assess for pe as underlying etiology of
recurrent afib as it would not change management (no
anticoagulation in setting of sdh).  at the time of discharge
her rate was well controlled in the 80's x >24hours, with 1-2
brief and self limited episodes of rates of 120.  in general,
the frequency of rvr, duration of episodes and amplitude of hr
were markedly improved.  given the limitations of her bp we were
not able to further uptitrate her nodal agents. the patient was
asymptomatic, hd stable throughout these bursts of tachycardia
without any adverse events such as ekg changes, hypotension or
cp.  given the size of her la, it is unlikely she would stay in
sinus rhythm; she is not currently a candidate for
anticoagulation.  she will follow up with her pcp for possible
further uptitration of her betablocker after discharge.
.
# hip fx: an orif was performed on [**2124-3-21**].  ortho followed the
patient throughout her stay.  an ivc filter was placed for dvt
ppx as the patient was not a candidate for anticoagulation given
her sdh.  physical therapy was started. she will require
extensive pt at discharge.  staples were removed [**4-4**].  she will
follow up with ortho in [**2-20**] weeks.
.
# pleuroparenchymal scarring/traction bronchiectasis at
bilateral apices: pt was aasymptomatic throughout her course.
there is a question of tb infection in the past. ppd negative
this admission. unlikely but possible etiologies include tb,
mac, fungal infection or malignancy. an attempt was made to rule
her out for tb, but given lack of cough and sputum production,
we could not obtain adequate specimens.  she did have one
induced sputum which was negative for afb.  as the patient has
no cough, no hymoptysis, no night sweats and a repeat cxr showed
only mild volume overload, tb precautions were discontinued and
the workup was halted based on low clinical suspicion of active
disease.  an outpatient workup may be considered if respiratory
symptoms develop.
.
# hypercholesterolemia, hypertension, osteoporosis: the patient
was continued on lipitor, hctz, and calcium/vitamin d.
alendronate was restarted at discharge.
.
# code status:dnr/dni


medications on admission:
aggrenox
prilosec
hctz
atenolol
lovastatin
fosamax
remeron
rhinocort
ativan prn


discharge medications:
1. rhinocort aqua 32 mcg/actuation spray, non-aerosol sig: one
(1) spray nasal once a day.
2. cholecalciferol (vitamin d3) 400 unit tablet sig: 2.5 tablets
po daily (daily).
3. atorvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
4. lovastatin 40 mg tablet sig: one (1) tablet po once a day.
5. calcium carbonate 500 mg tablet, chewable sig: one (1)
tablet, chewable po bid (2 times a day).
6. hexavitamin     tablet sig: one (1) cap po daily (daily).
7. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1)
tablet po bid (2 times a day) as needed for uti for 5 days: last
day: [**4-7**].
8. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily
(daily).
9. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h
(every 4 to 6 hours) as needed.
10. diltiazem hcl 240 mg capsule, sustained release sig: two (2)
capsule, sustained release po daily (daily).
11. mirtazapine 15 mg tablet sig: 0.25 tablet po hs (at
bedtime).
12. alendronate 70 mg tablet sig: one (1) tablet po once a week.

13. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: generic okay.
14. metoprolol succinate 50 mg tablet sustained release 24 hr
sig: one (1) tablet sustained release 24 hr po daily (daily).
15. acetaminophen 325 mg tablet sig: two (2) tablet po q6h
(every 6 hours).
16. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg
po twice a day.


discharge disposition:
extended care

facility:
[**location (un) **] - [**location (un) 620**]

discharge diagnosis:
primary:
1. left peritrochanteric hip fracture.
2. bilateral acute on chronic subdural hematoma.
3. aphasia, dysarthria, right facial droop - seizure vs. mass
effect (resolved w/o intervention).
4. e. coli urinary tract infection.
5. atrial fibrillation with rapid ventricular response.
6. diastolic heart failure.
7. malnutrition.
8. blood loss anemia.

secondary:
1. biapical pleural parenchymal scarring.
2. traction bronchiectasis.
3. nph s/p right occipital vps - [**first name4 (namepattern1) **] [**last name (namepattern1) 4887**], md [**hospital1 112**] [**2122**].
4. osteoporosis.
5. hypertension.
6. hypercholesterolemia
7. osteoporosis
8. melanoma




discharge condition:
afebrile and hd stable. rate controlled. pain controlled.


discharge instructions:
during this admission you have been treated for a l hip
fracture, subdural hematomas (bleeding around your brain), a
urinary tract infection and atrial fibrillation.
.
please continue to take all medications as prescribed.
.
please seek immediate medical care if you develop increasnig
pain, confusion, weakness, difficulty speaking, numbness, or any
other concerning symptoms.

followup instructions:
follow up with your pcp within one week of leaving rehab.  call
[**telephone/fax (1) 18377**] for an appointment.  you should discuss whether you
will eventually start anticoagulation for your afib at this
visit.
.
follow up with dr [**last name (stitle) 1005**] (orthopedics) in 3 weeks.  call
([**telephone/fax (1) 2007**] to make this appointment.
.
follow up with your neurologist, dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 4887**], 2-4 weeks.
call for an appointment.



"
212,"admission date:  [**2154-12-2**]              discharge date:   [**2155-1-1**]

date of birth:  [**2097-7-11**]             sex:   m

service: surgery

allergies:
lisinopril

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2154-12-2**]:
1. takedown fundoplication from previous mark iv thoracotomy.
2. paraesophageal hernia repair.
3. roux-en-y gastric bypass, open.
4. open cholecystectomy.
5. [**last name (un) **] gastrostomy tube.

[**2154-12-10**]:
1.  central line placement

[**2154-12-10**]:
1. exploratory laparotomy and irrigation of abdominal cavity.
2. placement of drains x3.
3. placement of chest tube, right

[**2154-12-13**]:
1 right-sided pigtail catheter placement


history of present illness:
[**known firstname **] has class iii morbid obesity with weight as of [**2154-4-1**]
304.4 pounds.  his initial screen weight on [**2154-3-20**] was 302.7
pounds and more recent weight recorded through his primary care
office was 293.5 pounds.  his height is 70 inches and his bmi is
42.2. his previous weight loss efforts have included 6 months of
optifast in [**2142**] losing 60 pounds that he maintained for 6
months, 12 weeks [**first name8 (namepattern2) 1446**] [**last name (namepattern1) **] in [**2141**] losing 20 pounds, 26 weeks
of weight watchers in [**2140**] losing 30 pounds and he lost about 25
pounds with 16 weeks of nutrisystem in [**2129**] that he maintained
for about 10 years.  he has not taken prescription weight loss
medications or used over-the-counter ephedra-containing appetite
suppressants/herbal supplements.  his weight at age 21 and was
172 pounds with his lowest adult weight 160 pounds and his
highest weight was 304.4 pounds on [**2154-4-1**].  he weight 281.6
pound in [**10/2147**], 293.4 pounds in [**3-/2149**] and 261 pounds one year
ago.  he states he has been struggling with weight since the age
of 40 and cites as factors contributing to his excess weight
large portions, inconsistent meal pattern, too many saturated
fats, emotional and stressful eating as well as lack of exercise
regimen.  her activity he does walk one hour one to two times
per week.  he denied history of eating disorders and has no
diagnosis of depression however has had anxiety/mood issues that
are weight related, has not seen a therapist nor has he been
hospitalized for mental health issues and he is currently on no
psychotropic medications.


past medical history:
pmh: morbid obesity, fatty liver, sleep apnea, diabetes type ii,
hypertension, severe esophagitis and reflux, mild congestive
heart failure

psh: [**last name (un) 13989**] mark iv in [**2130**], pilonidal cyst, appendectomy in
[**2142**], laminectomy, and abdominoplasty

social history:
he denied tobacco or recreational drug usage, has one to two
glasses of wine twice per week, drinks both caffeinated and
carbonated beverages.  he works as
coo at [**state 350**] biologics and has a very hectic schedule
traveling mostly domestically, lives with his spouse age 48 who
is a professor of business, he has no children

family history:
his family history is noted for father deceased age 73 secondary
to congestive heart failure, copd and thyroid disorder; mother
living in her mid 80s with heart disease s/p cabg x 4, valve
replacement, hypertension, diabetes and overweight; has two
brothers and two sisters living with younger sister borderline
hypertension and one brother with hypertension and a younger
brother with diabetes.

physical exam:
vs: t97.7 hr 95 bp 121/76 rr 20 02 95% ra

constitutional: nad
neuro: alert and oriented to person, place and time
cardiac: rrr, nl s1,s2
lungs: cta bilaterally
abdomen: soft, non-tender to palpation, no rebound
tenderness/guarding
wounds: abd midline incision, open to air, intact, no periwound
erythema, no drainage; jp insertion site without erythema or
drainage; g-tube insertion
ext: no edema


pertinent results:
[**2154-12-2**] ecg: normal sinus rhythm with a-v conduction delay and
left bundle-branch block with secondary st-t wave abnormalities.
compared to the previous tracing of [**2152-10-27**] no diagnostic
interval change

[**2154-12-3**] ecg: sinus rhythm. atrio-ventricular conduction delay.
left atrial abnormality.  left bundle-branch block. compared to
the previous tracing of [**2154-12-2**] the findings are similar

[**2154-12-3**] cxr: impression: ap chest compared to [**7-27**]:
lung volumes are lower and there is a mild-to-moderate degree of
subsegmental atelectasis at both lung bases. upper lungs are
clear. moderate cardiomegaly is stable and there is no good
evidence of pulmonary edema. small left pleural effusion may be
present. no pneumothorax. nasogastric tube passes below the
diaphragm and out of view. likely an epidural catheter
projecting over the midline but course indeterminate \

[**2154-12-4**]:
cta chest w&w/o c&recons, non-; ct abd & pelvis with contrast:
impression:
1. pulmonary embolism in the right superior lobar segmental
artery.
2. bilateral pleural effusions, greater on the right than the
left.
3. small right lower lobe consolidation, likely atelectasis,
although in the proper clinical setting could represent
aspiration or pneumonia.
4. post-surgical air within the mediastinum.
5. small amount of fluid in the lesser sac, likely
postoperative.
6. normal postoperative appearance of roux-en-y without evidence
of leaks or adjacent fluid collections.

[**2154-12-6**]:
unilat up ext veins us right: impression: superficial
thrombophlebitis of the right cephalic vein

[**2154-12-6**]:
bilat lower ext veins: impression: no evidence of lower
extremity dvt

[**2154-12-9**]:
echo: suboptimal image quality. borderline left ventricular
cavity enlargement with extensive systolic dysfunction c/w
multivessel cad or other diffuse process. pulmonary artery
hypertension. compared with the prior study (images reviewed) of
[**2154-4-23**], left ventricular dysfunction is more pronounced c/w
interim ischemia.

[**2154-12-9**]:
ecg: sinus tachycardia with first degree a-v delay. frequent
ventricular premature beats. intraventricular conduction delay
of the left bundle-branch block type. compared to the previous
tracing of [**2154-12-3**] the rate is faster and ventricular ectopy is
new.

[**2154-12-9**]:
chest (portable ap): there is no evidence of pneumothorax on the
current radiograph. bibasilar areas of atelectasis are unchanged
associated with small amount of pleural effusion. infectious
process in the lung bases, in particularly on the right, cannot
be excluded

[**2154-12-9**]:
chest port. line placement: the right internal jugular line tip
is at the level of superior svc. within the limitations of this
extremely lordotic and limited radiograph, no evidence of
complications demonstrated. left upper mediastinal drain is
partially imaged.

[**2154-12-9**]:
ct chest w/contrast; ct abdomen w/contrast: impression:
1. a large collection from the distal esophagus into the upper
mid abdomen
that contains gas bubbles and debris within it, compatible with
an abscess, which is most probably secondary to a leak.
2. enlarging lesser sac fluid collection as described.
3. small fluid collection just anterior to the first part of the
duodenum.
4. small right pneumothorax.
5. right pleural effusion with secondary atelectasis.

[**2154-12-9**]: bas/ugi air/sbft: impression: leak at the
gastrojejunal anastomosis

[**2154-12-11**]: echo: impression:severe global left ventricular
systolic dysfunction with potential regionality

[**2154-12-12**]: echo: impression: mild to moderate global left
ventricular systoilc dysfunction. mild mitral regurgitaiton.
mild pulmonary hypertension. compared with the prior study
(images reviewed) of [**2154-12-11**], biventricular systolic function
has improved.

[**2154-12-13**]: chest port. line placement
new left ij catheter tip is at the confluence of the
brachiocephalic veins.  there is no evident pneumothorax. new
right basal pleural catheter is in place. right pleural effusion
has decreased. there are no other interval changes.

[**2154-12-14**]: ct chest w/contrast; ct abd & pelvis with contrast:
impression: 1. several fluid loculations in the right hemithorax
with complete collapse of the right lower lobe.
2. fluid in the mid abdomen adjacent to the gastroesophageal
junction has
decreased in size since recent washout.
3. poorly defined fluid collection posterior to the stomach has
slightly
increased in size and is not in continuity with any of the
surgical drains.

[**2154-12-16**]: ecg: sinus rhythm. p-r interval prolongation. consider
left atrial abnormality. intraventricular conduction delay of
left bundle-branch block type. since the previous tracing the
rate is somewhat slower. left atrial abnormality pattern is more
recognizable

[**2154-12-18**]: cxr:
findings: orogastric tube ends approximately just below the
level of the
preliminary reportcarina. left internal jugular line terminates
at the mid svc. right chest preliminary reporttube ending at mid
thorax and right basal pigtail catheter present, unchanged
preliminary reportin position. low lung volumes and
mild-to-moderate right pleural effusion preliminary
reportassociated with right lower lung atelectasis is similar.
no pneumothorax.  preliminary reportheart size, mediastinal and
hilar contours are unchanged. no consolidation or preliminary
reportpleural effusion on the left side.

[**2154-12-22**]: chest (portable ap)
impression: ap chest compared to [**12-22**], 4:39 a.m.:
moderate right pleural effusion is smaller. i see only one right
pleural
drain, pigtail catheter unchanged in position at the base of the
right
hemithorax. previous pulmonary edema and mediastinal vascular
engorgement
have also improved. heart size is normal. left lung is clear. no

pneumothorax. left jugular line ends in the upper svc.
nasogastric tube ends just inferior to the level of the left
main bronchus in the upper esophagus

[**2154-12-22**]: chest port. line placement:
a left subclavian picc line is present -- the tip lies at the
svc/ra junction. no pneumothorax is detected. an additional tube
which appears to terminate in the mid mediastinum apparently
represents an enteric tube with tip near the left mainstem
bronchus and sideport near the thoracic inlet. the picc line and
enteric tube findings were discussed by radiology resident, dr.
[**last name (stitle) **] with the iv nurse, [**first name8 (namepattern2) **] [**doctor last name 7830**], at 9:30 a.m. on
[**2154-12-23**].
there is lordotic positioning. the cardiomediastinal silhouette
is probably unchanged. again seen is opacity at the right lung
base likely representing a combination of pleural fluid and
right base collapse and/or consolidation.  there is a small left
effusion, with some patchy retrocardiac density, also probably
unchanged. tube overlying the right lung base on [**2154-12-22**] film
is not visualized on the current film. no pneumothorax is
detected.

[**2154-12-30**]: ugi sgl contrast w/ kub:
impression: no evidence of anastomotic leak or obstruction at
the
gastrojejunostomy.


brief hospital course:
the patient presented to pre-op on [**2154-12-2**]. pt was
evaluated by anaesthesia and taken to the operating room where
he underwent a takedown fundoplication from previous mark iv
thoracotomy, paraesophageal hernia repair, roux-en-y gastric
bypass, open, open cholecystectomy and [**last name (un) **] gastrostomy tube
placement. there were no adverse events in the operating room;
please see the operative note for details.

patient was extubated and taken to the pacu. it should be noted
that patient required an insulin drip intra-operatively to
control persistently high blood glucose levels, which was
continued in the pacu and eventually replaced on post-operative
day 1 with an insulin sliding scale while on the floor at the
direction of [**last name (un) **] who was consulted for diabetes management.
also while in the pacu, the patient was experiencing mild chest
pain. cardiology was consulted and the patient received
nitroglycerin, pr aspirin and metoprolol. no ekg changes were
observed. once stable, the patient was transferred to the
inpatient surgery [**hospital1 **] for further observation.

on pod 1, the patient's oxygen saturation levels dropped to
below 85% after maintaing sats in the 90s on 3l nc, the patient
triggered on the floor and required 5l of continuous oxygen via
face mask to maintain >90% oxygen saturation. the patient denied
shortness of breath, chest pain, palpitations, headache at this
point. a stat cxr was ordered and revealed mild-to-moderate
degree of subsegmental atelectasis at both lung bases with no
evidence of pneumothorax. ekg was unchanged from previous study.
with the lack of any clinical symptoms, volume overload was
suspected as the most likely culprit for the dropping o2 sats.
the patient was continued on 5l face mask overnight. on pod 2,
he was given a dose of lasix and a ct scan was ordered.
following the lasix dose, the patient was weaned from the
facemask to 3l nc, however, the chest ct revealed a right
segmental pulmonary embolism.  subsequently, a heparin gtt was
initiated to maintain ptt 60-80 and eventually transitioned to
therapeutic lovenox.  the patient continued to deny sob or cp
and was weaned from supplemental oxygen and maintained on room
air.

he remained stable on the floor until he reported severe
abdominal pain, chest pain, fever and tachycardia following an
episode of coughing on pod7.  he was subsequently transferred to
the sicu where he was noted to be febrile, tachycardic,
tachypneic and diaphoretic with a stable bp.  also, given
bandemia empiric broad spectrum intravenous antibiotics were
intiated.  a central line was also placed at this time.  an abd/
chest ct and ugi series was suggestive of a large collection
from the distal esophagus into the upper mid abdomen containing
gas bubbles and debris, compatible with an abscess, likely
secondary to leak; also a small right sided pneumothorax was
noted.  given the findings, the patient returned to the
operating room where he underwent an exploratory laparotomy and
irrigation of abdominal cavity, placement of drains x3 and
placement of a right-sided chest tube.  post-operatively, the
patient remained intubated and was transferred back into the
sicu.

neuro: the patient was initially alert and oriented
post-operatively; pain was initially managed with an epidural.
on pod 2, due to findings of a right-sided pulmonary embolism
requiring anticoagulation via heparing gtt, the epidural was
d/c'd and pca was started for pain control.  on pod4, the pain
regimen was transitioned to oral roxicet.  however, on pod7, the
patient was transferred to the sicu and was taken to the
operating room.  post-operatively he remained intubated and
sedated with fentanyl and versed until pod 15/9.  following
extubation, pain was controlled with prn iv hydromorphone and
transitioned to an oral regimen of liquid oxycodone.

cv: vital signs were routinely monitored. the chest pain the
patient experienced immediately post-operatively subsided by pod
1 and did not recur until the patient required transfer to the
icu on pod7 as described above.  an ekg remained unchanged
showing left bundle branch block, a troponin x 1 was negative
and an echo revealed ef 20-25% likely related to demand ischemia
per report. cardiology re-evaluated the patient and felt was
mildly fluid overloaded but that his decompensation was related
to possible anastomotic leak and was not ischemic in nature.
recommendations included gentle diuresis once clinically stable
and daily electrolyte monitoring.  a repeat echo cardiogram was
performed on pod [**8-24**] and [**9-24**] with progressively improved
systolic function (ef 35-40%).  intravenous lasix was resumed on
pod [**10-26**] with goal of negative 1liter daily until shortly before
leaving the icu on pod 20/13. he remained hemodynamically stable
while on the floor and remained on telemetry for monitoring.

pulmonary: on pod2, following an acute desaturation, a right
segmental pe was identified on cta as described above.  he
remained stable from a pulmonary standpoint with a heparing gtt
for anticoagulation until pod7.  on pod7, the patient returned
to the operating room (as described above) and remained
intubated post-operatively.  a chest tube was placed
intra-operatively due to findings of a small pneumothorax
following central line placement. on pod [**10-26**], the patient
underwent thoracentesis with pigtail catheter placement by
interventional pulmonary with drainage of 100 cc purulent fluid.
 an abdominal ct obtained the following day indicated several
fluid loculations in the right hemithorax with complete collapse
of the right lower lobe. on pod 13/6, the patient underwent
bronchoscopy with evidence of mucus plug or excessive
secretions. he was gradually weaned from the ventilator and
extubated on pod 16/9; he was maintained on cpap overnight for
known osa for the remainder of the hospitalization.  the chest
tube output gradually decreased and was removed on pod 14/7.
the pigtail catheter output also decreased gradually and was
removed on pod 20/13. he was on room air and was noted to have
no desaturation on ambulation on pod 21/14. as he was able to
ambulate more and no longer experienced epsiodes of desaturation
and was ambulating on room air without difficulty by pod 25/18.

gi/gu/fen: the patient was initially kept npo, however, his diet
was gradually advanced beginning on pod1 following a negative
abd ct scan and subsequent removal of the ngt.  his diet was
progressively advanced to a stage 3 diet, which was well
tolerated until the episode of coughing with severe abdominal
pain (described above) occured on pod7.  at this time he was
made npo.  a repeat abd ct and ugi series were performed and
indicative of a large collection from the distal esophagus into
the upper mid abdomen most likely from an anastamotic leak at
the ge anastamosis; as described above, the patient was
subsequently taken back to the operating room for an abdominal
washout and placement of 2 additional jp drains.  as the
patient's diet was unable to be advanced, tpn was initiated on
pod [**11-26**]. after ugi study and subsequent methylene blue test
showed no evidence of leak he was started on trophic tube feeds
at 10cc/hr on pod 19/12.  this was advanced slowly and
eventually reached goal rate on pod 26/19. tpn was weaned as the
tf rate increased and eventually disconitnued on pod 24/17.
following a repeat methylene blue dye test (pod 22/15) in
conjuction with minimal drain output, the ngt and jp #2 were
removed on pod 23/16 followed by jp#1 on pod 24/17 as drain
input did not increase.  on pod 28/21, a repeat ugi series
suggested no leak, therefore, the diet was advanced to stage 1,
which was well tolerated.  on pod 29/22, following removal of jp
#3 and a negative repeat methylene blue dye test, the diet was
advanced to stage 3 and tube feedings were discontinued.  the
patient tolerated the diet advancement well.  he will remain on
this diet until outpatient follow-up with dr. [**last name (stitle) **].

id: patient was noted to have low grade fevers in the immediate
post op course and was found to have positive blood cultures,
growing g+ cocci in pairs and clusters on pod [**7-23**] and was
started on vanc/zosyn/fluc. id was consulted and transitioned
him to vanc/[**last name (un) **]/fluc on pod [**8-24**]. his wbc peaked at 12.6 on pod
[**9-24**]. there was concern for hap but his mini bal and sputum were
negative. repeat blood cultures afterwards had no growth. he had
pleural fluid sampled on pod [**9-24**] that grew veillonella species
on placment of a right sided pigtail that returned 100cc of
purulent drainage on insertion. the following day his ct scan
showed that he had a loculated enhancing pleural effusion. he
underwent a bronch on pod [**10-26**] and was weaned to extubation on
pod 13/6. his antibiotics were narrowed to unasyn on pod 17/10
and remained afebrile and without a leukocytosis afterwards.
unasyn was discontinued on pod 29/22 following a negative ugi
series.  the patient subsequently remained afebrile without
leukocytosis.  he was started on nystatin swuch and spit for
presumed thrush on pod 20/13. after the ngt was removed he had
no further issues with pain in his throat.

heme: he required one unit transfusions on pod [**7-23**], pod [**11-26**],
and pod 14/7. otherwise his hematocrit remained stable.

endo: immediately post-operatively, he maintained on an insulin
gtt as described above.  post-operatively, blood sugars were
controlled with a regular insulin sliding scale.  once on a
stage 3 diet, the patient did not require insulin coverage.

prophylaxis: he was maintained on subcutaneous heparin until he
was found to have a pulmonary embolism as mentioned above, at
which point he was transitioned to a heparin drip, with goal ptt
of 60-80. he was maintained on this until 23/16 when he was
tranistioned to lovenox. hematology recommended 1 mg/kg
therapeutic dosing with anticoagulation for 6 months.  a factor
xa was therapeutic at the time of discharge.  the patient will
follow-up with hematology in [**3-3**].  additionally, wore pneumatic
boots throughout this hospitalization.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received extensive discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
acyclovir 400 mg daily prn
albuterol ih prn
amlodipine 10 mg daily
chlorthalidone 25 mg daily
fluticasone 50 mcg 2 sprays [**hospital1 **]
losartan 100 mg daily
metformin 1000 mg [**hospital1 **]
metoprolol succinate 50 mg daily
pantoprazole 40 mg daily
potassium kcl 10 meq daily
sildenafil 100 mg daily prn
simvastatin 20 mg daily
vitamin d3 1000 units daily
mvi w/ minerals 1 tablet daily


discharge medications:
1. enoxaparin 120 mg/0.8 ml syringe [**hospital1 **]: one (1) syringe
subcutaneous [**hospital1 **] (2 times a day).
disp:*60 syringe* refills:*2*
2. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1)
tablet,rapid dissolve, dr [**last name (stitle) **] once a day.
disp:*30 tablet,rapid dissolve, dr(s)* refills:*0*
3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler [**last name (stitle) **]:
1-2 puffs inhalation every six (6) hours as needed for shortness
of breath or wheezing.
4. insulin regular human 100 unit/ml solution [**last name (stitle) **]: 2-10 units
injection four times a day as needed for refer to sliding scale:
sliding scale:101-150-0 units; 151-200-0 units; 201-250-2
units;251-300-4 units;301-350-6 units;351-400-8 units; >400-10
units.
disp:*1 vial* refills:*2*
5. oxycodone 5 mg/5 ml solution [**last name (stitle) **]: [**5-1**] ml po every 4-6 hours
as needed for pain: administer via g-tube; flush w/ 30 ml water
before and after administration.
disp:*300 ml* refills:*0*
6. docusate sodium 50 mg/5 ml liquid [**month/year (2) **]: ten (10) ml po bid (2
times a day) as needed for constipation: administer via g-tube;
flush w/ 30 ml water before and after administration.
disp:*300 ml* refills:*0*
7. lorazepam 0.5 mg tablet [**month/year (2) **]: one (1) tablet po every twelve
(12) hours as needed for anxiety: sublingual; do not combine
with oxycodone.
disp:*10 tablet(s)* refills:*0*
8. insulin syringe-needle u-100 1 ml 25 x 1  syringe [**month/year (2) **]: one
(1) syringe miscellaneous four times a day as needed for refer
to sliding scale.
disp:*1 box* refills:*2*
9. multivitamin with minerals     tablet [**month/year (2) **]: one (1) tablet po
once a day: chewable only; no gummy.


discharge disposition:
home with service

facility:
[**hospital3 **] [**doctor last name **]

discharge diagnosis:
1. sepsis.
2. pneumothorax.
3. gastrointestinal leak.
4. recurrent hiatal hernia with obstruction.
5. cholelithiasis.
6. obesity.
7. fatty liver.
8. type 2 diabetes.
9. severe reflux esophagitis.
10. sleep apnea.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
100.7, chills, chest pain, shortness of breath, severe abdominal
pain, pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stage 3 diet; do not self-advance

medication instructions:
you will be starting some new medications:
1.  lovenox: 120 mcg subcutaneous injection, twice daily
2.  lorazepam sublingual: 0.5 mg twice daily as needed for
anxiety.  do not take with oxycodone.
3.  prevacid sublingual: 30 mg tablet daily.  this medication is
being prescribed in place of pantoprazole (protonix) as
pantoprazole cannot be crushed.
4.  regular insulin sliding scale: please check your blood
sugars four times daily and adhere to the provided sliding scale
to determine dosage of insulin.  your will not require insulin
if your blood sugar is less than 200 mg/dl.
1.  you are being discharged on medications to treat the pain
(liquid oxycodone) from your operation. this medications will
make you drowsy and impair your ability to drive a motor vehicle
or operate machinery safely. you must refrain from such
activities while taking these medications. also, do not combine
with lorazepam (ativan).
2. you should begin taking a complete multivitamin with
minerals, crushed and administered via your g-tube. no gummy
vitamins.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-6**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: orthopedics
when: tuesday [**2155-1-7**] at 9:40 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: orthopedics
when: tuesday [**2155-1-7**] at 10:00 am
with: hand clinic [**telephone/fax (1) 3009**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 551**]
campus: east     best parking: [**hospital ward name 23**] garage

department: [**last name (un) **] diabetes center
when: tuesday [**2155-1-7**] at 0830 am
with: [**first name8 (namepattern2) **] [**doctor last name **], n.p. [**telephone/fax (1) 2384**]

department: bariatric surgery
when: wednesday [**2155-1-15**] at 4:00 pm
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2155-1-15**] at 4:30 pm
with: [**first name4 (namepattern1) **] [**last name (namepattern1) **], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: [**hospital3 249**]
when: friday [**2155-1-31**] at 10:20 am
with: [**first name11 (name pattern1) 569**] [**last name (namepattern4) 12637**], m.d. [**telephone/fax (1) 250**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 895**]
campus: east     best parking: [**hospital ward name 23**] garage

department: hematology/oncology
when: friday [**2155-2-28**] at 10:30 am
with: [**first name4 (namepattern1) 569**] [**last name (namepattern1) **], 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: friday [**2155-2-28**] at 10:30 am
with: [**first name8 (namepattern2) 25**] [**last name (namepattern1) **], md [**telephone/fax (1) 22**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2155-1-1**]"
213,"unit no:  [**numeric identifier 44622**]
admission date: [**2113-4-17**]
discharge date: [**2113-4-24**]
date of birth:  [**2091-7-11**]
sex:  m
service:


history of present illness:  the patient is a 21-year-old
male with a history of end-stage renal disease (on
hemodialysis) secondary to reflux nephropathy, and focal
segmental glomerulosclerosis who presented with fevers to 102
and a facial rash.

initially, he had a temperature of 100.6 at [**location (un) 4265**]
hemodialysis unit on [**2113-3-27**].  there, he received
vancomycin which was complicated by red man syndrome.  this
consisted of a fever and rash from the forehead down to his
waistline.  he was given benadryl and tylenol and sent home.

he received hemodialysis on [**2113-4-12**] uneventfully.  at
hemodialysis on [**2113-4-14**] he had a temperature to 102.7.
blood cultures were taken from his hemodialysis line.  he was
given 1 gram of kefzol and referred to the emergency
department.

in the emergency department, a chest x-ray showed no
pneumonia.  laboratories with a white blood cell count of
5.4.  urinalysis had small leukocyte esterase, but no
nitrites.  therefore, he was started empirically on
ciprofloxacin 500 mg twice per day times seven days for a
possible urinary tract infection.  urine culture ultimately
returned negative.  he began taking ciprofloxacin in the
morning of [**2113-4-15**].  he woke up on [**2113-4-16**] with
""dots"" all over and pruritus.  he took his last dose of
ciprofloxacin on [**2113-4-16**] in the evening.  his rash was
not relieved with benadryl or tylenol, so he came to the
emergency department for further evaluation.

in the emergency department - on [**2113-4-17**] - he was
noted to have a temperature of 98.8, his blood pressure was
128/64, his pulse was 98, his respiratory rate was 16, and
his oxygen saturation was 100 percent on room air.  in the
emergency department, he was pan-cultured and given one dose
of vancomycin intravenously and ceftriaxone intravenously.
laboratories at that time showed a potassium of 6.3 with
questionable peaked t waves on his electrocardiogram.
therefore, he also received calcium gluconate 1 gram, 10
units of regular insulin, 1 ampule of dextrose, 1 ampule of
bicarbonate, and kayexalate 60 grams.  before leaving to the
emergency department, he spiked a temperature to 103.6.
therefore, tylenol was given.

of note,  he had a recent admission in [**month (only) 956**] after two
generalized tonic-clonic seizures.  at that time he was
started on dilantin.  also during that admission, he
completed a 3-day course of ciprofloxacin for a urine culture
that grew out acinetobacter.

during this admission, review of systems was significant for
fevers, sore throat, and generalized malaise.  he denied any
rigors, night sweats, or weight loss.  he denied chest pain,
shortness of breath, palpitations, orthopnea, or paroxysmal
nocturnal dyspnea.  there was no cough, wheezing, or
hemoptysis.  there was no dysuria, abdominal pain, or
suprapubic tenderness.  no nausea, vomiting, diarrhea, or
constipation.  no recent travel.  no recent medication
changes.  no outdoor activities or camping.  no recent
vaccinations.  no pets or tic exposures.  no recent sexual
contacts other than his longtime girlfriend with whom he is
in a monogamous relationship.

past medical history:  end-stage renal disease (on
hemodialysis) secondary reflux, nephropathy, and focal
segmental glomerulosclerosis.  he is dialyzed on monday,
wednesday, and friday.  he started hemodialysis on [**2113-3-1**].  reflux nephropathy resulted in recurrent ascending
escherichia coli infections.  he is status post placement of
a right subclavian perm-a-cath on [**2113-3-15**] and an
arteriovenous fistula was placed on [**2113-3-17**].

spina bifida; status post repair as an infant - complicated
by bowel and bladder incontinence, with a history of straight
catheterization three times daily - complicated by numbness
in the soles of the feet and backs of both thighs as well as
left foot weakness and hyperreflexive bilateral lower
extremities.

newly diagnosed seizure disorder on [**2113-3-14**] for two
generalized tonic-clonic seizures - started on dilantin on
[**2113-3-26**].  seizures characterized by initial head
deviation toward to the right followed by generalized tonic-
clonic movements.  his first seizure on [**2113-3-14**] was
felt to be secondary to hypercalcemia in the setting of a
calcium level of 6.  his second seizure took place on
[**2113-3-26**] and was felt to be idiopathic.  at that
time, he was loaded on dilatation 300 mg three times per day.
he erroneously continued on dilantin 300 mg three times per
day until a follow-up appointment on [**2113-4-6**].  at that
time, he was switched to a regimen of 300 mg in the morning
and 200 mg in the evening.

hypoparathyroidism.

history of multiple urinary tract infections; last diagnosed
in [**2113-2-26**] and treated with ciprofloxacin.

anemia of chronic disease.

allergies:  the patient reports no known drug allergies.

medications prior to admission:
1. dilantin 300 mg by mouth in the morning alternating with
   200 mg by mouth in the evening.
2. lisinopril 10 mg by mouth once per day.
3. epogen subcutaneously every week.
4. sodium bicarbonate tablets four tablets by mouth twice per
   day.
5. oxybutynin 5 mg by mouth twice per day.
6. tums 500 mg by mouth three times per day.
7. calcitriol at each hemodialysis session.
8. nephrocaps once per day.


social history:  the patient is a sophomore at [**university/college 5130**]
[**location (un) **].  he lives in a dormitory.  he is originally from
[**location (un) 17004**], [**state 531**].  he denies any tobacco or illicit drug use,
but he reports occasional social alcohol intake.  he is in a
monogamous sexual relationship with a longstanding
girlfriend.

family history:  the patient reports no family history of
seizures or kidney disease.

physical examination on presentation:  generally, this was
well-developed, well-nourished, thin, young male.  he was
uncomfortable and ill-appearing, but nontoxic.  vital signs
revealed his temperature was 99.8, his blood pressure was
128/64, his heart rate was 98, his respiratory rate was 16,
and his oxygen saturation was 100 percent on room air.  head
and neck examination was remarkable for normocephalic and
atraumatic.  the pupils were equal, round, and reactive to
light.  the mucous membranes were moist.  the posterior
oropharynx was erythematous, but there were no lesions
exudates.  the neck was supple with no masses or
lymphadenopathy.  the chest wall had hemodialysis catheter
site bandaged with no evidence of edema, fluctuance or
purulent discharge.  the lungs were clear to auscultation
bilaterally.  there were no rhonchi, rales, or wheezes.
cardiovascular examination revealed a regular rate and rhythm
with normal first and second heart sounds auscultated.  there
were no murmurs, rubs, or gallops.  the abdomen was soft,
nontender, and nondistended.  there were positive normal
active bowel sounds.  there was no hepatosplenomegaly.
examination of the back revealed no spinal or costovertebral
angle tenderness.  the extremities were warm and well
perfused.  there was no clubbing, cyanosis, or edema.  the
left forearm arteriovenous fistula had some serous drainage;
but no erythema, edema, or fluctuance.  a bruit was
auscultated over the arteriovenous fistula.  his skin
demonstrated erythematous, raised, maculopapular rash
diffusely, but concentrated mostly on the face, abdomen,
extremities, palms, and soles.  the lesions were
approximately 1 cm in diameter.  on the face, the eyelids
were spared.  otherwise, the rash was confluent, pruritic,
blanching, nonconfluent on the body with a questionable
appearance of wheels.  there were no bullae formation.  no
target lesions.  the skin examination was also remarkable for
a tuft of hair on his back and a scar overlying his previous
spina bifida surgery site.  neurologically, he was alert and
oriented times three with no tremor or asterixis.

pertinent laboratory values on presentation:  a complete
blood count on admission revealed his white blood cell count
was 5.1 (with 61 percent neutrophils, 26 percent lymphocytes,
5 percent monocytes, 7.2 percent eosinophils - 2.9 percent on
[**2113-3-26**] - and 0.5 percent basophils), his
hematocrit was 41.6, and his platelets were 194.  chemistries
showed his sodium was 138, potassium was 6.3, chloride was
95, bicarbonate was 27, blood urea nitrogen was 58,
creatinine was 13.5, and his blood glucose was 87.  his
calcium was 10.6, his phosphorous was 4.4, and his magnesium
was 2.5.  coagulation profile revealed his prothrombin time
was 12.7, his partial thromboplastin time was 26.4, and his
inr was 1.1.  hemolysis studies on [**2113-4-18**] showed a
haptoglobin of 87, his fibrinogen was 253, and his d-dimer
was elevated at 2274.  an additional workup for his rash and
fever revealed a throat swab with culture negative for beta
streptococcal infection.  stool culture was negative.  mono
spot was negative.  aso titer from [**4-19**] demonstrated a
positive aso screen with a titer positive to 200 to 400.
rapid plasma reagin nonreactive.  [**doctor last name 3271**]-[**doctor last name **] virus titer
showed the patient to be igg positive and igm negative.
urine culture from [**2113-4-14**] was also negative for
growth.

brief summary of hospital course:  fever issues:  a concern
over line source of fevers in the emergency department, the
patient received a vancomycin.  he was started on ceftriaxone
for gram-negative coverage given his history of multiple
urinary tract infections and a history of straight
catheterization use.  prior to antibiotic initiation, he was
pan-cultured.  on the night of admission, he spiked a
temperature to 103.7 which decreased to 101.5 with tylenol.

on the morning of [**2113-4-18**] he went to hemodialysis and
there spiked a temperature to 105.  he was cultured from his
hemodialysis line and sent back to the general medicine
floor.  as the fever started after hemodialysis sessions and
appeared to worsen with accessing his hemodialysis line, the
interventional radiology service was contact[**name (ni) **] for removal of
the patient's tunnel catheter.  initially, the interventional
radiology service did not feel the catheter needed to be
removed.  thereafter, the patient himself refused removal.
later on the day of [**2113-4-18**] he was dialyzed via his
arteriovenous fistula with no adverse events.

he was seen in consultation by the infectious disease service
who recommended holding vancomycin, ciprofloxacin, and
dilantin.  an exhaustive workup; including pan cultures,
liver function tests, mono spot, cytomegalovirus, [**doctor last name 3271**]-
[**doctor last name **] virus, mycoplasma, and titers, rapid plasma reagin, aso,
throat swab, antineutrophil cytoplasmic antibody, rheumatoid
factor, and sedimentation rate was initiated out of concern
for drug fevers, viral infection, line infection, vasculitis,
toxic shock syndrome, primary human immunodeficiency virus
infection.

the patient was covered initially with aztreonam after he
spiked a fever to 107.3 in the setting of a normal blood
pressure of 140/90 and a heart rate of 120.  in addition to
aztreonam during this temperature spike he also received 1
gram of tylenol and benadryl.  he was moved from the floor to
the medical intensive care unit for further monitoring.

out of continued concern for a line infection in spite of
negative culture data, the patient's tunneled port-a-cath was
removed on [**2113-4-19**].  he continued to have dialysis and
was dialyzed on [**2113-4-20**] through his arteriovenous
fistula.  about one hour into that hemodialysis session, he
had rigors.  there was some question of whether his fevers
and rigors could be secondary to a membrane issue.

as all of the patient's culture data was negative, and his
fevers subsided status post discontinuation of vancomycin and
dilantin, it was felt that his fevers were most likely
secondary to an acute drug reaction.  it is therefore
recommended that he avoid exposure to vancomycin and dilantin
in the future.

rash issues:  it was unclear whether the patient's rash was
drug related versus infectious in etiology.  the onset
occurred after therapy with ciprofloxacin and had an
urticaria appearance and peripheral eosinophilia which was
suggestive of a drug related process.  however, in light of
the high fevers ________ was maintained for infectious
sources as well.

an exhaustive workup (as outlined above) was undertaken in
order to help delineate the source of the patient's fevers.
an infectious workup was negative.  for symptoms, he was
continued on benadryl and an h2 blocker to decrease histamine
release.  he was not initially treated with steroids out of
concern for infection.

on [**2113-4-18**] he was noted to have cracking and peeling
as well as a edema of his lips and a question ulcerative
lesion in his oropharynx and conjunctivae.  this was
concerning for [**doctor last name **]-[**location (un) **] syndrome.  he was seen in
consultation by the dermatology, infectious disease, and
ophthalmology services.  ophthalmology saw only mild
conjunctivitis on their examination and recommended
artificial tears and lacri-lube.  per dermatology, the likely
culprits for the patient's rash included vancomycin and
dilantin.  however, there was really no way to delineate
which of these two agents were the cause of this.  with
conservative and symptomatic therapy, the patient's rash
improved.

end-stage renal disease issues:  on the day of his admission,
the patient had discontinuation of his tunneled port-a-cath.
he started hemodialysis via an arteriovenous fistula.  he
tolerated this well with the exception of intermittent fever
spikes.  he was continued on nephrocaps, calcium acetate,
epogen, and calcitriol per the renal team.

seizure disorder issues:  in light of the suspicion of
dilantin as an etiologic [**doctor last name 360**] for the patient's fevers and
rash, dilantin was discontinued.  he was monitored closely in
the setting of fevers due to the fact that fevers can
decrease seizure threshold.  he was started on gabapentin
after consultation with the neurology service.  outpatient
neurology followup was arranged as well.

code status issues:  the patient was a full code.

condition on discharge:  good - afebrile times 36 hours and
hemodynamically stable.  dilantin and vancomycin levels were
trending down.  skin rash was improving.  all culture data
was negative for acute infection.

discharge status:  the patient was discharged to home.

discharge diagnoses:  drug fever and reaction secondary to
vancomycin or dilantin.

end-stage renal disease (on hemodialysis).

history of recurrent urinary tract infections.

history of a seizure disorder.

history of spina bifida; status post surgical repair.

bowel and bladder incontinence.

anemia of chronic disease.

medications on discharge:
1. gabapentin 300 mg by mouth at hour of sleep.
2. lisinopril 20 mg by mouth once per day.
3. epogen injections subcutaneously at hemodialysis.
4. oxybutynin 5 mg by mouth twice per day.
5. calcium acetate 670 mg two tablets by mouth three times
   per day (with meals).
6. nephrocaps one capsule by mouth every day.
7. artificial tears 1 drop each eye q.2h.
8. lacri-lube one application each eye at hour of sleep.
9. benadryl 25 mg one capsule by mouth q.4-6h. as needed (for
   itching).
10.      calcitriol.


follow-up plans:  the patient was instructed to call his
primary care physician or visit [**name initial (pre) **] local emergency room if he
experienced recurrent fevers, shaking chills, headaches,
chest pain, confusion, recurrent skin rash, or any other
worrisome symptoms.  he was instructed if he feels fevers and
rash, the most likely reaction was medications; however, we
could not ascertain whether the reaction was due to dilantin
or vancomycin.  we strongly suggested that he absolutely
avoid both of these agents in the future.  he was instructed
to discontinue his dilantin and sodium bicarbonate.

additionally, he had follow-up appointments with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] in the neurology department on [**2113-6-6**].  he was
instructed to call both dr. [**last name (stitle) 44623**] and dr. [**last name (stitle) **] from the
renal division for follow-up appointments after discharge.


                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 20314**]

dictated by:[**last name (namepattern1) 14378**]
medquist36
d:  [**2113-7-6**] 16:30:22
t:  [**2113-7-6**] 22:13:09
job#:  [**job number 44624**]

cc:[**last name (namepattern1) 44625**]



"
214,"admission date:  [**2130-10-16**]       discharge date:  [**2130-10-24**]


service:  ccu

history of present illness:  this is an 83-year-old white
male with history of coronary artery disease status post
coronary artery bypass graft times three vessels in [**2121**], end
stage renal disease on hemodialysis three times a week,
diabetes mellitus and hypertension transferred from [**hospital 1474**]
hospital for cardiac catheterization.

the patient initially presented to [**hospital 1474**] hospital with
complaints of increased dyspnea on exertion, weakness and
dizziness.  in the emergency department their he was found to
have new ekg changes, new t wave depressions in v2 through v3
and more depressed t wave depressions in v4 through v6 and
atrial fibrillation.  the patient was ruled out for mi by
serial enzymes, although he did have an initial ck mb index
of 3.2 and had an echocardiogram which showed lv enlargement
with akinesis of the inferior and posterior walls.  also with
hypokinesis of other lv walls and ejection fraction of 30%,
mitral tricuspid regurgitation with a pulmonary artery
systolic pressure of 45 mg of mercury, mild mr with
significant left atrial enlargement.  patient then had a
persantine mibi which showed a small lateral wall ischemia
and small inferior wall infarct.

decision was then made to transfer to [**hospital1 190**] for cardiac catheterization.  cardiac
catheterization showed a pulmonary capillary wedge pressure
of 22 mg of mercury, right atrial pressure of 25 mg of
mercury, pa pressure of 46/17, right ventricular pressure
48/9.  a totally occluded lad with positive collateral flow,
70% stenosis of the left circumflex.  the svg to om graft was
totally occluded.  svg to dm graft was patent and lima to lad
graft was patent.  overall severe three vessel disease.  two
out three grafts had moderately decreased left ventricular
ejection fraction of 40%, moderate mitral regurgitation and
moderately diffuse hypokinesis.

during the procedure, the patient became hypertensive with a
210/110 and intravenous prior to nitroglycerin was started.
patient also had flash pulmonary edema after a
................. load of about 500 cc and was electively
intubated for increased shortness of breath and agitation.
the patient was then transferred to the ccu for nipride wean
and extubation.

medications on transfer:
1.  tylenol p.r.n.
2.  ambien p.r.n.
3.  metoprolol 25 mg p.o. b.i.d.
4.  captopril 6.25 mg p.o. t.i.d.
5.  ec-asa 325 mg p.o. q.d.
6.  coumadin 5 mg h.s. then 2 mg h.s.
7.  nitroglycerin drip 0.052.2 mcg per kilogram per minute.
8.  nephrocaps one cap p.o. q.d.
9.  regular insulin sliding scale.
10. glipizide xl 10 mg p.o. q.d.
11. propofol drip.

past medical history:
1.  coronary artery disease status post coronary artery
bypass graft for three vessels in [**2121**].
2.  end stage renal disease on hemodialysis on tuesday,
thursday and saturday.
3.  hypertension.
4.  diabetes mellitus.
5.  anemia.
6.  prostate ca.
7.  new onset atrial fibrillation.

social history:  not obtainable.

family history:  not obtainable.

initial ekg showed atrial fibrillation at 65 beats per
minute, normal axis, qrs mildly elongated, left ventricular
hypertrophy by voltage, t wave inversions in v2 through v5,
st depressions in i and l, unchanged from outside hospital
ekgs.

physical examination:  vital signs with a temperature of 97.6
f, blood pressure 106/45, heart rate 68.  pulmonary artery
pressure 37/11.  in general elderly, sedated, intubated male
lying still in bed.  head, eyes, ears, nose and throat:
normocephalic, atraumatic.  pupils are 2 mm bilaterally,
equal, round, reactive to light.  endotracheal tube in place.
neck:  no jugular venous distention.  cardiovascular:  iv/vi
systolic murmur loudest at the apex radiating to the axilla
into the back, irregular.  pulmonary:  loud bronchial sounds
bilaterally.  abdomen:  soft, nondistended with normal
abdominal bowel sounds, no hepatosplenomegaly.  positive
abdominal bruit.  extremities:  warm, no edema, no hematoma
at right groin.  neuro:  patient sedated.  withdraws from
touching of feet.

initial laboratory results:  white blood cell count of 5.7,
hematocrit 32.7, platelets 134.  differential was 72.4%
neutrophils, 18.2% lymphocytes, 8.2% monocytes, 1.0%
eosinophils, 0.2% basophil.  inr was 1.3. potassium 5.5,
calcium 8.3, magnesium 2.7, phosphorus was 9.7.

abg done was 7.45, 73 and 345 on 100% oxygen.

initial assessment:  this is an 83-year-old male with history
of coronary artery disease, diabetes mellitus, end stage
renal disease on hemodialysis transferred from outside
hospital for cardiac catheterization secondary to abnormal p
mibi with dyspnea and hypertension in cath lab.  started on
nipride and nitroglycerin drips, intubated and electively
transferred to ccu for extubation and drip weaning.

hospital course:
1.  cardiac:  patient is being kept on the nitroglycerin drip
throughout the entire course when he was on the ventilator
and it was discontinued once he had been weaned.  the patient
was started on imdur 50 mg p.o. q.d. for approximately six
hours prior to stopping the nitroglycerin drip with no ill
effects.

patient was noted to have a moderately decreased left
ventricular ejection fraction of 30 to 40%.  the patient was
started on an ace inhibitor and was gradually titrated up,
however two days into ace inhibitor therapy with captopril,
the patient developed an erythematous rash which was
pruritic.  at this point, it was assumed that the rash was
secondary to the sulfur group of the captopril and patient
was switched to lisinopril 40 p.o. q.d. with eventual
clearing of rash and no other ill effects.

the patient was switched over from nitroglycerin drip to
imdur with no ill effects.  patient remained moderately
hypertensive throughout the hospital course with blood
pressures up to 160 mg of mercury systolic were tolerated as
this patient is on hemodialysis.

2.  rhythm:  patient was noted to have new onset atrial
fibrillation.  patient was maintained on telemetry and had
frequent episodes of nonsustained ventricular tachycardia as
well as ventricular tachycardia throughout the first two days
of hospitalization with gradual clearing of these.  the
patient was tried on a beta blocker and pr prolongation was
noted.  at this point, the beta blocker was discontinued and
patient had a pacemaker placed so that he would be able to
tolerate amiodarone therapy.

patient had a dual chamber rate responsive pacemaker placed
and was started on amiodarone loading 400 mg p.o. b.i.d.  at
pacemaker placement, the patient received a dose of
vancomycin.  the patient tolerated the pacemaker placement
and was kept on telemetry for 24 hours after pacemaker was
placed with no adverse events noted.

the patient was also restarted on coumadin for
anticoagulation after pacemaker placement.  the decision of
how long to continue coumadin will be left up to the pcp.
[**name10 (nameis) **] patient's amiodarone loading should be 400 mg p.o. b.i.d.
times one week then 400 mg p.o. q.d. times one week and then
200 mg p.o. q.d.  the patient should be seen at [**hospital **]
clinic in one week.

3.  coronaries:  patient with status post coronary artery
bypass graft in [**2121**], lima to lad, svg to lpda, and svg to om
which is totally occluded, 70% stenotic lesion in mid
circumflex.  patient was started on lipitor 10 mg p.o. q.d.
and was kept on aspirin throughout hospital course.  the
patient should continue to take these two drugs indefinitely.


4.  pulmonary:  patient had an initial weaning trial
approximately 12 hours after admission to the ccu.  the
patient became tachypneic as he was initially weaned from the
ventilator and it was decided to rest him for another day.
the patient was switched over to pressure support and
successfully weaned on hospital day #2.  the patient
initially required oxygen, but soon was able to tolerate room
air with o2 saturations of 95% and above.  there were no
further pulmonary issues in the hospital course.

5.  renal:  patient was continued on hemodialysis throughout
hospital course and initially started on amphojel and phos-lo
as patient had increased phosphorus on presentation.
eventually, amphojel was able to be discontinued after four
hospital days as per renal's recommendation.  patient to
continue hemodialysis as an outpatient on tuesdays, thursdays
and sundays.

6.  endocrine:  the patient was noted to become hypoglycemic
with blood sugars as low as 48.  patient had his glipizide
discontinued and had some hypoglycemia for one day after
discontinuation and subsequently high blood sugars of 160s to
200s while continuing regular insulin sliding scale.  it was
decided to reinitiate glipizide at a lower dose of 2.5 mg
q.d. and further watch for hypoglycemia as an outpatient.

7.  dermatologic:  patient developed an erythematous
maculopapular and some areas ................ pruritic rash
over the trunk and upper thighs and back on day #2 of
captopril.  a dermatology consult was called and a skin
biopsy was performed.  the patient was switched from
captopril to lisinopril.  skin biopsy confirmed a lymphocytic
infiltrate with rare eosinophils, focal rbc extravasation
consistent with systemic hypersensitivity reaction, no
leukocytoclastic vasculitis was seen.

the patient's rash eventually cleared, although not
completely after lisinopril was initiated.  the patient was
given sarna lotion, [**doctor first name **] and benadryl p.r.n. for itching
with moderate effect.

8.  prophylaxis:  patient received aspirin, lipitor, coumadin
and protonix for gi prophylaxis during hospital course.

discharge diagnosis:
1.  new onset atrial fibrillation status post dual chamber
pacemaker placement, initiation of amiodarone therapy.
2.  coronary artery disease.
3.  end stage renal disease on hemodialysis tuesday, thursday
and saturday.
4.  hypertension.
5.  diabetes mellitus type 2.
6.  anemia.
7.  prostate ca.

discharge medications:
1.  warfarin 2 mg p.o. q.h.s.
2.  amiodarone 400 mg p.o. b.i.d. times seven days started
[**2130-10-23**] then 400 mg p.o. q.d. times seven days then
200 mg p.o. q.d.
3.  lisinopril 40 mg p.o. q.d.
4.  imdur 60 mg p.o. q.d.
5.  lipitor 10 mg p.o. q.h.s.
6.  enteric coated aspirin 325 mg p.o. q.d.
7.  benadryl 25 mg p.o. q. six hours p.r.n.
8.  docusate 100 mg p.o. b.i.d.
9.  [**doctor first name **] 60 mg p.o. b.i.d.
10. sarna tp p.r.n.
11. phos-lo three caps p.o. t.i.d.
12. [**doctor last name **] two tabs p.o. b.i.d. p.r.n.

condition on discharge:  good.

discharge status:  to short term rehab.  patient to follow up
with own cardiologist to arrange pulmonary function test as
patient is now being started on amiodarone and also to follow
up tsh and lfts.




                            [**first name11 (name pattern1) **] [**last name (namepattern4) 1008**], m.d.  [**md number(1) 1009**]

dictated by:[**name8 (md) 45172**]
medquist36

d:  [**2130-10-24**]  16:26
t:  [**2130-10-24**]  14:35
job#:  [**job number 45173**]
"
215,"admission date:  [**2176-10-29**]              discharge date:   [**2176-11-5**]

date of birth:  [**2136-3-10**]             sex:   f

service: surgery

allergies:
nsaids

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
1. laparoscopic repair of paraesophageal hernia.
2. placement of laparoscopic adjustable band and port device.


history of present illness:
[**known firstname 45779**] has class iii morbid obesity with weight of 276.2
pounds as of [**2176-9-10**] (her initial screen weight on [**2176-8-8**] was
280 pounds), height of 64 inches and bmi of 47.4.  her previous
weight loss efforts have included weight watchers, the salad
diet, the south beach diet, the [**doctor last name 1729**] diet, over-the-counter
ephedra-containing ma [**doctor last name **], slim-fast, prescription weight loss
medication and pancreatic lipase inhibitor orlistat (xenical),
and [**first name8 (namepattern2) 1446**] [**last name (namepattern1) **].  her weight and age 21 was 140-145 pounds with
her lowest adult weight 130 pounds at age 20 and her highest
weight 281.7 pounds on [**2176-8-19**].  she weighed 140-145 pounds 10
years ago and 165 pounds 5 years ago.  she states she developed
significant [**last name 4977**] problem in childhood and cites as factors
contributing to her excess weight genetics, large portions,
grazing, late night eating, too many carbohydrates in saturated
fats, stress, compulsive eating and emotional eating as well as
lack of exercise regimen.  her current activity includes
swimming 30 minutes 2-3 times per week and walking 10-15 minutes
twice per week.  she denied anorexia, bulimia, diuretic or
laxative abuse but stated she does have binge eating without
purging.  she has significant psychological history of
depression/bipolar disorder/anxiety and suicide attempts
admitted to [**hospital 1191**] hospital in [**location (un) 10059**] x 2 in [**2171**] for drug
overdose and lithium toxicity with auditory hallucinations,
followed by psychiatrist and a therapist and is currently on
psychotropic medications (paroxetine, abilify and lorazepam).


past medical history:
pmh: copd, fatty liver, htn, hl, hypothyroidism,gerd, bipolar
disorder, iron deficiency anemia, renal insufficiency,
nephrogenic diabetes insipidus

psh:  wisdom teeth, breast implants, precervical cancer surgery


social history:
she smoked one pack per day of cigarettes for 25 years quit
[**2176-7-29**], no
recreational drugs, no alcohol and does drink both carbonated
and caffeinated beverages. two daughters age 20 and age 21 who
had been in dss group homes and in [**doctor last name **] homes.  she is
divorced and is on disability, used to work in cosmetic sales,
lives alone but does have supportive friends.


family history:
her family history is noted for both parents living father with
history of stroke, mother with heart disease, hyperlipidemia,
asthma, thyroid disorder; sister living with heart disease and
thyroid disorder; multiple family members with mental illness

physical exam:
vs: t 98 hr 80 bp 120/78 rr 20 o2 99%ra

constitutional: nad
neuro: alert and oriented to person, place and time; affect flat
cardiac: rrr, nl s1,s2, no mrg
lungs: cta b
abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
wounds: abdominal lap sites with steri-strips, no periwound
erythema/ induration, mild periwound ecchymosis
ext: 2+ dp pulses

pertinent results:
labs:
[**2176-11-5**] 10:09am blood wbc-8.4 rbc-3.77* hgb-9.7* hct-30.8*
mcv-82 mch-25.7* mchc-31.5 rdw-16.0* plt ct-207
[**2176-11-5**] 06:27am blood glucose-90 urean-24* creat-1.5* na-146*
k-3.7 cl-108 hco3-26 angap-16
[**2176-11-5**] 10:09am blood glucose-124* urean-22* creat-1.5* na-143
k-4.1 cl-106 hco3-27 angap-14
[**2176-11-5**] 10:09am blood calcium-9.7 phos-3.3 mg-2.2
[**2176-11-4**] 02:05am blood glucose-100 urean-21* creat-1.4* na-143
k-4.0 cl-107 hco3-23 angap-17
[**2176-11-4**] 04:05pm blood na-139 k-3.9 cl-103
[**2176-11-4**] 08:39pm blood na-141 k-3.7 cl-105
[**2176-11-3**] 04:04am blood glucose-102* urean-19 creat-1.6* na-149*
k-3.9 cl-112* hco3-26 angap-15
[**2176-11-2**] 12:31am blood glucose-102* urean-15 creat-1.7* na-155*
k-4.1 cl-119* hco3-23 angap-17
[**2176-11-2**] 04:44am blood na-158* k-4.0 cl-121*
[**2176-11-2**] 12:31am blood glucose-102* urean-15 creat-1.7* na-155*
k-4.1 cl-119* hco3-23 angap-17
[**2176-11-2**] 04:44am blood na-158* k-4.0 cl-121*
[**2176-11-2**] 07:58am blood glucose-147* urean-17 creat-1.8* na-159*
k-4.4 cl-122* hco3-28 angap-13
[**2176-11-2**] 12:28pm blood glucose-95 urean-19 creat-1.8* na-154*
k-4.5 cl-117* hco3-26 angap-16
[**2176-11-2**] 04:15pm blood glucose-101* urean-18 creat-1.6* na-149*
k-4.0 cl-113* hco3-25 angap-15
[**2176-11-2**] 08:25pm blood glucose-105* urean-19 creat-1.6* na-150*
k-4.2 cl-114* hco3-26 angap-14
[**2176-11-1**] 09:27am blood na-159* cl-122*
[**2176-11-1**] 09:48am blood glucose-139* urean-15 creat-2.0* na-159*
k-3.9 cl-123* hco3-26 angap-14
[**2176-11-1**] 12:05pm blood na-156* k-3.5 cl-120*
[**2176-11-1**] 02:10pm blood na-154* k-3.9 cl-120*
[**2176-11-1**] 10:10pm blood na-152* k-3.5 cl-116*
[**2176-11-1**] 01:25am blood glucose-128* urean-15 creat-2.1* na-168*
k-3.9 cl-131* hco3-26 angap-15
[**2176-10-31**] 08:50am blood glucose-136* urean-15 creat-1.9* na-167*
k-3.7 cl-129* hco3-27 angap-15
[**2176-10-31**] 10:50am blood glucose-100 urean-15 creat-1.9* na-167*
k-4.5 cl-132* hco3-23 angap-17
[**2176-10-31**] 04:02pm blood na-164* k-3.6 cl-128*
[**2176-10-31**] 08:50am blood calcium-10.7* phos-2.5*# mg-2.6
[**2176-10-31**] 10:50am blood osmolal-346*
[**2176-11-4**] 02:05am blood osmolal-304
[**2176-10-31**] 10:50am blood tsh-0.71
[**2176-10-31**] 10:50am blood t4-13.1*
[**2176-10-31**] 05:31pm blood na-163*
[**2176-10-31**] 08:36pm blood na-159*
[**2176-10-31**] 11:32pm blood na-163*
[**2176-11-1**] 04:50am blood na-163*
[**2176-11-1**] 04:12pm blood na-154*
[**2176-11-1**] 06:40pm blood na-154*
[**2176-11-1**] 08:48pm blood na-153*
[**2176-11-3**] 12:29am blood na-148*
[**2176-11-3**] 09:08am blood na-145
[**2176-11-3**] 12:32pm blood na-146*
[**2176-11-3**] 04:38pm blood na-143 k-4.4
[**2176-11-3**] 08:36pm blood na-144
[**2176-11-4**] 06:33am blood na-144
[**2176-11-4**] 11:58am blood na-144

imaging:
[**2176-10-30**]: ugi sgl contrast w/ kub:
impression: appropriate lap band position, patent stoma, no
evidence of leak.

[**2176-10-31**] ecg:
sinus tachycardia. low precordial lead voltage. st-t wave
changes in the
anterolateral leads which raise the question of active
anterolateral ischemic process. followup and clinical
correlation are suggested. no previous tracing available for
comparison

[**2176-11-1**]: chest (portable ap):
impression: no pneumothorax, hematoma, or other sequela of
procedural
complication identified. bibasilar atelectasis.

[**2176-11-1**]:
chest port. line placement:
impression: new right picc terminating within the right atrium,
4.5-5.0 cm
beyond the cavoatrial junction.


brief hospital course:
the patient presented to pre-op on [**2175-10-30**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic adjustable gastric band placement. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient became intermittently agitated beginning on
pod1, pulling at her ngt, iv lines and threatening to leave
against medical advice and complaining of thirst.  psychiatry
was consulted, however, the patient declined visitation; the
patient's home psychiatric medication regimen was resumed at
this time.  overnight on pod2, the pt became progressively
disoriented, again attempting to leave against medical advice
and lacked insight into all aspects of her hospitalization and
expected post-operative recovery.  psychiatry was re-consulted
as the patient appeared to lack any capacity for decision
making.  at this time, electrolytes had been checked and the
serum sodium was noted to be 167 making a metabolic cause for
the patient's disorientation more likely; upon reviewing the
sodium level, psychiatry felt her mental status changes were
more likely the result hypernatremia induced delerium related to
diabetes insipidus.  after normalization of serum sodium levels,
the patient remained alert and oriented x 3 without any further
issues regarding agitation or insight into her care.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.  of note, the
patient's innopran xl was changed to regular release propranolol
as all medications must be crushed.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially on bariatric stage 1 diet, which
was well tolerated despite patient consuming more liquid than
ordered.  an upper gi study was performed on pod 1 which
revealed appropriate band position without evidence of
obstruction.  her diet was further advanced to stage 2 and then
3 due to the patient's extreme thirst and dietary
non-compliance; the patient tolerated this level of intake well.
 additionally, on pod2, the patient was noted to be
hypernatremic with a serum sodium level of 167.  renal was
consulted and felt this was due to diabetes insipidus related to
prior lithium use; [**name8 (md) **] rn at the patient's pcp's office confirmed
this was a known diagnosis.  the patient was identified as
having a free water deficit of approximately 10 liters; lr was
discontinued, d5w initiated, fluid intake liberalized and the
patient was transferred to the tsicu for q 3-4 hour serum sodium
monitoring.  while in the tsicu, the patient's hypernatremia
gradually resolved over the course of 4 days with resolution of
her delerium; she was transferred back to the general surgical
[**hospital1 **] on pod6.  her serum sodium remained between 141-146; renal
felt it was safe for discharge to home with liberal fluid
intake, a stage 3 diet and a repeat serum sodium level within 1
week.  both the patient's pcp and nephrologist were contact[**name (ni) **]
and follow-up appointments were made for the patient.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a
liberalized stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled.  the patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan including
follow-up with her pcp tomorrow and her nephrologist on [**11-25**], [**2175**].


medications on admission:
aripiprazole 15 mg daily
paroxetine 10 mg daily
perphenazine 32 mg q hs
propranolol xl 160 mg daily
levothyroxine 88 mcg daily
zolpidem 10 mg daily
omeprazole 40 mg [**hospital1 **]
lorazepam 1 mg qid
diphenhydramine 25 mg daily

discharge medications:
1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
disp:*250 ml* refills:*0*
2. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls
po q4h (every 4 hours) as needed for pain.
disp:*100 ml(s)* refills:*0*
3. aripiprazole 15 mg tablet sig: one (1) tablet po once a day:
please crush.
4. paroxetine hcl 10 mg tablet sig: one (1) tablet po once a
day: please crush.
5. perphenazine 8 mg tablet sig: four (4) tablet po qhs (once a
day (at bedtime)).
6. propranolol 40 mg tablet sig: two (2) tablet po bid (2 times
a day).
disp:*120 tablet(s)* refills:*0*
7. levothyroxine 88 mcg tablet sig: one (1) tablet po daily
(daily).
8. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime):
please crush.
9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day: open capsule,
sprinkle contents onto applesauce, swallow whole.  do not chew
beads.
10. lorazepam 1 mg tablet sig: one (1) tablet po four times a
day: please crush.


discharge disposition:
home

discharge diagnosis:
1. gastroesophageal reflux with paraesophageal hernia.
2. obesity.
3. fatty liver.
4. diabetes insipidus
5. hypernatremia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, nausea or vomiting,
difficulty drinking fluids, severe abdominal bloating, inability
to eat or drink, foul smelling or colorful drainage from your
incisions, redness or swelling around your incisions, confusion,
headache, weakness, increased thirst or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.  please drink fluids freely and contact dr. [**last name (stitle) 15645**] office
or report to the emergency department immediately if you are
unable to tolerate liquids.

medication instructions:
resume your home medications except for the following changes:
1.  please stop innopran xl (propranolol) as this medication
cannot be crushed.  a new prescription for propranolol (regular
release) has been provided to you as you may crush this
medication.  please notify your primary care provider of this
change.
2.  please stop amiloride per our nephrologist.
crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-12**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.



completed by:[**2176-11-5**]"
216,"admission date:  [**2197-4-26**]       discharge date:  [**2197-5-6**]

date of birth:   [**2130-3-5**]       sex:  m

service:  card-[**last name (un) **]

history of present illness:   this is a 67 year old male who
presented to his primary care provider with [**name initial (pre) **] chief complaint
of progressive dyspnea on exertion over the past 18 months.
the patient's wife reported that the patient has become
progressively more and more dyspneic upon walking up a flight
of stairs and has episodes every day that resolve with rest.
the patient denied ever experiencing any chest pain in
association with these episodes.  the patient subsequently
underwent a stress test in [**2197-3-28**], which was stopped
after six minutes and 34 seconds of the [**doctor first name **] protocol
secondary to shortness of breath.  the patient did not
experience any chest pain during this test.

the patient's ekg at this time demonstrated [**street address(2) 49111**] depressions in leads ii, iii, avf and v5 through
6 during the last stage of exercise.  in the recovery room,
the patient developed [**street address(2) 49112**] depressions
in leads i, ii, iii, avf and v1 through v6, with t wave
inversions which persisted until 12 minutes after exercise.

imaging studies demonstrated moderate reversible anterior and
septal wall defects.  the patient's ejection fraction was
estimated to be 43%.  the patient was subsequently referred
to [**hospital1 69**] for an outpatient
cardiac catheterization to evaluate heart function.

the catheterization took place on [**2197-4-26**], and
demonstrated 80% distal stenosis of the left main coronary
artery and 80% occlusion of the left anterior descending.
ejection fraction was noted to be 49%.  the patient was
subsequently admitted to the [**hospital unit name 196**] service under the direction
of dr. [**first name (stitle) **] k. w. ho, on [**2197-4-26**] for further
evaluation and management.

past medical history:
1.  hypertension.
2.  hypercholesterolemia.
3.  penile cancer status post resection.
4.  crohn's disease status post resection.
5.  chronic cough.

home medications:
1.  aspirin.
2.  pravachol.
3.  b12.
4.  atenolol.

allergies:   no known drug allergies.

social history:   the patient lives with his wife and works
as a cashier.  the patient has a remote history of smoking
cigarettes which he quit approximately 15 years ago.  he
drinks one to two alcoholic drinks per week.  no intravenous
drug use history.

hospital course:   the patient was admitted to the [**hospital unit name 196**]
service on [**2197-4-26**], under the direction of dr. [**last name (stitle) **].  a
cardiothoracic surgery consultation was obtained upon
admission; following an extensive discussion with the patient
and his family regarding the relative risks and benefits of
surgery, the patient agreed to undergo coronary artery bypass
graft on [**2197-4-27**].

on [**2197-4-27**], the patient underwent a coronary artery
bypass graft times three.  anastomoses included left internal
mammary artery to left anterior descending; saphenous vein
graft to diagonal; and saphenous vein graft to obtuse
marginal.  the patient tolerated the procedure well and had a
bypass time of 79 minutes and a cross clamp time o4 44
minutes.  the patient's pericardium was left open;
intraoperative lines placed included a right radial and right
internal jugular line; both ventricular and atrial wires were
placed; mediastinal and left pleural tubes were placed.

the patient was subsequently transferred from the operating
room to the cardiac surgery recovery unit, intubated, for
further evaluation and management.  on transfer, the
patient's mean arterial pressure was 80; his central venous
pressure was 6; his pad was 13 and his [**doctor first name 1052**] was 17.  the
patient was atrially paced at a rate of 88 beats per minute.

active drips on transfer included neo-synephrine and
propofol.  following arrival in the csru, the patient was
successfully weaned and extubated.  his postoperative
hematocrit was noted to be 36.1.  in the csru, the patient
progressed well clinically.  he was advanced successfully to
oral medications without adverse events and was successfully
weaned from pressor drips.  the patient's chest tubes were
successfully removed without complication as were his pacer
wires, after which point he was cleared for transfer to the
floor on postoperative day number four.

the patient was subsequently admitted to the cardiothoracic
service under the direction of dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 70**].
postoperatively, the patient's clinical course was
uneventful.  the patient was evaluated by physical therapy
who deemed him an appropriate candidate for eventual
discharge to home following completion of the acute medical
care.

the patient was noted to develop atrial fibrillation
refractory to medical therapy, after which point he was begun
on a coumadin anti-coagulation pathway.  as the patient was
progressively dosed with coumadin for a therapeutic inr of
over 2.0, the patient was noted to be successfully
transitioned to a full regular diet and his pain was
controlled adequately with oral pain medications.  the
patient was noted to be independently ambulatory and was
noted to be independently productive of adequate amounts of
urine for the duration of his stay.

by postoperative day number eight, the patient was noted to
be afebrile and stable.  his incisions were noted to be
healing well with steri-strips intact and no evidence of
cellulitis or purulent drainage.  the patient was noted to be
fully tolerant of a regular diet and his pain was well
controlled.

following a final inr [**location (un) 1131**] of 2.3, the patient was cleared
for discharge to home on postoperative day number 9, [**2197-5-6**], with instructions for follow-up.

condition on discharge:   the patient is to be discharged
home with instructions for follow-up.

discharge status:   stable.

discharge medications:
1.  colace 100 mg p.o. twice a day.
2.  amiodarone 400 mg p.o. q. day times 14 days, followed by
200 mg p.o. q. day times four weeks.
3.  vicodin one to two tablets p.o. q. four to six hours
p.r.n.
4.  pravastatin 80 mg p.o. q. day.
5.  coumadin 5 mg p.o. q. day times four days, with the
patient's dose to be titrated thereafter by his primary care
physician, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **].

discharge instructions:
1.  the patient is to maintain his incisions clean and dry at
all times.
2.  the patient may shower but should pat-dry incisions
afterwards; no bathing or swimming until further notice.
3.  the patient is to resume a cardiac diet.
4.  the patient has been instructed to limit physical
activities; no heavy exertion.
5.  no driving while taking prescription pain medications.
6.  the patient is to have his coumadin dosage schedule
managed by his primary care provider, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **]; the
patient is to receive biweekly blood draws on mondays and
thursdays beginning [**2197-5-8**], and is to call dr. [**last name (stitle) **]
with his results following each blood draw for subsequent
modification of his coumadin dosing schedule for a target inr
of 2.0.
7.  the patient is to have additional primary care physician
[**name9 (pre) 702**] as needed.
8.  the patient is to follow-up with dr. [**first name4 (namepattern1) 919**] [**last name (namepattern1) 911**] in
cardiology within three to four weeks.
9.  the patient is to follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 70**] six
weeks following discharge.

the patient is to call to schedule all appointments.



                            [**first name11 (name pattern1) **] [**initials (namepattern4) **] [**last name (namepattern4) **], m.d.  [**md number(1) 75**]

dictated by:[**last name (namepattern1) 1053**]
medquist36

d:  [**2197-5-6**]  15:39
t:  [**2197-5-6**]  16:08
job#:  [**job number 49113**]
"
217,"admission date:  [**2125-2-9**]              discharge date:   [**2125-2-18**]

date of birth:  [**2058-2-22**]             sex:   f

service: medicine

allergies:
ace inhibitors

attending:[**first name3 (lf) 69838**]
chief complaint:
hematuria

major surgical or invasive procedure:
trans-urethral resection of bladder


history of present illness:
66 y.o. female with cad s/p mi and bm stent, chf, s/p mechanical
avr on coumadin and recently discovered bladder tumor who was
transferred from [**hospital 8125**] hospital with hematuria. patient developed
hematuria on [**1-17**], which prompted her to go to the
hospital. at that time, she was felt to have a uti and was
treated wtih tetracyclin. additionally a ct abdomen showed a
bladder tumor, that as of yet has not been biopsied. after
completing antibiotics, the hematuria cleared and the patient
was doing well, being followed by dr. [**last name (stitle) 770**] for eventual plans
to biopsy the tumor. on [**2-7**], patient noticed blood in her
urine, but says it was minimal. she spoke to her urologist who
reassured her but told her to continue to monitor the symptoms.
on the following day, she developed clots and by the day of
admission, [**2-9**], felt as though she was ""hemorrhaging"". prior to
this, she was asymptomatic, but on the day of presentation,
reports feeling dizzy without chest pain or palpitations. she
additionally denies f/c, n/v but does endorse some mild back
pain and dysuria.
.
patient initially presented to [**hospital 8125**] hospital with her
complaints, but was then transferred to [**hospital1 18**] because her
urologist was here. in the ed, labs revealed an inr of 4.3 and a
strongly positive ua and wbc of 21 with 84% neutrophils, no
bands. she was afebrile and hemodynamically stable. urology was
consulted and placed a 22 french foley and hand irrigated many
clots from the bladder, after which the urine remained pink.
patient's cardiologist, dr. [**last name (stitle) **], saw the patient in the ed and
recommended holding her asa and coumadin for now. patient was
given ceftriaxone empirically for the uti and was then admitted
to the medicine team for continued management of her hematuria.



past medical history:
bladder tumor
chf (ef 40-45% in 10/'[**23**])
cad s/p mi and stents to lcx [**8-5**]
carotid stenosis
hypertension
hypercholesterolemia
s/p hysterectomy


social history:
former smoker, but stopped in [**2124-7-29**]. denies alcohol
or illicit drug use. patient lives in [**hospital3 **] and works in real
estate.

family history:
non-contributory

physical exam:
physical exam:
t: 96.9, bp: 110/60, p: 83, rr: 18, o2 sats: 94% ra
gen: awake, alert, nad
heent: nc/at; perrla, eomi; op clear, nonerythematous
neck: supple, no lad, no jvd
cv: s1, s2 nl, no m/r/g appreciated, though valvular click was
ausculated
resp: ctab
abd: soft, tender to palpation in suprapubic area, nd, + bs
back: no flank tenderness
gu: normal female genitalia with foley in place, draining frank
blood
ext: no c/c/e
neuro: grossly intact


pertinent results:
=================
  admission labs
=================

wbc-21.3*# rbc-3.53* hgb-8.9*# hct-28.0* mcv-79*# mch-25.2*#
mchc-31.7 rdw-14.6 plt ct-458*
neuts-84.2* lymphs-10.8* monos-3.9 eos-1.0 baso-0.1
pt-39.4* ptt-37.2* inr(pt)-4.3*
glucose-114* urean-17 creat-0.7 na-136 k-4.6 cl-97 hco3-28
angap-16

===============
  radiology
===============

chest (pa & lat)  [**2125-2-10**] 3:07 pm
median sternotomy wire and mitral valve annuloplasty again
noted. the lungs are grossly clear. cardiac contour within
normal limits. aortic arch is calcified. aorta is ectatic.
impression:
1. no active disease in the chest.
2. ectatic aorta.

ct pelvis w&w/o c   [**2125-2-11**] 11:15 am
findings: there is a large intraluminal filling defect within
the urinary bladder, predominantly on the right, slightly
adherent to the wall, measuring 6 x 5.5 x 5.3 cm. this filling
defect is heterogeneous in appearance and has irregular margins.
it is also directly related to the right ureterovesical
junction. there is a foley catheter within the urinary bladder
as well as foci of air. there is no evidence of significant
retroperitoneal lymphadenopathy. there is no evidence of
hydronephrosis. multiple small foci of hypodensity within the
right renal parenchyma, most likely representing small cysts.
the bilateral adrenal glands are unremarkable. the spleen, the
liver and the pancreas are unremarkable. there is evidence of
cholelithiasis. there is no evidence of free fluid or free air.
the bowel appears unremarkable. there is a thoracoabdominal
aortic aneurysm, measuring 4.4 cm in maximum diameter at the
inlet to the abdomen, after which it tapers to 2.5 cm at the
level of the sma.
bilateral lung bases are unremarkable.
there are no suspicious bony lesions.
impression:
1. large filling defect within the urinary bladder, which is
heterogeneous, measuring 6 cm in maximal diameter. differential
diagnosis includes a bladder tumor versus a blood clot given
that the patient has been on coumadin

================
 microbiology
================

urine culture (final [**2125-2-14**]):    no growth.

=================
 discharge labs
=================

wbc-13.3* rbc-3.60* hgb-9.5* hct-29.8* mcv-83 mch-26.2*
mchc-31.8 rdw-16.4* plt ct-420
pt-17.9* ptt-125.2* inr(pt)-1.6*
glucose-102 urean-10 creat-0.8 na-139 k-4.3 cl-99 hco3-29
angap-15
calcium-8.8 phos-3.2 mg-2.0

brief hospital course:
66 y.o. female with known bladder tumor and mechanical mitral
valve, presenting with gross hematuria, now with stable hct, s/p
transurethral tumor resection
.
# hematuria / bladder tumor: although culprit for hematuria was
a known tumor, intervention was not possible upon admission
secondary to anticoagulation. patient has mechanical valve at
the mitral position, for which she is anticoagulated with
coumadin. patient required a single transfusion of 2 units of
pbrc after warfarin was stopped. continuous bladder irrigation
was initiated and inr was allowed to drift down without reversal
due to increased risk of adverse events in setting of mechanical
valve.
patient was started on heparin drip when inr reached 2.5 and
urology performed trans-urethral bladder tumor resection once
inr reached 1.5.
tissue sent to pathology, this however is pending at the time of
discharge. patient will follow up with dr [**last name (stitle) 770**] for further
management.

# mechanical mitral valve: as above, patient with ([**hospital3 **])
valve in place. after procedure was performed patient was
re-startedd on heparin drip and transitioned to lovenox. she was
discharged on a lovenox to coumadin drip and asked to have inr
checked at her primary care provider, [**name10 (nameis) **] request of her
cardiologist. patient given script for [**name10 (nameis) **] work. defer further
management to primary care physician.

# uti: history of vre uti in the past. this admission, patient
had infection with streptococcus species. she will complete 10
day course of [**last name (lf) **], [**first name3 (lf) **] require two more doses as outpatient.
.
# cad: patient is s/p mi with bare metal stent [**8-5**]. we
re-started aspirin at time of discharge, and continued beta
blocker and statin during entire admission.
.
# chronic systolic heart failure: ef 40-45% on [**9-4**], following
mvr. patient remained well compensated during this admission and
no changes in medication regimen were made.
.
# carotid artery stenosis: per ultrasound ([**2124-9-6**]) 80-99%
right ica stenosis, with no significant left ica stenosis. no
neurological symptoms during this presentation.
.
# fen: patient tolerated a cardiac/heart-healthy diet
.
# code: patient remained full code during this admission.


medications on admission:
lipitor 20 mg po qd
lasix 80 mg po bid
potassium
coumadin 5mg mwf, 2.5mg tuthsasu
asa 81 mg po qd
toprol xl 50 mg po qd
digoxin 125 mcg
advair


discharge medications:
1. atorvastatin 20 mg tablet sig: one (1) tablet po daily
(daily).
2. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a
day).
3. metoprolol succinate 50 mg tablet sustained release 24 hr
sig: one (1) tablet sustained release 24 hr po daily (daily).
4. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily).

5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
6. lovenox 80 mg/0.8 ml syringe sig: one (1) syringe (80 mg)
subcutaneous twice a day: until your doctor asks you to stop.
[**hospital1 **]:*28 syryinges* refills:*0*
7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
8. warfarin 5 mg tablet sig: one (1) tablet po at bedtime:
please note, dose will be modified by your primary care
physician.
[**name initial (nameis) **]:*30 tablet(s)* refills:*0*
9. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h
(every 12 hours) for 2 days.
[**name initial (nameis) **]:*4 tablet(s)* refills:*0*
10. percocet 5-325 mg tablet sig: one (1) tablet po every six
(6) hours as needed for pain for 7 days.
[**name initial (nameis) **]:*28 tablet(s)* refills:*0*
11. outpatient [**name initial (nameis) **] work
please have cbc and pt/ptt/inr drawn on [**2-21**]


discharge disposition:
home

discharge diagnosis:
primay:
mechanical mitral valve
hematuria
bladder tumor


discharge condition:
hemodynamically stable, afebrile


discharge instructions:
you were admitted to the hospital because you were having
bleeding from your bladder and required a different type of
anticoagulation that would allow for a surgery to find the cause
of your bleeding. you underwent the procedure and tolerated it
well. the results of the tissue analysis will not availabe for a
few days, your primary care doctor will need to follow this up.

you will need to follow up with your primary care doctor and
take all medications as prescribed. you will also need to give
yourself lovenox injections twice daily until your inr (level of
coumadin) is at a good range.

if you experience any chest pain, nausea, vomiting, diarrhea, or
any other symptom that concerns you, please seek medical
attention immediatly.

followup instructions:
please make schedule a follow up appointment with your primary
care physician [**name initial (pre) 176**] 1 week. you will need to have your
coumadin level checked in his office on [**2-21**].

[**last name (lf) **],[**first name3 (lf) **] h [**telephone/fax (1) 57926**]


                             [**first name4 (namepattern1) **] [**last name (namepattern1) **] md [**md number(2) 69841**]

"
218,"admission date:  [**2103-6-23**]              discharge date:   [**2103-7-8**]

date of birth:  [**2035-8-7**]             sex:   m

service: medicine

allergies:
azilect

attending:[**first name3 (lf) 2763**]
chief complaint:
hypoxia

major surgical or invasive procedure:
intubation, trach, peg

history of present illness:
67yom with parkinson's disease, bipolar disorder, htn,
dyslipidemia, right vertebral artery aneurysm who presents for
hypoxia.
.
per ed report and per the patient's sister's report (who spoke
directly to the nurses who were taking care of the patient
today), the patient was in his usual state of health at [**hospital 100**]
rehab and had just eaten breakfast and was waiting to be wheeled
to his room for his routine nap. the nurse turned away to finish
feeding another patient and turned back to see the patient with
emesis coming out of his nose and mouth. the patient was
unresponsive during this episode and was rapidly suctioned.
however, he was hypoxic and ems was called who found the patient
to be hypoxic en route to the ed and bag masked and ventilated
for initial apnea, per report. he was lethargic en route and
transferred to the [**hospital1 18**] ed for further evaluation. there was no
reports of fevers or symptoms preceeding the event, but the
sister states that the patient does not typically complain of
symptoms even when he feels unwell. the patient's sister reports
the patient has never had difficulties with swallowing or
eating, and has never had an aspiration episode in the past.
.
in the ed, initial vs: 99.6 (rectal) 67 132/94 91% nrb
the patient was reportedly not responsive to commands and had
coarse rales diffusely. he was given vanc/levofloxacin/flagyl in
the ed and intubated for hypoxia. ekg showed sinus rhythm at
62bpm without evidence of acute ischemia. cxr was obtained which
showed possible rml infiltrate. cta chest was obtained to r/o pe
which instead showed evidence of aspiration pneumonia. ct head
showed enlargement of the patient's known right vertebral artery
aneurysm, and neurology and neurosurgery were consulted out of
concern that the intracranial aneurysm could be contributing to
his symptoms. neurosurgery recommended mri head/neck and
neurology planned to have the stroke consult see him in the am
pending mri/mra results. he was transferred to the micu for
further management. transfer vitals were: 84 109/68 19 100% tv
500 peep 8 rr 20 fio2 100
.
on arrival to the micu, the patient was minimally responsive to
pain off sedation after having received paralytics. he went to
for the mri/mra during which time his respiratory rate increased
and sedation was initiated with propofol boluses, then a low
dose gtt. he became fully responsive to commands and his
respiratory rate and blood pressures increased on cmv/ac.


past medical history:
- htn
- hyperlipidemia
- bipolar disorder
- parkinson's disease (pet in [**2094**] consistant with diagnosis)
- gastropathy
- unruptured right vertebral artery aneurysm (cta from an
outside facility was reviewed; right vertebral artery aneurysm,
longest dimension 9-10 mm located intradurally in the region of
the right vertebral artery. he could not becertain whether the
aneurysm involved the pica origin, but most likely it seemed to
be separate from it.)
- depression
- degenerative arthritis/multilevel spondylosis
- knee oa, s/p tka


social history:
- tobacco: denies
- etoh: denies
- illicit drugs: denies
non-ambulatory at baseline. lives at nursing home, [**hospital 100**] rehab
since [**2099**]. retired ph.d. psychologist.


family history:
father with ""ataxia"" and prostate cancer. mother with breast
cancer.  pt denies family cardiac history.

physical exam:
vs: 100.1 80 130/75 100% on cmv fio2 100% tv 6000 peep 5
gen: intubated, not following commands, no acute distress
heent: perrl, sclera anicteric, mmm
cv: soft heart sounds, rrr, normal s1/s2, no m/r/g
resp: equal bs b/l, rhonchi and coarse crackles at rlb, no
wheezes
abd: soft, nt/nd, +bs, no masses or hepatosplenomegaly
ext: wwp, no c/c/e, 2+ dp pulses b/l
skin: no rashes/no jaundice/no splinters
neuro: corneal reflexes b/l, rare spontaneous non-purposeful
movements of right finger.


pertinent results:
[**2103-6-23**] 10:55am blood wbc-10.6 rbc-4.82 hgb-14.5 hct-40.5
mcv-84 mch-30.2 mchc-35.9* rdw-13.5 plt ct-213
[**2103-6-23**] 10:40pm blood neuts-39* bands-39* lymphs-5* monos-2
eos-1 baso-0 atyps-3* metas-11* myelos-0
[**2103-6-23**] 10:55am blood pt-13.0 ptt-22.9 inr(pt)-1.1
[**2103-6-23**] 10:55am blood fibrino-334
[**2103-6-23**] 10:55am blood glucose-119* urean-24* creat-1.1 na-140
k-5.7* cl-104 hco3-20* angap-22*
[**2103-6-23**] 10:40pm blood alt-12 ast-15 ck(cpk)-111 alkphos-38*
totbili-0.5
[**2103-6-23**] 10:55am blood lipase-37
[**2103-6-23**] 10:55am blood ctropnt-<0.01
[**2103-6-23**] 10:40pm blood ck-mb-4 ctropnt-<0.01
[**2103-6-24**] 04:14am blood ck-mb-4 ctropnt-<0.01
[**2103-6-23**] 10:55am blood calcium-8.5 phos-4.8* mg-2.5
[**2103-6-23**] 10:55am blood triglyc-136
[**2103-6-28**] 06:20am blood vanco-13.6
[**2103-6-23**] 10:55am blood asa-neg ethanol-neg acetmnp-6*
bnzodzp-neg barbitr-neg tricycl-neg
[**2103-6-23**] 12:12pm blood type-art rates-16/ tidal v-500 peep-8
fio2-100 po2-436* pco2-56* ph-7.27* caltco2-27 base xs--1
aado2-233 req o2-46 -assist/con intubat-intubated
[**2103-6-23**] 11:41am blood lactate-2.9*
[**2103-6-23**] 11:48pm blood lactate-2.3*
[**2103-6-24**] 04:34am blood lactate-2.7*
[**2103-6-24**] 03:23pm blood lactate-1.6
[**2103-7-4**] 04:49pm blood lactate-1.4
[**2103-6-24**] 03:23pm blood freeca-1.14

reports:

cxr ap [**2103-6-23**]
impression:
1. standard position of endotracheal tube.
2. nasogastric tube extends below level of diaphragm, but
inferior aspect not well seen. consider repeat if desire to
confirm that it terminates in the stomach.
3. low lung volumes with mild bibasilar atelectasis.

ct head [**2103-6-23**]
1. interval increased size of a right-sided vertebral artery
aneurysm with
increased mass effect upon the brainstem. cta should be
considered for
further evaluation.
2. parenchymal atrophy and small vessel ischemic disease. no
other acute
findings.

cta chest [**2103-6-23**]
1. bibasilar, and perihilar opacities with peribronchial
thickening may
reflect aspiration pneumonia. hilar lymph nodes may be reactive.

2. no pulmonary embolism.
3. ng tube tip at the ge junction and should be further advanced
to achieve gastric positioning.

mra head/neck [**2103-6-23**]
impression: right vertebral artery aneurysm at the v3 segment,
apparently
partially thrombosed, the carotid bifurcations and the left
vertebral artery are grossly normal.

cta head w and w/o contrast [**2103-7-7**] (prelim read!) - (final
report dictation confirms preliminary findings.)
1. right vertebral artery aneurysm measuring smaller on cta than
routine head ct - likely secondary to differences in technique.
difficult to measure on non-contrast images due to artifact.
continues to demonstrate compression on the brainstem.
reconstructions pending at this time.
2. no evidence for other aneurysm, vascular malformation or
proximal large
arterial occlusion.
3. new fluid in mastoid air cells bilaterally, may be secondary
to recent
intubation and supine positioning. clinical correlation
recommended.

micro
[**2103-7-6**] sputum gram stain-final; respiratory
culture-preliminary inpatient
[**2103-7-4**] blood culture blood culture, routine-pending
inpatient
[**2103-7-4**] blood culture blood culture, routine-pending
inpatient
[**2103-7-4**] urine urine culture-final inpatient
[**2103-7-3**] stool clostridium difficile toxin a & b
test-final inpatient - negative
[**2103-7-2**] rapid respiratory viral screen & culture
respiratory viral culture-final; respiratory viral antigen
screen-final inpatient
[**2103-7-2**] bronchial washings gram stain-final;
respiratory culture-final {stenotrophomonas (xanthomonas)
maltophilia, gram negative rod #2, yeast}; immunoflourescent
test for pneumocystis jirovecii
(carinii)-final; fungal culture-preliminary {yeast} inpatient
+
   gram stain (final [**2103-7-2**]):
      2+   (1-5 per 1000x field):   polymorphonuclear
leukocytes.
      no microorganisms seen.
      smear reviewed; results confirmed.

   respiratory culture (final [**2103-7-4**]):
      commensal respiratory flora absent.
      due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      stenotrophomonas (xanthomonas) maltophilia.
         10,000-100,000 organisms/ml..
         identification and sensitivities performed on culture #
324-8468n
         ([**2103-6-27**]).
      gram negative rod #2.    rare growth.
      yeast.    10,000-100,000 organisms/ml..

[**2103-7-2**] stool clostridium difficile toxin a & b
test-final inpatient - negative
[**2103-7-1**] urine urine culture-final inpatient
[**2103-6-30**] blood culture blood culture, routine-final
inpatient
[**2103-6-30**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification} inpatient

   gram stain (final [**2103-6-30**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2103-7-3**]):
      commensal respiratory flora absent.
      stenotrophomonas (xanthomonas) maltophilia.    sparse
growth.
         identification and sensitivities performed on culture #
324-8468n
         ([**2103-6-27**]).
      [**female first name (un) **] albicans, presumptive identification.    sparse
growth.
         identification performed on culture # 324-8468n
([**2103-6-27**]).

[**2103-6-29**] blood culture blood culture, routine-final
inpatient
[**2103-6-28**] blood culture blood culture, routine-final
inpatient
[**2103-6-28**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification} inpatient
[**2103-6-28**] urine urine culture-final inpatient
[**2103-6-28**] blood culture blood culture, routine-final
inpatient
[**2103-6-27**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification, serratia species}
inpatient
[**2103-6-26**] blood culture blood culture, routine-final
inpatient
[**2103-6-24**] sputum gram stain-final; respiratory
culture-final {yeast} inpatient
[**2103-6-24**] blood culture blood culture, routine-final
inpatient
[**2103-6-23**] sputum gram stain-final; respiratory
culture-final inpatient
[**2103-6-23**] mrsa screen mrsa screen-final inpatient
[**2103-6-23**] urine urine culture-final emergency [**hospital1 **]
[**2103-6-23**] blood culture blood culture, routine-final
emergency [**hospital1 **]
[**2103-6-23**] blood culture blood culture, routine-final
emergency [**hospital1 **]

discharge labs:
na 143
k 4.3
cl 108
bun 26
bun 9
cr 0.5
gluc 94
ca 8.5
mg 2
phos 3.7

wbc 5.5
hct 31 (stable)
plt 243

brief hospital course:
67yom with parkinsonism & cognitive impairment with known r
vertebral aneurysm (prior eval by [**doctor last name **] in [**2099**]). pt admitted
after syncopal episode after which he was unresponive, apneic.

#. hypoxic respiratory distress: per report, the patient's
episode of coughing while eating, hypoxia, and subsequent loss
of consciousness is consistent with aspiration pneumonia. he was
intubated for his hypoxemic respiratory failure. his chest
imaging, and purulent sputum from endotracheal tube all confirm
this diagnosis. patient was treated with an 8 day course of
vanc/cefepime/flagyl from [**2103-6-23**] until [**2103-7-1**] for
health-care-associated pneumonia. given that he had
stenotrophamonas growing in his sputum sensitive to bactrim, he
was started on bactrim 40 ml po/ng qid d1=[**6-29**] for a long 2-week
course, last dose to be given on [**2103-7-13**]. given his baseline
parkinson's disease, likely icu myopathy, and generalized
weakness, the patient was unable to be weaned from the
ventilator successfully. he was extubated on [**2103-7-2**] but had to
be emergently reextubated the same day for acute respiratory
failure. a trach and peg was placed on [**2103-7-6**] without
complication and he was successfully weaned off of the
ventilator on [**2103-7-8**], currently satting in the mid-high 90s on
50% fio2 trach mask. he would benefit from continued antibiotics
and pulmonary rehabilitation/chest pt. blood and repeat sputum
cultures remained negative.

#. loss of consciousness: given the limited history, it is
unclear whether the patient had loss of consciousness following
or preceeding the emesis and aspiration event. cardiac enzymes
negative x2. neurologic work up revealed slightly larger known
vertebral artery aneurysm (more on this below) thought not to be
related to his current presentation per neurology and
neurosurgery consultation. this was thought to be related to his
hypoxic respiratory failure per above. the patient remained
sedated throughout the admission and on day of discharge.

#. vertebral artery aneurysm: patient with known right vertebral
artery aneurysm, currently 14x12mm as compated to 11x9mm in
[**2101-8-6**]. neurosurgery was consulted and did not recommend
acute treatment of the aneurysm, but recommended mri brain, mra
head and neck. neurology stroke consult was also recommended
given the as stroke is a possibility given this limited history
and exam. repeat cta head/neck revealed a slightly smaller
aneurysm. these findings were discussed with neurosurgery on day
of discharge and a follow up appointment with neurosurgery
should be arranged [**telephone/fax (1) 1669**] within 4-8 weeks.

#. fever: patient persisted to have multiple low grade fevers
for several days all thoughout his icu course (tmax in 24 hours
100.5 last evening [**2103-7-7**]) and 100 this morning [**2103-7-8**]. a large
number of blood, urine, stool, and sputum cultures were drawn
and only positive for stenotrophomonas (xanthomonas) maltophilia
per above and negative for c diff x 2 over the course of [**7-15**]
days. yeast grew in the sputum as well that was thought to be
nonpathologic. the patient developed an acne-like rash on his
backside thought to be secondary to diaphoresis, however,
drug-hypersensitivity secondary to bactrim was considered but
felt to be unlikely. eosinophil count remained normal on day of
discharge. his picc line was also pulled as a potential source
of infection on day of discharge. his fever was therefore
thought to be secondary to stenotrophomonas infection of the
lungs. monitoring of the rash by [**hospital 100**] rehab staff would be
appropriate as well.

#. elevated lactate: patient with lactate of 2.9 on initial
presentation, likely secondary to volume depletion and
hypovolemia. this cleared after ivf.

#. parkinson's disease: continued home sinemet 25/100mg 0.5 tab
at 5pm, 8pm, 1.5 tabs at 8am, 12pm, 2pm

#. bipolar disorder: stable. continued home seroquel 50mg [**hospital1 **],
hold seroquel 25mg q6h prn given patient is intubated, continued
neurontin 100mg daily, continued valproic acid 250mg tid with no
adverse events.

#. hypertension: bp stable, no evidence of shock or hypotension.
held lisinopril , metoprolol 25mg [**hospital1 **], held klonipin 0.5mg tid
as patient sedated and intubated, can be restarted at rehab.

#. dyslipidemia: continued simvastatin 20mg qhs

#. depression: continued cymbalta 40mg [**hospital1 **] per home regimen

#. prophylaxis: patient continued on heparin subcutaneous 5,000
units tid. ppi and chlorhexadine were discontinued upon
discharge as he became vent independent today.
lidoderm patch for chronic pain was continued.
senna/colace/miralax. ppi.

#. contact: sister [**name (ni) **] - [**name (ni) **] [**name (ni) **] [**telephone/fax (1) 74952**] (home),
[**telephone/fax (1) 74953**] (cell). sister [**name (ni) 382**], poa) - [**name (ni) **] [**last name (namepattern1) **]
[**telephone/fax (1) 74954**] (home), [**telephone/fax (1) 74955**] (cell).

#. code status: after extensive family meetings, patient was
deemed dnr but not dni. ambulance services refused to accept dnr
order, despite md signature, demanded hcp signature,
unfortunately, she was not available for signature, therefore
she remained full code for transport. he would return to dnr
status upon arrival to [**hospital 100**] rehab.


medications on admission:
- lisinopril 40mg qhs
- lopressor 25mg [**hospital1 **]
- simvastatin 20mg qhs
- seroquel 25mg q6h prn
- seroquel 50mg [**hospital1 **]
- sinemet 25/100mg 0.5 tab at 5pm, 8pm, 1.5 tabs at 8am, 12pm,
2pm
- valproic acid 250mg tid
- lidoderm patch
- tylenol 1gm q8h prn pain
- vitamin d 1000 units daily
- klonipin 0.5mg tid
- cymbalta 40mg [**hospital1 **]
- neurontin 100mg daily
- nitro tp 0.2mcg/day
- miralax 17g [**hospital1 **]
- dulcolax 5mg qday prn
.


discharge medications:
1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid
(2 times a day).
2. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
3. quetiapine 25 mg tablet sig: two (2) tablet po bid (2 times a
day).
4. quetiapine 25 mg tablet sig: one (1) tablet po q6h (every 6
hours) as needed for agitation.
5. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po
tid (3 times a day).
6. carbidopa-levodopa 25-100 mg tablet sig: 0.5 tablet po q 5pm,
8pm ().
7. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: five
(5) ml (250 mg) po q8h (every 8 hours).
8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) adhesive patch, medicated topical daily (daily).
9. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain, fever.
10. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1)
tablet po daily (daily).
11. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times
a day).
12. duloxetine 20 mg capsule, delayed release(e.c.) sig: two (2)
capsule, delayed release(e.c.) po bid (2 times a day).
13. gabapentin 250 mg/5 ml solution sig: 100 mg (2 ml)  po daily
(daily).
14. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day): ok to hold if pt is able to
ambulate tid.
15. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: [**1-7**]
drops ophthalmic prn (as needed) as needed for dry, red eyes.
16. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension sig:
forty (40) ml po qid (4 times a day) for 5 days: take through
[**7-13**].
17. erythromycin 5 mg/gram (0.5 %) ointment sig: one (1)
ophthalmic [**hospital1 **] (2 times a day) for 2 days.
18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1)  inhalation q6h (every 6 hours) as
needed for wheezing, shortness of breath.
19. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
qid (4 times a day) as needed for wheezing, shortness of breath.

20. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
21. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2)
tablet, delayed release (e.c.) po daily (daily) as needed for
constipation.
22. docusate sodium 50 mg/5 ml liquid sig: one (1)  po bid (2
times a day).
23. polyethylene glycol 3350 17 gram/dose powder sig: one (1)
po daily (daily) as needed for constipation.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - macu

discharge diagnosis:
primary: aspiration pneumonia, respiratory failure, altered
mental status
.
secondary: conjunctivitis, parkinson's, bipolar, loss of
conciousness, verterbral artery anuerysm


discharge condition:
mental status: confused - always.
level of consciousness: lethargic but arousable.
activity status: bedbound.


discharge instructions:
you were admitted to the hospital for hypoxic respiratory
distress thought to be due to aspiration pneumonia.  you were
treated with antibiotics and you improved, however you were
unable to be weaned from the ventilator, therefore a
tracheostomy was performed and a peg tube was placed for
nutrition.  additionally while in the hospital you were treated
for conjunctivitis and followed for your vertebral artery
anuerysm which was stable.  your home psychiatric and
parkinson's medications were continued.
.
the following changes were made to your medications:
-start bactrim, continue taking through [**7-13**]
-stop lisinopril and nitroglycerin pathc, this can be restarted
if you are hypertensive, however it was discontinued during the
admission because your pressures were well controlled
-start sc heparin for dvt prophylaxis
-start erythromycin eye ointment and moisturizing eye drops
-start albuterol and ipratroprium nebs as needed for shortness
of breath
-start senna and docusate for constipation

followup instructions:
please follow up with your rehab physician.  [**name10 (nameis) 357**] schedule
follow up with neurosurgery in [**4-13**] weeks by calling:
[**telephone/fax (1) 1669**].


                             [**name6 (md) **] [**name8 (md) **] md [**md number(2) 2764**]

completed by:[**2103-7-8**]"
219,"admission date:  [**2131-8-2**]              discharge date:   [**2131-8-21**]

date of birth:  [**2067-11-7**]             sex:   m

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 2297**]
chief complaint:
reason for admission: seizures


major surgical or invasive procedure:
none.

history of present illness:
mr. [**known lastname 916**] is a 63yo male with pmh significant for seizures,
atrial fibrillation, and s/p cabg who is being transferred from
osh for management of seizures. per patient's wife, on tuesday
the patient complained of seeing spots in his eyes. on wednesday
night/early morning the patient complained of seeing spots
again. at approximately 4am mr. [**known lastname 916**] attempted to go the
bathroom but fell on the floor at which time his wife woke up
and found her husband seizing. she called 911 and the patient
was brought to [**hospital 1562**] hospital. initial vitals in ed were t
100.4 bp 182/66 ar 128 rr 14 o2 sat 96% ra. in the ed he had
another generalized tonic clonic seizure. he was given keppra
via the ngt. he was intubated for airway protection. per osh
records, the intubation was difficult and required help of
anesthesiologist. ct scan of head and c spine were unrevealing.

.
he was then transferred to the icu for closer management. in the
icu the patient spiked a temperature to 102 and he was given
rocephin and clindamycin for suspected aspiration pneumonia. on
[**8-2**] at 3am patient went into 15-30 minutes of status
epilepticus. he was loaded with dilantin 500mg iv x1. and placed
on benzos. ventilation settings at this time were: simv tv 600
rr 10 fio2 60% ps 15 peep 5. he was then transferred to [**hospital1 18**]
for further management.
.
per patient's wife, he was diagnosed with seizures 1 year ago
when he had a seizure at home and presented to [**hospital1 2025**]. found to
have cva which was thought to be cause of seizure. he was
started on keppra. he has not had a seizure since then but has
complained of seeing spots occasionally. she is followed closely
by her neurologist and saw him 1 month ago.
.
no recent fevers, chills, chest pain, sob, dizziness, or
dysuria. per wife, the patient has good and bad days but had
been feeling well prior to this admission.


past medical history:
1)cad s/p cabg 9 years ago
2)seizure disorder-last seizure 1 year ago
3)atrial fibrillation on anticoagulation
4)ulcerative colitis


social history:
patient lives with wife in [**hospital3 **]. currently retired. no
history of tobacco, alcohol, or ivda.

family history:
nothing relevant, per wife

physical exam:
vitals t 102.4 bp 159/114 ar 103 rr 14
vent settings: ac fi02 1.0 tv 600 rr 14 peep 5
gen: patient sedated, responsive to sternal rub
heent: ett in place
heart: irregularly, irregular. +systolic murmur
lungs: course breath sounds anteriorly
abdomen: obese, soft, nt/nd, decreased bss
extremities: no edema, 2+ dp/pt pulses bilaterally


pertinent results:
[**2131-8-2**] 05:30pm   pt-24.6* ptt-43.6* inr(pt)-2.5*
[**2131-8-2**] 05:30pm   plt count-259
[**2131-8-2**] 05:30pm   wbc-5.7 rbc-3.38* hgb-12.9* hct-37.5*
mcv-111* mch-38.3* mchc-34.6 rdw-16.1*
[**2131-8-2**] 05:30pm   tsh-0.39
[**2131-8-2**] 05:30pm   albumin-3.1* calcium-8.1* phosphate-3.1
magnesium-2.4
[**2131-8-2**] 05:30pm   ck-mb-6 ctropnt-0.10*
[**2131-8-2**] 05:30pm   lipase-12
[**2131-8-2**] 05:30pm   alt(sgpt)-25 ast(sgot)-27 ld(ldh)-312*
ck(cpk)-187* alk phos-47 amylase-174* tot bili-1.5
[**2131-8-2**] 05:30pm   glucose-124* urea n-14 creat-1.2 sodium-143
potassium-3.9 chloride-111* total co2-21* anion gap-15
[**2131-8-2**] 06:11pm urine  uric acid-few
[**2131-8-2**] 06:11pm urine  rbc-[**5-13**]* wbc-[**2-5**] bacteria-few
yeast-none epi-0-2
[**2131-8-2**] 06:11pm urine  blood-lg nitrite-neg protein-tr
glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0
leuk-neg
[**2131-8-2**] 06:11pm urine  color-amber appear-clear sp [**last name (un) 155**]-1.028
[**2131-8-2**] 09:51pm   phenytoin-4.5*
[**2131-8-2**] 09:51pm   digoxin-0.9
[**2131-8-2**] 10:51pm   type-art temp-38.2 rates-14/0 tidal vol-600
peep-5 o2-60 po2-133* pco2-43 ph-7.36 total co2-25 base xs--1
-assist/con intubated-intubated
[**2131-8-3**] 03:22am blood wbc-5.0 rbc-3.24* hgb-12.3* hct-34.8*
mcv-107* mch-38.0* mchc-35.4* rdw-17.3* plt ct-223
[**2131-8-4**] 03:14am blood wbc-4.5 rbc-2.98* hgb-11.3* hct-32.0*
mcv-107* mch-38.1* mchc-35.4* rdw-16.8* plt ct-209
[**2131-8-3**] 03:22am blood glucose-115* urean-12 creat-1.2 na-143
k-4.0 cl-113* hco3-21* angap-13
[**2131-8-3**] 03:44pm blood glucose-119* urean-10 creat-1.0 na-143
k-3.7 cl-111* hco3-21* angap-15
[**2131-8-4**] 03:14am blood glucose-119* urean-8 creat-0.9 na-143
k-3.6 cl-110* hco3-21* angap-16
[**2131-8-5**] 03:01am blood glucose-92 urean-5* creat-0.8 na-146*
k-3.2* cl-111* hco3-25 angap-13
[**2131-8-5**] 03:01am blood lipase-75*
[**2131-8-3**] 03:22am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-pos barbitr-neg tricycl-neg

[**hospital 93**] medical condition:
63 year old man with sob, hypoxia
reason for this examination:
r/o dvt
shortness of breath and hypoxia. question dvt.

grayscale and doppler son[**name (ni) 1417**] were performed of the ij,
subclavian and axillary veins on the left and of the ij on the
right. there was diminished compressibility in the left cephalic
vein compatible with acute thrombosis. there was normal
compressibility, flow, and augmentation in the other vessels.

impression: superficial venous thrombus noted in the cephalic
vein. no dvt.

[**hospital 93**] medical condition:
63 year old man with sob, hypoxia
reason for this examination:
r/o dvts
indication: rule out dvt.

[**doctor last name **] scale and doppler son[**name (ni) 1417**] of bilateral common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins was performed. there is normal compressibility, color
flow, and augmentation.

impression: no evidence of right or left leg dvt.

the study and the report were reviewed by the staff radiologist.
dr. [**first name4 (namepattern1) 19115**] [**last name (namepattern1) **]
dr. [**first name11 (name pattern1) 8711**] [**initial (namepattern1) **] [**last name (namepattern4) **]
approved: fri [**2131-8-17**] 8:37 am

brief hospital course:
hd#1 ([**2131-8-2**]):  patient arrived in the [**hospital1 18**] micu-6 the
afternoon of [**2131-8-2**] intubated, sedated and in stable condition
with ngt in place.  on arrival active patient medications
included keppra 1000 mg [**hospital1 **] and sedation with fentanyl 50 mcg/hr
and midazolam 4 mg/hr.  all other home medications were intially
held.  given suspicion for meningitis in the setting of seizure
+ fevers patient was given one dose of ceftriaxone 2 gm iv with
infectious disease consent required for further treatment.
also, a history suspicious for patient was sent for urgent mra
of head & neck and mr of head which showed:  1)no enhancing
lesions.  chronic infarct in left parieto-occipital lesion, and
2)50% narrowing of right proximal ica.  left ica origin
atheroma.""  patient was initially seen on unit by neurology who
recommended continuation of keppra, eeg to evaluate for seizure
activity, echo for new murmur + fever, lp when inr < 1.5, and an
increase in versed drip with consideration of dilantin load if
patient seized again.  suctioning from ett showed brownish-grey
aspirate and ua that day showed no organisms.  patient remained
febrile throughout first day in micu.
.
hd#2 ([**2131-8-3**]):  patient received tylenol for fever overnight
and had echo and eeg in the morning.  echo showed no signs of
valvular vegetations and eeg showed no signs of an epileptiform
focus.  in the setting of seizure + fevers meningitis remained
at the top of our differential diagnosis and an lp was arranged.
 prior to admission patient had taken coumadin for his atrial
fibrillation and on transfer to micu initial inr was 2.5,
patient was initially given 3 units of ffp with following
inr=1.7.  transfusion of two more units of ffp resulted in no
change in inr so plan for lp was aborted.  during the day
patient became very anxious, became tachycardic to the 140s,
began demonstrating tremor in his lower extremities bilaterally
and started pulling against his restraints.  his fentanyl was
incresaed to 75 mg/hr and versed was increased to 5.0 mcg/hr.
he was also bolused with dilantin 1000 mg iv once since patient
was also displaying tremor in le bilaterally while sedated.
patient remained tachycardic to the 120s-130s depsite the
increase in sedation and diltiazem 60 mg po qid was started with
diltiazem 5 mg iv for immediate control.  to empirically cover
aspiration pneumonia vancomycin & flagyl were started and id
approval for ceftriaxone therapy (to cover pneumococcus) was
obtained.  ampicillin was also started to cover listeria
monocytogenes and acyclovir was started due to concern for hsv
encephalitis after blood drawn for hsv pcr.  temperature spiked
to 101 at 18:00 with repeat panculture including mini-bal which
showed 1+ pmns and oropharyngeal flora.  ett was advanced 1 cm
after cxr showed approx 5 cm above the carina.  patient remained
npo.
.
hd#3 ([**2131-8-4**]):  patient remained febrile and began having
episodes of loose stools.  patient with long history of
ulcerative colitis, but stool sample sent for c.diff toxin which
was negative.  restarted on 6-mercaptopurine for uc.  lp was
re-attempted prior to which patient received an additional 5
units of ffp with following inr=1.3.  following lp tube feedings
were intiated and changed later in the day to include fiber with
a goal of 90 cc/hr.  urine output was noted to be poor, patient
putting out approximately 15 cc/hr.  two fluid boluses of 500 cc
were given with no effect.
.
hd#4 ([**2131-8-5**]):  patient remained febrile, with attempts to wean
sedation aborted due to increased patient anxiety/agitation.  in
light of negative blood/csf/urine cultures acyclovir, ampicillin
and ceftriaxone were discontinued.  mr. [**known lastname 916**] continued to take
vancomycin for [**8-4**] sputum culture that grew 2+ g(+) cocci in
pairs and clusters and flagyl for empiric tx of c.diff diarrhea
despite negative stool toxin screens.  ct of chest with contrast
showed:  1)bilateral pleural effusions with associated
atelectasis & consolidation, left>right, 2)2 small pulmonary
nodules in rul ~4 cm in diameter, 3)airspace disease in the lul,
and 4)coronary artery and mitral annulus calcifications.
.
hd#5 ([**2131-8-6**]):  patient continued to be febrile, reaching
temperature of 102 degrees overnight.  also continued to have
loose stools with output of 2l, flagyl discontinued due to
multiple negative c.diff toxin screens.  however, stool was
re-sent for c.diff a&b toxins and banana flakes were added to
tube feeds to bulk-up stools.  plan for gi consult the following
day.  urine output continued to be poor, patient was given
one-time dose of lasix iv 40 mg with transient increase in uop.
patient was placed on trial of pressure support starting @ 13:00
and continuing on throughout the night without adverse events.
sedation was gradually weaned with fentanyl decreased from 75
mcg/hr to 60 mcg/hr and versed at 4.0 mg/hr.  patient continued
to have episodes of anxiety throughout the day for which he was
given lorazepam 1 mg iv for breakthrough relief.  picc line was
place in right arm in the a.m.  zosyn 4.5 mg iv q8h was started
to empirically cover g(-) organisms causing pneumonia
.
hd#6 ([**2131-8-7**]):  no high fever spikes, but patient ran low-grade
fever of 100.5.  per cxr, pna not progressing/worsening.
azithromycin 500 mg po bid added to cover atypical causes of pna
(mycoplasma/chlamydia/etc).  gi consulted for increased, watery
stool output (patient has h/o uc treated with 6-mp, requested
consult to determine any additional management
options/symptomatic relief).  no recommendations per gi, cannot
determine at this time if current stooling is any change from
baseline.  per neurology, keppra dose was increased to 1250 mg
po bid (from 1000 mg).  patient on coumadin as outpatient for
a.fib, held on admission to perform lp.  heparin ggt restarted
for dvt prophylaxis.  given another single dose of lasix 40 mg
iv to removed third-spaced fluid, net -850 cc at end of day with
los fluid net +8.6l.  diltiazem ggt titrated up to 10 u/hr to
maintain hr<100 bpm.  overnight, patient became agitated on
cpap+ps, ac restarted briefly for a few hours and placed back on
pressure support.
.
hd#7 ([**2131-8-8**]):  patient placed back on pressure support with ps
15/peep 8 (increased from [**11-7**]).  arterial line placed in right
arm without complications.  abg showed 7.44/33/102/23.  dosed
again with lasix 40 mg iv to removed fluid that had third spaced
into tissues/pleural space.  continued vanc/zosyn/azithro.
again spiked temperature to 101.5 degrees at mid-day and was
pancultured.  patient also became tachycardic with hr increase
to 130s-140s, diltiazem drip increased to 10 mg/hr.  began
having apneic episodes on pressure support and was placed back
on ac at 20:00.  sedation weaned to versed 3.0 mg/hr and
fentanyl 25 mcg/hr.  lost last piv access, patient only with
arterial line and right picc line.  k 3.2, corrected.  tube
feeds held due to continued high gastric residuals.  during late
afternoon/evening patient was dosed once again with lasix 20 mg
iv with repeat cr 1.8.
.
hd#8 ([**2131-8-9**]):  cr this a.m. 2.0.  urine sent for urine lytes
(na, bun, creatinine), urine eosinophils, microscopic analysis.
likely due to hypovolemia secondary to diuresis.  lasix held
today, monitoring cr for improvement of [**last name (un) **].  throacic
ultrasound performed to look for possible empyema/loculated
plueral effusions and did not reveal any significant fluid
collection that would benefit from throacentesis.  patient
remained on ac vent overnight, risbi in the a.m. 103, mid-day
abg on ac 7/46/36/106.  decided to give patient spontaneous
breathing trial.  patient maintained own ventilation for 30 min
at which time respirations were ~40/min, sao2 92% and patient
having difficulty breathing.  trial was stopped and patient put
back on pressure support with ps 5/peep 0.  id consulted for
further work-up of fuo.  recommended checking borellia and
ehrlichia serologies and inspecting peripheral smear of blood
for parasites (babesiosis) if spiked temp again.  also
recommended changing azithromycin to doxycycline if spiked temp
again.  later in evening patient spiked temp to 102.5 and id
recs were instituted.
.
hd#9 ([**2131-8-10**]):  renal consulted for decline in renal fxn and
proposed atn vs. prerenal azotemia vs. ain, though most likely
non-oliguric atn.  recommended increase in free water intake as
patient was also hypernatremic and renally dosing medications.
renal us showed no evidency of hydronephrosis.  had ct of
head/sinuses which showed no acute sinusitis with mild mucosal
thickening and non-contrast ct of chest & abdomen which showed:
1.  bilateral pleural effusions with associated atelectasis and
consolidation, greater on the left than the right.  this is
stable from prior exam. 2.  stable pulmonary nodules in the
upper lobe. 3.  stable extensive coronary artery and aortic
calcifications. 4.  no discrete focus of infection is identified
although this study is limited by lack of contrast. 5.  anasarca
of the body wall in abdomen and pelvis.
.
hd#10 ([**2131-8-11**]):  stopped diltiazem gtt & started esmolol gtt to
control hr & bp.  sedation weaned and discontinued and patient
extubated, after which patient was tachypneic but abgs looked
good.  id recommended further checking cmv serologies, patient
spiked temp to 101 and blood was cultured again for anaerobic
bacteria and fungus.
.
hd#11 ([**2131-8-12**]):  patient continued tx with iv vancomycin (dosed
by levels) and renally-dosed zosyn.  received 1 gm vanc when
afternoon levels 13.5.  attempted to wean esmolol gtt, could not
maintain adequate control of hr & bp.  stopped drip and gave
metoprolol 25 mg po tid, soon increased to 75 mg po tid with
additional dosing of diltiazem 10 mg iv once to control rate.
patient then started on diltiazem 30 mg po qid in addition to
metoprolol 75 mg po tid to control rate, though patient
continued to be tachycardic and htnive throughout day.
metroprolol increased to 100 mg po tid and diltiazem increased
to 60 mg po qid.  overnight patient remained confused, likely
residual effect of multiple heavy sedatives, and attempted to
climb out of bed and required one-time doses of ativan &
zyprexa.  patient will require one-on-one sitter upon tx to
floor.  patient had tee which showed no vegetations and severely
deformed aortic valve.  d/c'd doxycycline per id recs and had
repeat cxr due to increased airway secretions and concern over
?aspiration while taking a.m. medications.  order placed for
speech & swallow eval, post-poned until tomorrow due to patient
having brief episode of tachypnea and sats down to 92% requiring
non-rebreating mask.  per renal, adjusted dose of keppra
according to gfr, approved by neuro and will be seen by their
service tomorrow.  na noted to be 149 and given 1l d5w over 24
hours.
.
hd#12 ([**2131-8-13**]):  patient not seen by neuro.  patient continued
to be hypernatremic and was given 1l d5w @ 200 cc/hr and another
at 125 cc/hr.  metoprolol was increased to 100 mg po tid and
diltiazem was increased to 60 mg po qid to control heart rate.
per nursing that morning, patient had questionable episode of
aspiration while taking morning medications.  repeat cxr showed
marginal worsening infiltrates in the rml.  later that night
patient dropped sats to 85% and given cpap for 30 minutes with
improvement.  he had several hours of respiratory stability but
eventually re-developed tachypnea (50) and hypoxemia (7.48/36/61
on nrb) followed by an episode of hypotension and was
re-intubated.  the rest of hospital summary will be in
problem-based format:
.
1)hypoxic respiratory failure: patient intubated @ osh in
setting of status epilepticus in order to protect airway.
initially struggling against ventilator requiring increases in
sedation, suctioning of ett showing brownish-[**doctor last name 352**] sputum. now
weaning sedation with vent on cpap+ps as patient tolerates,
decreased sputum production. arterial line placed [**2131-8-8**], d/ced
by pt on [**8-11**]. pt extubated [**8-11**], required supplemental o2 via nc
and hiflow nrb over following days & developed tachypnea and
hypoxia early morning of [**8-15**] requiring re-intubation. [**8-15**] leni
and l ueni show no dvt, ct chest same day showing new bilat ll
consolidation concerning for aspiration, bridging
small-to-moderate pleural effusions and new hydrostatic
pulmonary edema. bnp 30,173 on [**8-15**]. serial cardiac enzymes r/o
mi.
-rested overnight on psv, good sbt this a.m. and extubated
without complications. ngt placed prior to extubation for tube
feedings due to recent h/o aspiration.
-continue suppl. 02, wean as tolerated to maintain sa02 >90%.
chest pt. patient oob with assist to chair.
-thoracic us [**8-16**] showed ~1.6 ml of pleural fluid, ip unable to
tap effusions.
-aspriation pna most likely culprit, cont iv vanc/zosyn renal
dosing. concern for developing lung abscess. currently on day
13/14 of zosyn regimen, will extend until chest can be re-imaged
and abscess confirmed/ruled-out.
-continue lasix gtt with goal of net negative 1l fluid balance
today. if patient auto-diureses may stop gtt and begin scheduled
regimen.
-daily cxr
-pt to evaluate for rehab.
.
2)fevers: patient presents with fevers since he was admitted to
osh. likely cause of new onset seizures. possible sources of
infection include lll infiltrate. no report of productive cough,
dysuria, other symptoms at home. still unclear source. tee done,
blood and urine negative to date, cdiff negative, csf negative.
lack of leukocytosis may be due to uc tx with 6-mp. [**8-4**], [**8-5**],
[**8-6**] c.diff screens negative.
[**8-4**] blood culture showing not growth. [**8-11**] non-contrast ct of
head/chest/abdomen for eval of possible sinusitis and
surveillance of occult focus of infection =>no infectious
source. pt continues to spike temps nightly. [**2131-8-13**] tee shows
not evidence of endocarditis and a severely deformed aortic
valve. -lyme, -hsv, c.diff toxin b negative. relatively afebrile
[**8-12**] through [**8-14**] but spiked temp to 102 degrees am of [**8-15**],
resolved to low-grade temp ~100.5 by [**8-20**]. negative
ehrlichia/coxiella/legionella bal culture.
- tylenol prn for fever
- continue broad coverage of pna. zosyn renally dosed to 2.25 gm
iv q6 hours, back on scheduled vanc 750 mg iv daily, follow vanc
levels
- check routine vanc levels.
- f/u [**8-15**] and [**8-17**] blood cultures as well as [**8-11**] fungal/afb
cultures. c.diff rechecked and negative [**8-17**].
- f/u additional id recs, appreciate input,
.
3)acute kidney injury: cr stable now. likely due to
hypovolemia/prerenal azotemia secondary to lasix diuresis. urine
lytes show no eosinophiluria, fena and feuria indicate intrinsic
renal etiology of [**last name (un) **].
- cr stable, monitor daily
- renal consult, appreciate recs
- dose medications for patient's creatinine
- continue lasix gtt, stop if cr >2.5. [**month (only) 116**] start schuled iv
lasix this pm.
.
4)hypernatremia: increased to 149 [**2131-8-14**] & decreased to 139
with d5w supplementation. morning of [**8-15**] found to be 155 but
patient sedated after reintubation and difficult to assess for
mental status changes. patient with good uop.
-na now wnl
-ngt placed prior to extubation and tube feedings stopped. [**month (only) 116**]
gently re-start tube feedings this pm. d/c free water boluses.
-continue lasix gtt and monitor uop.
-daily chem7.
.
5)atrial fibrillation: patient remains in atrial fibrillation;
confirmed by ekg on admission to osh and [**hospital1 18**]. previously on
coumadin for a.fib.
- on heparin drip at 1400 u/hr. holding coumadin 5 mg po daily.

- [**2131-8-9**] shows severe as with valve diameter of 0.8 cm2. patient
will need aggressive rate control to decrease stress to heart.
- continue metoprolol 100 mg tid, po diltiazem increased at 90
mg po qid.
.
6)seizure disorder (requiring intubation): patient was diagnosed
with seizure disorder 1 year ago in setting of cva. now presents
with recurrent seizures despite being on keppra. differential
for seizures include infection, stroke, metabolic
encephalopathy, drugs, head trauma, tumors, etc. most likely
infection since patient has been febrile. concerned about
meningitis as a possible etiology though ruled out by negative
lp. [**2131-8-3**] mra head/neck and mr of head show no new enhancing
lesions. same day echo for new murmur showed no vegetations and
eeg showed no epileptiform focus.
- infectious etiology continues to be at top of differential,
but pneumonia only foci identified thus far.
- keppra renally-dosed to 750 mg po bid, approved by neuro.
- iv ativan if patient becomes symptomatic for seizures
.
7)ulcerative colitis: patient on mercaptopurine as outpatient.
per wife, patient has history of cramping and loose stools on a
regular basis.
- continue mercaptopurine 75 mg po daily. 400 cc stool op
yesterday.
- per gi consult, no evidence current stool op is change from
baseline.
- banana flakes added to tube feeds if having loose stools.
.
8)cad s/p cabg: no complaint of recent sob or chest pain during
this admission.
- continuing home statin, on oral beta blocker and ccb for rate
& pressure control.
.
9)fen:
- speech & swallow evaluation shows okay to take pre-thickened
nectar feeds, however will initially feed via ngt s/p
extubation.
- repeat speech & swallow study in the am
- restart nutren full-strength tube feedings tonight at 10 cc/hr
with goal of 45 cc/hr, advance as tolerated and checking
residuals q6 hours
.
10)access: right picc line placed [**2131-8-6**]. arterial line placed
[**2131-8-15**] in rue and pivx1 (20g).
.
11)prophylaxis: iv heparin, ppi.
.
12)code: full (verified with wife
.
13)dispo:  c/o to floor bed.
.
final instructions to accepting team:
1)  monitor na
2)  follow mental status for return to baseline.  will likely
need 1:1 sitter due to increased pm agitation, pulling ngt,
well-controlled with iv ativan.
3)  continue iv zosyn (day 14) due to concern for ? lung
abscess.  per id okay to d/c vanc (18 day course total)
4)  follow-up 9/12 & [**8-17**] blood cultures, [**8-11**] fungal/afb culture
5)  wean 02, continue chest pt and
6)  speech & swallow to perform video swallow eval once mental
status improves
7)  screen for rehab
8)  f/u pt/ot consult on day of transfer, oob with assistance.

medications on admission:
digoxin
diltiazem 240mg po daily
lasisx 40mg po daily
isordil
coumadin
omeprazole
purinethol 75mg po daily
keppra 750mg po daily


discharge medications:
keppra 750 mg po bid
diltiazem 90 mg po qid
metoprolol 100 mg po tid
asa 81 mg po daily
lasix 40 mg iv bid
zosyn 2.25 gm iv q6 hours (day 14/16)
protonix 40 mg iv daily
mercaptopurine 75 mg po daily
ativan 1 mg iv prn agitation

discharge disposition:
extended care

facility:
[**hospital3 105**] northeast - [**location (un) 701**]

discharge diagnosis:
recurrent seizures/status epilepticus of unknown etiology
requiring intubation complicated by aspiration pneumonia and
recurrent fevers.

discharge condition:
stable, mental status not returned to baseline.

discharge instructions:
please keep all scheduled medical appointments.  call a
physician or go to the emergency room if experiencing the
following symptoms:  chest pain, shortness of breath, change in
mental status/increased confusion, fever greater than 102
degrees, recurrent seizures or loss of consciousness, onset of
weakness or loss of sensation or any other concerning symptoms.

followup instructions:
please call your neurologist and primary care provider within
two weeks of leaving rehabilitation to set up an appointment.
please also have your primary care provider refer you to a
cardiologist or see your pre-existing cardiologist to evaluate a
valvular abnormality that was noted during your hospital stay.


"
220,"admission date:  [**2119-2-22**]              discharge date:   [**2119-2-25**]

date of birth:  [**2088-12-4**]             sex:   m

service: neurosurgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1835**]
chief complaint:
headache

major surgical or invasive procedure:
[**2119-2-22**]:  suboccipital craniotomy for chiari decompression


history of present illness:
patient is a 30m electively admitted for chiari type i
decompression.

past medical history:
osa
chiari malformation(type i)

social history:
non-contributory

family history:
non-contributory

physical exam:
exam on discharge:
neurologically intact

pertinent results:
[**2119-2-25**] 06:05am blood wbc-8.2 rbc-4.07* hgb-12.4* hct-35.7*
mcv-88 mch-30.4 mchc-34.6 rdw-12.4 plt ct-284
[**2119-2-25**] 06:05am blood plt ct-284
[**2119-2-25**] 06:05am blood glucose-106* urean-13 creat-0.8 na-136
k-4.1 cl-98 hco3-26 angap-16
[**2119-2-25**] 06:05am blood calcium-9.6 phos-4.3 mg-2.1
[**2119-2-25**] 06:05am blood glucose-106* urean-13 creat-0.8 na-136
k-4.1 cl-98 hco3-26 angap-16
[**2119-2-25**] 06:05am blood calcium-9.6 phos-4.3 mg-2.1

brief hospital course:
patient is a 30m electively admitted for suboccipital craniotomy
for chiari type i malformation. operative course was uneventful,
and he was taken to the icu post-operatively for close
neuromonitoring overnight. post-op head ct showed no hemorrhage.
there were no adverse events overnight. he was transfered to the
floor on [**2119-2-23**], his pca was discontinued and given po
medications. he continued with normal expected headaches
throughout his hospitalization. his incision was clean and dry.
on discharge he was voiding, tolerating a regular [**date range **] and had a
normal neurological exam.

medications on admission:
ambien prn, motrin prn, fluocinonide prn

discharge medications:
1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
disp:*60 capsule(s)* refills:*2*
2. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours)
as needed for pain.
disp:*40 tablet(s)* refills:*0*
3. methocarbamol 500 mg tablet sig: 1.5 tablets po qid (4 times
a day).
disp:*180 tablet(s)* refills:*2*
4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
5. glucagon (human recombinant) 1 mg recon soln sig: one (1)
recon soln injection q15min () as needed for hypoglycemia
protocol.


discharge disposition:
home

discharge diagnosis:
chiari type i malformation


discharge condition:
neurologically stable


discharge instructions:
general instructions
wound care
??????	you or a family member should inspect your wound every day and
report any of the following problems to your physician.
??????	keep your incision clean and dry.
??????	you may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
??????	do not apply any lotions, ointments or other products to your
incision.
??????	do not drive until you are seen at the first follow up
appointment.
??????	do not lift objects over 10 pounds until approved by your
physician.
[**name10 (nameis) **]
usually no special [**name10 (nameis) **] is prescribed after a craniotomy. a
normal well balanced [**name10 (nameis) **] is recommended for recovery, and you
should resume any specially prescribed [**name10 (nameis) **] you were eating
before your surgery.
medications:
??????	take all of your medications as ordered.  you do not have to
take pain medication unless it is needed.  it is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
??????	do not use alcohol while taking pain medication.
??????	medications that may be prescribed include:
-narcotic pain medication such as dilaudid (hydromorphone).
	-an over the counter stool softener for constipation (colace or
docusate). if you become constipated, try products such as
dulcolax, milk of magnesia, first, and then magnesium citrate or
fleets enema if needed). often times, pain medication and
anesthesia can cause constipation.
??????	unless directed by your doctor, do not take any
anti-inflammatory medicines such as motrin, aspirin, advil, and
ibuprofen etc, as this can increase your chances of bleeding.
activity:
the first few weeks after you are discharged you may feel tired
or fatigued. this is normal. you should become a little stronger
every day. activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. in general:
??????	follow the activity instructions given to you by your doctor
and therapist.
??????	increase your activity slowly; do not do too much because you
are feeling good.
??????	you may resume sexual activity as your tolerance allows.
??????	if you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
??????	do not drive until you speak with your physician.
??????	do not lift objects over 10 pounds until approved by your
physician.
??????	avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
??????	   do your breathing exercises every two hours.
??????	   use your incentive spirometer 10 times every hour that you
are awake.

when to call your surgeon:
with any surgery there are risks of complications. although your
surgery is over, there is the possibility of some of these
complications developing. these complications include:
infection, blood clots, or neurological changes. call your
physician immediately if you experience:

??????	confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
??????	double, or blurred vision. loss of vision, either partial or
total.
??????	hallucinations
??????	numbness, tingling, or weakness in your extremities or face.
??????	stiff neck, and/or a fever of 101.5f or more.
??????	severe sensitivity to light. (photophobia)
??????	severe headache or change in headache.
??????	seizure
??????	problems controlling your bowels or bladder.
??????	productive cough with yellow or green sputum.
??????	swelling, redness, or tenderness in your calf or thigh.

call 911 or go to the nearest emergency room if you experience:
??????	sudden difficulty in breathing.
??????	new onset of seizure or change in seizure, or seizure from
which you wake up confused.
??????	a seizure that lasts more than 5 minutes.

important instructions regarding emergencies and after-hour
calls
??????	if you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
??????	should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
.

followup instructions:
follow-up appointment instructions

??????please return to the office in [**11-9**] days (from your date of
surgery) for removal of your sutures and a wound check. this
appointment can be made with the nurse practitioner.  please
make this appointment by calling [**telephone/fax (1) 1669**]. if you live quite
a distance from our office, please make arrangements for the
same, with your pcp.
??????please call ([**telephone/fax (1) 88**] to schedule an appointment with dr.
[**last name (stitle) **], to be seen in 2 weeks.
??????you will not need a ct scan of the brain.



completed by:[**2119-10-4**]"
221,"admission date:  [**2101-5-17**]              discharge date:   [**2101-5-22**]

date of birth:  [**2072-12-18**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2101-5-17**]
1. open cholecystectomy.
2. open roux-en-y gastric bypass.


history of present illness:
[**known firstname 87221**] has class iii extreme morbid obesity with bmi of 60.7.
previous weight loss efforts have included weight watchers,
slim-fast, prescription [**street address(1) 87222**]/pcp [**name initial (pre) 51433**]. she has
been struggling with weight her entire life and  cites as
contributors large portions, late night eating, too many
carbohydrates and saturated fats, stress and lack of exercise.
she denies history of eating disorders - no anorexia, bulimia,
diuretic or laxative abuse.  has history of depression but has
not been followed by a therapist nor has she been hospitalized
for mental health issues. she was once on psychotropic
medication (citalopram), but is no longer.


past medical history:
htn, migraine, osa(recommended cpap), fatty liver,
cholelithiasis


social history:
denies tobacco or recreational drug usage, does drink about 8
alcoholic beverages weekly and has both carbonated and
caffeinated drinks. works as a day care teacher and she is
single living with her mother age 62 and she has no children.

family history:
father deceased age 72 with cancer, diabetes and hyperlipidemia.
mother living age 62 with heart disease, hyperlipidemia, dm, oa
and obesity.  sister in her 40s also with obesity and underwent
roux-en-y gastric bypass.

physical exam:
admission physical exam:
bp 129/79, pulse 73, respirations 18 and o2 saturation 100% on
room air.
gen: casually dressed, pleasant and in no distress.
skin: warm, dry with no rashes.
heent: sclerae were anicteric, conjunctiva clear except for mild
hyperemia of the right lower conjunctiva, pupils were equal
round and reactive to light, fundi noted sharp optic disks
without hemorrhage, mucous membranes were moist,
tongue was pink and the oropharynx was without exudates or
hyperemia. trachea was in the midline and the neck was large but
supple with no adenopathy, thyromegaly or carotid bruits.
chest: ctab, symmetric, good air movement
cv: distant but present s1 and s2 heart sounds, regular rate and
rhythm, no murmurs, rubs or gallops.
abd: very obese, soft and non-tender, non-distended with bowel
sounds activity and no appreciable masses or hernias, no
incision scars. no spinal tenderness or flank pain.
ext: lower extremities 1+ edema to the mid-shin of the left
lower extremity, very mild venous insufficiency, no clubbing and
perfusion was good.  there was no joint swelling or inflammation
of the joints.
neuro: there were no gross neurological deficits and gait was
normal.

pertinent results:
post-operative: [**2101-5-17**] 03:27pm
hct-45.7

discharge labs: [**2101-5-21**] 03:06am
wbc-7.2  hgb-11.4*  hct-34.1*  plt-210
na-136 k-3.6 cl-101 hco3-28 urean-8 creat-0.7 glucose-109*
calcium-8.3* phos-3.0 mg-2.0

[**2101-5-19**] - cta chest
no large central pe. evaluation of segmental and subsegmental
branches is limited.

[**2101-5-19**] - ct abdomen
the patient is status post recent gastric bypass surgery. no
contrast is noted in the peritoneal cavity. the liver, spleen,
both adrenals, both kidneys, pancreas are unremarkable. the
patient is status post cholecystectomy. a drain is noted in the
right upper quadrant appropriately. the small bowel loops are
mildly prominent, likely representing ileus. the large bowel is
unremarkable. no free fluid or air noted. no evidence of leak.

[**2101-5-19**] - ugi
approximately 20 cc of optiray contrast was administered orally
which passed freely into the gastric pouch and proximal loops of
bowel without evidence of a leak. subsequently, thin barium was
orally administered, which demonstrated no further evidence of a
leak.


brief hospital course:
ms [**known firstname 87221**] was evaluated by anaesthesia and taken to the
operating room for open cholecystectomy and roux-en-y gastric
bypass. there were no adverse events in the operating room;
please see dr[**name (ni) 78793**] operative note for details. she was
extubated in the or, taken to the pacu until stable, then
transferred to the [**hospital1 **] for observation. she remained on the
surgical [**hospital1 **] for 2 days then was transferred to the icu given
her persistent tachycardia and concern for anastamotic leak. she
was transferred back to the floor 2 days later and was
discharged on pod 5.

neuro: she was alert and oriented throughout her
hospitalization. her pain was initially managed with an epidural
which was removed on post-operative day 4. she was transitioned
to low dose oral roxicet but this appeared to make her
somnolent, so she was provided liquid acetaminophen as
monotherapy for pain relief.

cv: she was persistently hypertensive and tachycardic beginning
immediately post-operatively. this was felt to be due primarily
to fluid deficit, given her post-op hemoconcentration (hct 45).
she was refractory to hydralazine and metoprolol iv. she
responded partially to fluid boluses, but not until starting a
labetolol drip in the icu were we able to control her heartrate
and blood pressure. after weaning her off the drip, her
hemodynamics sustained in a normal range using only her home
dose of chlorthalidone. serial ekgs were performed for
intermittent dull epigastric pain; these showed no changes from
prior.

pulmonary: she was administered cpap during some of her nights
while admitted. she did not tolerate this well, and preferred to
sleep without it. she had mild oxygen demand pod [**3-17**] and given
persisent tachycardia, she was evaluated by cta chest to
rule-out pulmonary embolus. the study was negative albeit
limited by body habitus. good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.

gi/gu/fen: she was initially kept npo until an upper gi study,
methylene blue test, and ct abdomen were performed on
post-operative day 2. all were negative for leak, therefore, her
diet was advanced to a bariatric stage i. she tolerated this for
over 24 hours before being advanced to stage ii. after a day of
stage ii, she was put on stage iii which was well tolerated. her
intake and output were closely monitored.
the jp bulb was removed on post op day 5 immediately prior to
discharge.

id: her fever curves and wbc count were closely watched for
signs of infection. perioperative antibiotics were
adminitstered; none other were warranted.

heme: her blood counts were closely watched for signs of
bleeding, of which there were none. her hematocrit returned back
down to baseline following resuscitation.

prophylaxis: she received subcutaneous heparin and venodyne
boots were used during this stay; she was encouraged to ambulate
as early as possible. she was ambulating independently by pod 4.


at the time of discharge, she was doing well, afebrile with
stable vital signs. she was tolerating a stage 3 diet,
ambulating, voiding without assistance, and pain was well
controlled. she received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.

medications on admission:
chlorthalidone 25'

discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: 20-30 ml po q6h
(every 6 hours) as needed for pain / fever: maximum 120ml per
day.
disp:*1000 ml* refills:*0*
2. colace 60 mg/15 ml syrup sig: two (2) tsp po twice a day:
hold for loose stool.
disp:*600 ml* refills:*0*
3. pediatric multivitamin-iron     tablet, chewable sig: one (1)
tablet, chewable po once a day.
4. zantac 15 mg/ml syrup sig: ten (10) ml po twice a day.
disp:*600 ml* refills:*0*
5. chlorthalidone 25 mg tablet sig: one (1) tablet po once a
day: please crush and mix with liquid.


discharge disposition:
home

discharge diagnosis:
1. obesity, body mass index of 64, weight of 394 pounds.
2. obstructive sleep apnea.
3. fatty liver.
4. gallstones.
5. borderline type 2 diabetes.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
[**hospital 1560**] clinic, surgical subspecialties, [**hospital ward name 23**] building
[**hospital1 **] [**last name (titles) 516**]
[**2101-6-1**] 11:00   dr. [**last name (stitle) **],md  [**telephone/fax (1) 305**]
[**2101-6-1**] 11:30   [**first name8 (namepattern2) **] [**doctor last name **],rd,ldn  [**telephone/fax (1) 305**]



"
222,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
223,"admission date:  [**2106-11-2**]              discharge date:   [**2106-12-3**]

date of birth:  [**2036-10-2**]             sex:   f

service: obstetrics/gynecology

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 7141**]
chief complaint:
pelvic mass

major surgical or invasive procedure:
exploratory laparotomy, total abdominal hysterectomy, bilateral
salpingo-oophorectomy, tumor debulking, omentectomy, extended
right colectomy, right pelvic peritoneal implant excision,
partial wedge gastrectomy, ileal descending colostomy, and rigid
proctosigmoidoscopy

history of present illness:
the patient is a 70-year-old g2, p2 sent by dr. [**first name8 (namepattern2) **] [**name (stitle) 468**] for
consultation regarding a possible diagnosis of ovarian cancer.
the patient presented with a several month history of increasing
abdominal distention, diffuse abdominal discomfort, and
exacerbation of heartburn symptoms. she was evaluated with an
upper endoscopy on [**2106-8-27**], at which time a submucosal mass in
the stomach was noted. no biopsy was obtained. she then had a ct
angiography of the abdomen and a ct of the pelvis on [**2106-10-8**].
this revealed the surface of the liver to be studded with
multiple discrete enhancing nodules. there were also nodules in
the region of the fissure for the ligamentum venosum and
ligamentum teres. the pancreas was normal. there was
disseminated peritoneal carcinomatosis, with large omental cakes
seen along the right flank.  there was a small amount of
perihepatic ascites. discrete nodules were identified studding
the surface the liver as previously described, as well as the
surface of the spleen and stomach. there was no significant
retroperitoneal adenopathy. in the pelvis, there was some
suggestion of uterine and bilateral adnexal masses. given the
nonspecific nature of these findings, a ct guided omental biopsy
was performed on [**2106-10-13**]. this revealed high-grade papillary
carcinoma, consistent with ovarian origin. the patient states
that she has had increasing abdominal girth and has difficulty
fitting into her clothes. she has had about a 12 pound
unintentional weight loss. she has some shortness of breath,
which she attributes to the increasing abdominal distention. she
has diffuse but low-grade abdominal discomfort.


past medical history:
gerd and hypothyroidism.
past surgical history:  rotator cuff repair and cholecystectomy.
ob history:  vaginal delivery x2.
gyn history:  last pap smear and mammogram were both recently
normal.


social history:
the patient does not smoke or drink.

family history:
significant for mother with stomach cancer, a brother with
pancreatic cancer, cousin with [**name2 (ni) 499**] cancer and aunts with
stomach cancer.


physical exam:
general:  well developed and moderately overweight.
heent:  sclerae anicteric.
lymphatics:  lymph node survey was negative.
lungs:  clear to auscultation.
heart:  regular without murmurs.
breasts:  without masses.
abdomen:  soft and moderately distended.  there was no
appreciable ascites.  there was a palpable mass extending along
the entire right side of the abdomen.  this was quite firm.
extremities:  without edema.
pelvic:  the vulva and vagina were normal.  the cervix was
normal.  bimanual and rectovaginal examination was limited by
body habitus.  no definite pelvic masses were appreciated.
there was no definite cul-de-sac nodularity and the rectal was
intrinsically normal.


pertinent results:
[**11-22**] ct abd/pelvis:
impression:
1. small-bowel obstruction with candidate transition point in
llq
2. large left pleural effusion with associated compressive
atelectasis.
3. overall, slight improvement in carcinomatosis and malignant
ascites.


brief hospital course:
on [**2106-11-2**], the patient underwent exploratory laparotomy, total
abdominal hysterectomy, bilateral salpingo-oophorectomy, tumor
debulking, omentectomy, extended right colectomy, right pelvic
peritoneal implant excision, partial wedge gastrectomy, ileal
descending colostomy, and rigid proctosigmoidoscopy, requiring 4
units of packed red blood cells intraoperatively.
post-operatively, she remained intubated and was transferred to
the sicu, with transfer to regular post-operative floor on
pod#2.
.
the patient's post-operative course was complicated by low
hematocrit, post-operative fever w/ clostridium perfringens on
blood culture, an intrahepatic ivc thrombus, bilateral upper
lobe opacities and bibasilar effusions l>r with dyspnea/hypoxia
and o2 requirement, lower extremity fungal infection, and small
bowel obstruction.
.
1) heme:
the pt's low hematocrit stabilized after 2 additional
transfusions of 2 units prbc's each, and was thought to be
dilutional gvien a fluid excess of 12l.  hcts subsequently
remained stable at ~27, and she had no evidence of bleeding. on
pod #6, the patient underwent a ct of the abdomen for evaluation
of fever, and an intrahepatic ivc thrombus was discovered
incidentally.  per surgery recommendation the patient was
started on heparin for anticoagulation, however this was
discontinued when the pt had another hct drop.  vascular surgery
recommended no further anticoagulation, and given the location
of the thrombus, filter placement was also not technically
feasible. on repeat ct scan [**11-22**], the thrombus was not
visualized.
.
2) id: the pt had post-operative fevers, for which blood
cultures were obtained.  1 of 2 bottles from [**11-4**] was positive
for c. perfringens. infectious disease was consulted and she was
started on vancomycin empirically, with ampicillin-sulbactam
added after identification and sensitivities. other cultures
from [**11-5**], 13, 14, 15 all showed no growth, therefore the c.
perfringens was thought to be a contaminant.  on pod#4, the pt
continued to require 4 l of oxygen by nc. she underwent a cta of
the chest which showed no pulmonary emboli but did show
bilateral upper lobe opacities concerning for pneumonia. she was
started on levofloxacin, and repeat chest x-ray showed that her
pneumonia improved after 4 days of levofloxacin, and this was
discontinued. given continued temperatures, cts of the abdomen
were obtained [**11-8**], [**11-12**] which showed increasing
carcinomatosis and multiple pelvic pockets of free fluid, some
loculated, which were thought to be malignant ascites; none
amenable to percutaneous drainage.  the pt remained afebrile on
vanco/zosyn from [**11-11**], with decreasing wbc, and v/z were
discontinued on [**11-23**].  the patient was also noted to have a
bilateral lower extremity and groin rash on [**11-23**]; id consult
was obtained, and it was felt that this was the result of a
fungal infection, and iv fluconazole was started.  the rash
improved on fluconazole, and the patient was switched to po
fluconazole on [**12-2**], to continue for a 6 week total course.
.
3) pulm:
in addition to the presumed pneumonia as above, the pt continued
to have subjective dyspnea and o2 requirement.  repeat cta [**11-12**]
was again negative for pe.  cxr's and cts showed bibasilar
effusions, l>r.  an interventional pulm consult was obtained for
possible thoracentesis, but per bedside u/s, the left effusion
was found to be subpulmonic and quite small, and therefore not
likely to account for pt's symptoms; given the location,
thoracentesis would also be at higher risk for adverse events
i.e. ptx, bleeding, per ip.  the patient's hypoxia and shortness
of breath resolved spontaneously, and for the last week of
admission she was 96-100% on ra.
.
3) fen/gi:
given nausea and poor po intake, the pt was started on tpn, with
diet slowly advanced.  however, on ct scan [**11-22**], the patient
was noted to have a small bowel obstruction, associated with
some nausea and vomiting.  she was made npo until passing flatus
and subjective resolution of nausea, and was advanced to clears
[**11-29**], then regular [**12-1**].  as she was tolerating regular po
without nausea, her tpn was d/c'd [**12-2**].
.
4) endocrine:
the patient's levoxyl was briefly increased to 200 mcg qd, but
this was decreased to 150 mcg [**11-17**].  she was covered for
somewhat elevated fsg's with an insulin sliding scale.
.
5) oncology:
per discussion with tumor board, medical oncology was consulted
for administration of chemotherapy while in-house.  it was
decided to administer first dose of carboplatin alone, given
greater potential toxicity with taxol.  on [**11-23**] the patient
received her 1st carboplatin dose and tolerated this adequately
with only some nausea.  she is to follow up with a medical
oncologist at [**hospital3 3583**] for further chemotherapy cycles.
.
the patient was discharged home on [**2106-12-3**], pod#30.


medications on admission:
levothyroxine alternating 0.112mg and 0.15mg daily, tricor 145mg
half tab daily, omeprazole 20mg daily

discharge medications:
1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q4-6h (every 4 to 6 hours) as needed.
disp:*60 tablet(s)* refills:*0*
2. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6
hours) as needed.
disp:*60 tablet(s)* refills:*0*
3. fluconazole 100 mg tablet sig: one (1) tablet po q24h (every
24 hours) for 5 weeks.
disp:*35 tablet(s)* refills:*0*


discharge disposition:
home with service

facility:
community vna

discharge diagnosis:
ovarian cancer
small bowel obstruction
lower extremity fungal infection


discharge condition:
good


discharge instructions:
no heavy lifting or strenuous exercise.  no driving while on
narcotics.  call for worsening pain, nausea/vomiting, fever
>101, other concerns.

followup instructions:
provider: [**name10 (nameis) **],[**first name3 (lf) **] b.  [**telephone/fax (1) 5777**]  call to schedule
appointment for next week



completed by:[**2106-12-3**]"
224,"admission date:  [**2189-1-2**]              discharge date:   [**2189-1-21**]

date of birth:  [**2116-1-21**]             sex:   f

service: cardiothoracic

allergies:
iodine; iodine containing / lipitor / codeine

attending:[**first name3 (lf) 165**]
chief complaint:
transfer from an outside hospital for non st elevation
myocardial infarction, congestive heart failure exacerbation

major surgical or invasive procedure:
cardiac catheterization without pci
coronary artery bypass grafts x 4
(lima-lad,svg-dg1,svg-om,svg-rca)& mitral valve repair (28mm
[**company 1543**] annuloplasty ring)- [**1-14**]
left heart catheterization, coronary angiography- [**1-4**]


history of present illness:
this is a 72-year-old female with a past medical history
significant for hypertension, diabetes, smoking, cad s/p mi x3
most recently in [**10-25**] complicated by cardiogenic shock, s/p rca
stenting x2 and lcx stenting x2, chf with ef of 40%, mr,
pulmonary hypertension, and pvd s/p lower extremity stenting
transfered from an osh for nstemi and chf exacerbation.

in brief, she was discharged from [**hospital1 18**] on [**2188-11-11**] after a
prolonged hospitalization notable for a nstemi with stenting of
the lcx and hemodynamic compromise requiring a iabp. she did
well after discharge with improvement of her sob and mobility.
she and her husband went on vacation during which time she
developed doe, the cp mostly a night with no correlation to
activity. her cp responded consistently to 1 to 2 ntg. she began
to notice orthopnea and pnd as well as ankle edema. she had
nausea and sob associated with her cp but not sweats or
dizziness. on [**2189-1-1**] she had a bacon and cheese omelet for
breakfast and clam chowder and [**location (un) 20935**] steak with french fries
for lunch. that afternoon she began to have persistent cp and
sob with associated nausea not relieved by ntg x3q5 minutes. ems
was called and she was admitted to [**hospital 67742**] medical center in
[**location (un) **], n.h. where she was found to be atrial fibrillation and
pulmonary edema with and an admission probnp of 5814.4. a
central line was placed and emergent cardioversion was
performed. she initially was hypotensive but stablized post
cardioversion. ekg revealed st depression in the lateral leads.
her tni trended 1.17, 3.03, 8.9 consistent with an nstemi. she
was maintained on a heparin drip with aggressive diuresis. proir
to transfer she had been on and off nitroglycerin drip. she has
chest pressure whenever it was shut off but she was hypertensive
when the nitro is increased. by report from the osh she was
wheezing on admission. her blood sugar on admission to the osh
was 515 and she was briefly on an insulin drip with improvement
of her sugars. there is also a question of whether she missed a
dose of her beta-block dose prior to her admission. she was
transferred to [**hospital1 18**] for further management.
.

she developed 7/10 chest pain with no ecg changes. she was
continued on heparin drip and ntg drip was restarted with
resolution of her cp.

she had recurrent chest pain w/ ekg chnages and was taken for an
emergent coronary srtery bypass graft and mv repair om [**2188-1-14**].

past medical history:
coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis


social history:
heavy smoker up to 2 ppd for 50 years, quit in [**10-25**]. denies
etoh or ivdu. pt is a retired x-ray technician. she lives with
her husband and two grandchildren in [**name (ni) 67740**], she is the
caregiver for her sister with [**name (ni) 309**] body dementia and her husband
as well as her two grandchildren.

family history:
no family history of cad or premature death, dm, htn, hld.
mother with pd. sister with [**name (ni) 309**] body dementia. sister with lung
ca.

physical exam:
admission:
gen: obese elderly lady in nad. oriented x3. mood, affect
appropriate.
heent: ncat. sclera anicteric. perrl, eomi. dry mm. no pallor or
cyanosis of the oral mucosa. no xanthalesma. no cervical or
axillary lad. neck supple with jvp of 10 cm. no carotid bruits
cv: pmi difficult to assess. rr, normal s1, s2. no m/r/g. no
thrills, lifts. no s3 or s4.
pulm: no chest wall deformities, scoliosis or kyphosis. resp
were unlabored, no accessory muscle use. poor air movement.
diffuse mile crackles greater in the bases with scattered
wheezes.
abd: bs+, soft, ntnd. no hsm or tenderness. gas on percussion.
limbs: no c/c/e. no stasis dermatitis, ulcers, scars, or
xanthomas.
pulses:
right: carotid 2+ radial 2+ dp 1+
left: carotid 2+ radial 2+ dp 2+


pertinent results:
[**2189-1-18**] 03:52am blood wbc-17.3* rbc-3.53* hgb-10.8*# hct-30.9*
mcv-87 mch-30.6 mchc-35.0 rdw-14.3 plt ct-191
[**2189-1-19**] 04:28am blood wbc-14.4*
[**2189-1-19**] 04:28am blood glucose-57* urean-28* creat-1.2* k-3.8

[**hospital1 18**] echocardiography report

[**known lastname **], [**known firstname **]       [**hospital1 18**] [**numeric identifier 67743**] (complete)
done [**2189-1-14**] at 10:54:24 am      final
referring physician     [**name9 (pre) **] information
[**name9 (pre) **], [**first name3 (lf) **]
division of cardiothoracic [**doctor first name **]
[**first name (titles) **] [**last name (titles) **]
[**hospital unit name 4081**]
[**location (un) 86**], [**numeric identifier 718**]  status: inpatient dob: [**2116-1-21**]
age (years): 72 f  hgt (in): 65
bp (mm hg): 123/67  wgt (lb): 230
hr (bpm): 67  bsa (m2): 2.10 m2
indication: intraoperative tee for cabg procedure and mitral
valve repair. chest pain. congestive heart failure. left
ventricular function. mitral valve disease. myocardial
infarction. preoperative assessment. right ventricular function.

icd-9 codes: 428.0, 786.05, 786.51, 440.0, 424.0
test information
date/time: [**2189-1-14**] at 10:54    interpret md: [**name6 (md) 1509**] [**name8 (md) 1510**],
md
test type: tee (complete) son[**name (ni) 930**]: [**last name (namepattern5) 9958**], md
doppler: full doppler and color doppler test location:
anesthesia west or cardiac
contrast: none tech quality: adequate
tape #: 2009aw2-: machine: [**doctor last name 11422**] 3d
echocardiographic measurements
results  measurements  normal range
left atrium - long axis dimension:  *5.0 cm  <= 4.0 cm
left ventricle - septal wall thickness:  1.0 cm  0.6 - 1.1 cm
left ventricle - inferolateral thickness:  1.0 cm  0.6 - 1.1 cm

left ventricle - diastolic dimension:  *6.0 cm  <= 5.6 cm
left ventricle - ejection fraction:  35%  >= 55%
aorta - annulus:  2.0 cm  <= 3.0 cm
aorta - sinus level:  2.7 cm  <= 3.6 cm
aorta - sinotubular ridge:  2.5 cm  <= 3.0 cm
aorta - ascending:  3.3 cm  <= 3.4 cm
aorta - arch:  2.3 cm  <= 3.0 cm
aorta - descending thoracic:  2.4 cm  <= 2.5 cm
aortic valve - peak velocity:  0.8 m/sec  <= 2.0 m/sec
mitral valve - peak velocity:  1.2 m/sec
mitral valve - mean gradient:  1 mm hg
mitral valve - pressure half time:  53 ms
mitral valve - mva (p [**12-19**] t):  4.2 cm2
mitral valve - e wave:  0.9 m/sec
mitral valve - a wave:  0.5 m/sec
mitral valve - e/a ratio:  1.80
mitral valve - e wave deceleration time:  *127 ms  140-250 ms

findings
left atrium: moderate la enlargement. no mass/thrombus in the [**name prefix (prefixes) **]
[**last name (prefixes) **] laa. all four pulmonary veins identified and enter the left
atrium.

right atrium/interatrial septum: a catheter or pacing wire is
seen in the ra and extending into the rv. no asd by 2d or color
doppler.

left ventricle: wall thickness and cavity dimensions were
obtained from 2d images. normal lv wall thickness. moderately
dilated lv cavity. moderate-severe regional left ventricular
systolic dysfunction. moderately depressed lvef. [intrinsic lv
systolic function likely depressed given the severity of
valvular regurgitation.]

right ventricle: normal rv systolic function.

aorta: normal diameter of aorta at the sinus, ascending and arch
levels. simple atheroma in aortic arch. normal descending aorta
diameter. complex (>4mm) atheroma in the descending thoracic
aorta.

aortic valve: normal aortic valve leaflets (3). no as. no ar.

mitral valve: mildly thickened mitral valve leaflets. no ms.
moderate to severe (3+) mr. [**name13 (stitle) 15110**] to the eccentric mr jet, its
severity may be underestimated (coanda effect).

tricuspid valve: physiologic tr.

pulmonic valve/pulmonary artery: physiologic (normal) pr.

pericardium: no pericardial effusion.

general comments: a tee was performed in the location listed
above. i certify i was present in compliance with hcfa
regulations. the patient was under general anesthesia throughout
the procedure. no tee related complications. the patient appears
to be in sinus rhythm. frequent ventricular premature beats.
patient.

regional left ventricular wall motion:





     n = normal, h = hypokinetic, a = akinetic, d = dyskinetic
conclusions
pre-bypass: the left atrium is moderately dilated. no
mass/thrombus is seen in the left atrium or left atrial
appendage. no atrial septal defect is seen by 2d or color
doppler. left ventricular wall thicknesses are normal. the left
ventricular cavity is moderately dilated. there is moderate to
severe regional left ventricular systolic dysfunction with
hypokinesis of the apex, apical portions of the inferior and
lateral walls as well as the mid portions of the inferior,
inferolateral and inferoseptal walls. overall left ventricular
systolic function is moderately depressed (lvef= 35 %). the
diameters of aorta at the sinus, ascending and arch levels are
normal. there are simple atheroma in the aortic arch. there are
complex (>4mm) atheroma in the descending thoracic aorta. the
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. no aortic
regurgitation is seen. the mitral valve leaflets are mildly
thickened. moderate to severe (3+) mitral regurgitation is seen.
due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (coanda effect). there is no
pericardial effusion.

dr. [**last name (stitle) **] was notified in person of the results in the
operating room.

post bypass

patient is av paced and receiving an infusion of epinephrine,
milrinone and phenylephrine. lvef is 40%. rv function is
unchanged. annuloplasty ring seen in the mitral position. mild
mitral regurgitation seen between the p2 and p3 scallops. dr
[**first name (stitle) **] aware. mean gradient across the mitral valve is 2 mm hg.
aorta intact post decannulation.
  i certify that i was present for this procedure in compliance
with hcfa regulations.

electronically signed by [**name6 (md) 1509**] [**name8 (md) 1510**], md, interpreting
physician [**last name (namepattern4) **] [**2189-1-14**] 16:03

[**known lastname **],[**known firstname **] m [**medical record number 67744**] f  72  [**2116-1-21**]

cardiology report c.cath study date of [**2189-1-6**]



brief history:   72 year old female with coronary artery disease
and
prior mi, status post pci of her lcx and rca, peripheral
vascular
disease, and mitral regurgitation who was recently admitted to
an
outside hospital with congestive heart failure and a non-st
elevation
mi. she is now transferred for cardiac catheterization.

indications for catheterization:
coronary artery disease

procedure:
right heart catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 french pulmonary wedge pressure
catheter,
advanced to the pcw position through an 8 french introducing
sheath.
cardiac output was measured by the fick method.
left heart catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 french angled pigtail catheter,
advanced
to the left ventricle through a 5 french introducing sheath.
coronary angiography: was performed in multiple projections
using a 5
french jl4 and a 5 french jr4 catheter, with manual contrast
injections.
left ventriculography: was performed in the 30 degrees [**doctor last name **]
projection,
using 39 ml of contrast injected at 13 ml/sec, through the
angled
pigtail catheter.
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

hemodynamics results body surface area:  2.13 m2
  hemoglobin: 10.3 gms %
  fick
**pressures
right atrium {a/v/m} 15/14/9
right ventricle {s/ed} 54/15
pulmonary artery {s/d/m} 54/28/45
pulmonary wedge {a/v/m} 36/41/33
left ventricle {s/ed} 135/36
aorta {s/d/m} 135/54/84
**cardiac output
heart rate {beats/min} 80
rhythm n
o2 cons. ind {ml/min/m2} 125
a-v o2 difference {ml/ltr} 46
card. op/ind fick {l/mn/m2} 5.8/2.7
**resistances
systemic vasc. resistance 1035
pulmonary vasc. resistance 166

**% saturation data (nl)
pa main 94
ao 61

other hemodynamic data:      the oxygen consumption was assumed.



left ventriculography:
volumetric data:
          lv ejection fraction (nl 50%-80%).                40
qualitative wall motion:
[**doctor last name **]:
          1. antero basal -    normal
          2. antero lateral -  normal
          3. apical -          normal
          4. inferior -        hypokinetic
          5. postero basal -   normal
other findings:
mitral valve showed the following abnormalities.
          1. regurgitation [**2-18**]+.
aortic valve was normal.


**arteriography results morphology % stenosis collat. from
**right coronary
1) proximal rca   discrete 70
2) mid rca   normal
2a) acute marginal   normal
3) distal rca   normal
4) r-pda   normal
4a) r-post-lat   normal
4b) r-lv   normal

**arteriography results morphology % stenosis collat. from
**left coronary
5) left main   discrete 30
6) proximal lad   normal
6a) septal-1   normal
7) mid-lad   discrete 60
8) distal lad   normal
9) diagonal-1   discrete 60
10) diagonal-2   normal
12) proximal cx   discrete 90
13) mid cx   discrete 99


technical factors:
total time (lidocaine to test complete) = 34 minutes.
arterial time = 18 minutes.
fluoro time = 6.0 minutes.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 94 ml
premedications:
          [**month/day (3) **] 325 mg p.o.
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          fentanyl 25mcg
          furosemide 60mg iv
          nahc03 75ml/hr
          midazolam 0.5mg
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - [**company **], left heart kit
          - [**company **], right heart kit
          5fr [**company **], multipack
          7fr [**company **], pulmonary wedge pressure catheter


comments:
1. selective coronary angiography of this right dominant system
revealed
three vessel disease.  the lmca had a 30% ostial stenosis.  the
lad had
a 60% mid-vessel lesion involving a major diagonal branch.  the
lcx had
a 95% proximal isr and a long 99% isr in the mid and distal
vessel.  the
rca had a 70% proximal isr.
2. resting hemodynamics revealed a severely elevated left heart
filling
pressure with a mean pcwp of 33mmhg.  there was moderate
pulmonary
artery hypertension with a mean pa of 45mmhg.  the cardiac index
was
preserved at 2.7l/min/m2.
3. left venticulography revealed an estimated lvef of 40% with
severe
inferior hypokinesis.  there was severe [**2-18**]+ mitral
regurgitation.

final diagnosis:
1. three vessel coronary artery disease.
2. severe mitral regurgitation.
3. moderate systolic and severe diastolic ventricular
dysfunction.
4. moderate pulmonary hypertension.

attending physician: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].
referring physician: [**name10 (nameis) **],[**first name4 (namepattern1) **] [**last name (namepattern1) 975**]
cardiology fellow: [**last name (lf) **],[**first name3 (lf) **] m.
attending staff: [**last name (lf) **],[**first name3 (lf) **] e.


carotid ultra sound
impression: right ica 60-69% stenosis. left ica 40-59% stenosis.
both have
bulky plaque. antegrade vertebral flow bilaterally. the right
has been
stable since [**2185**]. the left has evidence of mild progression on
today's
study.


brief hospital course:
[**hospital1 1516**] cardiology service brief hospital course:
this is a 72-year-old female with a past medical history
significant for hypertension, diabetes, smoking, cad s/p mi x3
most recently in [**10-25**] complicated by cardiogenic shock, s/p rca
stending x2 and lcx stenting x2, systolic chf with ef of 40%,
pulmonary hypertension, and pvd s/p lower extremity stenting
transfered from an osh for nstemi and chf exacerbation. on her
second day of hospitalization she developed flash pulmonary
edema. given she was in sinus when she flashed there was concern
for ischemic mr. [**first name (titles) **] [**last name (titles) 1834**] cath on [**2189-1-6**] and was found to
have 3vd (lad and isr of lcx and rca) and servere mr. [**first name (titles) **] [**last name (titles) 67745**]s were taken and cardiac [**doctor first name **] referral was made. pt
agreed to cabg. she had egd-colonoscopy to rule out possible
sources of gib which was negative. also developed worsening of
cri, but improved with holding lasix and [**doctor first name 21177**]. developed
recurrent cp with ecg changes and was ultimately sent to ct
surgery for emergent cabg the day following her egd-[**last name (un) **].
.
#. cad: pt s/p mix4 (the latest nstemi this admission) and found
to have 3vd at cath + mr. [**first name (titles) **] [**last name (titles) **] 325mg po daily. held
plavix 75mg po daily for cabg washout but had recent bms to the
lcx in [**10-25**]. continued metoprolol 37.5mg po bid in place of
toprolxl 75mg daily. holding statins for now given history of
adverse events to these and excellent cholesterol panel. lipid
panel: cholest 147, triglyc 134, hdl 60, ldlcalc 60. cath on
[**2189-1-6**] showed severe mr with angio showing that lad with 60%
mid-vessel lesion involving a major diagonal branch, lcx with
95% proximal isr and a long 99% isr in the mid and distal
vessel, and rca with 70% proximal isr. last dose of plavix was
on [**2189-1-6**]. had cp [**2-24**] with ecg changes on the am of [**2189-1-13**]
during bowel prep. resolved completely with ntgx1. again had cp
[**5-27**] overnight 1/27-28/09 resolved after ntg x2. triggered for
cp x2 in <24hrs with 3vd. sent emergently to cabg on the morning
of [**2189-1-13**] for recurrent cp.
.
#. pump: pt with chf with known ef of 40%. pt continues to be in
sinus (chf preivously exacerbated by afib s/p cardioversion).
however, on [**2189-1-4**] pt triggered for sob, hypoxia to high 80s on
room air. pt's exam showed acute worsening of fluid status
concerning for flash pulmonary edema. also concern for ischemic
mr. [**first name (titles) **] [**last name (titles) 21177**] at 5mg po daily ([**12-19**] home dose). lisopril was
held the am of transfer to ct surgery to improve renal function.
continued metoprolol as above. will consider spironolactone for
naturesis in the future. echo on [**2189-1-6**] showed ef of 40%,
systolic dysfunction with akinesis of the inferolateral wall and
hypokinesis of the inferior and anterolateral walls, and severe
unchanged mr. initially on lasix drip, but discontinued lasix iv
and started lasix 80mg po bid. was retaining some additional
fluid so increased lasix to 100mg po bid. this was held on the
day of transfer to ct surgery.
.
#. rhythm: nsr, s/p afib on admission to osh with cardioversion
into sinus.
.
#. renal insufficiency: pt with mild elevation of cr to 1.8 from
lasix, [**date range 21177**], hypovolemia, and bowel prep. held lasix and
lisopril the am of transfer to ct surgery.
.
admission to cardiac surgery post-op. [**2189-1-14**]

pt was taken to the or on [**2189-1-14**] for cabg x4 - lima-lad; svg to
d1, om, rca and mv repair.  please see operative note for
details. the patient arrived to the cardiac icu on milrinone,
epi, neo, propofol and insulin drips. she was readily weaned
from milrinone and epi and extubated on pod#1. chest tubes and
wires were removed. the patient was begun on betablocker and
diuresis and transferred to the floor for ongoing management and
rehab.
patient's insulin [**date range 4319**] were adjusted to achieve glucose
control.
rehab screening was recommended by physical therapy.
postoperative course was uneventful and the patient was
discharged to rehab on pod 6.

medications on admission:
insulin nph 36u [**hospital1 **] and humalog 4u [**hospital1 **]
toprol xl 75mg po daily
lisinorpil 10mg po daily
prilosec 20mg po bid
advil 200mg po daily
[**hospital1 **] 325mg po daily
plavix 75mg po daily
hctz 25mg po daily
iron
colace


discharge medications:
1. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day.
3. insulin nph human recomb 300 unit/3 ml insulin pen sig:
thirty six (36) units subcutaneous twice a day.
4. insulin lispro 100 unit/ml insulin pen sig: four (4) units
subcutaneous twice a day.
5. atrovent hfa 17 mcg/actuation aerosol sig: one (1) puff
inhalation four times a day.
disp:*2 inhaler* refills:*5*
6. xopenex hfa 45 mcg/actuation hfa aerosol inhaler sig: one (1)
puff inhalation four times a day.
disp:*2 inhalers* refills:*5*
7. [**hospital1 **] 10 mg tablet sig: one (1) tablet po once a day.
8. metolazone 5 mg tablet sig: two (2) tablet po daily (daily).

9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
10. simvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
11. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
12. albuterol 90 mcg/actuation aerosol sig: two (2) puff
inhalation q6h (every 6 hours) as needed.
13. ipratropium bromide 17 mcg/actuation aerosol sig: two (2)
puff inhalation qid (4 times a day).
14. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
15. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q4h (every 4 hours) as needed for pain.
16. amiodarone 200 mg tablet sig: two (2) tablet po once a day:
2 daily for 7 days then one daily for one month.
disp:*45 tablet(s)* refills:*0*
17. metoprolol succinate 25 mg tablet sustained release 24 hr
sig: three (3) tablet sustained release 24 hr po daily (daily).

18. potassium chloride 20 meq tab sust.rel. particle/crystal
sig: one (1) tab sust.rel. particle/crystal po twice a day.
disp:*60 tab sust.rel. particle/crystal(s)* refills:*2*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis


discharge condition:
good


discharge instructions:
shower daily, no baths or swimming
no driving for 4 weeks and off all narcotics
no lotions, creams or powders to incisions
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain gretaer than 2 pounds a day or 5 pounds a
week
take all medications as directed


followup instructions:
dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] in 2 weeks
dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3314**] in [**12-19**] weeks ([**telephone/fax (1) 3183**])
dr. [**first name (stitle) **] in 4 weeks
wound clinic in 2 weeks
please call for appointments


                             [**name6 (md) **] [**name8 (md) **] md [**md number(2) 173**]

completed by:[**2189-1-20**]"
225,"admission date:  [**2150-4-16**]              discharge date:   [**2150-4-21**]


service: medicine

allergies:
nsaids / bactrim

attending:[**first name3 (lf) 358**]
chief complaint:
angioedema

major surgical or invasive procedure:
intubation

history of present illness:
pt is an 85 y/o f with a h/o gave s/p argon treatment last on
[**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc, portal
htn/grade 1 varices but no hx of bleeding varices, cri (baseline
cr = 1.2-1.5) who is transfered from [**hospital3 **] intubated
s/p angioedema. by report the pt has some mild abdominal pain
and some irritation in her throat a day prior to admission to
[**hospital3 **]. the following morning she called her son with
complaints of oral swelling; son states that her speach was
garbled. the son reports that the patient denies having had any
sob, no wheezing, no hives. he called an abmulance who
transported the pt to [**hospital3 **].
.
per omr, the patient present to [**hospital1 18**] pheresis unit on [**2150-4-10**]
for blood transfusion for chronic slow upper gi bleeding. she
had no pretreatment medications given and no adverse events;
vitals on leaving the unit were 97.4 - 67 - 119/55. she has also
been recently treated for a uti with bactrim started on [**2150-4-3**].

.
at st elizabeths', she was hd stable but had a large, edematous
tongue. she recevied decadron, epinephrine, benadryl, famotidine
and hydroxazine in the ed. the ed was unable to intubate and she
was taken to the or. laryngeal edema was noted, but the et tube
was passed successfully. she was then transfered to the ccu. she
received hydroxazine tid and her tongue swelling improved. sbt
was attempted early on but failed likely secondary to sedation.
per report, pt did have a cuff leak. family requested transfer
to [**hospital1 18**] as pt receives all her care here.
.
on arrival in the micu she passed an sbt and was successfully
extubated. she did well throughout the day but continued to have
an o2 requirement. by the time of transfer to the floor she was
on 2l of nc o2 satting 94%. on the floor she is alert and
oriented. she does not know what caused her swelling. she denies
new pills, new medications, or new foods. she feels well and has
no sob, itching, or complaints.
.


past medical history:
# gave - s/p argon treatment, last on last on [**2150-3-11**]
# hepatitis c
# cirrhosis
- child's class a, portal htn, grade 1 varices
- no h/o ascites, encephalopathy, variceal bleeding, synthetic
function intact
# dm type ii
# htn
# iron deficiency anemia
# s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
# hypercholesterolemia
# osteopenia
# insomnia
# angioedema [**3-26**] possibly due to bactrim but as yet not proven

social history:
lives alone in [**location (un) 583**] in [**hospital3 4634**] complex. is widowed.
has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
holidays). worked in food business in sales.


family history:
no family history of allergic diseases

physical exam:
gen: pleasant elderly lady in nad, speaking comfortably, no
cyanosis, jaundice, or dyspnea
vs: 99.4 124/58 82 18 94% on 2l nc
heent: mmm, no op lesions, tongue nl size, neck supple, no lad
or thyromegaly
cv: rr, nl s1 s2 no s3 s4 mrg
pulm: roncherous breath sounds with scattered wheezes and
crackles 1/4 up the lung fields
abd: bs+, nt, ventral hernia, gas on percussion, no masses or
hsm, no fluid wave, + collaterals and angiomata
limsb: no le edema, + clubbing
neuro: perrla, eomi, moving all limbs, reflexes 2+ of the biceps
and petellar tendons.


pertinent results:
admission labs:
[**2150-4-17**] 05:15am blood wbc-7.4 rbc-3.41* hgb-10.2* hct-31.4*
mcv-92 mch-29.9 mchc-32.5 rdw-16.7* plt ct-139*
[**2150-4-17**] 05:15am blood glucose-132* urean-27* creat-1.1 na-143
k-4.3 cl-112* hco3-24 angap-11
[**2150-4-18**] 08:30am blood alt-112* ast-59* ld(ldh)-203 alkphos-99
totbili-1.7*
[**2150-4-17**] 05:15am blood calcium-8.6 phos-2.8 mg-2.4
.
discharge labs:
[**2150-4-21**] 05:50am blood wbc-5.0 rbc-3.13* hgb-9.6* hct-28.4*
mcv-91 mch-30.7 mchc-33.8 rdw-16.9* plt ct-200
[**2150-4-21**] 05:50am blood glucose-91 urean-34* creat-1.4* na-137
k-3.9 cl-103 hco3-24 angap-14
[**2150-4-20**] 05:40am blood alt-55* ast-34 ld(ldh)-182 alkphos-83
totbili-1.3
[**2150-4-20**] 05:40am blood albumin-2.6* calcium-8.3* phos-3.5 mg-2.0

brief hospital course:
85f with a h/o gave s/p argon laser treatment last on [**2150-3-11**],
iron deficiency anemia due to chronic ugib, cirrhosis [**1-19**] hcv,
portal htn with grade 1 varices but no history variceal
bleeding, cri (baseline cr = 1.2-1.5) who is s/p prolonged
intubatation for angioedema of unknown etiology - possibly due
to bactrim. she is doing very well on s/p extubation at this
point. all antihistamines have been discontinued at this point.
she was progressively be restarted on her home meds.
.
# angioedema: resoved. lack of hives, bronchospasm or
hypotension suggests that this was not allergic angioedema but
rather bradykinin related. c3 and c4 were low. c1 esterase
inhibitor pending, [**doctor first name **] neg. per allergy consult at [**hospital 7302**] prior to transfer, non-allergic angioedema
is due to complement depletion (either hereditary or ca related)
or complement activation (infection or transfusion). the patient
did have a transfusion recently which may be related.
medications would also be high on the list of etiologies. common
offenders are nsaids and aceis, but arbs have also been
implicated.  it was discovered that the pt was taking bactrim
when the reaction leading to her admission. this is a possible
offender and has been added to her allergy list. restarted home
meds one by one. all but felodipine have been restarted. had
hives and itching the day prior to discharge which did not
generalize and seemed more of a contact dermatitis on the l arm.
no new medications were started so it is unclear what initiated
this. responded to hydroxyzine x1. also of note, the patient
refused to shower or be washed down this admission which may
contribute to her itchiness.
.
# chronic ugib: received regular blood transfusions as an
outpatient for any hct < 30. in the past she only needed them
infrequently but her transfusion requirements have increased
lately. transfused prior to discharge. [**month (only) 116**] need outpatient
follow up with gi (dr [**first name8 (namepattern2) 1158**] [**last name (namepattern1) 679**] has been recommended by her
outpatient gastroenterologist [**first name4 (namepattern1) 2127**] [**last name (namepattern1) 10113**]).
.
# wheezes and ronchi: related to angioedema and volume overload
most likely. resolved with diuresis and nebulizers.
.
# hx hcv complicated by cirrhosis. no evidence of encephalopathy
now, but is at risk. continued lactulose. continued
spironolactone [aldactone] - 50 mg daily. continue furosemide
[lasix] - 40 mg daily. continue nadolol - 80 mg daily as ppx
against variceal bleeding.
.
# htn: holding home ccb as normotensive. on nadolol as above.
.
# cri: baseline 1.5, was elevated on admission to [**hospital3 5097**] to
1.7. at baseline on discharge.
.
# diabetes: iss in house. discharged on metformin.

medications on admission:
home medications:
felodipine - 10 mg qam and 5 mg qpm
folic acid - 1 mg daily
furosemide [lasix] - 40 mg daily
hydrocortisone acetate [anusol-hc] - 25 mg daily
lactulose 10 gram/15 ml daily
metformin - 1000 mg qam and 500 mg qpm
mupirocin - 2 % ointment [**hospital1 **]
nadolol - 80 mg daily
pantoprazole - 40 mg [**hospital1 **]
spironolactone [aldactone] - 50 mg daily
sucralfate - 1 g tid
zolpidem - 5 mg tablet - [**12-21**] qhs prn
calcium carbonate-vitamin d2 - 500 mg-375 unit [**hospital1 **]
cyanocobalamin - 500 mcg daily
ferrous gluconate - 325 mg 5 times a day
sarna ultra [**hospital1 **]


discharge medications:
1. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one
(1) tablet po twice a day.
disp:*60 tablet(s)* refills:*11*
2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*11*
3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
4. anusol-hc 25 mg suppository sig: one (1) suppository rectal
once a day.
disp:*30 suppositories* refills:*6*
5. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po once a
day.
disp:*450 ml(s)* refills:*11*
6. metformin 500 mg tablet sig: two (2) tablet po qam.
disp:*60 tablet(s)* refills:*5*
7. metformin 500 mg tablet sig: one (1) tablet po qpm.
disp:*30 tablet(s)* refills:*5*
8. nadolol 80 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*5*
10. spironolactone 50 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*5*
11. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
disp:*30 tablet(s)* refills:*0*
12. b-12 dots 500 mcg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*11*
13. ferrous gluconate 325 mg tablet sig: one (1) tablet po five
times a day.
disp:*150 tablet(s)* refills:*11*


discharge disposition:
home

discharge diagnosis:
angioedema

discharge condition:
stable vital signs, at baseline

discharge instructions:
you were admitted at [**first name8 (namepattern2) 1495**] [**hospital **] hospital with angioedema,
or swelling in your mouth and throat. you had a breathing tube
placed for this. you were then transfered to [**hospital1 771**] where you had the breathing tube taken
out. you improved clinically and were discharged to home.
.
please continue to take your medications as ordered. because you
had a likely medication reaction that led to your angioedema you
should throw out your old medications. do not take any
supplements. here is your updated medication list list:
1. stop taking felodipine for now
2. calcium + vitamin d twice daily
3. vitamin b12 daily
4. folic acid daily
5. furosimide 40mg daily
6. anusol daily as needed for hemorrhoids
7. metformin 1000mg (2 pills) in the morining and 500mg (1 pill)
in the evening
8. lactulose 15ml daily to 3 bowel movements per day
9. nadolol 80mg daily
10. pantoprazole (protonix) 40mg twice daily
11. spironolactone 50mg daily
12. zolpidem (ambien) 5mg at night as needed for insomnia
13. iron 5 times daily
.
please attend your follow up appointments.
.
please call your doctor or come to the emergency room if you
experience swelling of you face or tongue, chest pain,
palpitations, shortness of breath, wheezing, bleeding, or other
concerning symptoms.

followup instructions:
md: [**name6 (md) 10160**] [**name8 (md) 10161**], np
specialty: priamry care
date and time: [**last name (lf) 766**], [**5-4**] at 4pm
location: [**hospital3 **]
phone number: [**telephone/fax (1) 250**]
special instructions if applicable: booked with russain
interpreter


completed by:[**2150-4-22**]"
226,"admission date:  [**2124-12-15**]     discharge date:  [**2124-12-16**]

date of birth:   [**2068-7-22**]     sex:  m

service:  micu

history of present illness:   this is a 56 year old man with
a history of lung cancer status post radiation therapy and
chemotherapy and chronic obstructive pulmonary disease, who
presents with acute dyspnea and oropharynx swelling.  the
patient states that he was in his usual state of health when
three hours after eating a dinner of shrimp and scallops,
began to develop burning and warmth of his posterior cervical
neck and forehead.  he went to cvs to get some benadryl and
on the way became progressively short of breath and
complained of upper and lower lip swelling.  the emergency
medical services was activated.  he was found to be
stridorous with a blood pressure of 60/palpation complaining
of his throat closing up.

the patient received epinephrine 0.3 subcutaneously and
benadryl 50 mg intravenous en route to the hospital and his
blood pressure normalized.  the patient was saturating at 98%
on room air.  he received intravenous solu-medrol and
intravenous cimetidine.

the patient reported a history of swelling after a bee sting
30 years ago for which he went to the emergency room and
received intravenous benadryl.  he consumes shellfish
regularly and has had no adverse events in the past.  the
patient is currently on chemotherapy, the cycle beginning in
[**month (only) 359**].  his last dosage of medication being approximately
two weeks prior to presentation.

past medical history:
1.  nonsmall cell lung cancer status post chemotherapy and
radiation therapy found to be non-surgical on thoracotomy.
evidence of metastases to the left adrenal gland.
2.  emphysema.
3.  depression.
4.  status post tonsillectomy.

medications:
1.  chemotherapy.
2.  combivent two puffs four times a day p.r.n.
3.  wellbutrin 150 mg twice a day.

allergies:   no known drug allergies.

physical examination:   vital signs were afebrile.  blood
pressure 94/48; pulse 109; respirations 20; saturation of 98%
on room air.  in general, in no apparent distress, alert and
oriented times three.  the patient is speaking in full
sentences.  no respiratory distress.  heent:  normocephalic,
atraumatic.  pupils are equal, round and reactive to light.
extraocular movements intact.  sclerae anicteric.  there is
swelling of the upper and lower lips and question of swelling
of the tongue; no airway compromise, no lymphadenopathy.
chest is clear to auscultation bilaterally.  cor:
tachycardia, normal s1, s2, no murmurs, rubs or gallops.
abdomen is soft, nontender, nondistended.  no
hepatosplenomegaly or masses.  positive bowel sounds.
extremities are warm and well perfused.  positive for
clubbing.  no cyanosis of edema.  neurological:  cranial
nerves ii through xii are intact.  he moves all extremities.
strength is five out of five.

laboratory:  white blood cell count 3.9, hematocrit 30.4,
platelets 494.  sodium 143, potassium 4.4, chloride 107,
bicarbonate 29, bun 13, creatinine 0.7, glucose 130.  serum
toxicology screen negative.

ekg with sinus tachycardia at the rate of 114.

chest x-ray with ill defined density overlying the right
superior hilum suggestive of a mass.  right lateral pleural
thickening, rib fractures and atelectatic changes consistent
with post surgical change.

hospital course:
1.  anaphylaxis:  the patient was started on intravenous
hydrocortisone, intravenous famotidine and intravenous
diphenhydramine,.  he was admitted and observed in the
medical intensive care unit given his history for previous
anaphylaxis in the setting of p.o. allergen.

the patient remained hemodynamically stable and his
angioedema resolved.  it seemed unusual that the patient
would develop an allergy to shellfish at the age of 56.  it
was suspected that the patient's history of chemotherapy may
have put him at risk for this allergic reaction.

the patient will be discharged with the plan to follow-up
with his primary care physician on [**name9 (pre) 766**], [**12-18**].  he
will be referred to an allergist and is instructed in the use
of an epinephrine pen which he will carry with him at all
times, keeping one in the glove compartment of his car and
one in his house.

the patient will complete a rapid steroid taper.

2.  lung cancer:  this is followed by the patient's
oncologist at the [**hospital3 328**].

3.  tachycardia:  the patient remained in sinus tachycardia
in the low 100s throughout his hospital course.  this was
felt to represent the physiologic response to the patient's
anemia.  this will be followed up at the patient's primary
care physician.

4.  the patient's anemia was felt to be secondary to
chemotherapy.  further evaluation is deferred to the
patient's primary care physician.

condition on discharge:   good.

discharge status:   to home.

discharge diagnoses:
1.  anaphylaxis to shellfish.
2.  nonsmall cell lung cancer.
3.  resting tachycardia.

discharge medications:
1.  prednisone taper, 40 mg times one day, then 20 mg times
one day.
2.  albuterol ipratropium mdi one to two puffs q. six hours
p.r.n.
3.  bupropion 150 mg p.o. twice a day.
4.  benadryl 50 mg p.o. q. six hours p.r.n.
5.  epinephrine pen 1/[**numeric identifier 4856**] syringe, one injection
intramuscular p.r.n. anaphylaxis.

discharge instructions:
1.  the patient will follow-up with his primary care
physician, [**last name (namepattern4) **]. [**last name (stitle) 6512**], at the southern [**hospital 12162**] health center on
[**12-18**], at 11:30 a.m.
2.  the patient will be referred to an allergist for further
evaluation.




dictated by:[**name8 (md) 96586**]

medquist36

d:  [**2124-12-16**]  12:15
t:  [**2124-12-16**]  19:17
job#:  [**job number 96587**]
"
227,"unit no:  [**numeric identifier 97681**]
admission date: [**2162-2-15**]
discharge date: [**2162-2-24**]
sex:
service:


history of present illness:  this is an 81-year-old female
with a history of recent cabg with avr, chf, protein s
deficiency who presented from [**hospital3 **] in the
morning on [**2162-2-14**] with fever and respiratory distress.  she
was felt at [**hospital1 **] to be in chf versus pneumonia and was
given levofloxacin, ceftriaxone, and lasix.  they were unable
to contact her proxy and thus sent her to ems, as her oxygen
saturation decreased to 90 percent on nonrebreather.

in the ambulance, she was given morphine and bipap was
attempted, but her saturations decreased and she was
intubated in the field.

past medical history:  recent cad, status post cabg and avr
in [**11-26**] complicated postoperatively by multiple recurrent
episodes of congestive heart failure versus pulmonary disease
of unclear etiology.

protein s deficiency with recurrent dvts and pes.

schizophrenia.

chronic renal insufficiency with creatinine ranging between
1.3 to 1.5.

chf with an ef of 25 percent by echo in [**11-26**].

copd.

dementia.

history of mrsa.

medications on admission:
1. singulair 10 mg by mouth every day.
2. coumadin.
3. colace 100 mg by mouth two times a day.
4. aricept 10 mg at bedtime.
5. aspirin 81 mg a day.
6. [**doctor first name **] 60 mg a day.
7. protonix 40 mg a day.
8. advair 100/50 mcg.
9. prednisone 5 mg every other day.
10.      celexa.
11.      zyprexa 2.5 mg at bedtime.
12.      toprol xl 100 mg two times a day.
13.      neurontin two times a day.
14.      magnesium gluconate 1 g three times a day.
15.      lasix 60 mg two times a day.
16.      ceftriaxone 1 g.
17.      levofloxacin 500 mg.


allergies:  no known drug allergies.

social history:  the patient quit tobacco several years ago,
lived in [**hospital3 **] prior to her hospitalization in
[**month (only) 1096**]; however, after her operation in [**month (only) 1096**] had a
prolonged hospital course with multiple attempts of
extubation and difficulties with this resulting in severely
deconditioned patient and need for [**hospital3 **]
afterwards.  she has been in there since her discharge in
[**month (only) 404**].  her husband lives in a nursing home.

physical examination:  notable for temperature of 102.6,
blood pressure of 100/39, and assist control 16/450 with 5
peep.  lungs with bilateral coarse rales and rhonchi with
mechanical ventilation in all lung fields.  neurological
examination, the patient opens eyes to voice.  cranial nerves
ii through xii intact, withdraws all 4 extremities to
peripheral painful stimuli, and toes are upgoing on the
right.

laboratory data:  notable labs on admission were white count
of 7.8 with left shift, hematocrit of 27.1, inr of 1.6, and
creatinine of 1.2.

abg 7.28, 67, 341 on ac 14/400.

radiographic studies:  chest x-ray with pulmonary
interstitial edema consistent with chf and left pleural
effusion.

hospital course:  the patient was admitted to the intensive
care unit for further care.  problem list at this time
included respiratory distress, congestive heart failure,
pneumonia, anemia, fever.  in addition, in the emergency
room, she had a left internal jugular line placed, which on
chest x-ray was noted to be cannulating the carotid.  this
was removed, ffp was given, and pressure was held for 1 hour
with no adverse events on follow-up cat scan of the neck.
the patient was noted to have a left-sided pneumothorax,
which in comparison to cat scan from her hospitalization in
[**12-27**] seemed to be there at that time also.

respiratory distress.  the patient was intubated in the
field.  she initially was diuresed and a repeat
echocardiogram demonstrated an ef of 25 percent again with an
lv aneurysm.

she also continued to spike a fever and levofloxacin and
flagyl were started.  on [**2162-2-17**], she continued to have
fevers and bronchoscopy was performed.  during her previous
admission, she had much difficulty being extubated and
bronchoscopy at that time had revealed tracheomalacia and the
patient was given a tracheal and left main stem bronchial
stent, which made it then easy for her to be extubated.  on
the repeat bronchoscopy on [**2162-2-17**], the stents were found to
be in place, and the patient was found to have no further
problems with her tracheomalacia.  however, she continued to
have difficulty with weaning off her vent and with continuous
fevers.

a cat scan of the chest on [**2162-2-19**] demonstrated increased
cervical lymphadenopathy, a small stable pneumothorax,
hydropneumothorax, and left lower lobe consolidation.  two
days later, the bal returned with mrsa positivity, which she
has had in the past.  although this is likely a colonizer,
vancomycin was started in addition to levofloxacin and flagyl
on [**1-/2087**].

in addition, lenis were ordered, which were negative for dvt.

on [**2-23**], the patient was able to tolerate pressure support
in the morning and thus was extubated later in the day on to
bipap.  she eventually was able to tolerate being off of the
bipap overnight, but then had recurrent respiratory distress
in the morning of [**2-24**].  at this time, she refused strongly
and clearly bipap and re-intubation.  she was able to state
back her understanding that she was going to die and
understood that we would make her as comfortable as possible.
she was allowed to discuss this with her family who agreed to
honor her wishes.

the patient's daughter [**name (ni) **] [**name (ni) 30864**] was her proxy and also
went in and spoke to her mother and confirmed that her
mother's wishes were to be cmo.

on [**2162-2-24**], the patient was given iv morphine and made as
comfortable as possible and passed soon after.

a postmortem was declined by the family.

in addition to the above hospital course, there were multiple
other problems that contributed very little to her final
outcome such as a minor gi bleed with hematocrit of 27
requiring 2 units of packed red blood cells, worsening
chronic renal insufficiency up to 1.4 to 1.5 that improved
with hydration, and agitation, anxiety that was treated with
her outpatient psychiatric medications.

discharge diagnoses:  multifocal pneumonia.

congestive heart failure.

chronic pneumothorax.

gastrointestinal bleeding.

anemia.

respiratory distress.

discharge medications:  none.


                        [**first name11 (name pattern1) **] [**last name (namepattern1) **], [**md number(1) 18138**]

dictated by:[**last name (namepattern1) 46369**]
medquist36
d:  [**2162-6-7**] 12:26:33
t:  [**2162-6-8**] 01:45:35
job#:  [**job number 97682**]



"
228,"admission date:  [**2160-6-15**]     discharge date:  [**2160-6-22**]


service:

chief complaint:  ""i've been feeling bad for the last few
days and since yesterday i have been nauseous and vomiting.""

history of present illness:  the patient is a 77-year-old man
who presents with the above chief complaint and his past
medical history includes numerous medical problems including
non q wave mi times two, status post cabg in [**2139**],
hypertension, insulin dependent diabetes mellitus,
hypercholesterolemia, history of tias, history of lower gi
bleed and diverticulosis.  the patient was in his usual state
of health until approximately 4-5 weeks ago when his
degenerative joint disease and disc disease of his lumbar
spine began causing shooting right lower extremity pains.  at
that time the patient was treated with steroid injections and
po prednisone which caused an increase in his blood sugars.
for this increase in blood sugars he was started on humalog
approximately 3-5 days ago as his sugars have been in the
300-400's on his previous regimen.  approximately one week
ago the patient began feeling bad and run down.  the
patient's primary care doctor believed it was due to the high
blood sugars and started the humalog 3-5 days ago.  yesterday
the patient reports the onset of nausea and vomiting after
eating.  he tolerated lunch as his last meal and he has not
taken any po today.  also today he reports the onset of loose
stools times three.  he denied any fevers, abdominal pain,
weight change or urinary symptoms.  he does acknowledge night
sweats and chills at night over the last two days.  he has a
chronic cough secondary to post nasal drip which is
unproductive of sputum.  there is no erythema over the skin
where he injects his insulin.  his exercise tolerance is
approximately one flight of stairs and he is limited by right
lower leg pain.  he also denies any chest pain, shortness of
breath, palpitations or diaphoresis.  he has no pnd.  the
patient finally came to the er as he was not able to take
anything by mouth.

past medical history:  1) insulin dependent diabetes
mellitus.  2) hypertension, poorly controlled.  3) chronic
renal insufficiency.  4) status post non q wave mi times two.
5) status post cabg in [**2139**].  6) hypercholesterolemia.  7)
history of tia.  8) gout.  9) lower gi bleed status post
polyp removal.  10) diverticulosis.  11) allergies and post
nasal drip.

medications:  [**doctor first name **] 60 mg po q d, lopressor 20 mg po q d,
multivitamin, doxazosin 4 mg q h.s., lipitor 20 mg po q d,
allopurinol 300 mg po q d, ranitidine 150 mg po q h.s.,
glyburide 10 mg po bid, diovan 80 mg po q d, enteric coated
aspirin 325 mg po q d, quinine as needed, nph 20-30 units q
a.m., 10-15 units q p.m., humalog sliding scale started three
days ago.

social history:  the patient lives with his wife.  [**name (ni) **] denies
any tobacco or alcohol use.

family history:  noncontributory.

allergies:  morphine makes him nauseous.

physical examination:  vital signs, temperature 99.5, heart
rate 83, blood pressure 170/125, respiratory rate 18, satting
100% on two liters nasal cannula.  in general he is an
elderly man lying in bed in no acute distress.  heent:  he
has alopecia, pupils are equal, round and reactive to light
from 3 to 2 mm, sclera are anicteric.  mucus membranes are
moist.  neck supple, no jugulovenous distension, no
lymphadenopathy, no bruits.  cardiac exam, irregularly
irregular, s1 and s2 normal, no murmurs, gallops or rubs.
lungs are clear to auscultation bilaterally. abdomen, mild
tenderness to deep palpation of the left lower quadrant.  he
is non distended, bowel sounds present and normal.  abdomen
is soft.  gu, normal male genitalia, trace guaiac positive on
exam.  prostate without any nodules, regular and smooth.
extremities, no clubbing, cyanosis or edema. neuro, he is
alert and oriented times three, cranial nerves ii through xii
normal.  reflexes 2+ bilaterally biceps and achilles
strength, [**3-29**] upper extremities bilaterally, in the left
lower extremity is 4+/5 strength in his right big toe and
plantar and dorsiflexion of his foot.  gait and coordination
were not tested.

laboratory data:  white count 14.6, differential with 84
neutrophils, 1 band, 10 lymphs, hematocrit 44.4, platelet
count 134,000, pt 11.7, ptt 21.4, inr 0.9.  sma 7, 137, 5.2
which was hemolyzed, 100, 21, 40, 1.4, glucose 297.  calcium
8.4, phosphorus 4.7, magnesium 2.1, ast 24, alt 28, total
bilirubin 0.9, ck 54, troponin 0.3, alkaline phosphatase 59,
amylase 114, lipase 41, albumin 3.3, uric acid 4.3, tsh is
pending at this time.  chest x-ray showed no signs of
pulmonary edema and no infiltrate.  ekg was irregularly
irregular at 92, axis -30, occasional p waves, looking like
flutter but there are also absent p waves.  intervals are
normal.  there is a q in 3 and f, no st changes, poor r wave
progression.  an echocardiogram from [**2160-4-25**] showed mild
left atrial dilatation, non obstructive focal septal
hypertrophy, depressed lv function 1+ aortic regurg, mild mr
[**first name (titles) **] [**last name (titles) **] fraction could not be estimated at that time.

impression:  this is a 77-year-old man with multiple ongoing
medical problems who presents with generalized complaints of
the last week and a [**11-27**] day history of nausea and vomiting
and loose stool.  he was found to be in new onset atrial
fibrillation in the er.  physical exam was remarkable for the
atrial fibrillation with guaiac positive stool and mild left
lower quadrant tenderness.  labs revealed an increased white
blood cell count with left shift and low albumin.  chest
x-ray and ekg are normal and unchanged respectively.

plan:
cardiac:  the patient has known cad.  his aspirin, beta
blocker, lipitor and [**last name (un) **] will be continued.  his hypertension
will be aggressively controlled.  although ischemia is
unlikely without any changes in ekg, cks will be followed.
the patient is in new onset atrial fibrillation but lopressor
will be increased to 50 mg [**hospital1 **] for rate control.  tsh is
pending after weighing the risks and benefits of heparin.
given the patient's trace guaiac positive stool, history of
lower gi bleed, the decision was made to start the patient on
heparin as he had multiple risk factors for stroke elevating
him into a higher level of category including his past
history of tias.

infectious disease:  he has an elevated white count with a
left shift.  he has night sweats, chills times two days.
cultures of urine, stool and blood will be sent.  blood
cultures will be obtained when the patient's fever curve is
greater than 101.  no empiric antibiotics will be started at
this time.

endocrine:  the patient has poor glucose control.  he will be
written for an insulin sliding scale while in the hospital
and fingersticks will be checked qid.  his oral hypoglycemics
will be held for now.

gi:  he is trace guaiac positive with left lower quadrant
tenderness and a history of diverticulosis.  diverticulitis
is certainly a possibility although given the benign
presentation of his abdomen on exam, it is unlikely.
however, we will continue to follow his abdominal exam.  we
will guaiac all stools and we will follow hematocrit q d on
heparin.  the patient will be given antiemetics as needed to
control the nausea and vomiting.

renal:  the patient has a creatinine of 1.4 with an elevated
bun to creatinine ratio.  he is most likely dehydrated given
his nausea and vomiting and slightly prerenal and will be
hydrated.

musculoskeletal and neuro:  he has decreased strength in his
right lower leg consistent with his past medical history of
djd and disc disease of his lumbar spine.  his pain will be
controlled with non opioids as much as possible as opioids
have given him bad reactions in the past.  the patient was
admitted and this plan was pursued.

hospital course:  on hospital day #2 the patient had no
adverse events overnight.  the stool samples and the tsh are
still pending.  the patient is maintained on heparin and the
plan will be to transition him to coumadin, then to discharge
the patient and bring him back at 1-2 months for tee and
cardioversion at that time after anticoagulation, as it is
unknown how long patient has been in atrial fibrillation.
also on this admission the plan is to control his blood
sugars, hopefully the combined approach will lead to a
resolution of his nausea and vomiting and he can go home.  on
hospital day #3 the patient complained of some right thigh
swelling.  he was neurovascularly intact and this was thought
to be secondary to a muscle pull the patient experienced
approximately five days prior to admission.  there was a
small hematoma.  this is most likely exacerbated because of
the heparin the patient has been on, but the team was not so
concerned about this.  also on the third hospital day the
patient became tachycardic and hypotensive with blood
pressure in the 60's/30's.  the patient was somnolent at this
time.  exam was unchanged from prior.  iv fluids were given
and ekg was done that was unchanged.  the heparin was
discontinued and an ng lavage was performed that showed dark
brown fluid in the stomach with occasional clots which were
gastroccult positive.  with the lavage, the red fluid did not
clear.  a stat hematocrit came back at 26 which was down from
44 on admission, although this is partly due to rehydration,
this is significantly due to an upper gi bleed.  the patient
was transferred to the ccu at that time and transfused two
units of packed red blood cells.  the patient underwent
emergent egd that showed clotted blood in the lower third of
the esophagus and multiple non bleeding diffuse erosions in
the lower third of the esophagus.  the stomach was normal.
in the duodenum there were multiple acute crater ulcers in
the bulb and in the second part of the duodenum.  pigmented
material coating these ulcers suggested recent bleeding in
one of the ulcers.  the patient was treated with proton pump
inhibitor [**hospital1 **], discontinuation of all nsaids and
anticoagulation.  hematocrits were continually followed and
an h. pylori antibody was checked.  the tsh level came back
as normal at this time.  on the fourth hospital day the
patient was transferred back to the floor from the unit after
the egd and the 2 units of packed cells when patient was
stabilized.  on hospital day #5 the patient's main complaint
was his right thigh swelling leading to right thigh weakness
when he stood up.  he denied anymore episodes of
lightheadedness, dizziness, chest pain, shortness of breath,
bright red blood per rectum, melena or vomiting of blood.  at
this time his aspirin was changed to 81 mg from 325 mg and
the patient was not on either heparin or coumadin.  the
patient's hematocrit post transfusion rose to 31 and has
continued to rise since then.  his creatinine and bun bumped
transiently during the patient's hypovolemia episodes.  they
are now trending down.  the nph and regular insulin sliding
scale is controlling the patient's blood sugars.  [**initials (namepattern4) **] [**last name (namepattern4) **]
consult was obtained because the patient is usually followed
in [**last name (un) **], to further optimize the patient's insulin regimen.
the plan is to treat the patient for one month with proton
pump inhibitors, to follow-up the results of the h. pylori,
treat that if positive and to allow the ulcers one month to
heal.  the patient will return for a repeat upper endoscopy
in one month.  at that time if the ulcers are healed,
anticoagulation will be pursued with the eventual goal of
performing a tee and cardioversion either chemical or
electrical, once the patient has been on stable
anticoagulation for one month.  hospital day #6 the patient's
diet was advanced as tolerated.  physical therapy saw the
patient who agreed he was safe for discharge home.  on
hospital day #7 the patient slowly was regaining his strength
in his right leg and mobility.  he was starting to ask to go
home.  on hospital day #8 he was discharged home.  he will
follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 1313**], dr. [**last name (stitle) 19862**] from endocrine
and dr. [**first name (stitle) 1104**] from cardiology.  all of those attendings are
aware of the [**hospital 228**] hospital course.  the patient's
lopressor dose at the time of discharge is 37.5 mg po tid.
the h. pylori result came back positive.  he will be treated
for h. pylori infection.  he will follow-up with gi in [**2-29**]
weeks for repeat upper endoscopy.




                          [**first name11 (name pattern1) **] [**last name (namepattern4) 31943**], m.d.  [**md number(1) 31944**]

dictated by:[**last name (namepattern1) 8228**]

medquist36

d:  [**2161-1-28**]  12:05
t:  [**2161-1-28**]  14:07
job#:  [**job number **]
"
229,"admission date:  [**2125-10-8**]              discharge date:   [**2125-10-19**]

date of birth:  [**2055-7-28**]             sex:   f

service: omed

allergies:
codeine / carboplatin / cisplatin

attending:[**last name (namepattern1) 5062**]
chief complaint:
fatigue, acute hematocrit drop

major surgical or invasive procedure:
none

history of present illness:
initial hx prior to icu admission:
this is a 70 yo f w/ h/o relapsing papillary serous ovarian
cancer last first diagnosed in [**2117**].  she was last admitted to
this hospital for her 7th cycle of cisplatin.  she was given
[**doctor last name **]/taxol once in [**2117**], and was changed to [**doctor last name **]-cytoxan for
low counts in 01/[**2118**].  she tne received six cycles of cisplatin
started in [**1-/2125**] and administered in the hospital because of
the questionable history of allergic reaction to carboplatin.
-
since that admission, she showed signs of fluid retention, both
in her legs and in her ascites but she did not have any evidence
of congestive heart failure based on exam with normal lungs and
flat jvd. there was concern that perhaps her cancer was
progressing and that is the reason for her tense ascites, but
consideration was also given to worsening renal failure as
explanation for increased ascites.  ct scan taken [**2125-9-21**] showed increased ascites, but otherwise stable exam with
mesenteric masses and evidence of peritoneal carcinomatosis that
appear unchanged when compared to [**2125-7-25**].
-
her husband reported some recent confusion during their clinic
visit on [**9-26**].  due to her creatinine clearance of about
20ml/min, the decision was made during this visit to switch the
patient to weekly gemzar despite the stability of dz achieved
w/cisplatin.  due to her decreased creatinine clearance, a
reduced dose of 500 mg per meters squared was chosen.  she was
started on this dose on [**10-3**] and acutely tolerated it well.  the
plan was for weekly gemzar, three weeks on and one week off.
-
the patient first felt different from her normal self on
saturday, when she ""started to feel lousy.""  she saw an
accupuncturist on sat. for posterior neck pain; needles were
inserted into her head, back and ankles.  on sunday, her
weakness progressed to the point that she could no longer stand.
 her husband noted a bloodshot left eye ealier today, now
resolved.  she recently fell on her left buttock.
-
on ros, the patient notes moderate to severe abdominal pain for
the past several days, especially before meals and sometimes
resolved with food.  she sleeps with three pillows.
-
today, the patient's fellow contact[**name (ni) **] her.  she reported the
above symptoms and was told to come to clinic.  her hematocrit
has decreased from 33 to 17 and so she was admitted to omed and
immediately transferred to icu as inr>60.

on transfer back to omed from icu:

mrs. [**known lastname 1661**] is a 70 y/o f with recurrent ovarian ca, s/p cabg,
s/p mv repair, and hypothyroid, presented from onc clinic on
[**2125-10-8**] with weakness, nausea, and decreased po intake since
gemcitabine tx on [**2125-10-3**] and on clinic visit [**10-8**] was found to
be hyptotensive, decrease hct (from 33.0 to 17.1), and inr>60.
patient was initially admitted to omed service, but transferred
to micu for further evaluation. please see micu admit note for
more information on past medical hx and course during stay. in
brief, patient was admitted for hemodynamic stability and work
up of coagulopathic state. mrs. [**known lastname 1661**] denied diarrhea,
hematuria but did report very slight brbpr on toilet paper. she
was trace guiac positive on admission. she had diffuse
ecchymosis over lower extremities, back, and buttocks. she
received 6 units of prbc's with appropriate bump in hct to 34.1
on [**10-16**].  in terms of her coagulopathy, it is thought that a
combination of coumadin (for h/o dvt), decrease po intake, and
recent administration of gemcitabine were instigating factors.
coumadin held on admission. she received 1 unit ffp and was
initially treated with po vitamin k while in micu, with decrease
in inr to 3.0 on morning of [**10-17**]. on [**10-17**] she received 1 mg iv
vitamin k. her initial mixing studies were negative for
inhibitors. shortly after receiving the 6 units of blood,
patient became sob secondary to fluid overloaded state. she was
diuresed and responded well to lasix; however, creatinine began
rising (above baseline of ~2.6) likely because of hypovolumia
and decrease blood flow to kidneys. patient was subsequently
gently hydrated, with impoved renal status.  creatinine 2.8 on
[**10-16**]. during fluid overloaded state, mrs. [**known lastname 1661**] also developed
afib, which per family was new onset. after cardiology consult
and discussion with primary oncology team, it was decided to
cardiovert patient. she tolerated well and is now in nsr.
nutrition is still an issue for patient, as she has decrease
appetite. also, she was seen by pt for gait instability/[**month (only) **]
balance. mrs [**known lastname 1661**] appears well and states that she is feeling
good. she is anxious to get up and walk around the floor.
patient currently denies and n/v/dizziness. no f/c/ns/sob/cp.
she has not urinated since foley d/c'ed this morning but feels
that she might be able to go soon. urinary retention was not a
problem for her prior to admission.


past medical history:
1.relapsing papillary serous ovarian ca as above--hx onc
therapy:
she was diagnosed in [**2117**].

she is status post carboplatin and taxol times one in [**2117**],
changed to [**doctor last name **]- cytoxan because of low counts in 01/[**2118**].

status post cytoxan and cisplatin times two and then cytoxan and

carboplatin times four from [**6-/2119**] to 09/[**2119**].
status post [**doctor last name **] times six until 05/[**2121**].
status post taxol times eight from [**3-/2123**] to 10/[**2123**].
status post oral etoposide times one, discontinued because of
mouth sores in 11/[**2123**].
status post carboplatin times two, discontinued because of an
allergic reaction that occurred in 12/[**2123**].
status post cisplatin times three from [**1-/2124**] to [**4-/2124**],
discontinued because of rising creatinine.
status post weekly taxol but discontinued because of disease
progression.
started on cisplatin 50 mg/m2 in [**9-/2124**] status post two cycles
at that time, discontinued because of rising creatinine.
status post two cycles with navelbine, discontinued because of
disease progression.
status post seven cycles of cisplatin started in [**1-/2125**] and
administered in the hospital because of the questionable history

of allergic reaction to this medication given the fact that she
had an allergic reaction to carboplatin in the past. cisplatin
was discontinued due to rising cr.
status post gemzar treatment last wednesday, [**2125-10-3**]
-
2. yeast infection [**2125-8-29**]
-
3.cad s/p cabg and mvr
-
4. h/o le dvt
-
5.cri
-
6. hyperchol.
-
7. gout
-
8. hypothyroidism


social history:
married, 30 pack yr tob, quitx20 years, no etoh, no ivda.

family history:
mother=[**name (ni) **]
father:prostate ca
brother:pd
m aunt=ovarian ca
cousin=ovarian ca


physical exam:
[**10-8**]:
vitals: 99.4  76-80 (76)  94/42
gen: pale woman relaxing in bed in nad, brighter appearing than
yesterday evening or this morning
neck: supple, perrl, eomi, conjunctivae remain pale, mouth and
oropharynx clear
lungs: ctab
heart: rrr
abd: soft, distended, nt
ext: warm x 4 with pulses x 4
skin: left large ecchymosis on buttocks slighly increased in
size and color since yesterday, bil hands, abdomen

[**10-16**]:
pe:t:98.0  p: 68-75   bp: 86-128/44-99   rr:24 o2:93-98%
gen: patient is pleasant, pale appearing elderly female, nad
heent: perrl - consenusally, eomi, sclerae anicteric; supericial
ulcer on r side of tongue, blood blister on back l tongue; neck:
supple, from, no lad
lungs: cta with bibasilar crackles
cardiac: rrr, no m/g/r
abd: moderate distention-but not firm, no peritoneal signs,
nontender, no masses appreaciated, +bs, resolving ecchymosis on
luq of abd.
ext: 2+ pitting edema of le bilat. diffuse ecchymosis of b/l
buttocks r>l, and upper thighs, mostly resolved on l left
extremity; few small ecchymosis on l wrist. resolving per micu
notes.
neuro: a&ox3; responding appropriately, very talkative, cn2-12
intact with no focal deficit. strength 5/5 throughout.


pertinent results:
crit: baseline mid 20s; [**10-3**] 33  [**10-5**] 17.1  9/21@1430 following
3u 28.6
pt: [**9-5**] 13.7  [**10-8**] >100  [**10-9**] following 1u ffp 24.8, 32.6
ptt: [**9-5**] 23.6  [**10-8**]  150, 143 [**10-9**] following 1u ffp 61.7, 48.8
platelets: [**10-8**] 263 [**10-9**] 162

ct of the chest without iv contrast: there are minor dependent
atelectatic
changes. extensive atherosclerotic changes of the aorta and
coronary arteries
are evident. multiple prominent but nonpathologically enlarged
mediastinal
lymph nodes are identified. there is a large hiatal hernia. no
pleural or
pericardial effusions are present.

ct of the abdomen without iv contrast: there is a
moderate-to-large amount of
ascites within the abdomen, but no evidence of an intra- or
retroperitoneal
hematoma. allowing for the limitations of a noncontrast exam,
the liver,
gallbladder, spleen, pancreas, adrenal glands, and kidneys are
within normal
limits. extensive aortic calcifications are again noted. no
pathologically
enlarged retroperitoneal or mesenteric lymph nodes are
identified in this
limited study. there is no free air.

ct of the pelvis without iv contrast: a large volume of ascites
is present
within the pelvis. the urinary bladder is unremarkable. there is
sigmoid
diverticulosis without diverticulitis.

bone windows: no suspicious lytic or blastic leions are
identified.

impression: moderate-to-large volume of ascites, but no evidence
of intra- or
retroperitoneal hemorrhage.

[**10-9**] chest ap:
portable ap chest: comparison is made with a chest ct scan from
[**2125-10-8**]. again seen is a left subclavian port with the tip in the
svc, in
satisfactory position. there is no pneumothorax. there are
multiple
mediastinal clips and a prosthetic mitral valve. there is stable
cardiomegaly
with mild upper lung zone redistribution. there is a large
hiatal hernia with
associated atelectasis in the left lower lobe. there is
worsening right lower
lobe atelectasis.


brief hospital course:
a/p: mrs. [**known lastname 1661**] is a 70 yo female with h/o recurrent ovarian
cancer who recieved first dose of gemcitabine on [**2125-10-3**] and
presented to clinic on [**10-8**] with hypotension, drop in hct
(33-->17), and inr>30, admitted to icu. icu course c/b fluid
overload, acute on chronic renal fl., and afib. transferred to
omed on [**10-16**] hemodynamically stable, inr 3.0 and 34.1.

1. coagulopathy - patient admitted with an inr >60, 3.0 on [**10-16**].
thought to be [**2-19**] combination of decrease po intake, coumadin,
and gemcatabine.  continue to hold coumadin. as per hpi, treated
with ffp and vitamin k in icu with inr decrease to 3.0. given
1gm vitamin k iv [**10-16**] prior to transfer to floor. inr 2.1 day
prior to discharge and 2.9 on day of discharge. per primary
oncology team, she was given 10mg po vitamin k prior to
discharge and will f/u in clinic in 3 days to have inr
rechecked. coumadin was held on discharge.
2. anemia - patient with chronic anemia, but acute blood loss
internally to buttocks thighs in setting of coagulopathic state.
responded appropriately to 6 units prbc's in icu with hct
remained stabe once transferred to oncology service. she was
receiving procrit about once a week prior to admission to
hospital and received injection 3x/week during admisison. she is
to f/u with primary team on monday to discuss continuation of
procrit.
3. htn: blood pressures had been fluctuating while in icu and
initially holding of metoprolol. outpatient dose of metoprolol
25mg [**hospital1 **] and was restarted and switched to 12.5mg tid for while
in the icu. her blood pressures were well controlled on this
dose and she was discharged on 12.5 mg tid.
4. acute on chronic renal insufficiency - patient with baseline
creatinine of 2.4-2.7. creatinine had increased [**2-19**] to prerenal
azotemia while being diuresed in icu. trending to baseline on
transfer to floor. creatinine was 2.7 on day of discharge.
nephrotoxic medications were avoided during admission.
5. ovarian cancer -  s/p gemcitabine treatment [**10-3**], preceeding
admission and onset of previoulsy discussed adverse events. will
discuss with primary oncologist future treatment plans.
6. nutrition - mrs [**known lastname 1661**] has had poor appetite for some time,
which may have attributed to coagulopathic state.  seen and
evaluated by nutrition service. patient notes that her appetite
is slowly increasing and appeared to be eating about [**date range (1) 5082**] of
food on tray. discussed importance of eating green vegetables -
ie broccoli- but encouraged any po intake for now.
7. constipation - mrs. [**known lastname 1661**] has had difficulty moving bowels
x 1 week despite aggressive treatment. she was managed on senna
and colace and responded well to .5l of golytely to get bowels
started and then occassional miralax.
8. pt: physical therapy evaluated patient today and suggested
3-5 visits/wk to help with balance, gait, and transfers.
suggested possible rehab on discharge, but patient refused and
stated that she preferred home pt. also with ot evaluation with
suggestion of home aide to supervise shower transfers and home
safety evaluations.
9. cad/hyperlipidemia - continue atorvastatin during admission
and on dsicharge.
10. hypothyroid - continued outpatient dose of levothyroxil
during admission and on discharge.
11. episode of afib - patient was noted to be in afib during icu
stay (as per hpi). because of the desire to avoid need for
anticoagulation (if need for cardioversion if in afib >48 hours)
she was successfully  cardioverted on [**10-12**]. nsr throughout rest
of hospitalization.
12. fen: continue protonix, phosphagel, tums, and pneumoboots.
13. code: dnr/dni


medications on admission:
levoxyl 75 mcg p.o. daily, prilosec, coumadin 1mg qd,
lipitor, atenolol, anzemet, celexa, oxycontin b.i.d., iron,
procrit, renagel 40mg qd and ativan daily.

discharge medications:
1. levothyroxine sodium 75 mcg tablet sig: one (1) tablet po qd
(once a day).
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 q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*2*
3. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po
qd (once a day).
disp:*30 tablet(s)* refills:*2*
4. sevelamer hcl 400 mg tablet sig: one (1) tablet po tid (3
times a day).
disp:*90 tablet(s)* refills:*2*
5. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2
times a day).
disp:*120 capsule(s)* refills:*2*
6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day).
disp:*60 tablet(s)* refills:*2*
7. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
8. calcium carbonate 500 mg tablet, chewable sig: one (1)
tablet, chewable po tid w/meals (3 times a day with meals).
disp:*30 tablet, chewable(s)* refills:*2*
9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3
times a day).
10. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as
needed for anxiety.


discharge disposition:
home with service

facility:
[**hospital 119**] homecare

discharge diagnosis:
primary diagnosis:
1. coagulopathy
secondary diagnosis
1. ovarian cancer
2. malignant ascities
3. chronic renal insufficiency
4. congestive heart failure
5. h/o dvt
6. s/p mvr


discharge condition:
stable.

discharge instructions:
please call your pcp or come to the ed if you have notice
worsening bruising, bloody stools, shortness of breath, chest
pain, feves/chills, or other worrisome symptoms.
please follow up on monday in the [**hospital **] clinic to have your
labs drawn.
do not restart coumadin on discharge. please discuss restarting
this medication with your doctor when you return to the [**hospital **]
clinic on [**10-22**].


followup instructions:
1. please return to the oncology clinic on monday, [**2125-10-22**] to have your labs drawn.
2. please call your oncologist for an appointment in [**1-19**] weeks.
3. please call your pcp, [**last name (namepattern4) **]. [**first name (stitle) **] at ([**telephone/fax (1) 95873**] for an
appointment in [**1-19**] weeks.



"
230,"admission date:  [**2145-4-9**]              discharge date:   [**2145-4-15**]

date of birth:  [**2064-8-29**]             sex:   m

service: surgery

allergies:
aspirin / lisinopril / morphine

attending:[**first name3 (lf) 695**]
chief complaint:
hepatic mass

major surgical or invasive procedure:
[**2145-4-9**] l hepatectomy, gold fiducial seed placement [**2145-4-9**]


history of present illness:
80-year-old male who underwent a routine chest x-ray and
subsequently
ct scan of the chest that demonstrated a mass in the liver
precipitating a ct scan of the abdomen. this demonstrated a
5.4 x 4.9 cm poorly marginating heterogeneous mass. a ct
guided liver biopsy on [**2-22**] demonstrated infiltrating
poorly differentiated adenocarcinoma. a chest ct scan
demonstrated no evidence of pulmonary metastases.  a
colonoscopy, upper gi and small-bowel follow-through did not
demonstrate any abnormal lesions. he is completely
asymptomatic and was referred for evaluation. a triphasic ct
scan of the abdomen at [**hospital1 18**] demonstrated a mass as primarily
in the medial segment of the left lobe (segment 4) but does
extend into the left lateral segment more superiorly. there
is encasement of the left and middle hepatic veins. the
lesion extends close to the bifurcation of the right anterior
and left portal vein. there is an early branch of the right
posterior portal vein, however, the portal vein does not
appear to be involved. the tumor appears to be more cephalad
to the portal vein. there is no evidence of extrahepatic
spread. the lesion did appear to be resectable with a left
hepatic lobectomy and measured approximately 5.4 x 4.9 cm.
his afp was 4.7, ca19-9 10 and cea less than 1. he has
provided informed consent for hepatic resection. he underwent
a thorough cardiac evaluation preoperatively and was cleared
for surgery. he is now brought to the operating room for left
hepatic lobectomy.


past medical history:
diverticulitis, hyperlipidemia, cardiac murmur,, cad s/p mi in
his 50s. psh: cabg [**2123**], knee surgery [**2136**],partial colectomy
[**2141**] with temporary colostomy with subsequent reversal. states
this was not for a malignancy

social history:
he is a widower and retired carpenter. he has six children. one
has polio, one has had an mi, and the third has type i dm, and
the other three children are healthy

family history:
mother died of a stroke at age 83, father died of heart failure
at age 89. strong family history of cardiac disease.

physical exam:
97.7 62  152/70 20  99%ra, 5'3"", 85.4kg
a&o, no scleral icterus
neck free range of motion. no carotid bruits
lungs bibasilar rales
cor rrr, 2/6 sem loudest @ rsb radiating to bilat neck.
abd obese, normal bowel sounds, no hsm or masses,
ext venostasis changes, no edema\
neuro: no asterixis


pertinent results:
on admission: [**2145-4-9**]
wbc-18.1* rbc-4.29* hgb-13.1* hct-38.9* mcv-91 mch-30.6
mchc-33.7 rdw-13.1 plt ct-241
pt-14.8* ptt-28.6 inr(pt)-1.3*
glucose-125* urean-17 creat-0.8 na-142 k-4.3 cl-108 hco3-23
angap-15
alt-246* ast-293* alkphos-53 totbili-1.5
albumin-3.3* calcium-7.8* phos-3.8 mg-1.9
on discharge: [**2145-4-13**]
wbc-12.1* rbc-3.66* hgb-11.1* hct-33.3* mcv-91 mch-30.4
mchc-33.4 rdw-13.3 plt ct-171
glucose-108* urean-18 creat-0.5 na-138 k-3.9 cl-104 hco3-30
angap-8
alt-98* ast-34 alkphos-62 totbili-0.7 albumin-2.5*

brief hospital course:
on [**2145-4-9**] he underwent left hepatic lobectomy, caudate lobe
resection, placement of gold fiducials and intraoperative
ultrasound for intra-hepatic cholangiocarcinoma. surgeon was dr.
[**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **]. please see operative report for further
details. a jp drain was placed. ebl was 1200cc and this was
replaced with crystalloid. he was extubated in the or then
transferred directly to the sicu for monitoring. on pod 1, the
patient was transferred to the floor from the sicu with no
adverse events.

neuro: an epidural was in place for pain control. when
appropriate, the epidural was removed, and the patient was put
on iv dilaudid.  when the patient was tolerating po pain
medications, he was transitioned to oral medication with good
relief of his pain.

cv: the patient was monitored on telemetry throughout his stay.
he received perioperative beta blockade.  when the patient
complained of nausea, ekgs were obtained, which were stable.
the patient was put on home medications when he was tolerating
adequate oral intake.

pulm:  good pulmonary toilet and early ambulation were
encouraged.

gi/gu/fen:  the patient's intake and output were closely
monitored throughout his stay.  the patient's ivf were adjusted,
and the patient was bolused when appropriate post operatively to
maintain adequate urine output and vital signs.  on pod1, the
patient received sips of clears, which was advanced to clears on
pod2.  the patient's foley was removed when the patient was
urinating adequately.  on pod 3, the patient was transitioned to
a regular diet, whcih he tolerated well, and was restarted on
most home medications (except cholesterol lowering medications,
which were to be started on discharge given the patient's
transaminitis).  the patient's jp drain was left in place as the
output was bilious.  he was instructed on home jp care and how
to record outputs for follow up, as the patient will be
discharged to rehab with the jp in place.  on pod 5, the patient
complained of nausea briefly, for which an ekg was obtained, and
was stable.  a jp bilirubin was obtained as well, which was
34.7.

heme: the patient's cbc was routinely followed; the patient did
not require a post operative transfusion

id:  the patient's fever curve and white blood count were
closely examined for signs of infection.  the patient's wound
was monitored as well, without signs of infection.
other: a physical therapy consult was obtained, who recommended
that the patient be discharged to a rehabilitation facility;
both the patient and his family were in agreement.  on pod 5,
the central venous line was removed.

path report as follows:  portal lymph node (a):fragments of
lymph node(s):  no tumor.
ii.  liver, left lobe (b-g):cholangiocarcinoma,  mild steatosis.

liver: resection synopsis macroscopic
specimen type:  left lateral segmentectomy.
focality:  solitary
tumor size:greatest dimension:  7.5 cm.  additional dimensions:
7.0 cm x 4.4 cm.

microscopic
histologic type:  cholangiocarcinoma, intrahepatic.
histologic grade:  g1:  well differentiated.

extent of invasion
primary tumor:  pt1:  solitary tumor with no vascular invasion.
regional lymph nodes:  pnx:  cannot be assessed.

lymph nodes none in specimen 2
distant metastasis:  pmx:  cannot be assessed.

margins:parenchymal margin:  involved by invasive carcinoma.
(less than 0.5 mm).
bile duct margin: cannot be assessed. other margins: cannot be
assessed
clinical: liver lesion; cholangiocarcinoma. specimen
submitted-1. portal lymph node 2. liver lobe. prior biopsy
outside showed tumor immunostains positive for ck-7,  negative
for ck20, heppar and ttf-1.

on discharge, the patient was doing well, tolerating a regular
diet.  his vital signs were stable, and the patient was
afebrile.  he was ambulating and voiding without difficulty.
the patient was discharged to a rehabilitation facility for
further care.

medications on admission:
simvastatin 40 mg', zetia 10 mg', atenolol 25 mg', zantac 300

discharge medications:
1. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection q8h (every 8 hours).
2. insulin regular human 100 unit/ml solution sig: one (1)
injection asdir (as directed): per insulin flowsheet.
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q6h (every 6 hours) as needed for pain.
5. ranitidine hcl 150 mg tablet sig: two (2) tablet po hs (at
bedtime).
6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
7. 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
8. ondansetron 4 mg iv q8h:prn nausea/vomiting
9. sodium chloride 0.9%  flush 3 ml iv daily:prn
peripheral iv - inspect site every shift
10. simvastatin 40 mg tablet sig: one (1) tablet po once a day.

11. zetia 10 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
extended care

facility:
[**hospital 12414**] healthcare center - [**location (un) 12415**]

discharge diagnosis:
cholangio ca


discharge condition:
good


discharge instructions:
please call dr.[**name (ni) 1369**] office [**telephone/fax (1) 673**] if fever, chills,
nausea, vomiting, inability to eat, increased abdominal pain,
incision redness/bleeding/drainage or jaundice.
continue jp drain care as instructed.  please record all daily
drain outputs, and bring information to your follow up
appointment with dr. [**last name (stitle) **]. please call dr[**name (ni) 1369**] office if
drainage increases in volume, develops purulence or foul odor.
it is currently bilious (greenish/yellow) in appearance due to
bile leak which is expected to decrease over time
incision care:  keep clean and dry.
-you may shower, and wash surgical incisions.
-avoid swimming and baths until your follow-up appointment.
-please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-your staples will be removed during at your follow up
appointment.
-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 vomiting and cannot keep in fluids or your
medications.
* you are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* you see blood or dark/black material when you vomit or have a
bowel movement.
* your skin, or the whites of your eyes become yellow.
* 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.

* do not drive or operate heavy machinery while taking any
narcotic pain medication.  you may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* continue to ambulate several times per day.
* no heavy ([**11-17**]  lbs) until your follow up appointment.


followup instructions:
provider: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **]  [**telephone/fax (1) 78154**]  call to schedule
appointment

please follow up with dr. [**last name (stitle) **] wednesday [**4-21**] @ 4:20pm; call
his office at ([**telephone/fax (1) 3618**] for any questions or changes.


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 707**] md, [**md number(3) 709**]

"
231,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
232,"admission date:  [**2170-12-31**]              discharge date:   [**2171-1-2**]


service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 106**]
chief complaint:
fatigue, stemi

major surgical or invasive procedure:
cardiac catheterization with a bare metal stent to left anterior
descending coronary artery

history of present illness:
[**age over 90 **]f with unknown pmhx presented to [**hospital3 4107**] this
afternoon after being found in her home, unable to get up from
toilet, complaining of fatigue. at [**hospital1 **] she was noted to have
st elevations on ecg in inferior and lateral leads. she was
given a full dose aspirin, high dose statin, plavix load and a
heparin bolus. she was transferred directly to the [**hospital1 18**] cath
lab and underwent left heart catheterization. she was found to
have a tight lesion in the proximal lad, and a bms was deployed.
she tolerated the procedure well. she was brought to the ccu for
further monitoring. she was noted to have persistent stes on ecg
post-catheterization.
.
on arrival to the ccu, she was tachycardic but was otherwise
stable. she had no complaints. she did not recall exactly what
prompted her ed referral and did not know why she was here. she
knew that her friend had tried calling her and that she was
unable to come to the phone but is unable to tell me more than
that. she denies current chest pain or having ever had chest
pain. no sob, doe, pnd, orthopnea. no syncope or presyncope. no
palpitations. she notes that she has had slight bilateral lower
extremity swelling for the past three days. other ros is
negative.


past medical history:
1. cardiac risk factors:: diabetes-, dyslipidemia-, hypertension
?
2. cardiac history: none
-cabg: n/a
-percutaneous coronary interventions: n/a
-pacing/icd: n/a
3. other past medical history:
osteoporosis
scarlet fever as a child
? hypertension


social history:
-tobacco history: never
-etoh: 1 scotch per night
-illicit drugs: none
pt lives alone, is twice widowed, her second husband passed away
in [**2151**]. she has a house cleaner weekly and a close friend in
the area. she is responsible for her own bills and cooking. she
walks with a cane, admits that she has been having more
difficulty at home with stairs.


family history:
non-contributory

physical exam:
vs 96.9 113 119/66 19 98% 2l nc
general: elderly, frail appearing woman, very pleasant. nad
heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. small
xanthalesma near palpebral fissure
neck: supple with jvp to the angle of the jaw.
cardiac: tachycardic, regular. very distant. unable to
appreciate clear heart sounds.
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.
extremities: no femoral bruits. r groin site c/d/i, non-tender,
no hematoma. trace b/l le edema to mid tibia. extremities cool,
sensation intact.
skin: no stasis dermatitis, ulcers. b/l heels and sacrum pink,
blanching.
pulses:
right: femoral 2+ dp 1+ pt 1+
left: femoral 2+ dp 1+ pt 1+


pertinent results:
admission labs:
[**2170-12-31**] 10:23pm blood wbc-15.2* rbc-4.13* hgb-12.1 hct-36.2
mcv-88 mch-29.2 mchc-33.3 rdw-14.4 plt ct-475*
[**2170-12-31**] 10:23pm blood pt-14.2* ptt-29.1 inr(pt)-1.2*
[**2170-12-31**] 10:23pm blood glucose-172* urean-18 creat-0.6 na-132*
k-4.5 cl-96 hco3-25 angap-16
[**2170-12-31**] 10:23pm blood calcium-8.3* phos-2.9 mg-1.7
.
discharge labs:
[**2171-1-2**] 06:30am blood wbc-14.2* rbc-3.32* hgb-9.8* hct-29.2*
mcv-88 mch-29.5 mchc-33.5 rdw-14.3 plt ct-400
[**2171-1-2**] 06:30am blood pt-13.7* ptt-29.7 inr(pt)-1.2*
[**2171-1-2**] 06:30am blood glucose-103 urean-13 creat-0.5 na-134
k-4.0 cl-97 hco3-27 angap-14
[**2171-1-2**] 06:30am blood albumin-2.9* calcium-7.8* phos-2.8 mg-1.7
.
cardiac enzymes:
[**2170-12-31**] 10:23pm blood ck(cpk)-207* ck-mb-6 ctropnt-0.43*
[**2171-1-1**] 04:50am blood ck(cpk)-161* ck-mb-5 ctropnt-0.46*
[**2171-1-2**] 06:30am blood ck(cpk)-127  ck-mb-3 ctropnt-0.37*
.
metabolic profile:
[**2171-1-1**] 04:50am blood %hba1c-5.5
[**2171-1-1**] 04:50am blood triglyc-91 hdl-40 chol/hd-2.8 ldlcalc-53
.
anemia studies:
[**2171-1-1**] 04:50am blood caltibc-194* vitb12-191* folate-11.3
ferritn-313* trf-149*
.
c.cath study date of [**2170-12-31**] 1. selective coronary angiography
of this right dominant system demonstrated single vessel
coronary artery disease.  the lmca was without significant
disease.  the lad had 80-90% serial lesions in the proximal lad
just before d1.  the lcx and rca had no significant coronary
artery disease. 2. limited resting hemodynamics demonstrated
normal systemic arterial pressure of 107/63 mmhg. 3. successful
ptca and stenting of the proximal lad with a 2.5 x 28 mm
minivision bms which was deployed at 14 atm. the proximal stent
was post dilated with a 2.75 x 12 quantum maverick balloon at 14
atm. final angiography revealed no residual stenosis in the
stent, no dissection and timi iii flow.  (see ptca comments) 4.
right femoral arteriotomy site was closed with a 6 french mynx
device. final diagnosis: 1. one vessel coronary artery disease.
2. acute anterior myocardial infarction, managed by acute ptca.
ptca and stenting of the proximal lad.
.
portable tte (complete) done [**2171-1-1**] at 11:56:38 am the left
atrium is dilated. the left ventricular cavity size is normal.
there is moderate to severe regional left ventricular systolic
dysfunction with mid to distal anterior and septal akinesis with
apical akinesis/dyskinesis. right ventricular chamber size and
free wall motion are normal. the aortic arch is mildly dilated.
the aortic valve leaflets are moderately thickened. there is a
minimally increased gradient consistent with minimal aortic
valve stenosis. mild (1+) aortic regurgitation is seen. the
mitral valve leaflets are mildly thickened. trivial mitral
regurgitation is seen. the tricuspid valve leaflets are mildly
thickened. there is mild pulmonary artery systolic hypertension.
there is a small pericardial effusion. there is brief right
atrial diastolic collapse. left ventricle - ejection fraction:
30% to 35%.

brief hospital course:
[**age over 90 **]f with no prior cardiac history presented with stemi, now s/p
bms to lad. echo showed systolic chf with ef 30-35%. pt was
medically optimized and discharged to rehabilitation in stable
condition.
.
# coronaries: single vessel cad, s/p 2 bms to lad. hba1c for
risk stratification 5.5, so wnl. lipid panel: cholest 111,
triglyc 91, hdl 40, ldlcalc 53, so all within acceptable ranges.
started high dose statin with atorvastatin 80mg po hs for recent
mi and discharged on atorvastatin 40mg po hs for ongoing lipid
management over high dose for risk of adverse events in this
elderly patient. trended ces until falling. ck peaked at 207 on
the day of transfer. continued asa 325mg po daily and plavix
75mg po daily for thombotic ppx. initialy beta blocker therapy
with metoprolol tartrate 25 mg po bid. discharged on toprol xl
50mg po daily.
.
# pump: patient stated that she has a history of lower extremity
swelling over the past several weeks which is new. no echo in
our system. tte this admisison showed ef 30-355 with apical
hypokinesis. held off anticoagulation for apical hypokinesis
given age and risk factors. will continue on asa + plavix for
antiaggregation therapy and as thrombosis ppx. started
lisinopril 2.5 mg po daily for decreased ef and chf.
.
# rhythm: currently in sinus tachycardia with low-normal blood
pressures, given large territory of infarct tachycaridia is
likely compensatory mechanism to maintain co. initially held
bblockers to avoid precipitating cardiogenic shock. was able to
titrate up bblockade. telemetry showed frequent pacs. pt very
pre-renal with falling hct. unclear if this is due to dilution
or hemorrhage. ultimately believed to be due to hypovolemia.
encouraged pos and improved.
.
# leukocytosis: pt with ongoing leukocytosis. unclear if this is
due to recent mi, infection, or clonal process such as cll. cbc
with diff with 17% lymphcytes. this may be early cll but
ultimately was felt to be reactive leukocytosis from the mi.
cdiff, ua, ucx all negative.
.
# hyponatremia - na on admission was 132 and fell to 130.
improved with improvement of volume status and was ultimately
believed to be [**12-17**] hypovolemia.
.
# anemia - patient with drop in hct this admission. ultimately
the admisison hct was believed to be hemoconcentrated. amemia
studies were sent which showed mild iron and b12 def. added
supplementation. stools were guaiac negative.

medications on admission:
fosomax 70mg qweek
pred forte 1% 1gtt l eye qid
vigamox 0.5% 1gtt l eye qid
combigen 1gtt both eyes [**hospital1 **]
aspirin 81mg daily
tums daily
occuvite


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).
3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6
hours) as needed for pain, fever.
4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
5. prednisolone acetate 1 % drops, suspension sig: one (1) drop
ophthalmic qid (4 times a day).
6. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day)
as needed for constipation.
7. toprol xl 50 mg tablet sustained release 24 hr sig: one (1)
tablet sustained release 24 hr po once a day.
8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1)
tablet po daily (daily).
9. cyanocobalamin 250 mcg tablet sig: one (1) tablet po daily
(daily).
10. calcium with vitamin d 600-400 mg-unit tablet sig: one (1)
tablet po twice a day.
11. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily):
hold sbp< 100.
12. atorvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
13. alphagan p 0.1 % drops sig: one (1) drop ophthalmic three
times a day: 1 drop ou tid.
14. vigamox 0.5 % drops sig: one (1) drop os ophthalmic four
times a day: 1 drop os qid
until your ophthalmology appointment .
15. xalatan 0.005 % drops sig: one (1) drop ophthalmic at
bedtime: 1 drop qhs ou.


discharge disposition:
extended care

facility:
[**hospital3 7**] & rehab center - [**hospital1 8**]

discharge diagnosis:
st elevation myocardial infarction
iron defeciency anemia
chronic systolic congestive heart failure, ef 30%
.
secondary:
osteoporosis
scarlet fever as a child
? hypertension


discharge condition:
stable vital signs, afebrile, chest pain free

discharge instructions:
you had a heart attack and a bare metal stent was placed in your
left coronary artery to fix a blockage. your heart function is
weakened now and you will need to be followed closely for signs
of fluid retention that include swelling in your feet, trouble
breathing, or a dry cough. you were started on multiple new
medicines to help your heart work better:
new medicines:
- plavix (clopidogrel) 75mg daily to prevent blood clots and
keep the arteries of your heart open. do not stop taking this
medication unless told to by your cardiolgist. stopping this
medications prematurely could lead to a heart attack.
- aspirin 325mg daily to prevent blood clots
- iron tablets and vitamin b12 to treat your anemia and help
your body make more red blood cells
- colace and senna to prevent constipation
- metoprolol succinate (toprol xl)50mg daily to slow your heart
rate and help your heart pump better
- atorvastatin (lipitor) 40mg before bed to treat high
cholesterol
- lisinopril 2.5mg daily to keep your blood pressure low and
help your heart pump better
.
please call your doctor if you have any chest pain, trouble
breathing, nausea, fevers, cough or any unusual bleeding.
.
weigh yourself every morning. please call your doctor if you
gain more than 3lbs in a day or 10lbs in a week.
adhere to 2000mg sodium diet

followup instructions:
we have made you a follow up appointment to see your
cardiologist as below.
cardiology:
[**last name (lf) **],[**first name3 (lf) 251**] t. phone: [**telephone/fax (1) 4475**] date/time: [**1-15**] at 2:45
pm



completed by:[**2171-1-2**]"
233,"admission date:  [**2180-3-29**]              discharge date:   [**2180-4-2**]

date of birth:  [**2099-1-25**]             sex:   f

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 7333**]
chief complaint:
chest pain

major surgical or invasive procedure:
2units prbcs transfused


history of present illness:
this is an 81 yo female with history of cad, htn, ?gib in the
past was transferred from [**hospital3 4107**] for management of
melena, doe and chest tightness.  the episode begain this
morning.  she was walking to the bathroom and began to
experience sob, along with 8/10 'chest tightness', +nausea,
+diaphoresis.  she denies vomiting, palpitations or radiating
pain.  this episode lasted for 5 minutes and resolved on its
own.  she was taken to her pcps office by her daughter and was
then referred to the [**name (ni) **] [**1-31**] ecg changes and concern for acs.
she reports similar episodes for the past two days, 4-5 episodes
each day, but today's episode was worse, which was the reason
she sought medical attention.  she was sent to [**hospital1 **] er where
she had witnessed melena, documented as guaiac positive.

at [**hospital1 **], she was hemodynamically stable.  her trop i was found
to be 7.37.  hct 26.6.  ecg showed st depressions ii, iii, avf,
v3-v5, st elevation avr. patient was given lopressor, 1uprbc,
tylenol, lasix 40mg x 1.  cxr showed small right pleural
effusion with minimal basilar atelectasis.  she was transferred
to [**hospital1 18**] ccu for further management.

on arrival here, the patient was asymptomatic.  she denied any
chest pain, sob, n/v, diarrhea, abd pain.  last bm was this
morning.  no fevers, chills.  +dry cough for the past few days.


past medical history:
cad s/p mi and cabg in [**2162**] at [**hospital1 112**]
hypertension
hypothyroidism
anxiety

cardiac risk factors: htn, former smoker 30 pack year, quit 15
years ago
cardiac history:
-cabg:  [**2162**]
-percutaneous coronary interventions:  [**12-5**]


social history:
lives alone, has daughter, 50 year pack history tobacco, quit 15

years ago, no etoh, no drugs. from poland.

family history:
unknown, parents died when she was young.

physical exam:
vs:
general: nad, lying comfortably in bed
heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were
pink. op clear, mmm
neck: supple with jvp of 10 cm.
cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3
or s4.
lungs: no chest wall deformities, scoliosis or kyphosis. resp
were unlabored, no accessory muscle use. ctab, no crackles,
wheezes or rhonchi.
abdomen: soft, non-tender, non-distended
extremities: no c/c/e
rectal: normal tone, minimal black specks of stool, guaiac
positive



pertinent results:
osh lab data:
[**2180-3-29**]: wbc 5.8, hct 26.6, plt 153
na 135, k 4.6, cl 103, co2 25, bun 31, cr 1.0
pt 12.6, ptt 32.4, inr 1.14
troponin i  7.37, bnp 1340
.
labs on admission:
[**2180-3-29**] 08:45pm   glucose-103 urea n-30* creat-1.0 sodium-139
potassium-3.9 chloride-102 total co2-26 anion gap-15
[**2180-3-29**] 08:45pm   ck(cpk)-140
[**2180-3-29**] 08:45pm   ck-mb-16* mb indx-11.4* ctropnt-1.12*
[**2180-3-29**] 08:45pm   calcium-8.7 phosphate-5.1* magnesium-2.2
[**2180-3-29**] 08:45pm   wbc-4.9 rbc-3.22* hgb-9.7* hct-27.9* mcv-87
mch-30.1 mchc-34.8 rdw-16.4*
[**2180-3-29**] 08:45pm   neuts-61.9 lymphs-28.0 monos-7.5 eos-2.1
basos-0.5
[**2180-3-29**] 08:45pm   plt count-153
[**2180-3-29**] 08:45pm   pt-12.8 ptt-24.1 inr(pt)-1.1

ecg:  nsr, 1mm st depressions i, ii, v2-v5, <1mm std v6, 1mm st
elevation avr
.
cxr:
.
ct chest:
.

brief hospital course:
# nstemi:  ms. [**known lastname **] had diffuse ecg changes and troponin leak
in the setting of melena and ugib.  global ecg changes and
troponin leak were consistent with demand ischemia in the
setting of her ugib.  enzymes trended down and she remained
chest pain free during her hospitalization. initially we held
her asa, plavix, metoprolol, lasix in setting of bleed. she was
started on a statin given her history of severe cad and no
reported adverse events in her prior history with statins. as
her stent was placed >1 month ago and was bare metal the plavix
was stopped, not to be restarted. she was continued on 81mg
aspirin for stent restenosis. metoprolol was restarted prior to
discharge once her blood pressure was found to be stable and she
had no evidence of further bleeding.  she was taking lasix as an
outpatient for unclear reasons, thus this was not restarted.
the patient was instructed to follow up with her primary
cardiologist, dr. [**last name (stitle) 10543**], in [**hospital1 **] for evaluation of possible
diagnostic cardiac catheterization given her ischemic event in
the setting of a gi bleed.  at this follow up visit, she should
discuss the future need for lasix.

# ugib:  the patient has a history of gave syndrome per her
records from dr.[**name (ni) 49335**] office, her primary
gastroenterologist.  she presented to [**hospital3 **] with
melena.  at that time she has a hct of 26 which was down from 31
on her last admission in 12/[**2178**].  on transfer to [**hospital1 18**], 2 large
bore ivs were placed and she was started on her first unit of
prbcs.  at [**hospital1 18**], serial hcts were monitored and remained stable
after transfusion of 4 units of prbcs total. she was initially
on ppi iv bid and then switched to oral once daily (40mg). in
the meantime gi was consulted and said in the setting of no
acute bleeding, there was no need for emergent egd.  she should
follow up with her primary gastroenterologist for outpatient egd
in the next 2-4 weeks. prior to discharge she was restarted on
her iron and sucralfate.

# htn: initially held metoprolol, lasix in setting of bleed.
metoprolol was restarted prior to discharge, however lasix was
held given not clear reason for lasix use.  blood pressures were
well controlled on metoprolol only.

# hypothyroidism: continued levoxyl

# anxiety: held lorazepam at first but then restarted when
patient was started back on pos.

# decreased breath sounds on rll:  cxr was initially ordered to
evaluate this finding on physical exam.  a ct scan was
recommended for follow up.  ct scan showed pleural thickening on
the right, either indicative of fat or fluid however not
evidence of infection.  the patient never reported symptoms of
dyspnea or cough during her hospitalization.  a small 2mm
pulmonary nodule was noted on her ct scan.  as she has a long
history of tobacco abuse, it would be indicated to follow this
nodule as an outpatient.

# access: 2 large bore pivs
# prophylaxis: ppi as above, hold home colace
# code: full code, confirmed with patient
# comm: with patient, hct is daughter [**name (ni) **] [**name (ni) 110**] [**telephone/fax (1) 81673**]


medications on admission:
aspirin 81 mg daily (took this morning)
lorazepam 0.5 mg q8h prn
colace 100 mg po bid
levothyroxine 175 mcg daily
omeprazole 20 mg [**hospital1 **]
clopidogrel 75 mg daily (took this morning)
metoprolol tartrate 25 mg [**hospital1 **]
nitroglycerin 0.3 mg prn chest pain
lasix 40mg daily
kcl 20 meq p0 daily
hydromorphone 2mg (one) tab tid
sucralfate qid
ferrous sulfate daily

discharge medications:
1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable
po daily (daily).
disp:*30 tablet, chewable(s)* refills:*2*
2. lorazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a
day) as needed for foot cramps.
3. levothyroxine 175 mcg tablet sig: one (1) tablet po daily
(daily).
4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2
times a day).
5. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one
(1) tablet po once a day.
6. sucralfate 1 gram tablet sig: one (1) tablet po four times a
day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day.
8. atorvastatin 80 mg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*2*


discharge disposition:
home with service

facility:
[**hospital3 **] vna

discharge diagnosis:
primary diagnoses:
gave
upper gib
anemia
nstemi in the setting of ugib

secondary diagnoses:
cad


discharge condition:
the patient was afebrile and hemodynamically stable without
chest pain prior to discharge.


discharge instructions:
you were admitted to the hospital with chest pain. you had low
blood counts because you were bleeding from your stomach. this
caused you to have strain on your heart which caused your chest
pain. you were given a blood transfusion and the pain went away.
the gi doctors here [**name5 (ptitle) **] not feel that you need to have another
procedure to look at your stomach because you have had several
that have all showed the same thing.

medication changes:
these medications were discontinued, do not restart these
medications on discharge:
-  plavix
-  lasix
.
these medications were started, please take them as prescribed
on discharge:

-  atorvastatin 80mg daily
.
these medications were continued, please take them as
prescribed:
-  aspirin 81mg daily
-  iron
-  sucralfate
-  levothyroxine
-  lorazepam
-  omeprazole to 20mg two times daily
.
please come back to the hospital or call your primary care
physician if you have fainting or near-fainting, dizziness,
light-headedness, shortness of breath, chest pain, jaw pain, arm
pain, abdominal pain, nausea, blood in your stools, black tarry
stools, leg swelling, or any other concerning symptoms.

followup instructions:
please follow up with dr. [**last name (stitle) 10543**] in the next 2-4 weeks.

please follow up with dr. [**first name (stitle) 15532**] in [**2-2**] weeks to schedule
outpatient upper endoscopy.

please follow up with dr. [**last name (stitle) 1005**] in about 4 weeks. he will
check your liver tests to make sure you can take the high doses
of the statin we gave you.



completed by:[**2180-4-2**]"
234,"admission date:  [**2132-12-2**]              discharge date:   [**2132-12-12**]

date of birth:  [**2084-1-7**]             sex:   m

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
1. diagnostic laparoscopy with conversion to open roux-en-y
gastric bypass.
2. exploratory laparotomy.
3. placement of gastrostomy tube.
4. application of fibrin glue to gastro-j and jj.


history of present illness:
[**known firstname 108243**] has class iii morbid obesity, weight 349.8 pounds,
height 69.5 inches and bmi 50.9.  previous weight loss efforts
have included optifast, off-label prescription weight loss
medications fenfluramine/phentermine.  he has not tried any
popular weight loss diets or used over-the-counter
ephedra-containing appetite suppressants/herbal supplements.  he
does not remember what his weight at age 21 was but he is at his
highest weight currently. he has been struggling with weight
""all my life"".  factors contributing to excess weight include
large portions, grazing, late night eating, and too many
carbohydrates in saturated fats and lack of exercise regimen
until recently when he started elliptical and treadmill at a gym
3 times per week. he denied history of eating disorders but does
have eating issues stating that he always eats and is never
satisfied and even if he is full he will still eat.  he comments
that the more food he sees the more food he will eat.  he does
have depression with adhd on medication but no hospitalizations
for psychological issues.


past medical history:
pmh:
-hypertension
-type 2 diabetes hemoglobin a1c of 7.6%
-obstructive sleep apnea on bipap
-hyperlipidemia
-mild asthma
-vertigo
-fatty liver

psh:
-fistulotomy
-hemorrhoidectomy with rubber band ligation x 2, [**2125**].


social history:
he denied tobacco or recreational drug usage, no alcohol and has
occasional
caffeinated beverage.  he is disabled having been injured at
work with a head injury.  he is married living with his wife age
45 and they have two daughters ages 15 and 24 and a
granddaughter living with them.


family history:
family history is noted for stroke in his parents and history of
diabetes and obesity.  his brother and daughter both had
[**name (ni) 33554**] gastric bypass procedures done for morbid obesity at
the [**hospital 882**] hospital.

physical exam:
vital signs:  temperature 98.3, heart rate 86, blood pressure
119/70, respiratory rate 20, oxygen saturation 100% on room air
constitutional: no acute distress, anxious for discharge
neuro: alert and oriented to person, place and time
cardiac: regular rate and rhythm; no murmurs/ rubs/ gallops;
normal s1 s2
lungs: clear to auscultation, bilaterally; no wheezes/ rales/
rhonchi
abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding; g-tube to gravity; jp drain x 1 w/ serous fluid
wounds: abdominal midline incision without erythema or
induration
extremities: no cyanosis, clubbing, edema

pertinent results:
[**2132-12-2**] 07:00pm blood hct-41.6
[**2132-12-3**] 05:29am blood hct-40.9
[**2132-12-3**] 12:25pm blood wbc-13.7*# rbc-4.66 hgb-14.6 hct-43.4
mcv-93 mch-31.3 mchc-33.5 rdw-13.8 plt ct-201
[**2132-12-4**] 04:35am blood wbc-13.9* rbc-4.30* hgb-13.4* hct-39.9*
mcv-93 mch-31.1 mchc-33.5 rdw-13.8 plt ct-176
[**2132-12-3**] 12:25pm blood plt ct-201
[**2132-12-4**] 04:35am blood plt ct-176
[**2132-12-3**] 12:25pm blood glucose-243* urean-19 creat-1.2 na-141
k-4.2 cl-101 hco3-27 angap-17
[**2132-12-4**] 04:35am blood glucose-225* urean-16 creat-0.9 na-141
k-4.0 cl-104 hco3-27 angap-14
[**2132-12-4**] 04:35am blood calcium-9.0 phos-1.9* mg-1.8
[**2132-12-4**] 08:30am blood po2-235* pco2-48* ph-7.39 caltco2-30 base
xs-3
[**2132-12-4**] 08:30am blood glucose-237* lactate-1.4 na-141 k-4.1
cl-102 calhco3-28
[**2132-12-4**] 08:30am blood freeca-1.11*
[**2132-12-5**] 02:14am blood albumin-3.2* calcium-8.3* phos-2.1*
mg-1.9
[**2132-12-5**] 03:51am blood type-art po2-69* pco2-40 ph-7.44
caltco2-28 base xs-2
[**2132-12-5**] 02:14am blood albumin-3.2* calcium-8.3* phos-2.1*
mg-1.9
[**2132-12-5**] 02:14am blood alt-301* ast-107* ld(ldh)-236
ck(cpk)-[**2083**]* alkphos-41 amylase-22 totbili-2.5*
[**2132-12-5**] 08:24pm blood ck(cpk)-2110*
[**2132-12-5**] 02:14am blood pt-15.6* ptt-25.6 inr(pt)-1.4*
[**2132-12-5**] 02:14am blood plt ct-148*
[**2132-12-5**] 02:14am blood wbc-11.7* rbc-3.88* hgb-12.5* hct-35.8*
mcv-92 mch-32.1* mchc-34.9 rdw-13.8 plt ct-148*
[**2132-12-6**] 02:21am blood glucose-228* urean-16 creat-0.9 na-142
k-3.7 cl-109* hco3-23 angap-14
[**2132-12-6**] 07:28pm blood glucose-260* urean-17 creat-0.8 na-144
k-3.3 cl-111* hco3-24 angap-12
[**2132-12-5**] 02:14am blood albumin-3.2* calcium-8.3* phos-2.1*
mg-1.9
[**2132-12-6**] 02:21am blood albumin-3.2* calcium-8.5 phos-1.7* mg-1.8
[**2132-12-6**] 04:08am blood type-art po2-87 pco2-37 ph-7.45
caltco2-27 base xs-1
[**2132-12-6**] 10:32am blood type-art po2-60* pco2-37 ph-7.47*
caltco2-28 base xs-3
[**2132-12-6**] 07:53pm blood type-art po2-63* pco2-33* ph-7.49*
caltco2-26 base xs-2
[**2132-12-6**] 10:32am blood glucose-239* lactate-1.8 na-143 k-3.5
[**2132-12-6**] 04:08am blood freeca-1.11*
[**2132-12-6**] 10:32am blood freeca-1.15
[**2132-12-6**] 02:21am blood ctropnt-<0.01
[**2132-12-6**] 02:21am blood alt-230* ast-82* alkphos-48 totbili-2.0*
[**2132-12-6**] 02:21am blood plt ct-162
[**2132-12-6**] 02:21am blood wbc-11.8* rbc-3.95* hgb-12.6* hct-36.6*
mcv-93 mch-31.8 mchc-34.4 rdw-13.7 plt ct-162
[**2132-12-6**] 07:28pm blood glucose-260* urean-17 creat-0.8 na-144
k-3.3 cl-111* hco3-24 angap-12
[**2132-12-7**] 01:10am blood calcium-8.9 phos-2.2* mg-2.0
[**2132-12-7**] 01:10am blood alt-187* ast-70* alkphos-54 totbili-1.4
[**2132-12-7**] 01:10am blood plt ct-192
[**2132-12-7**] 01:10am blood wbc-11.2* rbc-4.00* hgb-12.6* hct-37.6*
mcv-94 mch-31.6 mchc-33.6 rdw-13.6 plt ct-192
[**2132-12-8**] 01:13am blood glucose-263* urean-16 creat-0.7 na-142
k-3.7 cl-108 hco3-25 angap-13
[**2132-12-8**] 01:13am blood calcium-8.8 phos-3.2 mg-1.8
[**2132-12-8**] 01:13am blood alt-144* ast-46* alkphos-55 totbili-1.0
[**2132-12-8**] 01:13am blood plt ct-208
[**2132-12-8**] 01:13am blood wbc-9.8 rbc-4.21* hgb-13.3* hct-39.8*
mcv-95 mch-31.5 mchc-33.3 rdw-13.9 plt ct-208
[**2132-12-9**] 02:37am blood glucose-122* urean-22* creat-0.9 na-144
k-3.4 cl-110* hco3-27 angap-10
[**2132-12-9**] 02:37am blood plt ct-228
[**2132-12-9**] 02:37am blood wbc-11.8* rbc-4.30* hgb-13.4* hct-40.5
mcv-94 mch-31.2 mchc-33.1 rdw-14.0 plt ct-228
[**2132-12-10**] 06:50am blood glucose-123* urean-24* creat-1.1 na-144
k-3.8 cl-108 hco3-30 angap-10
[**2132-12-10**] 06:50am blood calcium-8.4 phos-3.5 mg-1.9
[**2132-12-10**] 06:50am blood plt ct-220
[**2132-12-10**] 06:50am blood wbc-12.3* rbc-3.89* hgb-11.9* hct-37.0*
mcv-95 mch-30.5 mchc-32.1 rdw-14.1 plt ct-220

[**2132-12-3**] ugi sgl contrast w/ kub:
high density material within the jp drain, suggests extraluminal
leak. no
definite leak is visualized, though there is a possible linear
focus of
extraluminal contrast near the gastrojejunostomy. no holdup or
stenosis

[**2132-12-4**] chest (portable ap)
impression:
1. mediastinal and hilar venous engorgement.
2. retrocardiac atelectasis with possible small bilateral
pleural effusions.

[**2132-12-5**] chest (portable ap)
impression:
no pulmonary edema


brief hospital course:
the patient presented to pre-op on [**2132-12-2**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic gastric banding. the patient was difficult to
intubate due to thickened neck circumference.  also, there was
difficulty placing the [**last name (un) **]-gastric tube into the stomach,
therefore, an open roux-en-y gastric bypass was performed.
otherwise, there were no adverse events in the operating room;
please see the operative note for details. pt was extubated,
taken to the pacu until stable, then transferred to the [**hospital1 **] for
observation.

on hospital day #1 an ugi was performed, which showed high
density material within the jp drain, suggestive of an
intraluminal leak.  given the results of the study, the patient
was monitored closely with [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube to low,
intermittent suction, a jp drain to bulb suction, and strictly
nothing by mouth.  the patient remained clinically stable
without abdominal exam changes throughout the day, however,
overnight the patient became persistently tachycardic to the
120s.  therefore, the decision was made to return to the
operating room for exploratory surgical intervention.

on post-operative day #2, the patient underwent an exploratory
laparotomy, placement of a gastrostomy tube and application of
fibrin glue to the gastro-jejunostomy and j-j anastomosis.
intra-operatively, no leak was identified.  there were no
adverse events in the operating room; please see operative note
for details.  the patient remained intubated, was brought to the
pacu until stable, then transferred to the surgical intensive
care unit for close observation.

neuro: the patient was alert and oriented throughout his
hospitalization except for brief period of visual hallucinations
which he experienced in the intensive care unit.  the
hallucinations, which were treated with intravenous haldol,
resolved without further occurrence; pain was initially managed
with a morphine pca, which required an increase in dosing on
post-operative day #1 due incisional abdominal pain.  in the
intensive care unit, the patient was managed briefly with
intravenous morphine, which was transition ed to rectal and then
oral tylenol, with well-controlled pain.

cv: on post-operative day #1 the patient remained stable from a
cardiovascular standpoint, however, overnight the patient became
persistently tachycardic as described above.  post-operatively,
in the intensive care unit, the patient became hypertensive to
the 170-180s.  he was initially managed with intravenous
metoprolol and hydralazine.  labetalol was trialed, but he
eventually required a nicardipine drip.  on post-operative day
#6/ #4, intravenous enalapril was added to the regimen as
nicardipine was weaned.  the patient was subsequently managed
successfully with intravenous metoprolol and enalapril until he
resumed an oral diet.  oral medication management included
losartan and amlodipine at the suggestion of his primary care
provider who will see him next week.

pulmonary: the patient self-extubated in the intensive care unit
on post-operative day #3/#1 and was maintained on cpap.  he
developed a brief period of respiratory distress which resolved
once the cpap mask was adjusted for his [**last name (un) **]-gastric tube.
arterial blood gasses were within acceptable limits at this
time.  on the floor, the patient was weaned from oxygen and
maintained on cpap at night due to known obstructive sleep
apnea.  he subsequently remained stable from a pulmonary
standpoint.  good pulmonary toilet, and incentive spirometry
were encouraged

gi/gu/fen: on post-operative day #1 the patient was npo, given
intravenous fluids and had [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube in place for
decompression of his gastric pouch. following his ugi study
described above, the patient was kept strictly npo with a
[**last name (un) **]-gastric tube maintained to low, intermittent wall suction.
the jp drain was maintained on bulb suction. serial abdominal
exams were performed every 2-3 hours until the patient returned
to the operating room.  upon return to the operating room, a
g-tube was placed which remained to gravity throughout the
remainder of his hospitalization.  total parenteral nutrition
was initiated in the intensive care unit and continued until the
patient was tolerating a stage 3 diet on post-operative day
#10/#8.  the patient tolerated an oral diet well.  patient's
intake and output were closely monitored with adjustments made
to the intravenous fluids as needed.  electrolytes were
monitored and repleted as needed routinely.  the patient's foley
catheter was discontinued on post-operative day #8/#6  without
subsequent issues with voiding. on day of discharge, one of the
two jp drains was pulled and the central line was discontinued.

id: on post-operative day #1 the patient remained afebrile with
a stable white blood cell count.  on post-operative day #2,
while in the pacu, the patient spiked a temperature.  pan
culture was performed with negative results.  intravenous
ciprofloxacin and metronidazole were initiated and continued
through post-operative day #9/#7.  the patient remained afebrile
without signs and symptoms of infection throughout the remainder
of his hospital course.

heme: the patient's hematocrit level was monitored routinely
without signs of bleeding.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.




medications on admission:
hydrochlorothiazide 12.5 mg daily
avapro 150 mg daily
lantus insulin 70 units twice daily
actos 45 mg daily
metformin 1000 mg twice daily
simvastatin 10 mg daily
baby aspirin 81 mg daily
modafinil 200 mg twice a day
strattera 60 mg daily for adhd
flintstones complete multivitamins daily
vitamin d [**2122**] units


discharge medications:
1. simvastatin 10 mg tablet sig: one (1) tablet po daily
(daily): please crush.
2. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times
a day).
disp:*60 capsule(s)* refills:*2*
3. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po bid (2
times a day) for 1 months.
disp:*600 ml* refills:*0*
4. multivitamin,tx-minerals     tablet sig: one (1) tablet po
daily (daily): please crush.
5. losartan 50 mg tablet sig: two (2) tablet po bid (2 times a
day): please crush.
disp:*120 tablet(s)* refills:*2*
6. vitamin d 2,000 unit capsule sig: one (1) capsule po once a
day.
7. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily):
please crush.
disp:*30 tablet(s)* refills:*2*
8. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a
day): please crush.
disp:*60 tablet(s)* refills:*2*


discharge disposition:
home with service

facility:
care group

discharge diagnosis:
1. obesity, body mass index of 51.
2. obstructive sleep apnea.
3. type 2 diabetes.
4. hypertension.
5. metabolic x syndrome
6. tachycardia, etiology unknown.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance
diet, do not drink out of a straw or chew gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-7**] pounds for 6 weeks. you may
resume moderate
exercise at your discretion, no abdominal exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
an appointment with your dr. [**last name (stitle) 1699**] has been scheduled for
[**2132-12-17**] at 3 pm.  it is imperative that you keep this
appointment.

provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2132-12-17**] 11:45
provider: [**first name4 (namepattern1) **] [**last name (namepattern1) 8021**], rd,ldn phone:[**telephone/fax (1) 305**]
date/time:[**2132-12-17**] 12:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2132-12-24**] 11:00



completed by:[**2132-12-12**]"
235,"admission date:  [**2130-4-26**]              discharge date:   [**2130-5-3**]

date of birth:  [**2048-7-7**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 3223**]
chief complaint:
incarcerated right inguinal hernia
left lower extremity cellulitis


major surgical or invasive procedure:
[**2130-4-26**]: right inguinal herniorraphy with mesh


history of present illness:
81m with right inguinal hernia with non-reducible bulge since
noon today.  pain in right groin since then. noted some
discomfort as early as this morning. has had some nausea
throughout day as well.  no vomiting or other abdominal pain.
has not noted a hernia before.  additionally left leg has been
red for a couple of weeks; has been using cream and has not seen
a physician for it.  did not notice that it was swolen.


past medical history:
past medical history: hearing impaired (fluent with sign
language), chronic 1st degree heart block, recurrent atrial
fibrillation/ atrial flutter, s/p dccv [**2120-1-24**], s/p dccv
[**2121-8-8**], bradycardia, elevated psa, htn, hyperlipidemia, m.r.,
basal cell ca s/p excision

past surgical history: none


social history:
lives alone. works for [**company 2318**], independent in adls. no tobacco,
rare etoh.


family history:
mother breast cancer, leg cancer, stomach cancer. father cva.
brother w/ cabg at 64yrs.


physical exam:
on admission:
vitals:97.2 95 182/91 16 100%
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: rrr, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds. right groin with palpable
non-reducible
large hernia, hernia contents extending into scrotum as well,
ttp.
dre: normal tone, no gross or occult blood
ext: no le edema, le warm and well perfused


pertinent results:
[**2130-4-29**]
labs: 05:30am blood wbc-10.0 rbc-3.50* hgb-10.9* hct-33.3*
mcv-95 mch-31.3 mchc-32.8 rdw-14.9 plt ct-197 glucose-93
urean-22* creat-0.6 na-140 k-3.7 cl-105 hco3-27 angap-12
[**2130-4-29**] 05:30am blood calcium-8.5 phos-2.4* mg-2.0

[**2130-4-28**]:
chest (portable ap):
severe bilateral opacities appear to be unchanged with no change
in the element of pulmonary edema. cardiomegaly is severe. known
pericardial effusion is most likely present. consolidations in
the left lower lobe are slightly asymmetric and might represent
superimposed abnormality such as infectious process, please
correlate clinically.

[**2130-4-27**]:
echo: impression: mildly depressed left ventricular systolic
function. moderately dilated right ventricle. focal asymetric
hypertrophy of the basal antero-septum. heavily calcified aortic
valve. moderate amount of pericardial effusion with no evidence
of tamponade physiology.

ecg: atrial fibrillation with rapid ventricular response and
probable ventricular premature beats. slight intraventricular
conduction delay may be incomplete left bundle-branch block.
delayed r wave progression may be due to intraventricular
conduction delay, left ventricular hypertrophy or possible prior
septal myocardial infarction, although is non-diagnostic. st-t
wave abnormalities are non-specific but cannot exclude
myocardial ischemia. clinical correlation is suggested. since
the previous tracing of [**2130-4-26**] the rate is faster and lateral
lead st-t wave changes appear more prominent.

chest (portable ap): findings: as compared to the previous
radiograph, there is unchanged massive cardiomegaly. in
addition, there is evidence of mild to moderate pulmonary edema.
presence of co-existing pneumonia cannot be excluded. no
pneumothorax.

bilat lower ext veins port: impression: no dvt in the right or
left lower extremity.

labs: 04:10am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-30*
11:02am blood ck-mb-4 ctropnt-<0.01 blood ck(cpk)-31* 06:33pm
blood ck-mb-4 ctropnt-<0.01 ck(cpk)-33*

[**2130-4-26**]:
ecg: atrial fibrillation. slight intraventricular conduction
delay may be incomplete left bundle-branch block. delayed r wave
progression with late precordial qrs transition may be due to
intraventricular conduction delay, left ventricular hypertrophy
or possible prior anterior wall myocardial infarction, although
is non-diagnostic. st-t wave abnormalities are non-specific.
since the previous tracing of [**2130-3-28**] the ventricular rate is
faster and the qtc interval is shorter.

labs: 05:50pm blood wbc-11.5* rbc-4.17* hgb-13.2* hct-39.1*
mcv-94 mch-31.6 mchc-33.7 rdw-15.1 plt ct-172 pt-13.9* ptt-27.1
inr(pt)-1.2* glucose-114* urean-19 creat-0.7 na-135 k-3.4 cl-98
hco3-27 angap-13 glucose-111* lactate-1.8 k-3.6 [**2130-4-26**] 05:50pm
blood ctropnt-<0.01


brief hospital course:
the patient presented to the emergency department on [**2130-4-26**] due to a non-reducible right groin bulge with associated
pain and nausea.  additionally, the patient reported left leg
erythema which had been present for a few weeks without fevers.
given physical findings consistent with incarcerated hernia, the
patient was taken to the operating room where he underwent a
laparoscopic right inguinal hernia repair with mesh. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

shortly following transfer to the general surgical [**hospital1 **], the
patient was triggered for lethargy, hypoxia and atrial
fibrillation with rapid ventricular response.  intravenous
metoprolol and lasix were administered and the patient was
maintained on a non-rebreather with improved oxygenation.  he
was subsequently transferred to the trauma intensive care unit
for further management.

neuro: the patient was somnolent post-operatively, which was
deemed post-operative baseline by the als interpreter, who
reportedely knew patient well.  the somnolence resolved by pod1
and he remained alert and oriented throughout the remainder of
his hospitalization.  the patient is deaf at baseline and was
able to communicate via an als interpreter.  pain was well
controlled with oral tylenol and intermittent intravenous
hydromorphone.
cv: the patient has baseline rate controlled atrial fibrillation
on warfarin.    however, as described above, he developed a fib
with rvr on pod 0, which responsed to intravenous metoprolol
without recurrence.  additionally, an ekg obtained upon transfer
to the icu revealed st changes; cycled cardiac enzymes were
negative.  an echocardiogram was obtained and revealed mildly
depressed left ventricular systolic function, a moderately
dilated right ventricle, focal asymetric hypertrophy of the
basal antero-septum, heavily calcified aortic valve and a
moderate amount of pericardial effusion with no evidence of
tamponade physiology.  his home medication regimen was resumed
and the patient remained stable from a cardiovascular standpoint
for the remainder of his hospitalization; vital signs were
routinely monitored.
pulmonary: as described above, the patient experienced an
episode of hypoxia on pod 0, likely due to pulmonary edema.
intravenous lasix was administered with immediate effect.  upon
arrival to the icu, the patient was placed on bipap, which was
weaned to nasal cannula on pod 1.  the patient remained stable
from a pulmonary standpoint for the remainder of his
hospitalization and was weaned off supplemental oxygen entirely
on pod 3. good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization.
gi/gu/fen: the diet was advanced to regular on pod 1, which was
well tolerated.   patient's intake and output were closely
monitored; electrolytes were repleted routinely.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.  the left lower extremity
cellulitis improved on intravenous cefazolin and treatment was
transitioned to oral antibiotics on pod 4, which will continue
for an additional seven days.
skin: a deep tissue injury to the sacrum was identified while in
the icu.  aggressive skin care was provided via nursing without
evidence of further skin breakdown.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to
ambulate early and often.  additionally, given the events of
pod0, a lower extremity ultrasound was obtained and was negative
for a dvt.
rehab: the patient received physical therapy while hospitalized
due to deconditioning, but was deemed unsuitable for discharge
to home.  short term rehabilitation was recommended to maximize
independence and regain conditioning and independence.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating with a walker and physical therapy, voiding
without assistance, and pain was well controlled.  the patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
he will be discharged to a rehab facility for additional
physical therapy.


medications on admission:
atenolol 25mg daily
finasteride 5mg daily
simvastatin 20mg daily
verapamil er 240mg daily
coumadin 1mg daily
vitamin d2 1,000 units daily
vitamin e 400 units daily

discharge medications:
1. verapamil 240 mg tablet extended release sig: one (1) tablet
extended release po q24h (every 24 hours).
2. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every
8 hours).
3. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm.
4. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five
(5) ml po q6h (every 6 hours) as needed for cough.
5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day): hold for loose stool.
6. finasteride 5 mg tablet sig: one (1) tablet po daily (daily).

7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
8. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
9. bisacodyl 10 mg suppository sig: one (1) suppository rectal
hs (at bedtime) as needed for constipation.
10. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).

11. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
12. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every
6 hours) for 7 days.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - [**location (un) 550**]

discharge diagnosis:
incarcerated right inguinal hernia
left lower extremity cellulitis


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 an incarcerated right
inguinal hernia and subsequently underwent surgical repair with
mesh.  additionally, you were noted to have cellulitis on the
lower aspect of your left leg, which was treated with
antibiotics.  during your stay, you also received treatment from
a physical therapist, who recommended discharge to a
rehabiliation facility to furhter improve your conditioning and
independence.  you are now preparing for disharge to a
rehabiliation facility with the following instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**4-18**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service at [**telephone/fax (1) 600**] to make a
follow-up appointment within 2 weeks.
please contact your primary care provider to make [**name initial (pre) **] follow-up
appointment within 1 week from discharge from the rehabilitation
facility.
provider: [**first name11 (name pattern1) 5445**] [**initial (namepattern1) **] [**last name (namepattern4) 5446**], dpm phone:[**telephone/fax (1) 543**]
date/time:[**2130-5-22**] 3:50
provider: [**first name8 (namepattern2) 6118**] [**last name (namepattern1) 6119**], rn,ms,[**md number(3) 1240**]:[**telephone/fax (1) 1971**]
date/time:[**2130-6-16**] 10:00


                             [**first name11 (name pattern1) **] [**last name (namepattern4) 520**] md, [**md number(3) 3226**]

completed by:[**2130-5-3**]"
236,"admission date:  [**2133-5-18**]              discharge date:   [**2133-6-1**]

date of birth:  [**2107-3-17**]             sex:   f

service: surgery

allergies:
penicillins / shellfish

attending:[**first name3 (lf) 301**]
chief complaint:
1. obesity with body mass index of 52.
2. fatty liver.
3. gallstones.
4. sleep apnea.
5. gastroesophageal reflux.
6. polycystic ovary syndrome.


major surgical or invasive procedure:
1.laparoscopic cholecystectomy converted to open; open roux-en-y
gastric bypass.

2.exploratory laparotomy for removal of foreign body.


history of present illness:
[**known firstname 4890**] has class iii morbid obesity with weight of 303.7 pounds
as of [**2133-4-29**] with her initial screen weight on [**2133-4-7**] as 304.6
pounds, height 64 inches and bmi of 52.1.  her previous weight
loss efforts have included 3 months of prescription weight loss
medication orlistat (xenical) in [**2131**] losing 10 pounds that she
gained back in two months, 4 months of slim-fast in [**2131**] without
results and she also took over-the-counter herbal preparation
green tea for weight loss in [**2132**] but achieved no results.  she
has not taken over-the-counter ephedra-containing appetite
suppressants.  her weight at age 21 was 260 pounds her lowest
adult weight with her highest weight being 307.8 pounds on
[**2133-4-21**].  she weighed 220 pounds one year ago.  she states she
developed a significant weight problems since her teenage years
and cites as factors contributing to her excess weight genetics,
late night eating, large portions, too many carbohydrates in
saturated fats as well as lack of exercise.  she denies history
of eating disorders or depression.  she has not been seen by a
therapist nor has she been hospitalized for mental health issues
and she is not on any psychotropic medications.


past medical history:
gastroesophageal reflux, hyperlipidemia with elevated
triglycerides, obstructive sleep apnea testing use cpap, vitamin
d deficiency, polycystic ovary syndrome, fatty liver and
cholelithiasis

social history:
she has been smoking two cigarettes a day for 6 years and quit
one month ago and has been using chantix for smoking cessation.
she denied recreational
drug usage and has alcoholic beverage on rare occasion, does
drink both caffeinated and carbonated beverages. she is a
student at [**location (un) 6188**]
community college studying hospitality.  she is single and has
no children.  she lives with her sister at age 34 and 3 nieces.


family history:
father living age 54 with obesity and sister living age 27 with
asthma.

physical exam:
vitals on discharge: temp-97.8 bp-120/77 p-104 rr-20 o2 100%
room air

constitutional: no acute distress; comfortable appearing
neuro: alert and oriented to person, place and time
cardiac: regular, rate and rhythm, nl s1,s2
lungs: cta bilaterally, no respiratory distress
abd: soft, nd, + peri-incisional tenderness, no rebound
tenderness/ guarding
wounds: abdominal midline incision superior aspect intact.
inferior aspect open: wound bed- 100% red granulation tissue,
drainage- serosanguinous, periwound edges- no erythema, no
edema.
ext: no edema

pertinent results:
laboratory results:
[**2133-5-18**] 06:32pm blood hct-33.6*
[**2133-5-19**] 09:05am blood wbc-12.4* rbc-4.34 hgb-11.8* hct-34.3*
mcv-79* mch-27.2 mchc-34.5 rdw-15.0 plt ct-338 neuts-88.7*
lymphs-6.9* monos-4.2 eos-0.1 baso-0.1 glucose-125* urean-7
creat-0.7 na-139 k-4.1 cl-105 hco3-27 angap-11 alt-141* ast-122*
alkphos-44 amylase-27 totbili-0.9 albumin-3.5 calcium-8.3*
phos-2.7 mg-1.5*
[**2133-5-19**] 08:00pm blood type-art po2-74* pco2-46* ph-7.40
caltco2-30 base xs-2
[**2133-5-20**] 03:30am blood wbc-13.0* rbc-3.81* hgb-10.5* hct-30.2*
mcv-79* mch-27.5 mchc-34.7 rdw-14.9 plt ct-329 glucose-105*
urean-6 creat-0.7 na-137 k-4.1 cl-103 hco3-29 angap-9 alt-119*
ast-103* alkphos-41 amylase-23 [**2133-5-20**] 02:06pm blood
calcium-8.6 phos-1.8* mg-1.9
[**2133-5-20**] 03:09pm blood type-art rates-/20 peep-5 po2-81*
pco2-54* ph-7.38 caltco2-33* base xs-4 intubat-not intuba
[**2133-5-21**] 01:59am blood wbc-11.5* rbc-3.50* hgb-9.7* hct-28.4*
mcv-81* mch-27.7 mchc-34.2 rdw-14.8 plt ct-298 glucose-78
urean-7 creat-0.6 na-139 k-3.8 cl-100 hco3-31 angap-12
calcium-7.9* phos-2.6* mg-1.9
[**2133-5-22**] 01:46am blood wbc-11.4* rbc-3.40* hgb-9.4* hct-27.1*
mcv-80* mch-27.8 mchc-34.8 rdw-15.0 plt ct-347 glucose-81
urean-6 creat-0.5 na-134 k-3.5 cl-95* hco3-28 angap-15
calcium-8.2* phos-2.5* mg-1.8
[**2133-5-23**] 06:40am blood wbc-13.7* rbc-3.49* hgb-9.7* hct-28.2*
mcv-81* mch-27.9 mchc-34.5 rdw-14.8 plt ct-365

[**2133-5-19**] chest (portable ap):
impression: findings concerning for retained sponge within the
right upper quadrant of the abdomen

[**2133-5-19**] abdomen (supine & erect):
impression: apparent interval removal of a retained sponge

[**2133-5-20**] chest (portable ap):
the lung volumes are low. the heart size is top normal, probably
exaggerated  by the presence of low lung volumes and portable
character of the study. there is a right perihilar opacity that
might represent infectious process or may be a combination of
infection and asymmetric pulmonary edema. left lung demonstrates
mild interstitial pulmonary edema. bilateral pleural effusions
cannot be excluded. no appreciable pneumothorax is seen.

[**2133-5-20**] cta chest w&w/o c&recon:
impression:
1. no evidence of pulmonary emboli. bilateral moderate
atelectasis.
2. no evidence of intra-abdominal fluid collection with close
attention paid to the region of the hepatic fossa of the
gallbladder as well as at the jejunostomy and gastrojejunostomy
site.

[**2133-5-21**] chest (portable ap):
impression:
1. stable bibasilar atelectasis and right upper lung zone linear
atelectasis.
2. no focal consolidation, pneumothorax or pulmonary edema.

[**2133-5-23**] chest (pa & lat):
impression:
findings concerning for developing pneumonia and possibly mild
fluid overload.

[**2133-5-24**] abdomen (supine & erect):
air in the colon and scattered small bowel segments, nonspecific
bowel gas pattern. no frank obstruction.no radiopaque foreign
body is identified.
clips are present in the right upper quadrant.

[**2133-5-24**] chest (pa & lat):
impression: developing pneumonia.

[**2133-5-25**] [**last name (un) **] dup extext bil (map/dvt): no evidence of deep vein
thrombosis either right or left lower extremity

microbilogy results:
[**2133-5-20**] urine culture (final [**2133-5-22**]): escherichia
coli.>100,000 org/ml
[**2133-5-20**] blood culture, routine (final [**2133-5-26**]): no growth.
[**2133-5-20**] mrsa screen (final [**2133-5-23**]):    no mrsa isolated.
[**2133-5-24**] blood culture:
[**2133-5-24**] urine culture: no growth
[**2133-5-26**] sputum gram stain (final [**2133-5-26**]): [**12-1**] pmns and >10
epithelial cells/100x field. gram stain indicates extensive
contamination with upper respiratory secretions. bacterial
culture results are invalid.
[**2133-5-26**] abdominal wound: no growth


brief hospital course:
pt was evaluated by anaesthesia and taken to the operating room
for laparoscopoic converted to open cholecystectomy and
roux-en-y gastric bypass. there were no adverse events in the
operating room; please see the operative note for details.
pt was extubated, taken to the pacu until stable, then
transferred to the [**hospital1 **] for observation.

pod 0 ([**2133-5-18**]): the patient was tachycardic (hr 120-130's)and
was given a bolus of 1 litre of intravenous fluids.

pod 1 ([**2133-5-19**]): the patient continued to be tachycardic during
the early morning hours. she was afebrile and had no pain. she
was scheduled for an urgent ugi of the abdomen to rule out any
leak. an abdominal film done at this time showed evidence of a
retained foreign body possibly a sponge in the right upper
quadrant of the abdomen.
she was then taken to the or for an emergent exploratory
laparotomy to remove the sponge. please see the operative note
for details. she was not extubated and transferred to the pacu
where she was extubated after a few hours. she was kept on bipap
overnight on which she stayed very stable.

pod 2 ([**2133-5-20**]): she was transferred to the trauma icu where
she had a brief episode of desaturation to 80% on 4 l of o2. she
was tachycardic and hemodynamically stable through out this
period. a ct angiogram of the chest was performed and ruled out
any pulmonary embolism. she required  15 l of o2/min during the
day and this was further weaned down to 10 l/min overnight. her
diet was advanced to stage 1 which was tolerated very well. she
also recieved intravenous lasix 20 mg twice since she was
thought to be fluid overloaded.

pod 3 ([**2133-5-21**]): she continued to do well on the 10l/min  of o2
which was further weaned down to 4l/min. she had a fever spike
to 102 f when she was pan cultured. her urine culture grew
e.coli and she was then started on ciprofloxacin. she recieved a
few hous of cpap overnight.

pod 4 ([**2133-5-22**]): she was transferred to the floor and her diet
was advanced to stage ii. this was tolerated well.

pod 5 ([**2133-5-23**]): diet was advanced to stage iii which was
tolerated well. there was an increase in the wbc count from 11.4
to 13.7. a chest x-ray was done given her persistent o2
requirement, which was concerning for a possible developing
pneumonia.

pod 6 ([**2133-5-24**]): she had a fever spike to 101.9f when she was
pan cultured again. a chest x-ray was done that showed
developing pneumonia. also there was an increase in the wbc
count noted.

pod 7 ([**2133-5-25**]): she did well during the day except for being
tachycardic to 130's & occasionally 140's with activity. she
stayed completely asymptomatic throught this period. in view of
her rising white count and recent chest x-ray, intavenous
vancomycin and cefepime were started empirically.

pod 8([**2133-5-26**]): the lower part of abdominal wound appeared
erythematous and was hence opened. wound swabs were sent for
gram stain & culture. the gram stain did not show any organisms.
she had a fever spike to 101.7f during the day. otherwise, she
conitnued to do well on stage iii. her tachycardia was better
than the day before and her hr stayed in the 120's and
occasionally in 130's with activity.

pod 9([**2133-5-27**]): the jp was removed and an infectious disease
consult was sought. a repeat chest x-ray was done and blood and
urine cultures were sent following their recommendations. she
stayed afebrile through out the day.

pod 10 ([**2133-5-28**]): the abdominal wound was examined and a wound
vac dressing was placed. her white cell count was down from 14.7
to 11.7.

pod 11 ([**2133-5-29**]): she remained afebrile with continued
intravenous antibiotics; a wound vac remained in place; her
tachycardia had resolved and vital signs remained stable.

pod 12 ([**2133-5-30**]): no new events

pod 13 ([**2133-5-31**]): no new events

pod 14 ([**2133-6-1**]): antibiotics were discontinued with completion
of a 7 day course.  the vac was removed and the wound was
dressed with dry, sterile gauze. the patient's sister was given
instruction and demonstrated efficiency in performing the
dressing changes.  the patient did not have a cpap machine at
home, therefore, it was arranged to have one delivered to her
home.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.  a cpap machine will be
delivered to her home with mask fitting and instruction for
machine operation.


medications on admission:
omeprazole 20mg od, mvi 1 tab od, vitd 5000u od

discharge medications:
1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po bid (2
times a day) as needed for constipation for 10 days.
disp:*200 ml* refills:*0*
2. oxycodone 5 mg/5 ml solution sig: one (1)  po every 4-6 hours
as needed for pain for 10 days: please do not drive or operate
heavy machinery while taking this medication.
disp:*100 ml* refills:*0*
3. multivitamin,tx-minerals     tablet sig: one (1) tablet po
bid (2 times a day): chewable.
4. vitamin d 5,000 unit tablet sig: one (1) tablet po once a
day: please crush.
5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day: open capsule; do
not chew beads.


discharge disposition:
home with service

facility:
caregroup vna

discharge diagnosis:
1. obesity with body mass index of 52.
2. fatty liver.
3. gallstones.
4. sleep apnea.
5. gastroesophageal reflux.
6. polycystic ovary syndrome.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-21**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
please perform dressing changes with dry, sterile gauze twice
daily as instructed or more frequently as needed.  please
contact dr. [**last name (stitle) 15645**] office if you have increased drainage from
the wound requiring more frequent changes.  also, please call
dr. [**last name (stitle) **] if you develop redness surrounding the wound and/ or
fevers greater than 101f.


followup instructions:
provider: [**first name8 (namepattern2) **] [**doctor last name **], rd,ldn phone:[**telephone/fax (1) 305**]
date/time:[**2133-6-3**] 11:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 304**], md phone:[**telephone/fax (1) 305**]
date/time:[**2133-6-3**] 12:00



completed by:[**2133-6-8**]"
237,"admission date:  [**2101-10-4**]              discharge date:   [**2101-10-12**]

date of birth:  [**2049-10-8**]             sex:   f

service: surgery

allergies:
motrin / erythromycin base

attending:[**first name3 (lf) 3200**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2101-10-4**]:
1. laparoscopic sleeve gastrectomy and concomitant laparoscopic
cholecystectomy.

[**2101-10-7**]:
1. exploratory laparoscopy converted to laparotomy.
2. abdominal washout.
3. oversewing of the gastric sleeve staple line.
4. evacuation of clot.
5. liver biopsy.


history of present illness:
[**known firstname **] has class iii morbid obesity with a weight of 344 pounds as
of [**2101-6-27**] with her initial screen weight 340 pounds on [**2101-5-31**],
height 66 inches and bmi of 55.5.  her previous weight loss
efforts have included weight watchers x 36 months [**2098**]-present
losing 50 pounds, the [**doctor last name 1729**] diet in [**2096**] for 6 months losing 24
pounds, slim-fast x 12 months and [**2094**] losing [**street address(1) 91840**]
visits x 4 as well as pcp counseling since [**2084**].  she is also
undergoing behavioral therapy for past 36 months.  she has not
taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements.  she stated that her weight at age 21 was 250
pounds her lowest adult weight and her highest weight was 384
pounds in [**2097-6-23**].  she has had weight issues since age 14
shortly before she was diagnosed with polycystic ovary syndrome
and when she graduated from high school she weighed 350 pounds.
she subsequently lost 100 pounds and had maintained the loss for
the following 15 years.  in [**2091**] she was diagnosed with lupus
and was
placed on high doses of prednisone and gained 180 pounds over
the course of 5 years.  factors contributing to her excess
weight include grazing a large portions, some refined
carbohydrates and saturated fats as well as stressful and
emotional eating.  her current exercise routine is one hour
twice per week of aqua-aerobics, one hour of personal training
in a pool and one hour of personal training in the gym with
resistance training and weights.  she attributes difficulty with
exercise because of her large pannus and impedance of her
mobility.  she denied history of eating disorders and does have
depression/anxiety, is followed by a therapist working on weight
issues, has not been hospitalized for mental health issues and
she is on psychotropic
medication that she does find useful (zoloft).


past medical history:
past medical history:  her medical history is significant for,
1.  polycystic ovarian syndrome.
2.  rheumatoid arthritis.
3.  discoid lupus.
4.  diabetes mellitus.
5.  depression.
6.  obstructive sleep apnea.
7.  cpap.

past surgical history:  the patient denies any significant
surgical history.


social history:
she used to smoke two packs of cigarettes daily for 20 years but
quit in [**2084**], denies recreational drug usage, no alcohol and
does consume caffeinated beverages.  she works as an underwriter
and is married living with her husband age 65 retired and her
stepson aged 24.


family history:
her family history is noted for mother living at age 70 with
diabetes and obesity; paternal grandmother deceased age 78 with
heart disease, hyperlipidemia, stroke and arthritis; maternal
grandmother deceased age 62 of
cancer.

physical exam:
vs:

constitutional: nad
neuro: alert and oriented x 3
cardiac: rrr, nl s1,s2
lungs: cta b
abd:
wounds:
ext:

pertinent results:
[**2101-10-10**] 04:57am blood wbc-9.5 rbc-3.21* hgb-9.7* hct-30.0*
mcv-93 mch-30.3 mchc-32.5 rdw-14.0 plt ct-294
[**2101-10-9**] 03:35pm blood wbc-8.9 rbc-3.22* hgb-9.7* hct-30.6*
mcv-95 mch-30.1 mchc-31.8 rdw-14.0 plt ct-292
[**2101-10-9**] 02:37am blood wbc-8.7 rbc-2.99* hgb-8.9* hct-28.0*
mcv-94 mch-29.7 mchc-31.7 rdw-14.2 plt ct-281
[**2101-10-8**] 02:58pm blood hct-28.8*
[**2101-10-8**] 09:27am blood hct-29.4*
[**2101-10-8**] 01:19am blood wbc-8.2 rbc-3.10* hgb-9.3* hct-28.7*
mcv-92 mch-30.1 mchc-32.5 rdw-14.3 plt ct-267
[**2101-10-7**] 03:30pm blood wbc-12.0* rbc-3.33* hgb-10.2* hct-30.5*
mcv-92 mch-30.7 mchc-33.5 rdw-14.5 plt ct-264
[**2101-10-7**] 12:15pm blood wbc-10.4 rbc-3.27* hgb-10.0* hct-30.4*
mcv-93 mch-30.5 mchc-32.8 rdw-14.3 plt ct-280
[**2101-10-7**] 06:40am blood hct-25.1*
[**2101-10-6**] 11:16pm blood hct-28.3*
[**2101-10-6**] 04:00pm blood wbc-9.8# rbc-3.02*# hgb-9.0*# hct-27.5*
mcv-91 mch-29.9 mchc-32.9 rdw-14.6 plt ct-249
[**2101-10-6**] 10:35am blood hct-28.3*
[**2101-10-5**] 05:27pm blood hct-29.7*
[**2101-10-4**] 10:10pm blood hct-30.5*
[**2101-10-4**] 05:58pm blood hct-31.1*
[**2101-10-4**] 02:44pm blood hct-34.9*
[**2101-10-7**] 12:15pm blood fibrino-657*
[**2101-10-9**] 02:37am blood glucose-132* urean-4* creat-0.5 na-143
k-3.5 cl-108 hco3-29 angap-10
[**2101-10-8**] 01:19am blood glucose-153* urean-6 creat-0.5 na-145
k-3.7 cl-110* hco3-31 angap-8
[**2101-10-7**] 03:30pm blood glucose-174* urean-8 creat-0.6 na-142
k-3.7 cl-107 hco3-26 angap-13
[**2101-10-5**] 05:27pm blood glucose-136* urean-8 creat-0.8 na-145
k-4.2 cl-107 hco3-28 angap-14
[**2101-10-9**] 02:37am blood calcium-7.8* phos-3.2 mg-1.7
[**2101-10-8**] 01:19am blood calcium-7.7* phos-2.6* mg-2.0
[**2101-10-7**] 03:30pm blood calcium-7.9* phos-2.6* mg-1.8
[**2101-10-5**] 05:27pm blood calcium-8.3* phos-2.9 mg-1.7
[**2101-10-7**] 12:27pm blood type-art po2-145* pco2-41 ph-7.40
caltco2-26 base xs-0
[**2101-10-7**] 10:35am blood type-art po2-199* pco2-42 ph-7.41
caltco2-28 base xs-2
[**2101-10-7**] 12:27pm blood glucose-146* lactate-1.2 na-140 k-3.6
cl-110*
[**2101-10-7**] 10:35am blood glucose-115* lactate-0.8 na-141 k-3.2*
cl-111*
[**2101-10-7**] 12:27pm blood hgb-11.2* calchct-34
[**2101-10-7**] 12:27pm blood freeca-0.99*
[**2101-10-7**] 10:35am blood freeca-0.97*

imaging:
[**2101-10-5**] ugi sgl contrast w/ kub: impression:
expected post-operative appearance of sleeve gastrectomy without
obstruction or leak

[**2101-10-5**] ecg: sinus tachycardia. delayed r wave transition. left
ventricular hypertrophy. possible prior inferior myocardial
infarction. compared to the previous tracing of [**2101-5-31**] the
ventricular rate is faster and the suggestion of a possible
prior inferior myocardial infarction is new. delayed r wave
progression was not previously seen.



brief hospital course:
the patient presented to pre-op on [**2101-10-4**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic sleeve gastrectomy and laparascopic
cholecystectomy. there were no adverse events in the operating
room; please see the operative note for details. pt was
extubated, taken to the pacu until stable, then transferred to
the [**hospital1 **] for observation.

on pod1, the patient's hematocrit trended downward to 28 (from
41.1 pre-op) with concomittant tachycardia to 110s and
sanguinous jp drainage, therefore, she was transfused a total of
2 units of prbcs; heparin was discontinued. of note, on pod1,
the patient complained of epigastric pain radiating to her left
arm; an ekg was reassuring and troponin was within normal
limits.

an ugi series, also performed on pod1, was negative for a leak,
therefore, her diet was advanced to stage 1, which was well
tolerated.  urine output remained adequate and the patient was
ambulating with assistance.

on pod3, due to persistent mild tachycardia, sanguinous jp
output and decreasing hematocrit levels to 25 requiring an
additional 2 units of prbcs, the patient returned to the
operating room where she underwent an exploratory laparoscopy
converted to laparotomy, abdominal washout, oversewing of the
gastric sleeve staple line, evacuation of clot and liver biopsy;
see operative note for details.  post-procedure the patient was
transferred to the surgical intensive care unit for close
observation.

the patient remained stable in the icu with resolution of
tachycardia and stable hematocrit levels.  pain was well
controlled with a dilaudid pca.  an ngt, placed
intra-operatively was discontinued and methylene blue dye was
administered orally without subsequent change in character of jp
drain output, therefore, her diet was advanced to stage 1 and
well tolerated. also, given concern for local tissue ischemia of
small portion of patient's wound, a few staples were removed and
a dry dressing was applied and changed twice daily.

on pod [**5-25**], the patient was transferred to the general surgical
[**hospital1 **].  while on the floor, she continued to have stable vital
signs and hematocrit levels; subcutaneous heparin was resumed on
[**10-8**].  her diet was advanced to stage 3, which was well
tolerated; fsbg was monitored and metformin was resumed at half
dose upon discharge.  the dilaudid pca, ivf and foley were
discontinued; po meds were initiated. pt evaluated the patient
and provided acute treatment with recommendations for continued
home pt upon discharge. ot was also consulted but did not
identify any acute ot needs.

on pod [**8-28**], the patient was discharged to home with visiting
nursing services and home physical therapy.  she continued to do
well, was afebrile with stable vital signs.  the patient was
tolerating a stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled.  both jp drains were
removed prior to discharge.

the patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
she will follow-up with dr. [**last name (stitle) **] in clinic in 1 week.

medications on admission:
preadmission medications listed are correct and complete.
information was obtained from patientwebomr.
1. hydroxychloroquine sulfate 200 mg po bid
2. metformin (glucophage) 1000 mg po bid
3. sertraline 50 mg po daily
4. vitamin e 1000 unit po daily
5. vitamin d 5000 unit po daily
6. multivitamins w/minerals 1 tab po daily
7. cinnamon bark *nf* dosage uncertain tablets oral daily
8. calcet creamy bites *nf* (calcium citrate-vitamin d3) 500 mg
calcium -400 unit oral [**hospital1 **]
9. fish oil (omega 3) 1000 mg po frequency is unknown


discharge medications:
1. oxycodone liquid 5-10 mg po q4h:prn pain
rx *oxycodone 5 mg/5 ml [**6-2**] ml by mouth every four (4) hours
disp #*150 milliliter refills:*0
2. ranitidine (liquid) 150 mg po bid
rx *ranitidine hcl 15 mg/ml 10 ml by mouth twice a day disp
#*600 milliliter refills:*0
3. acetaminophen (liquid) 650 mg po q6h:prn pain
rx *acetaminophen 325 mg/10.15 ml 20 ml by mouth every six (6)
hours disp #*300 milliliter refills:*0
4. calcet creamy bites *nf* (calcium citrate-vitamin d3) 500 mg
calcium -400 unit oral [**hospital1 **]
5. fish oil (omega 3) 1000 mg po daily
6. multivitamins w/minerals 1 tab po daily
7. vitamin d 5000 unit po daily
8. miconazole powder 2% 1 appl tp tid
rx *miconazole nitrate [anti-fungal] 2 % 1 application twice a
day disp #*90 gram refills:*0
9. nystatin oral suspension 5 ml po qid:prn thrush duration: 7
doses
swish and spit
rx *nystatin 100,000 unit/ml 5 ml by mouth four times a day disp
#*140 milliliter refills:*0
10. docusate sodium (liquid) 100 mg po bid:prn constipation
rx *docusate sodium 50 mg/5 ml 10 ml by mouth twice a day disp
#*150 milliliter refills:*0
11. metformin (glucophage) 500 mg po bid
rx *metformin [riomet] 500 mg/5 ml 500 mg by mouth twice a day
disp #*300 milliliter refills:*1
12. sertraline 50 mg po daily
rx *sertraline 20 mg/ml 50 mg by mouth daily disp #*75
milliliter refills:*1


discharge disposition:
home with service

facility:
[**hospital1 **] vna, [**hospital1 1559**]

discharge diagnosis:
morbid obesity
diabetes mellitus.
cholelithiasis.
chronic cholecystitis.
sleep apnea.
intraabdominal bleeding after laparoscopic gastric sleeve and
cholecystectomy.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications except for the following changes.
1. please reduce your metformin to 500 mg, twice daily. please
check your blood sugars twice daily and report elevated or low
readings to your prescribing [**provider number 34259**]. please hold hydroxychloroquine (plaquenil).  discuss your
ability to resume this medication with dr. [**last name (stitle) **] at your
follow-up visit.
*crush all pills*

you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
5. nystatin oral swish four times per day as needed to treat
oral thrush.
6. miconazole powder applied twice daily to affected area.
5. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**11-7**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: bariatric surgery
when: tuesday [**2101-10-18**] at 1 pm
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: tuesday [**2101-10-18**] at 1:30 pm
with: [**first name11 (name pattern1) 177**] [**last name (namepattern4) 13365**], md [**telephone/fax (1) 3201**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2101-10-13**]"
238,"admission date:  [**2146-6-15**]              discharge date:   [**2146-6-28**]

date of birth:  [**2081-10-25**]             sex:   m

service: surgery

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1556**]
chief complaint:
colon cancer
s/p jejunoileal bypass in [**2109**]

major surgical or invasive procedure:
[**2146-6-15**]: rt hemicolectomy, reversal of jejunoileal bypass, liver
biopsy (tru-cut needle).
[**2146-6-27**]: exploratory laparotomy with washout, repair of
perforation in ileum, placement of vacuum-assisted closure
dressing.


history of present illness:
64-year-old man with a history of colonic polyps, who on
screening colonoscopy ([**2146-5-17**]) demonstrated an ulcerated,
clamshell, nonobstructing mass in the cecum.  the length was
approximately 3 cm.  biopsy confirmed invasive
adenocarcinoma grade ii.  otherwise, he has had no change in his
health. no blood per rectum, no weight loss, no abdominal pain.
he currently has [**12-24**] formed bowel movements per day.  he does
experience loose bowel movements if he eats fatty foods or
cheese.

past medical history:
past medical history:
1.  myocardial infarction, [**2143**].
2.  right-sided nephrolithiasis.
3.  morbid obesity (bmi 44.3 kg/m2).
4.  hypertension.
5.  history of colonic polyps.

past surgical history:
1.  jejunoileal bypass, [**2109**] (16 inches of jejunum anastomosis
    to the last 6 inches of ileum) appendectomy was performed at

    that time.
2.  open cholecystectomy with choledochostomy tube and
    gastrostomy tube for acute gallstone pancreatitis, [**2109**].
3.  ureteroscopy with stenting, 05/[**2144**].  this was complicated
    by bradycardia into the 20s.
4.  cardiac pacemaker placement, [**2145-4-6**].
5.  right flank incision with stone extraction, [**2145-5-5**].
6.  cystoscopic attempted stone extraction and stenting,
    [**2145-5-21**].
7.  surgical extraction of right renal stone, [**2145-6-4**].
8.  cardiac stents (drug-eluting), [**2143**].
9.  right shoulder surgery, [**2140**], no metallic implants.

social history:
he does not smoke, drink excessively or use
drugs.  he manages an insurance firm.  he is accompanied by his
wife and daughter today.


family history:
significant for mother with [**name (ni) 2481**] disease,
father with [**name (ni) 5895**] disease.


physical exam:
bp: 123/62. heart rate: 62. weight: 322.4. height: 71.5. bmi:
44.3. temperature: 98.6. resp. rate: 15. o2 saturation%: 99.

physical examination:  general:  he is alert, oriented, in no
acute distress.  heent:  pupils are equal, round and reactive to
light.  sclerae anicteric.  oropharynx is clear.  neck:  supple
without lymphadenopathy, jugular venous distention, bruits,
thyromegaly or nodules.  trachea is midline.  lungs:  clear to
auscultation bilaterally.  heart:  regular.  abdomen:  obese.
he
has a right subcostal incision (cholecystectomy).  he has a
right
lower abdominal transverse incision (intestinal bypass).  he has
a right flank incision (renal surgery).  there are no obvious
hernias.  there is no tenderness.  genitourinary:  penis is
circumcised.  testicles are descended bilaterally.  extremities:

without edema.  neurologic:  grossly nonfocal.


pertinent results:
[**2146-6-15**] 04:50pm   glucose-187* urea n-12 creat-1.0 sodium-141
potassium-4.1 chloride-104 total co2-27 anion gap-14
[**2146-6-15**] 04:50pm   estgfr-using this
[**2146-6-15**] 04:50pm   calcium-9.2 phosphate-3.9 magnesium-1.4*
[**2146-6-15**] 04:50pm   wbc-10.6# rbc-4.73 hgb-11.3* hct-36.6*
mcv-77* mch-23.8* mchc-30.8* rdw-15.5
[**2146-6-15**] 04:50pm   plt count-102*
[**2146-6-15**] 12:44pm   type-art rates-/12 tidal vol-700 po2-330*
pco2-39 ph-7.43 total co2-27 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 12:44pm   glucose-153* lactate-2.1* na+-135 k+-3.8
cl--101
[**2146-6-15**] 12:44pm   hgb-10.7* calchct-32 o2 sat-97
[**2146-6-15**] 12:44pm   freeca-1.19
[**2146-6-15**] 10:53am   type-art rates-/12 tidal vol-700 po2-84*
pco2-39 ph-7.45 total co2-28 base xs-2 intubated-intubated
vent-controlled
[**2146-6-15**] 10:53am   na+-135
[**2146-6-15**] 10:53am   hgb-10.3* calchct-31 o2 sat-94

brief hospital course:
the patient presented to pre-op on [**2146-6-15**]. pt was evaluated by
anaesthesia and taken to the operating room where a laparoscopic
adjustable gastric band placement was performed. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout the
hospitalization; until her was intubated and sedated. pain was
well controlled with iv pain medications.
cv: vital signs were routinely monitored. the patient remained
stable from a cardiovascular standpoint until he developed
tachycardia and hypotension on [**2146-6-27**]. following that the
patient was placed on multiple pressors by the icu team. cardiac
enzymes were initially negative, a tee revealed a hyperdynamic
myocardium.
pulmonary: vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. the patient remained
stable from a pulmonary standpoint until [**2146-6-27**] when he
developed shortness of breath, new and increasing oxygen
requirement and desaturation. cta of the chest revealed no
evidence of pe, but the patient had evidence of worsening
pulmonary function and ards. he was intubated and his peep was
optimized using an intraesophageal balloon. he remained
intubated until the decision of comfort measures only was
executed terminally extubating the patient.

gi/gu/fen: he was kept npo with ng tube to suction. the patient
was initially putting out about 7-8 liters of bilious fluid a
day. this was adequately replaced with iv fluids. the patient
was later decreasing his ng tube outputs to 4 liters by day 6
post-operatively. the patient passed gas on the 5th day
post-operatively, and bowel movements pod6. tpn was started due
to the elevated ng outputs (dark green bile). patient's intake
and output were closely monitored.
 pod#12, the patient decompensated with sudden onset chest and
shoulder pain, shortness of breath, tachypnea, new oxygen
requirement, ekg new right bundle branch block, and transient
abdominal pain.
the patient was taken to the or and exploration revealed a total
of 5 liters of fluid non bilious. he was found to have one small
hole at the proximal anastomosis and purulent pocket. 3 drains
were placed. subsequently the patient developed multiple organ
system failure, with acute renal failure requiring continuous
venovenous hemodialysis. worsening refractory metabolic acidosis
requiring multiple boluses and iv drip bicarbonate. acute liver
failure was also noted with inr>3 and liver transaminases >[**2133**].


id: the patient's fever curves were closely watched for signs of
infection. the
patient developed sepsis as discussed above with multiple
organisms (k. pneumonia, b. fragilis,...) the patient was placed
on broad spectrum iv antibiotics.

prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.

 the patient was showing signs of multiple organ system collapse
with refractory hypotension and acidosis despite maximal medical
therapy. a family meeting was conducted with the family deciding
that the patient's wishes would be to withdraw care at that
point. the patient was extubated terminally and the patient
passed away shortly after on [**2146-6-28**] at 17:37.

medications on admission:
medications - prescription
atorvastatin -  (prescribed by other provider) - 40 mg tablet -
1
tablet(s) by mouth once a day
hydrochlorothiazide -  (prescribed by other provider) - 25 mg
tablet - 1 tablet(s) by mouth once a day
sildenafil [viagra] -  (prescribed by other provider) - dosage
uncertain
valsartan [diovan] -  (prescribed by other provider) - 80 mg
tablet - 1 tablet(s) by mouth once a day

medications - otc
aspirin -  (prescribed by other provider) - 81 mg tablet,
chewable - 1 tablet(s) by mouth once a day
cholecalciferol (vitamin d3) [vitamin d] -  (prescribed by other
provider) - dosage uncertain


discharge medications:
none

discharge disposition:
expired

discharge diagnosis:
cecal cancer with positive lymph node
reversal of jejunoileal bypass
liver cirrhosis secondary to jejunoileal bypass
acute respiratory distress syndrome
acute liver failure
acute renal failure
intraabdominal severe septic shock

discharge condition:
dead

discharge instructions:
na

followup instructions:
na


completed by:[**2146-7-26**]"
239,"admission date:  [**2115-10-14**]              discharge date:   [**2115-10-24**]

date of birth:  [**2076-6-1**]             sex:   f

service: surgery

allergies:
zofran

attending:[**first name3 (lf) 1556**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2115-10-14**]:
1. laparoscopic roux-en-y gastric bypass.
2. endoscopy
[**2115-10-17**]:
1. exploratory laparotomy.
2. small-bowel resection with primary anastomosis.
3. gastrostomy tube placement.


history of present illness:
[**known firstname **] has class iii morbid obesity with a weight of 228.4
pounds as of [**2115-8-20**] (her initial screen weight on [**7-8**]/level was
231.5 pounds), height of 63 inches and bmi of 41.8.  her
previous weight loss efforts have included self-initiated diet
for 3 months in [**2115**] losing 5 pounds, 12 weeks weight watchers
in [**2106**] losing 3 pounds, 8 weeks of the [**doctor last name 1729**] diet in [**2104**]
losing only 5 pounds, 4 months of over-the-counter
ephedra-containing metabolife in [**2102**] losing 10 pounds and two
months of slim-fast in [**2098**] losing 19 to 20 pounds.  she has not
taken prescription weight loss medications.  her highest adult
weight was 234.6 pounds in [**month (only) 205**] and she weight 224 pounds one
year ago.  she stated she has been struggling with weight since
childhood and cites as factors contributing to her excess weight
large portions, genetics, too many carbohydrates in saturated
fats and convenience heating as well as lack of exercise.  she
stated that she currently is not exercising due to physical
limitations/knee problems.  she denied history of eating
disorders and does have issues with depression/anxiety but has
not been followed by a therapist in no are hospitalized for
mental health issues and she is on psychotropic medication
(celexa).


past medical history:
pmh: morbid obesity, hypertension, hypothyroidism,
osteoarthritis of the cervical spine with neck pain, migraine or
tension headaches, shoulder impingement syndrome, bilateral
carpal tunnel syndrome, eczema, allergic rhinitis, ovarian
cysts, uterine fibroids, sciatica and vertigo

psh: bilateral breast reduction, bilateral carpal tunnel repair
and appendectomy


social history:
she denied tobacco or recreational drug usage, has occasional
glass of beer/wine once or twice per week and does drink both
carbonated and caffeinated beverages.  she is employed as [**initials (namepattern4) **] [**last name (namepattern4) **]
collector for utilities company.  she is divorced and she has
one son age 22.


family history:
her family history is noted for mother living age 56 with
hyperlipidemia and arthritis; sister living age 35 with obesity.

physical exam:
vs upon discharge: 97.8, 75, 152/95, 18

constitutional: appropriate affect, pleasant and cooperative.
neuro: alert and oriented x4, nad.
cardiac: rrr, n s1, s2 no mrg.
lungs: lungs clear to auscultate bilaterally.
abdomen: obese, soft, nondistended, tender to deep palpation.
gtube clamped.
wounds: midline incision with staples, open to air; umbilicus
with small amt serous drainage. gtube insertion site without
drainage or erythema.
ext: + pedal pulses bilaterally, warm to touch.


pertinent results:
labs:
[**2115-10-19**] 07:00am blood wbc-9.8 rbc-3.54* hgb-10.8* hct-30.7*
mcv-87 mch-30.5 mchc-35.2* rdw-12.7 plt ct-[**numeric identifier 92387**]/05/11 07:40am
blood calcium-9.2 phos-2.7 mg-2.1 glucose-100 urean-8 creat-0.6
na-139 k-3.7 cl-102 hco3-28 angap-13 hct-34.5*
[**2115-10-18**] 01:45am blood wbc-13.3*# rbc-4.21 hgb-12.5 hct-37.9
mcv-90 mch-29.8 mchc-33.1 rdw-12.6 plt ct-321
[**2115-10-15**] 07:15am blood hct-31.0*
[**2115-10-15**] 07:45pm blood hct-31.1*
[**2115-10-14**] 11:54am blood hct-35.2*

imaging:
[**2108-10-15**] ugi sgl contrast w/ kub:
normal appearance of post-roux-en-y stomach with no evidence of
leak or obstruction

[**2115-10-16**]: abdomen (supine & erect):
impression: small bowel dilation with air-fluid levels
concerning for small bowel obstruction.

[**2115-10-17**]: ct abd & pelvis with contrast:
impression:
1. small bowel obstruction likely complete distal to the
roux-en-y anastomosis with dilation of both limbs of the
roux-en-y gastric bypass resulting in distention of the excluded
stomach.
2. the transition point is not definitely identified, however it
is not in
relation to the abdominal wall hernia and there is no mass or
internal hernia. thus this is most likely due to an adhesion.
3. umbilical hernia containing omentum with surrounding fluid
collection.


brief hospital course:
the patient presented to pre-op on [**2115-10-14**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic roux-en-y gastric bypass and endoscopy. there were
no adverse events in the operating room; please see the
operative note for details. pt was extubated, taken to the pacu
until stable, then transferred to the [**hospital1 **] for observation.

on pod 3, the patient was noted to have a complete small bowel
obstruction.  she was taken back to the operating room where she
underwent an exploratory laparotomy, small-bowel resection with
primary anastomosis and gastrostomy tube placement.  again, she
was extubated and taken to the pacu.  once deemed stable, she
was brought to the surgical icu for further management.
post-operative recovery in the sicu was uneventful, therefore,
the patient was transferred to the general surgical [**hospital1 **] on pod
[**4-12**].

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed on pod0 with a
morphine pca, which required adjustment to dilaudid in the pacu
due to inadequately controlled pain.  the patient required an
increase in the amount of dilaudid on pod1 with improved pain
control.  following return to the operating room on pod3/0, the
patient's pain was adequately controlled with a morphine pca,
which was transitioned to oral roxicet once tolerating a stage 2
diet.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially kept npo on pod0 with complaints of
intermittent nausea, which was managed with intravenous
phenergan.  a methylene blue dye test, performed on pod0, and an
upper gi study, performed on pod1, were both negative for a
leak. given normal test results and improved nausea, the diet
was advanced to a bariatric stage 1 and then a stage 2 diet.
the patient initially tolerated the diet advancement, however,
on the evening of pod 2, the patient's abdomen became
progressively distended. jp output had also significantly
increased during the day on pod2 and and changed from
serosanguinous to serous.  additionally, a small area of
induration without fluctuance or erythema was noted at the
midline port site.  a kub was obtained later that evening, which
suggested 'small bowel dilation with air-fluid levels concerning
for small bowel obstruction'.  the following day, pod3, an
abdominal ct scan was obtained and suggested 'small bowel
obstruction likely complete distal to the roux-en-y anastomosis
with dilation of both limbs of the roux-en-y gastric bypass
resulting in distention of the excluded stomach' without
definitive identification of a transition point.  it was also
suggested that the obstruction was not related to the abdominal
wall hernia, which was described as an umbilical hernia
containing omentum with surrounding fluid collection, but was
most likely due to an adhesion. given these findings, the
patient was brought back to the operating room where she
underwent an exploratory laparatomy as described above.
post-operatively, the patient had a g-tube to gravity for
gastric decompression.  her diet was resumed on pod [**9-17**]
following return of bowel function, which was well tolerated.
jp drainage decreased significantly and was removed prior to
discharge from the hospital.  a foley catheter, which was placed
intra-operatively, was removed on pod1; urine output was
adequate throughout the hospitalization. on pod [**10-18**], jp drain
was discontinued prior to discharge.
id: intravenous cefazolin was administered prophylactically for
24 hours following the roux-en-y gastric bypass.  however,
intravenous metronidazole and ciprofloxacin were intitiated
following repair of the strangulated hernia and continued until
pod [**9-17**]. the patient's fever curves were closely watched for
signs of infection, of which there were none.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
amlodipine 10 mg daily
lisinopril 20 mg daily
atenolol 50 mg daily
levothyroxing 225 mcg daily
citalopram 20 mg daily
mvi w/ minerals 1 tablet daily
vitamin d (dosage uncertain)

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day:
crush.
2. lisinopril 20 mg tablet sig: one (1) tablet po once a day:
crush.
3. levothyroxine 200 mcg tablet sig: one (1) tablet po once a
day: crush.
4. levothyroxine 25 mcg tablet sig: one (1) tablet po once a
day: crush.
5. citalopram 20 mg tablet sig: one (1) tablet po once a day.
6. multivitamin with minerals     tablet sig: one (1) tablet po
once a day: chewable. tablet(s)
7. vitamin d-3  oral
8. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: [**5-21**] ml
po every 4-6 hours as needed for pain.
disp:*250 ml* refills:*0*
9. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
disp:*300 ml* refills:*0*
10. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po twice a
day for 1 months.
disp:*600 ml* refills:*0*
11. ursodiol 300 mg capsule sig: one (1) capsule po twice a day
for 6 months.
disp:*360 capsule(s)* refills:*0*


discharge disposition:
home with service

facility:
[**location (un) 15739**] district vna

discharge diagnosis:
1. hypertension.
2. morbid obesity.
3. osteoarthritis.
4. depression.
5.  strangulated hernia comprised of small intestine.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.

medication instructions:
resume your home medications, crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you will be taking zantac liquid 150 mg twice daily for one
month. this medicine prevents gastric reflux.
4. you will be taking actigall 300 mg twice daily for 6 months.
this medicine prevents you from having problems with your
gallbladder.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-26**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
provider: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd phone:[**telephone/fax (1) 305**]
date/time:[**2115-10-31**] 8:30
provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 9325**], md phone:[**telephone/fax (1) 305**]
date/time:[**2115-10-31**] 9:15



completed by:[**2115-10-24**]"
240,"admission date:  [**2199-9-22**]              discharge date:   [**2199-10-2**]

date of birth:  [**2143-12-23**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 598**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
[**2199-9-23**]: laparascopic repair of gastric ulcer


history of present illness:
55f w/ h/o carotid stenosis/le claudication and diverticulosis
(last c-scope ~ 1 yr ago @ osh) presents with an acute onset of
epigastric pain 4 hours prior to arrival in ed. she was seen at
[**hospital3 **] and was reportedly hypotensive
initially to sbp 80s.  upright cxr showed a question of bowel
gas vs free air below left diaphragm. there was no ct scanner
available at [**hospital1 **] due to power outage and so patient was
transferred here for further eval/management. the patient
reports recent h/o of nausea vomiting (from ""some stomach bug"")
and diarrhea x2 days (described as ""dark"" but no brbpr) but
wasn't sure about passing flatus recently.  she denies fevers or
chills, nausea/vomiting, hematemesis, history of gi
bleeds/diverticulitis, cp, sob.


past medical history:
past medical history: htn, hypercholesterolemia, diverticulosis
(last c-scope ~1yr ago), carotid stenosis, le claudication

past surgical history: tonsillectomy


social history:
lives in [**location 2624**] w/ husband, occupation is assistant to husband
in furniture business, +tobacco smoking h/o ~35yrs on/off,
social etoh, no ivdu


family history:
n/c

physical exam:
on admission:
physical exam:
vitals: 96.5  104  106/79  20  98% 4l nasal cannula
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: tachycardic, regular rhythm, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: hypoactive bowel sounds, soft, mild distension, +ttp
midepigastrium/luq w/ focal rebound, no palpable masses
ext: no le edema, le warm and well perfused


pertinent results:
labs:
[**2199-10-2**] 07:05am blood wbc-7.4 rbc-3.30* hgb-11.0* hct-31.4*
mcv-95 mch-33.4* mchc-35.2* rdw-13.4 plt ct-567* glucose-94
urean-8 creat-0.4 na-143 k-3.9 cl-105 hco3-29 angap-13
calcium-8.8 phos-3.5 mg-2.3

[**2199-9-29**] 02:42pm blood gastrin-pnd

[**2199-9-26**] 10:01am blood vanco-6.9* 03:29am blood type-art
po2-111* pco2-33* ph-7.45 caltco2-24 base xs-0

[**2199-9-24**] 01:18am blood pt-13.7* ptt-34.2 inr(pt)-1.2* [**2199-9-24**]
01:18am blood probnp-988* [**2199-9-24**] 01:33am blood lactate-0.9

[**2199-9-22**] 04:15pm blood wbc-10.1 rbc-4.19* hgb-14.5 hct-40.0
mcv-95 mch-34.6* mchc-36.2* rdw-13.5 plt ct-433 neuts-85*
bands-1 lymphs-10* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0
hypochr-1+ anisocy-occasional poiklo-occasional macrocy-1+
microcy-normal polychr-occasional stipple-occasional
how-jol-occasional pappenh-1+ pt-11.9 ptt-20.8* inr(pt)-1.0
glucose-106* urean-15 creat-0.9 na-136 k-4.7 cl-101 hco3-23
angap-17 alt-18 ast-20 alkphos-67 amylase-159* totbili-0.7
lipase-58 calcium-9.7 phos-4.8* mg-1.6
glucose-98 lactate-1.6 na-135 k-4.2 cl-102 10:53pm blood
hgb-12.1 calchct-36 hgb-13.8 calchct-41 10:53pm blood
freeca-1.25

imaging:
[**2199-9-22**]:
cxr: impression: pneumoperitoneum. please correlate with ct
abdomen
ct abd & pelvis with contrast: impression: pneumoperitoneum with
active intraperitoneal spillage of oral (water soluble)
contrast, likely secondary to a perforated duodenal ulcer.
please note, given the mural edema and mucosal irregularity in
the gastric antrum, malignancy cannot be excluded.

[**2199-9-24**]:
impression: cta chest w&w/o c&recons, non-coronary: impression:
1. no evidence of pulmonary embolism.
2. multifocal consolidations concerning for pneumonia.
3. new bilateral pleural effusions and bilateral lower lobe
atelectasis.

[**2199-9-25**]:
ecg: impression: sinus rhythm. possible septal myocardial
infarction, age indeterminate. low voltage in the limb leads. no
previous tracing available for comparison

[**2199-9-27**]:
chest (portable ap): impression: since [**2199-9-26**], there
is mild interval worsening of the pulmonary edema. again, stable
left lung base atelectasis and bilateral mild pleural effusions.


[**2199-9-29**]:
impression: normal upper gi without evidence of leak.


brief hospital course:
ms. [**known lastname **] presented to an osh [**2199-9-22**] with acute onset
epigastric pain and hypotension.  an upright cxr was obtained at
the osh suggested a possible bowel gas pattern under the left
diaphragm versus free air.  the patient was subsequently
transferred to the [**hospital1 18**] emergency department for further
management.  an abdominal ct scan was obtained and revealed
pneumoperitoneum with active intraperitoneal spillage of oral
(water soluble) contrast attributed to a perforated duodenal
ulcer.  intravenous fluids, pain, and nausea medication were
administered.  intravenous ciprofloxacin was also administered.
the patient was then taken emergently to the operating room
where a perforated gastric ulcer was identified and a
laparascopic repair of the perforated gastric ulcer was
performed.  there were no adverse events in the operating room;
please see operative note for details.  pt was extubated, taken
to the pacu until stable, then transferred to the surgical
intensive care unit for further management. the patient remained
in the intensive care unit until pod 4.  she was then
transferred to the general surgical [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed with a dilaudid pca.
 pain medication was transitioned to oral oxycodone once
tolerating a diet.
cv: the patient required intraoperative pressors, which were
resumed on pod0, in addition to a fluid bolus, in the sicu due
to hypotension.  pressors were discontinued on pod2.
additionally, a lasix drip was initiated on pod1 due to. .; the
lasix drip was transitioned to [**hospital1 **] intravenous dosing on pod 4
and discontinued on pod 9; electrolytes were repleted prn.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially kept npo. patient's intake and
output were closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
toprol xl 200 mg daily
amlodipine 5 mg daily
lisinopril 20 mg daily
aspirin 81 mg daily
cilostazol 100 mg [**hospital1 **]
lovastatin 40 mg daily
ambien 5 mg q hs prn
aspirin 81 mg daily
caltrate + d 600 mg- 400 mg [**hospital1 **]
glucosamine 1000 mg daily

discharge medications:
1. oxycodone 5 mg tablet sig: one (1) tablet po every four (4)
hours as needed for pain.
disp:*50 tablet(s)* refills:*0*
2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily).

3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every
6 hours): do not exceed 3000 mg per 24 hour period.
4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
disp:*30 tablet, delayed release (e.c.)(s)* refills:*2*
5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid
(2 times a day).
disp:*60 tablet(s)* refills:*0*
6. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).

7. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day as needed for constipation.
disp:*30 capsule(s)* refills:*0*
8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable
po once a day.
9. cilostazol 100 mg tablet sig: one (1) tablet po twice a day.

10. lovastatin 40 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
perforated gastric ulcer


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
you were admitted to the hospital with abdominal pain.  an
abdominal ct scan was obtained and was suspicious for an
intestinal perforation , therefore, you were taken to the
operating room and subsequently underwent a laparascopic repair
of a perforated gastric ulcer.  you recovered in the hospital
and are now preparing for discharge to home with the following
instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications except for the
following changes:
1.  stop toprol xl(extended releas metoprol).  a new
prescription for twice daily metoprolol has been provided to
you.  please notify your primary care provider of this change.
please seek immediate medical attention if you experience a
severe headache, blurred vision, weakness, difficulty speaking
and/ dizziness.
2.  please take 20 mg lisinopril daily (current home dose 40 mg
daily).  please follow the above instructions regarding your
blood pressure.
also, please take any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-4**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service to make a follow-up
appointment within 2 weeks.
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2200-2-26**] 12:30
provider: [**name10 (nameis) 14633**],equipment [**name10 (nameis) **] lmob (nhb) phone:[**telephone/fax (1) 1237**]
date/time:[**2200-2-26**] 12:30
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2200-2-26**] 1:15


                             [**first name8 (namepattern2) **] [**name8 (md) **] md [**md number(2) 601**]

completed by:[**2199-10-2**]"
241,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
242,"admission date:  [**2120-2-21**]       discharge date:  [**2120-3-27**]

date of birth:   [**2075-1-21**]       sex:  m

service:  [**hospital1 **]

addendum:

the patient was not discharged as initially thought on
[**2120-3-23**].  he remained inpatient and date of discharge will
be in the future.

hospital course:
1.  infectious disease - no active issues since the previous
discharge summary.  fevers were followed and the patient will
be cultured if he spikes.

2.  hypertension - the patient's blood pressure continued to
be well controlled on multiple medications.

3.  gastrointestinal bleed - the patient had no active
bleeding.  hematocrit was followed as needed and remained
stable.

4.  type 2 diabetes mellitus - the patient continued to have
good blood sugar control on regular insulin sliding scale.

5.  medication ingestion - on the evening of [**2120-3-23**], the
patient was observed to be ingesting multiple medications by
the sitter in his room. the patient had obtained these
medications from a box in his belongings.  it is unclear how
many pills the patient took and exactly which type of
medications were taken.  they were most likely
antihypertensives and psychiatric medications.   the patient
was given activated charcoal.  he was transferred to the
[**hospital ward name 332**] intensive care unit for close monitoring of his blood
sugar, electrocardiogram and vital signs.  the patient
remained in the [**hospital ward name 332**] intensive care unit for approximately
24 hours with no adverse events.  at that time, the
toxicology service felt any possibility of danger or adverse
events from the medications had passed.   the patient was
transferred back to the [**hospital1 139**] firm and had no resultant
problems from the medication ingestion.

6.  deep vein thrombosis - on [**2120-3-24**], it was noted on
examination that the patient's right leg was significantly
swollen in comparison to his left lower extremity.  a lower
extremity ultrasound was obtained which showed a partially
occluded thrombus in the right common femoral vein.  flow was
seen around the thrombus but the vein was not compressible.
no deep vein thrombosis was present in the left lower
extremity. the patient was very cautiously started on
anticoagulation with enoxaparin and coumadin.  given his
history of gastrointestinal bleeds, his hematocrit is being
followed very closely.  in addition, the patient has had
several falls during the admission and is a fall risk in the
future.  he will have a one to one sitter at all times.  in
addition, a custom made helmet is being obtained for the
patient to wear when he is awake.

the remainder of this dictation will be finished at a later
time.




                            [**first name11 (name pattern1) 2515**] [**last name (namepattern4) 4517**], m.d.  [**md number(1) 4521**]

dictated by:[**name8 (md) 315**]
medquist36

d:  [**2120-3-27**]  17:37
t:  [**2120-3-27**]  18:00
job#:  [**job number 102686**]
"
243,"admission date:  [**2127-12-7**]              discharge date:   [**2127-12-17**]

date of birth:  [**2063-4-18**]             sex:   f

service: surgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1556**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
1. exploratory laparotomy.
2. lysis of adhesions.
3. oversew of colonic deserosalization.


history of present illness:
64 year old female who presents with sudden onset of
periumbilical pain that started early this morning at around
5am. abdominal pain is mid abdomen with no radiation; relieved
by pain meds and no definite aggravating factors. associated
nausea and vomiting ~6 times. bilious; no blood. denies any
fevers, chills. bowel movements this morning; flatus last night.


past medical history:
- ovarian cancer, diagnosed in [**2109**] and treated with tah bso and
6 runs of chemotherapy complicated by deep vein thrombosis in
left lower extremity and was on coumadin briefly
- bladder cancer, diagnosed in [**2114**] and treated with cystecomy
and ileal conduit and stoma
- documented to have chronic anemia of unknown etiology
- pt. reported last colonoscopy 5 years ago with no abnormal,
she did have polyp removed during colonoscopy 10 years ago but
was not sure if malignancy was found.
-osteoporosis

psychiatric history:
patient has a diagnosis of ""psychotic disorder"" and has been
treated by her primary care provider successfully with
thorazine. she does not see any therapists or psychiatrists at
this time. she saw dr. [**last name (stitle) 100898**] in therapy 1x/mo for 6yrs
until she changed her insurance in [**month (only) 547**]. she reports trying
zoloft for a short time in [**2111**] but did not mention results.

hospitalizations: [**2111**] - ""[**first name4 (namepattern1) **] [**last name (namepattern1) **] accomodations""
                  [**2110**] - [**hospital1 336**]
                  [**2092**] - [**hospital1 **] [**hospital1 **] 4

patient reports 1 prior suicide attempt in [**2084**] when she
""stopped eating and wearing warm clothes and stayed out all
night, everything to excess."" she was then hospitalized for
pneumonia, no history of hurting herself.

social history:
born in mission [**doctor last name **] and raised in [**location (un) 669**], one of 11 children
(10 per omr). she reports 7 living (omr notes say 6) and all
except two sisters are in the [**name (ni) 86**] area.  lives alone. remote
smoker, no drugs/etoh


family history:
she had ten siblings. malignancy in the family: deceased sister:
ovarian ca
sister: breast cancer brother : ca brain brother: liver cancer
father: prostate cancer; mother's sister had schizophrenia.

physical exam:
constitutional: comfortable
chest: clear to auscultation
cardiovascular: regular rate and rhythm, normal first and second
heart sounds
abdominal: diffuse tenderness to palpation. no guarding or
rebound tenderness to palpation. abdomen nondistended, soft.
extr/back: no cyanosis, clubbing or edema
skin: no rash, warm and dry
neuro: speech fluent
psych: normal mood, normal mentation


pertinent results:
[**2127-12-7**] 02:45pm urine  hours-random
[**2127-12-7**] 02:45pm urine  gr hold-hold
[**2127-12-7**] 02:45pm urine  color-yellow appear-clear sp [**last name (un) 155**]-1.016
[**2127-12-7**] 02:45pm urine  blood-tr nitrite-neg protein-25
glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-7.0 leuk-sm
[**2127-12-7**] 02:45pm urine  rbc-0-2 wbc-[**4-18**] bacteria-many yeast-none
epi-0-2
[**2127-12-7**] 02:11pm   k+-4.1
[**2127-12-7**] 02:02pm   glucose-129* urea n-28* creat-1.4* sodium-144
potassium-4.1 chloride-108 total co2-26 anion gap-14
[**2127-12-7**] 12:30pm   glucose-137* urea n-31* creat-1.4* sodium-143
potassium-5.1 chloride-104 total co2-28 anion gap-16
[**2127-12-7**] 12:30pm   alt(sgpt)-13 ast(sgot)-32 alk phos-75 tot
bili-0.3
[**2127-12-7**] 12:30pm   lipase-55
[**2127-12-7**] 12:30pm   calcium-9.6
[**2127-12-7**] 12:30pm   wbc-6.3# rbc-3.65* hgb-10.6* hct-32.6* mcv-89
mch-29.2 mchc-32.7 rdw-13.9
[**2127-12-7**] 12:30pm   neuts-87.4* lymphs-9.4* monos-2.4 eos-0.5
basos-0.3
[**2127-12-7**] 12:30pm   plt count-190

[**2127-12-8**] abdominal ct w/ contrast: 1. high-grade small-bowel
obstruction, with dilation of the mid small bowel up to 3.4 cm.
the proximal and distal small bowel are decompressed and two
closely approximated transition points are seen in the
mid-abdomen, concerning for a closed loop obtruction, possibly
secondary to either internal hernia or
adhesion. while there is associated wall edema, mesenteric
fluid, and
adjacent ascites, there is no pneumatosis or portal venous air
identified to definitively suggest ischemia.
2. status post right nephroureterectomy and radical cystectomy,
with
unremarkable appearance of urostomy in the right lower quadrant.
no definite evidence of metastatic disease. small nodular
density at the left lung base is stable, though attention on
followup is warranted.
3. stable 4 mm hypodensity within the body of the pancreas,
unchanged.
4. ivc filter in standard position.

[**2127-12-12**] ekg: sinus rhythm with sinus arrhythmia. borderline low
limb lead voltage. diffuse non-specific st-t wave abnormalities.
compared to the previous tracing of [**2127-12-8**] findings are
similar.



brief hospital course:
ms. [**known lastname 20400**] presented to the emergency department on [**2127-12-7**] with complaints of sudden onset abdominal pain at the
umbilical level associated with nausea and vomiting and not
relieved with over the counter pain medication.  an abdominal
x-ray was obtained, which indicated a small bowel obstruction.
therefore, [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube was placed and the patient was
transferred to the general surgical [**hospital1 **] for management.

on hospital day #1 the patient developed worsening abdominal
pain.  additionally, an abdominal ct scan had beeb obtained,
which revealed a high grade small bowel obstruction.  given the
worsening abdominal exam and the results of the ct scan, the
patient was brought to the operating room, where an exploratory
laparotomy, lysis of adhesions and oversew of colonic
deserosaliazation was performed.  there were no adverse events
in the operating room; please see the operative note for
details. pt was extubated, taken to the pacu until stable, then
transferred to the surgical intensive care unit for close
observation.

on hosptial day #2 the patient remained stable, was weaned from
the ventilator and extubated.  she was subsequently transferred
to the general surgical [**hospital1 **] for further management.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially controlled with intravenous
dilaudid.  the patient reported complete resolution of pain by
post-operative day #5 and did not require pain medication for
the remainder of her hospitalization.

cv: the patients vital signs were routinely monitored. she
became hypertensive in the intensive care unit with a systolic
blood pressure in the 160s.  additionally, she had 8 beats of
non-sustained ventricular tachycardia on post-operative day #4.
she was maintained on intravenous metoprolol which was initiated
in the intensive care unit and continued until post-operative
day #8; her blood pressure and heart rate remained within
acceptable limits without metoprolol administration.

pulmonary: the patient tolerated extubation postoperatively
without difficulty and maintained appropriate oxygen saturation
levels throughout her admission.

gi/gu/fen: she was initially npo with iv fluids and a
[**last name (un) **]-gastric tube, which was removed on post-operative day #4.
diet was advanced sequentially, which was well tolerated,
however, oral liquid and solid intake was initially suboptimal.
nutritional supplements were then provided with each meal with
improved overall oral intake; she will continue this regimen at
home to optimize her nutritional status  patient's intake and
output were closely monitored, and iv fluid was adjusted when
necessary; electrolytes were routinely monitored and repleted as
necessary.

id: the patient's white blood cell counts and fever curves were
monitored routinely throughout her admission and did not show
any signs of intrabdominal or wound infections.

hematology: the patient's complete blood count was examined
routinely; no transfusions were required.

prophylaxis: the patient received subcutaneous heparin and
venodyne boots were used during this stay; she was encouraged to
get up and ambulate as early as possible.

rehab: given her prolonged hospital course and operation, a
physical therapy consult was requested.  she was evaluted on
post-operative day #8 and deemed safe for discharge home without
additional physical therapy requirements.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding via her urostomy tube, and pain was
well controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
risperidone 1 mg tab qpm
vitamin d 800 unit tab daily
calcium 1200 mg chewable tab daily

discharge medications:
1. risperidone 0.5 mg tablet sig: two (2) tablet po hs (at
bedtime).
2. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2)
tablet po daily (daily).
3. calcium 500 mg tablet sig: 2.5 tablets po once a day.


discharge disposition:
home

discharge diagnosis:
small bowel obstruction


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-23**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.


followup instructions:
please call dr. [**last name (stitle) **] at [**telephone/fax (1) 3201**] to make a follow-up
appointment for friday, [**2127-12-26**].
provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 6198**], md phone:[**telephone/fax (1) 22**]
date/time:[**2127-12-12**] 3:30



completed by:[**2127-12-18**]"
244,"admission date:  [**2189-12-30**]       discharge date: [**2190-1-5**]


service:  neurology

date of discharge:  pending at this time.

history of the present illness:  [**known firstname **] [**known lastname 102182**] is an
88-year-old retired ophthalmologist with the past medical
history of cll in remission, peripheral neuropathy,
hypertension times 20 years, history of irregular heart
beats, history of gastritis and history of gout.  the patient
presented originally for elective stenting of left internal
carotid artery.  he is known to have bilateral high-grade
stenoses.  in [**month (only) 359**] of this year he had had some repeated
episodes of difficulty expressing himself and difficulty
finding words, but no focal weakness.  he was worked up at
that time for presumed tia and he was found to have the
carotid stenosis, as described above.  on the day of
admission he underwent elective stenting and he was doing
well.  however, during the procedure it was noted acutely
that he was not moving his right hand and face well and that
he had difficulty responding to questions, and he became
progressively less verbal, although he was still alert.
angiogram was done emergently, which revealed likely
occlusion of the left angular branch of the middle cerebral
artery on the left, but because the patient could not
tolerate the placement of the catheter, he could not receive
intra-arterial tpa.  he was started reapro and heparin and
transferred to the pacu.  the ct done at that time showed no
bleed and only slight contrast extravasation.

past medical history:  history is as described above.

allergies:  the patient has allergies to codeine and
tetracycline.

outpatient medications:
1.  cardura.
2.  allopurinol.
3.  prilosec.
4.  baby aspirin.

at the time that he was seen in the neurological icu he was
on a integrilin 3 ml per hour, heparin, zantac, labetalol
p.r.n. for blood pressure control.

social history:  history is significant for the fact that he
quit smoking 30 years ago and before that he smoked one pack
per day.  he does not use alcohol at present.  he is a
retired ophthalmologist.  he was previously head of the
department of ophthalmologist at the [**hospital1 190**].

physical examination:  on examination, vital signs were blood
pressure 165/56, pulse 60, respirations 20 and temperature
908.5.  heart showed a regular rate and rhythm with
occasional pvcs intruding.  lungs were clear to auscultation.
abdomen was soft, and nontender.  neurological examination
revealed that the patient is alert, awake, and only saying
minimal words.  he was not able to say the date.  he
initially called the thumb the ""thumble"" and after that,
during all subsequent questions he would simply repeat
thumble in a perseverative fashion.  he was able to repeat
accurately.  he could read simple sentences.  he could not
write.  his comprehension was intact for some simple
commands, but inconsistent overall.

on motor examination, he was moving the right arm left, but
he was able to lift it and did not have any appreciable
drift.  his hand seemed somewhat clumsy, but this was
difficult to assess.  it was not clear whether he was apraxic
or simply weak.  he was able to move his lower extremities
equally well.  on cranial nerve examination, he had equal and
round and reactive pupils.  extraocular movements were
intact and he blinks to threat bilaterally.  he had a right
facial droop.  tongue was midline.  it was difficult to
assess sensation secondary to language.  coordination tests
were not able to be done secondary to comprehension problems.

hospital course:  the patient was kept in the icu under the
care of neurology and his blood pressure was controlled at
140 to 150 systolic.  he was kept flat initially.  he
initially tolerated the heparin and integrilin well, but on
the day after admission it was noted that his hematocrit had
dropped to 30 from a preoperative level of 37.  the following
day, he had had a drop to 29.  he then dropped to 25.7.  the
heparin and reapro were held.  urinalysis and stool guaiac
were obtained, which were negative for bleed.  he was given
two units of packed red blood cells and the hematocrit came
up nicely.

while he was in the unit, he also received some
neo-synephrine for blood pressure support.  this was able to
be discontinued on [**2189-12-31**] and he did not have any change
in his symptoms or clinical condition following this.

slowly, over the course of his hospital stay, the aphasia,
which was predominately a conduction aphasia previously,
began to resolve.  he was more fluent, able to comprehend
complex commands, and had a very mild residual anomia for
low-frequency words.

following the discontinuation of the integrilin and heparin,
he was started on aspirin and plavix.  he was also seen by pt
and occupational therapy who felt that he would do well with
three to five outpatient visits per week for continued
rehabilitation of the right upper extremity.  bedside swallow
test was performed, which demonstrated that he could swallow
thickened liquids and diet was advanced as tolerated with no
adverse events.

discharge planning:  this will be included as an addendum to
the current dictation.

discharge diagnosis:
1.  acute stroke.
2.  hypertension.
3.  history of cll in remission.
4.  gout.
5.  history of irregular heart beat.
6.  peripheral neuropathy.
7.  history of gastritis.

medications:
1.  aspirin at 325 mg p.o.q.d.
2.  plavix 75 mg p.o.q.d.

other medications:  other medications will be included in the
discharge addendum.




                            [**doctor last name **] [**name8 (md) 8346**], m.d.  [**md number(1) 8347**]

dictated by:[**last name (namepattern1) **]
medquist36

d:  [**2190-1-4**]  14:08
t:  [**2190-1-4**]  14:14
job#:  [**job number **]
"
245,"admission date:  [**2144-3-7**]              discharge date:   [**2144-3-18**]

date of birth:  [**2103-11-10**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 3200**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
1. exploratory laparotomy with [**location (un) **] patch of the duodenal
ulcer.
2. repair of internal hernia at the jejunojejunostomy.
3. upper endoscopy.
4. gastrostomy tube.


history of present illness:
patient is a 40 yo female transferred from [**hospital3 **] with past medical history gastric bypass who presented
with diffuse abdominal pain.  patient with complaints of
intermittent pain and constipation for over a week.  her pain
has become gradually worse and constant she rates her pain as a
[**10-26**] diffuse pain with associated nausea.  she denies any
vomiting.  patient is passing flatus and is tolerating a regular
diet.  she denies any diarrhea, any brbpr.  patient seen at osh
with ngt placed.  she was transferred to [**hospital1 18**] for further
evaluation and management.


past medical history:
pmh: anxiety

psh: lap gastric bypass [**2133**]


social history:
lives with boyfriend, 2 cats.  not working. smokes 1-1.5 packs
of cigarettes per day.  heavy alcohol use history, less
recently.  denies drug use.  no recent travel.  history of
domestic violence including current relationship.


family history:
obesity

physical exam:
vital signs:  t 99.2, hr 82, bp 104/61, rr 18, o2 96% ra

constitutional: no acute distress
neuro: alert and oriented to person, place and time
cardiac: rrr
lungs: no acute respiratory distress
abdomen: soft, non-tender. no active bleeding
wounds: open midline abdominal wound 80% granular, 20% fibrotic,
no active drainage. wound edges are clean. there is one proximal
and one distal simple interrupted 2-0 prolene suture
extremities: symmetric 2+ le edema, pulses palpable, no calf
pain b/l

pertinent results:
admission labs [**2144-3-7**]:
wbc-4.3 rbc-4.60 hgb-9.3 hct-34.6 plt ct-307 pt-11.9 ptt-19.5
inr(pt)-1.0
neuts-83 bands-9 lymphs-3 monos-5 eos-0 baso-0 atyps-0 metas-0
myelos-0
hypochr-2+ anisocy-2+ poiklo-3+ macrocy-1+ microcy-1+
polychr-occasional ovalocy-1+ tear dr[**last name (stitle) 833**]
[**name (stitle) 15924**]
glucose-123 urean-14 creat-0.9 na-135 k-3.9 cl-106 hco3-15
alt-9 ast-18 totbili-0.2
totprot-6.3 albumin-3.4 globuln-2.9 calcium-8.1 phos-4.2 mg-2.0
hgb-9.6 calchct-29 freeca-1.12
.
wbc trend:          k+ trend
[**3-7**]: 8.6          3.9
[**3-8**]: 7.2          3.6
[**3-9**]: 7.8          3.3
[**3-10**]: 7.4          3.7
[**3-11**]: 7.5          2.8
[**3-12**]: 9.3          3.3
[**3-13**]: 9.7          3.3
[**3-15**]: 10.6         2.8
[**3-16**]: 4.3          3.8
[**3-17**]:              3.4
[**3-18**]:              4.1
.
urine:
blood-lg nitrite-neg protein-30 glucose-neg ketone-150
bilirub-neg urobiln-neg ph-5.0 leuks-neg
urine color-yellow appear-clear sp [**last name (un) **]-1.014
.
blood cx negative x 3, h.pylori abx negative, mrsa screen:
negative
.
abdominal wound swab:
gram stain (final [**2144-3-14**]):
      2+   (1-5 per 1000x field):   polymorphonuclear
leukocytes.
      no microorganisms seen.

   wound culture (final [**2144-3-18**]):
      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..
      full work up per dr.[**first name (stitle) **],d [**2144-3-16**].
      full work up cancelled per dr.[**last name (stitle) **] [**2144-3-17**].

   anaerobic culture (final [**2144-3-18**]):    no anaerobes isolated.

.
g-tube wound swab:
gram stain (final [**2144-3-16**]):
      no polymorphonuclear leukocytes seen.
      no microorganisms seen.

   wound culture (final [**2144-3-18**]):    no growth.

   anaerobic culture (preliminary):    results pending.
.
cardiology report ecg study date of [**2144-3-7**]:
sinus tachycardia. baseline artifact makes evaluation of st-t
waves in limb leads difficult. no previous tracing available for
comparison. suggest repeat tracing if clinically indicated.
.
radiology report chest (portable ap) study date of [**2144-3-8**]:
et tube is in standard placement at the thoracic inlet, right
jugular line
ends in the upper svc. moderately severe left lower lobe
atelectasis, small left pleural effusion, and moderate right
pleural effusion are all new. the heart is not enlarged. dr. [**last name (stitle) **]
[**last name (stitle) **] paged.
.
radiology report chest (portable ap) study date of [**2144-3-11**]:
no consolidations suggestive of pneumonia, but persistent
right-sided effusion and mild interstitial edema.
.
radiology report chest (pa & lat) study date of [**2144-3-13**]
there are low lung volumes. cardiomediastinal contours are
unchanged. a
small right pleural effusion has decreased in amount. right
lower lobe
opacity is a combination of pleural effusion and consolidation,
given the
clinical suspicion of pneumonia, these area could correspond to
a focus of
pneumonia. mild vascular congestion is stable. left lower lobe
atelectasis
has improved.
.
radiology report small bowel only (gastrograf) study date of
[**2144-3-13**]
no evidence of duodenal leak status post duodenal ulcer repair.
.
radiology report bilat lower ext veins study date of [**2144-3-17**]
no evidence of deep vein thrombosis in either leg.
.


brief hospital course:
ms. [**known lastname 84323**] was transferred from an outside hospital on [**3-7**], [**2144**] for further management based upon ct scan results
suggestive of fluid in the abdomen and extravasation of
contrast. as she appeared to decompensate clinically, she
required an emergent exploratory laparotomy due to concerns of a
perforated duodenal ulcer.  pre-operative consent was obtained
and the patient was taken to the operating room for exploratory
laparotomy with [**location (un) **] patch of the duodenal ulcer, repair of
internal hernia at the jejunojejunostomy, upper endoscopy and
gastrostomy tube placement.  there were no adverse events in the
operating room; please see the operative note for details. the
patient remained intubated was taken to the pacu until stable,
then transferred to the surgical intensive care and finally the
general surgical [**hospital1 **] for further observation.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed with a pca and then
transitioned to oral dilaudid once tolerating a stage 2 diet.
her pain was well controlled with oral dilaudid, however, she
did occassionally require intravenous breakthrough medication
with good effect.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
pulmonary: the pt was weaned from the ventilator and extubated
shortly after arriving in the sicu.  she remained stable from a
pulmonary standpoint; vital signs were routinely monitored. good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. it was initially believed
that the pt may have developed hospital acquired pneumonia - she
was impirically started on v/az/f. her temperature came down.
(subsequently, her abdominal incisional wound dehisced &
drained, so it was then believed that this wound infection
resulted in her temperature spikes, not pneumonia. she was
switched to po antibiotics - levo & flagyl)
gi/gu/fen: she was kept npo post-operatively with maintenance
intravenous fluids.  a gastrograffin study via her g-tube was
performed on post-operative 5, this study negative for any type
of leak or obstruction.  on post-operative day 7, her diet was
advanced to a bariatric stage 5 diet, which was well tolerated.
on post-operative day 9, the g-tube was clamped and jp #2 was
removed.  there was no bilious drainage present in the remaining
jp drain, therefore, the g-tube remained clamped.  on
post-opertive day 10, this drain was also removed.
additionally, the patient required frequent potassium repletion
due to persistent hypokalemia, which had resovled prior to
discharge.  she did not experience any adverse effects from the
hypokalemia.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none. as mentioned above, it was
initially believed that the pt may have developed ha pna,
however, it was later found out that her temp spikes likely are
related to the wound infection.
electrolytes: the pt was found to have hypokalemia +
hypocalcemia while in house. her potassium & calcium were
repleted accordingly.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.  the pt will be sent home
with oral iron due to iron deficiency anemia (dosage recommended
by bariatric dietitian) and she was encouraged to follow-up with
the hematologist and bariatric dietitian.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.
social:  the pt was initially placed on a ciwa scale due to a
history of etoh abuse.  she did not exhibit any signs or
symptoms of withrdrawal, therefore, the ciwa monitoring was
discontinued.  additionally, a history of past domestic violence
was identified during the initial nursing assessement, including
a history with her current boyfriend who was released from jail
recently.  she was seen by the social worker and reported
feeling safe at home and that her boyfriend has not either
physically or emotionally abused her since being released from
jail.  please defer to social work notes for further details.
of note, a representative from the domestic violence prevention
and treatment team provided resources to the patient.
dispo:

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 5
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
none (advil in excessive amounts)

discharge medications:
1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every
6 hours) as needed for pain/fever: do not exceed 4000 mg in a 24
hour period. tablet(s)
2. levofloxacin 500 mg tablet sig: one (1) tablet po daily
(daily) for 10 days.
3. hydromorphone 2 mg tablet sig: 1-2 tablets po every four (4)
hours as needed for pain: please do not drive or operative heavy
machinery while taking this medication.
4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig:
1-2 puffs inhalation q6h (every 6 hours) as needed for
congestion, wheezing, shortness of breath.
6. senna 8.8 mg/5 ml syrup sig: five (5) ml po twice a day as
needed for constipation.
7. vitron c  sig: one (1) tablet po three times a day.
8. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every
8 hours) for 10 days.
9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day: open capsule; do
not chew beads.


discharge disposition:
home with service

facility:
[**location (un) 932**] vna

discharge diagnosis:
1. perforated duodenal ulcer.
2. internal hernia.
3. anterior gj ulcer, not perforated.
4. peritonitis.
5. hypokalemia + hypocalcemia


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 a perforated duodenal
ulcer, and an internal hernia, which were repaired during your
surgery. also, an ulcer at the gastrojejunal anastamosis was
noted.  you will be going home with a gastrostomy tube in place.
 please see instructions below for the care of this drain. also,
it has been discussed with you that you must not ever take
nsaids (including but not limited to ibuprofen, motrin, advil,
naproxen, aspirin).  if you are unsure if a medication is
considered an nsaid you must ask your primary care provider or [**name initial (pre) **]
[**name9 (pre) 109961**] pharmacist before taking the medication.  also, you
must not smoke or drink alcohol.

 please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**5-26**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.
general drain care:
*please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*if the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. call
the doctor, nurse practitioner, or vna nurse if the amount
increases significantly or changes in character. be sure to
empty the drain frequently. record the output, if instructed to
do so.
*wash the area gently with warm, soapy water.
*keep the insertion site clean and dry otherwise.
*avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.


followup instructions:
please call dr. [**first name (stitle) **] [**name (stitle) **] at [**telephone/fax (1) 18462**] to make a follow-up
appointment.  this physician will be your new primary care
provider as discussed with his office, which is the same office
as your previous physician who is no longer at this site.
please note he will not be seeing patients until [**2144-4-20**].  dr.
[**first name4 (namepattern1) **] [**last name (namepattern1) **] will be the covering physician if needed.

please call dr. [**last name (stitle) **] at [**telephone/fax (1) 3201**] to make an appointment
within 2 weeks.

please contact the hematology department at [**telephone/fax (1) 39833**] for
further management of your iron status.

please contact the bariatric dietitian at [**telephone/fax (1) 305**]



completed by:[**2144-3-19**]"
246,"chief complaint: hypotension, fever, chronic renal failure, anemia
   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:
   levophed at slightly lower dose this am. cvp has ranged from [**6-27**].
   oxygenation has remained good on trach mask.
   hct stable.
   24 hour events:
   history obtained from [**hospital 85**] medical records
   allergies:
   penicillins
   unknown;
   sulfa (sulfonamides)
   unknown;
   last dose of antibiotics:
   acyclovir - [**2150-11-4**] 03:30 am
   metronidazole - [**2150-11-4**] 07:49 am
   daptomycin - [**2150-11-5**] 12:00 pm
   ciprofloxacin - [**2150-11-6**] 02:12 am
   meropenem - [**2150-11-6**] 04:12 am
   vancomycin - [**2150-11-6**] 05:38 am
   infusions:
   norepinephrine - 0.04 mcg/kg/min
   other icu medications:
   heparin sodium (prophylaxis) - [**2150-11-6**] 08:00 am
   other medications:
   famotidine, renagel, vasopressin, atrovent, albuterol
   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:
   flowsheet data as of  [**2150-11-6**] 11:37 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.6
c (99.7
   tcurrent: 37.6
c (99.7
   hr: 86 (75 - 89) bpm
   bp: 98/40(60) {78/32(55) - 117/49(330)} mmhg
   rr: 27 (16 - 34) insp/min
   spo2: 95%
   heart rhythm: 1st av (first degree av block)
   height: 63 inch
   cvp: 7 (-2 - 15)mmhg
   total in:
                                                                  3,794 ml
                                                                    940 ml
   po:
   tf:
                                                                    631 ml
                                                                    341 ml
   ivf:
                                                                  2,174 ml
                                                                    529 ml
   blood products:
                                                                    750 ml
   total out:
                                                                      0 ml
                                                                      0 ml
   urine:
   ng:
   stool:
   drains:
   balance:
                                                                  3,794 ml
                                                                    940 ml
   respiratory support
   o2 delivery device: trach mask
   spo2: 95%
   abg: ///19/
   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
   head, ears, nose, throat: normocephalic, no(t) endotracheal tube, ng
   tube, no(t) og tube, trach tube
   cardiovascular: (pmi normal, no(t) hyperdynamic), (s1: normal, no(t)
   absent), (s2: normal, distant, no(t) loud, no(t) widely split , no(t)
   fixed), no(t) s3, no(t) s4, 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), (breath
   sounds: clear : anterior and lateral)
   abdominal: soft, non-tender, bowel sounds present, no(t) distended,
   no(t) tender: , obese
   extremities: right: bka, left: 1+ edema, no(t) cyanosis, no(t) clubbing
   musculoskeletal: no(t) muscle wasting, unable to stand
   skin:  warm, no(t) rash: , no(t) jaundice
   neurologic: attentive, follows simple commands, responds to: verbal
   stimuli, oriented (to): person, place, movement: purposeful, no(t)
   sedated, no(t) paralyzed, tone: not assessed
   labs / radiology
   7.9 g/dl
   335 k/ul
   162 mg/dl
   4.2 mg/dl
   19 meq/l
   4.7 meq/l
   66 mg/dl
   101 meq/l
   138 meq/l
   25.6 %
   14.0 k/ul
        [image002.jpg]
                            [**2150-11-4**]  01:50 am
                            [**2150-11-4**]  05:25 am
                            [**2150-11-4**]  11:03 am
                            [**2150-11-4**]  03:40 pm
                            [**2150-11-4**]  09:52 pm
                            [**2150-11-5**]  04:01 am
                            [**2150-11-5**]  04:31 am
                            [**2150-11-5**]  03:48 pm
                            [**2150-11-6**]  04:01 am
   wbc
   19.5
   20.5
   13.9
   9.7
   14.0
   hct
   29.2
   28.2
   24.1
   20.1
   25.8
   25.6
   plt
   [**telephone/fax (3) 6568**]90
   335
   cr
   3.4
   3.8
   3.7
   3.7
   4.1
   4.2
   tropt
   0.46
   0.49
   tco2
   27
   23
   24
   glucose
   [**telephone/fax (3) 6569**]78
   224
   162
   other labs: pt / ptt / inr:23.1/40.2/2.2, ck / ckmb /
   troponin-t:34/3/0.49, alt / ast:22/13, alk phos / t bili:113/0.2,
   amylase / lipase:22/23, differential-neuts:80.8 %, band:0.0 %,
   lymph:14.4 %, mono:4.4 %, eos:0.2 %, lactic acid:0.8 mmol/l,
   albumin:2.4 g/dl, ldh:96 iu/l, ca++:7.8 mg/dl, mg++:2.3 mg/dl, po4:6.5
   mg/dl
   imaging: cxr: bilateral alveolar infiltrates and probable bilateral
   effusions
   assessment and plan
 renal failure, end stage (end stage renal disease, esrd)
 sepsis, severe (with organ dysfunction)
 hypotension (not shock)
 impaired skin integrity
 respiratory failure, acute (not ards/[**doctor last name **])
 diabetes mellitus (dm), type i
 peripheral vascular disease (pvd) with critical limb ischemia
   copd
   anemia
   patient's hemodynamics improved. we reduced dose of levophed on rounds
   without adverse events. use patient's mental status as marker of
   adequate perfusion. try to remove levophed today. maintain vasopressin
   an additional 24 hours.
   continue antibiotics.
   o2 sat down slightly. cxr suggests that there may be increased lung
   water. getting closer to need for dialysis.
   hct stable. not at transfusion threshold now.
   icu care
   nutrition: tube feeds
   nutren 2.0 (full) - [**2150-11-5**] 07:29 pm 30 ml/hour
   glycemic control:  regular insulin sliding scale
   lines:
   dialysis catheter - [**2150-11-4**] 01:10 am
   arterial line - [**2150-11-4**] 03:44 pm
   multi lumen - [**2150-11-4**] 06:30 pm
   prophylaxis:
   dvt: sq uf heparin
   stress ulcer: ppi
   vap:
   comments: not applicable.
   communication:  comments:
   code status: full code
   disposition :icu
   total time spent: 30 minutes
   patient is critically ill
"
247,"chief complaint:  abdominal pain
   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:
   37 year old male with hx alcoholic pancreatitis s/p distal pancr.
   presented after 4 wk alcohol binge with n/v/abd pain no hematemsis.
   last drink 24 h before admission. no cp/f/sob/tremors
   in ed 97.6, 76, 145/84, r 20, sats 96% ra. received 4 liters ivf;
   levaquin/flagyl, dilaudid and transferred to floor. ct abd without
   contrast confirmed pancreatitis.
      on floor, rec'd 2.5 liters fluid but became hypoxic, tachycardic,
   agitated. repeat labs showed worsening acidosis and increasing lactate.
   transferred here with p140, rr 26, sats 96% on 100% fm
   patient admitted from: [**hospital1 19**] [**hospital1 158**]
   patient unable to provide history: sedated/intubated
   allergies:
   shellfish
   anaphylaxis;
   topamax (oral) (topiramate)
   diarrhea;
   augmentin (oral) (amox tr/potassium clavulanate)
   diarrhea;
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   wellbutrin, fioricet [**hospital1 7**] prn, klonipin, gemfibrozil, methadone,
   oxycodone, seroquel, zanaflex, advair, flovent, albuterol
   past medical history:
   family history:
   social history:
   hx etoh pancreatitis [**2194**] c/b ards, splenic hematoma s/p splenectomy
   gerd
   htn
   osa not on cpap
   chronic pain
   hyper triglycridemia
   hx etoh withdrawals/dt's
   ruq abscess s/p draininge
   asthma
   depression hx suicide attempts (last age 18)
   occupation:
   drugs:
   tobacco: former 17 pack year history
   alcohol: ++. [**6-26**] drinks daily recently
   other: lives with mother and sister
   review of systems:
   constitutional: no(t) fatigue, no(t) weight loss
   eyes: no(t)  blurry vision, no(t) conjunctival edema
   ear, nose, throat: no(t) dry mouth, no(t) epistaxis, no(t) og / ng tube
   cardiovascular: no(t) chest pain, no(t) palpitations, no(t) edema
   nutritional support: no(t) tube feeds, no(t) parenteral nutrition
   respiratory: no(t) dyspnea, no(t) wheeze
   gastrointestinal: abdominal pain, nausea, emesis, no(t) diarrhea, no(t)
   constipation
   genitourinary: no(t) dysuria
   musculoskeletal: no(t) joint pain, no(t) myalgias
   integumentary (skin): no(t) jaundice, no(t) rash
   endocrine: no(t) hyperglycemia, no(t) history of thyroid disease
   heme / lymph: no(t) lymphadenopathy, no(t) coagulopathy
   neurologic: no(t) numbness / tingling, no(t) headache
   psychiatric / sleep: no(t) agitated, no(t) suicidal
   allergy / immunology: no(t) immunocompromised
   flowsheet data as of [**2201-9-5**] 09:58 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.4
c (99.4
   tcurrent: 37.4
c (99.4
   hr: 147 (142 - 147) bpm
   bp: 145/110(115) {145/103(109) - 150/110(115)} mmhg
   rr: 26 (26 - 26) insp/min
   spo2: 90%
             total in:
             1,205 ml
   po:
             tf:
   ivf:
   1,205 ml
   blood products:
   total out:
                                                                      0 ml
                                                                    600 ml
   urine:
   600 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    605 ml
   respiratory
   o2 delivery device: endotracheal tube
   spo2: 90%
   abg: 7.39/30/54 on 2 liters; 7.37/33/102 on 100% fm
   ve: 11.3 l/min
   pao2 / fio2: 170
   physical examination
   general: wd white male, intubated/sedated
   head, ears, nose, throat: endotracheal tube, og tube
   peerl
   chest: old trach scar
   lungs: few scattered rhonchi, symmetrical expansion
   cardiovascular: tachycardic, rr
   abdomen: distended, tympanic,  tender to palpation epig, no
   guarding/rebound
   ext: no cce
   skin: normal turgor
    neurologic: sedated, responds to pain
   labs / radiology
   270
   0.8
   12
   22-->16
   104
   4 (3.8)
   142 (135)
        [image002.jpg]
                             [**2201-9-5**]  07:46 pm
   wbc
                                 23.7-->24.6
   hct
                                  38->-42.8
   plt
                                     332
   tc02
                                     20
   other labs: pt / ptt / inr:13.4/29.5/1.1, ck / ckmb /
   troponin-t:176/2/<0.01, alt / ast:55/59, alk phos / t bili:83/0.6,
   amylase / lipase:376-->[**telephone/fax (1) 1368**]-->1292, lactic acid:3.9 mmol/l,
   ca++:8.2, mg++:1.2
   fluid analysis / other labs: ag 16-->22 this am-->18 this afternoon
   ldh 216
   lactate: 3.2-->1.8-->4.2
   imaging: abd/pelvic ct: extensive pancreatitis
   cxr this afternoon pre-intub: limited inspiration with atelectasis.
   post intub: ett1.5 above carina (will pull); +effusions
   ecg: pseudonormalization of biphasic t waves v3-6
   assessment and plan
   etoh pancreatitis: on ed arrival, had relatively low [**name (ni) 1369**] criteria,
   but acutely worsening status since admission.
     *fluid resuscitation; bowel rest
     *surgery consulted
     *question of whether pt has necrotic pancreatitis, which could not be
   assessed on last scan due to lack of iv contrast
         [**hospital 1370**] medical chart. recently, pt had gotten ct's without iv
   contrast due to history of shellfish allergy, although he actually got
   an iv contrasted ct in [**2194**] with no mention of adverse events in his
   discharge summary. discussed with surgery, radiology and reviewed
   uptodate literature on association between iodine and shellfish (not
   believed to be a definite association). given his critically ill
   status, feel a ct is indicated but will still pre-med with h1/h2
   blockers and 1 dose of steroids
   acute resp failure: electively intubated given worsening resp distress
   with plans for further resucitation. abg pending
   etoh abuse: previously, concern for dt's. now on midazolam/fentanyl gtt
   will titrate
   lactate acidosis: mild improvement after additional fluid resuscitation
   fen: repleting mg. on bowel rest; will event. need tpn
   chronic pain: hold usual meds; receiving fentanyl gtt
   access: needs cvl
   icu care
   nutrition:
   glycemic control:
   lines / intubation:
   18 gauge - [**2201-9-5**] 06:37 pm
   20 gauge - [**2201-9-5**] 06:37 pm
   22 gauge - [**2201-9-5**] 06:58 pm
   comments:
   prophylaxis:
   dvt:
   stress ulcer:
   vap: hob elevation, mouth care
   comments:
   communication:  comments:
   code status: full code
   disposition:
   total time spent:
   patient is critically ill
"
248,"chief complaint:  abdominal pain
   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:
   37 year old male with hx alcoholic pancreatitis s/p distal pancr.
   presented after 4 wk alcohol binge with n/v/abd pain no hematemsis.
   last drink 24 h before admission. no cp/f/sob/tremors
   in ed 97.6, 76, 145/84, r 20, sats 96% ra. received 4 liters ivf;
   levaquin/flagyl, dilaudid and transferred to floor. ct abd without
   contrast confirmed pancreatitis.
      on floor, rec'd 2.5 liters fluid but became hypoxic, tachycardic,
   agitated. repeat labs showed worsening acidosis and increasing lactate.
   transferred here with p140, rr 26, sats 96% on 100% fm
   patient admitted from: [**hospital1 19**] [**hospital1 158**]
   patient unable to provide history: sedated/intubated
   allergies:
   shellfish
   anaphylaxis;
   topamax (oral) (topiramate)
   diarrhea;
   augmentin (oral) (amox tr/potassium clavulanate)
   diarrhea;
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   wellbutrin, fioricet [**hospital1 7**] prn, klonipin, gemfibrozil, methadone,
   oxycodone, seroquel, zanaflex, advair, flovent, albuterol
   past medical history:
   family history:
   social history:
   hx etoh pancreatitis [**2194**] c/b ards, splenic hematoma s/p splenectomy
   gerd
   htn
   osa not on cpap
   chronic pain
   hyper triglycridemia
   hx etoh withdrawals/dt's
   ruq abscess s/p draininge
   asthma
   depression hx suicide attempts (last age 18)
   occupation:
   drugs:
   tobacco: former 17 pack year history
   alcohol: ++. [**6-26**] drinks daily recently
   other: lives with mother and sister
   review of systems:
   constitutional: no(t) fatigue, no(t) weight loss
   eyes: no(t)  blurry vision, no(t) conjunctival edema
   ear, nose, throat: no(t) dry mouth, no(t) epistaxis, no(t) og / ng tube
   cardiovascular: no(t) chest pain, no(t) palpitations, no(t) edema
   nutritional support: no(t) tube feeds, no(t) parenteral nutrition
   respiratory: no(t) dyspnea, no(t) wheeze
   gastrointestinal: abdominal pain, nausea, emesis, no(t) diarrhea, no(t)
   constipation
   genitourinary: no(t) dysuria
   musculoskeletal: no(t) joint pain, no(t) myalgias
   integumentary (skin): no(t) jaundice, no(t) rash
   endocrine: no(t) hyperglycemia, no(t) history of thyroid disease
   heme / lymph: no(t) lymphadenopathy, no(t) coagulopathy
   neurologic: no(t) numbness / tingling, no(t) headache
   psychiatric / sleep: no(t) agitated, no(t) suicidal
   allergy / immunology: no(t) immunocompromised
   flowsheet data as of [**2201-9-5**] 09:58 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 37.4
c (99.4
   tcurrent: 37.4
c (99.4
   hr: 147 (142 - 147) bpm
   bp: 145/110(115) {145/103(109) - 150/110(115)} mmhg
   rr: 26 (26 - 26) insp/min
   spo2: 90%
             total in:
             1,205 ml
   po:
             tf:
   ivf:
   1,205 ml
   blood products:
   total out:
                                                                      0 ml
                                                                    600 ml
   urine:
   600 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    605 ml
   respiratory
   o2 delivery device: endotracheal tube
   spo2: 90%
   abg: 7.39/30/54 on 2 liters; 7.37/33/102 on 100% fm
   ve: 11.3 l/min
   pao2 / fio2: 170
   physical examination
   general: wd white male, intubated/sedated
   head, ears, nose, throat: endotracheal tube, og tube
   peerl
   chest: old trach scar
   lungs: few scattered rhonchi, symmetrical expansion
   cardiovascular: tachycardic, rr
   abdomen: distended, tympanic,  tender to palpation epig, no
   guarding/rebound
   ext: no cce
   skin: normal turgor
    neurologic: sedated, responds to pain
   labs / radiology
   270
   0.8
   12
   22-->16
   104
   4 (3.8)
   142 (135)
        [image002.jpg]
                             [**2201-9-5**]  07:46 pm
   wbc
                                 23.7-->24.6
   hct
                                  38->-42.8
   plt
                                     332
   tc02
                                     20
   other labs: pt / ptt / inr:13.4/29.5/1.1, ck / ckmb /
   troponin-t:176/2/<0.01, alt / ast:55/59, alk phos / t bili:83/0.6,
   amylase / lipase:376-->[**telephone/fax (1) 1368**]-->1292, lactic acid:3.9 mmol/l,
   ca++:8.2, mg++:1.2
   fluid analysis / other labs: ag 16-->22 this am-->18 this afternoon
   ldh 216
   lactate: 3.2-->1.8-->4.2
   imaging: abd/pelvic ct: extensive pancreatitis
   cxr this afternoon pre-intub: limited inspiration with atelectasis.
   post intub: ett1.5 above carina (will pull); +effusions
   ecg: pseudonormalization of biphasic t waves v3-6
   assessment and plan
   etoh pancreatitis: on ed arrival, had relatively low [**name (ni) 1369**] criteria,
   but acutely worsening status since admission.
     *fluid resuscitation; bowel rest
     *surgery consulted
     *question of whether pt has necrotic pancreatitis, which could not be
   assessed on last scan due to lack of iv contrast
         [**hospital 1370**] medical chart. recently, pt had gotten ct's without iv
   contrast due to history of shellfish allergy, although he actually got
   an iv contrasted ct in [**2194**] with no mention of adverse events in his
   discharge summary. discussed with surgery, radiology and reviewed
   uptodate literature on association between iodine and shellfish (not
   believed to be a definite association). given his critically ill
   status, feel a ct is indicated but will still pre-med with h1/h2
   blockers and 1 dose of steroids
   acute resp failure: electively intubated given worsening resp distress
   with plans for further resucitation. abg pending
   etoh abuse: previously, concern for dt's. now on midazolam/fentanyl gtt
   will titrate
   lactate acidosis: mild improvement after additional fluid resuscitation
   fen: repleting mg. on bowel rest; will event. need tpn
   chronic pain: hold usual meds; receiving fentanyl gtt
   access: needs cvl
   icu care
   nutrition:
   glycemic control:
   lines / intubation:
   18 gauge - [**2201-9-5**] 06:37 pm
   20 gauge - [**2201-9-5**] 06:37 pm
   22 gauge - [**2201-9-5**] 06:58 pm
   comments:
   prophylaxis:
   dvt: hep sq
   stress ulcer: iv ppi
   vap: hob elevation, mouth care
   comments:
   communication:  comments:
   code status: full code
   disposition: icu
   total time spent: 80 minutes
   patient is critically ill
"
249,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: intermittently opens eyes and possibly answers
   yes/no questions. waxing and [**doctor last name 533**]. no focal signs.
   - f/u 24 hour eeg (completed yesterday at noon)
   - avoid sedating meds
   - check abg this morning for acid/base abnormalities
   .
   # ileus: abdomen protruberant but not distended. good stool output.
   tolerating tube feeds
   - continue tube feeds
   - serial abdominal exam
   - kub prn if redistends
   # a fib/flutter: on digoxin and labetalol, nifedipine d/c
   historically difficult to control, s/p ablation. takes sotalol as
   outpatient
   - c/w daily digoxin
   - verify therapeutic dig levels
   - increase labetalol to 600 mg tid
   - ep consult today
   # fevers: daily low-grade fevers. infectious workup unrevealing, aside
   from past mrsa in sputum. dvt may represent source
   - will send c. diff given new stool output (low index of suspicion for
   infection)
   # dvt: on heparin gtt since yesterday. non occluding thrombi per u/s
   report. [**month (only) 51**] represent source of fevers.
   - c/w conservative heparin gtt for goal ptt 60-80, given recent ich
   - serial neuro exams to detect early re-bleed
   - d/w neurosurg long-term oral anti-coagulation
   # hypertension: on ace/[**last name (un) **] as outpatient, these have been held for [**last name (un) **]
   during hospitalization. given plateau in creatinine improvement, he may
   have new baseline and may warrant re-initiation of ace/[**last name (un) **] therapy
   - pending ep recs, start short acting captopril
   - continue labetalol as above
   # mrsa pneumonia: on day 12 of 14 day vanco course. respiratory status
   stable.
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   - follow periodic abgs
   # aocki: creatinine has plateaued at 1.5, with historical baseline of
   1.2. [**month (only) 51**] represent new baseline. good urine output
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # skull fracture/sah/sdh: course of cipro/dexamethasone ear drops now
   complete. ct unrevealing for worsening or new fractures.
   # etoh: holding benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: added standing glargine to sliding scale for elevated
   fingersticks; glipizide held
   # fen: tube feeds. dobhoff to be placed today
   # proph: pantoprazole, heparin gtt
   # access: triple lumen, right radial line, picc
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 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
   resident note, including the assessment and plan.  68m with etoh,
   s/p fall with ich, course c/b ams, difficult to control a-fib, resp
   failure now extubated, low grade fevers. leni with dvt, started on hep
   gtt. continue titrating labetolol for improved heart rate control.
   100.8--> 96.2  100  135/71  24  98% nc
   somnolent, awake intermittently, not following commands
   scant basilar rales
   [**last name (un) **], tachy
   distended, + bs, soft and nt
   2+ edema
   7.43/39/79  wbc 9.4  hct 11.2  cr 1.5 inr 1.2
   cxr with new picc in position, l basilar atelectasis/sm eff, no sig
   change
   in a-fib/flutter. hr control remains suboptimal.  will
   uptitrate labetolol, continuing dig, level pending, ep consulted for
   additional input.  bp control also remains suboptimal, consider
   resuming ace-i monitoriing renal function closely. his acute on cri is
   improving, cr possibly at new baseline, urine outpt remains
   adequate.  will adjust meds/ vanco dosing for improving gfr.  his ms
   remains altered--? delirium, neuro is following, eeg is pending, no
   evidence of new ic process on repeat imaging.   will check abg to r/o
   co2 retention/narcosis. he is on vanco day [**12-13**] for mrsa pna. he
   continues to have low grade fevers, no leukocytosis, ? [**2-1**] dvt.  now on
   heparin.  infection w/u has otherwise been unremarkable. will send c
   diff given stool output. he is tolerating tfs well.    follow abd
   exams, kubs for abd distention.  continue glargine and ssi for improved
   bs control.  icu: ppi, hep gtt, picc. pt following. continue case
   management screening/ for rehab.
   remainder of plan as outlined in resident note.
   patient is critically ill
   total time: 50 min
   ------ protected section addendum entered by:[**name (ni) 215**] [**last name (namepattern1) 216**], md
   on:[**2129-2-8**] 15:54 ------
"
250,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: seems more alert, eyes open, tracking, trying
   to speak
   - f/u 24 hour eeg (completed yesterday at noon)
   .
   # hypernatremia: serum [na+] 146
 144
   -  continue with free water po and flushes with tube feeds
   - check pm lytes.
   - note urine osmolality not c/w di
   # ileus: good stool output, ileus resolving. just written for tubefeeds
   but can start to take occasional gentle po
   - continue tube feeds
 when mental status improved, will order
   speech/swallow evaluation and advance diet as tolerated
   - serial abdominal exam
   # a fib/flutter: loaded with digoxin, also continues on esmolol gtt.
   known to be difficult to rate control in past.
   - c/w daily po digoxin
   - discontinue esmolol gtt today
   # hypertension:
   - continue labetalol po and will increase to tid today if becomes more
   hypertensive with esmolol off
   - continue nifedipine po
   # respiratory failure: respiratory status stable, with reasonable abgs
   now extubated
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   # [**last name (un) **]: creatinine improvement continuing
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # rash: cefepime has been d/c
d, rash resolved.
   # skull fracture: course of cipro/dexamethasone ear drops now complete
   # sah/sdh: ct unrevealing for worsening or new fractures.
   # etoh: now beyond duration during which withdrawal expected. holding
   benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: increased sliding scale for elevated fingersticks;
   glipizide held
   # fen: tube feeds now
   # proph: pantoprazole, pneumoboots
   # access: triple lumen, right radial line
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status: full code
   disposition:
"
251,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   physical examination
   general: intubated, opens eyes to verbal stimulus, can squeeze fingers
   and barely wiggle toes on command
   heent: sclera anicteric, dried blood in op and nares. mmm
   neck: supple
   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
   gu: no foley
   ext: 1+ edema b/l warm, well perfused, rue dsg c/d/i. cap refill <3 sec
   bl.
   labs / radiology
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
 bacteremia
   assessment and plan
   61 year old female with biphenotypic leukemia admitted with persistent
   neutropenia and high grade vre bacteremia attributed to line infection
   and septic thrombophlebitis now pod #0 s/p excision right basilic [**hospital 13196**]
   transferred from or intubated with transient hypotension.
   .
   # hypotension: resolved at present. most concerning for evolving sepsis
   given known bacteremia and immunocompromised status. cardiogenic,
   hypovolemic, or obstructive etiology less likely.
   - no need for bolus at present give pt is normotensive
   - if needed, would bolus with 1l d5 3amps bicarb as resuscitation fluid
   given renal failure metabolic acidosis and maintain map>65
   - changed sedation from propofol to dexmedetomidine to decrease
   hypotension, but weaning sedation nonetheless
   - maintain pivs, would like to avoid central access if possible given
   need for line holiday given high grade vre bacteremia
   - broad abx (dapto and zosyn) as below
   - if pressors/central line needed, will discuss placing hd catheter
   with vip port with renal since likely to need hd
   - if hd needed will need hd catheter placed, will d/w reanl
   # vre bacteremia: patient with high grade vre bacteremia but recent
   blood cx [**2-9**] ngtd and now has had removal of one source of infection
   (basilic vein) as well as picc. could also consider endocarditis as
   possibility but tte negative
   - continue daptomycin per id recommendations; continue zosyn for broad
   coverage and fever and neutropenia
   - appreciate id recommendations
   - consider adding linezolid if continues to have positive blood cx or
   increased mic to dapto
   - consider tee while intubated but unlikely to currently change
   management, will make sure to discuss with bmt and id
   # anuric arf: patient with rapidly progressive renal failure last 48
   hours, likely related to atn from hypotension as well as gentamycin (3
   doses [**date range (1) 120**]). uop 275cc last 24 hours, previously 850cc prior 24
   hours. nephrology following and medicatiosn redosed for creatinine
   clearance, may need cvvh next 24-72 hours if remains anuric/oliguric.
   - avoid nephrotoxic agents
   - appreciate renal recommendations
   - if hypotensive again, recommend maintaining renal perfusion and
   correct metaboli acidosis with boluses d5 with bicarb
   - renally dose meds, will discuss holding acyclovir with bmt
   # intubation: kept intubated overnight for white cell infusion. patient
   remained post-operatively intubated for unclear reasons. per
   anesthesia, had tachypnea pre-op but cxr relatively clear and without
   infiltrate other than possible pulmonary edema but difficult to
   interpret in setting of low lung volumes. oxygen saturations 100% on
   60%.
   - decrease fio2 to 40% and check abg
   - change to psv ventilation
   - short acting sedation to enable probable extubation in am
   - will wait to make sure no procedures need to be completed before
   extubation, will d/w consulting teams
   #) biphenotypic leukemia/pancytopenia: wbc improved from 0.2 to 0.5
   after infusion. patient is s/p hyper cvad x 2, mec and clofarabine and
   ara-c, now with persistent neutropenia and thrombocytopenia and
   decreased ability to clear infection and bacteremia.
   - monitor cbc w/diff after granulocyte infusion
   - maintain an active type and screen
   - transfuse for platelets<10,000 or any signs of bleeding and hct<24
   - touch base with renal and bmt if we should continue ppx with
   voriconazole and acyclovir
   - continue neupogen
   #) h/o positive ppd: continue prior regimen of moxifloxacin 400mg daily
   as per prior id recs
   # fen: npo, replete lytes, bolus 1l d5w with bicarb
   # ppx: pneumoboots and thrombocytopenia, ppi
   access: peripherals
   code:  full confirmed with patient and husband
   communication: [**name2 (ni) **]
   disposition: pending clinical improvement
   icu care
   nutrition:
   glycemic control: blood sugar well controlled
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   prophylaxis:
   dvt: boots
   stress ulcer: ppi
   vap: hob elevation, mouth care, daily wake up, rsbi
   comments:
   communication: icu consent signed comments:
   code status:
   disposition:
"
252,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   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
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
   assessment and plan
   61 year old female with biphenotypic leukemia admitted with persistent
   neutropenia and high grade vre bacteremia attributed to line infection
   and septic thrombophlebitis now pod #0 s/p excision right basilic [**hospital 13196**]
   transferred from or intubated with transient hypotension
   .
   # hypotension: patient initially transferred to [**hospital unit name 1**] with hypotension
   on peripheral neo but upon arrival, weaned off pressors immediately
   with maps in 60s. hypotension most likely related to sedation intra-op
   but also concerning for evolving sepsis given known bacteremia and
   immunocompromised status. cardiogenic or obstructive etiology less
   likely.
   - bolus with 1l d5 3amps bicarb as resuscitation fluid given renal
   failure and maintain map>65
   - change sedation from propofol to dexmedetomidine to decrease
   hypotension
   - maintain pivs, would like to avoid central access if possible given
   need for line holiday
   - broad abx (dapto and zosyn) as below
   - if pressors/central line needed, will discuss placing hd catheter
   with vip port with renal since likely to need hd
   # vre bacteremia: patient with high grade vre bacteremia but recent
   blood cx [**2-9**] ngtd and now has had removal of one source of infection
   (basilic vein) as well as picc. could also consider endocarditis as
   possibility but tte negative
   - continue daptomycin per id recommendations; continue zosyn for broad
   coverage and fever and neutropenia
   - appreciate id recommendations
   - consider adding linezolid if continues to have positive blood cx or
   increased mic to dapto
   - consider tee while intubated but unlikely to currently change
   management
   # arf: patient with rapidly progressive renal failure last 48 hours,
   likely related to atn from hypotension as well as gentamycin (3 doses
   [**date range (1) 120**]). uop 275cc last 24 hours, previously 850cc prior 24 hours.
   nephrology following and medicatiosn redosed for creatinine clearance,
   may need cvvh next 24-72 hours if remains anuric/oliguric.
   - avoid nephrotoxic agents
   - appreciate renal recommendations
   - maintain renal perfusion and correct metaboli acidosis with boluses
   d5 with bicarb
   - renally dose meds, will discuss holding acyclovir with bmt
   # intubation: patient remains intubated for unclear reasons. per
   anesthesia, had tachypnea pre-op but cxr relatively clear and without
   infiltrate other than possible pulmonary edema but difficult to
   interpret in setting of low lung volumes. oxygen saturations 100% on
   60%. no reason to expect she will be difficult to extubate but given
   granulocyte infusion overnight will keep intubated for now for airway
   protection and risk of hemodynamic instability
   - decrease fio2 to 40% and check abg
   - change to psv ventilation
   - short acting sedation to enable extubation in am
   #) biphenotypic leukemia/pancytopenia: patient is s/p hyper cvad x 2,
   mec and clofarabine and ara-c, now with persistent neutropenia and
   thrombocytopenia and decreased ability to clear infection and
   bacteremia
   - granulocyte infusion overnight per bmt recommendations with
   premedication and cbc pre and post
   - maintain an active type and screen
   - transfuse for platelets<10,000 or any signs of bleeding and hct<24
   - continue ppx with voriconazole and acyclovir
   - continue neupogen
   #) h/o positive ppd: continue prior regimen of moxifloxacin 400mg daily
   as per prior id recs
   # fen: npo, replete lytes, bolus 1l d5w with bicarb
   # ppx: pneumoboots and thrombocytopenia, ppi
   access: peripherals
   code:  full confirmed with patient and husband
   communication: [**name2 (ni) **]
   disposition: pending clinical improvement
   icu care
   nutrition:
   glycemic control: blood sugar well controlled
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   prophylaxis:
   dvt: boots
   stress ulcer: ppi
   vap: hob elevation, mouth care, daily wake up, rsbi
   comments:
   communication: icu consent signed comments:
   code status:
   disposition:
   icu care
   nutrition:
   glycemic control:
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   arterial line - [**2150-2-11**] 10:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
"
253,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: intermittently opens eyes and possibly answers
   yes/no questions. waxing and [**doctor last name 533**]. no focal signs.
   - f/u 24 hour eeg (completed yesterday at noon)
   - avoid sedating meds
   - check abg this morning for acid/base abnormalities
   .
   # ileus: abdomen protruberant but not distended. good stool output.
   tolerating tube feeds
   - continue tube feeds
   - serial abdominal exam
   - kub prn if redistends
   # a fib/flutter: on digoxin and labetalol, nifedipine d/c
   historically difficult to control, s/p ablation. takes sotalol as
   outpatient
   - c/w daily digoxin
   - verify therapeutic dig levels
   - increase labetalol to 600 mg tid
   - ep consult today
   # fevers: daily low-grade fevers. infectious workup unrevealing, aside
   from past mrsa in sputum. dvt may represent source
   - will send c. diff given new stool output (low index of suspicion for
   infection)
   # dvt: on heparin gtt since yesterday. non occluding thrombi per u/s
   report. [**month (only) 51**] represent source of fevers.
   - c/w conservative heparin gtt for goal ptt 60-80, given recent ich
   - serial neuro exams to detect early re-bleed
   - d/w neurosurg long-term oral anti-coagulation
   # hypertension: on ace/[**last name (un) **] as outpatient, these have been held for [**last name (un) **]
   during hospitalization. given plateau in creatinine improvement, he may
   have new baseline and may warrant re-initiation of ace/[**last name (un) **] therapy
   - pending ep recs, start short acting captopril
   - continue labetalol as above
   # mrsa pneumonia: on day 12 of 14 day vanco course. respiratory status
   stable.
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   - follow periodic abgs
   # aocki: creatinine has plateaued at 1.5, with historical baseline of
   1.2. [**month (only) 51**] represent new baseline. good urine output
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # skull fracture/sah/sdh: course of cipro/dexamethasone ear drops now
   complete. ct unrevealing for worsening or new fractures.
   # etoh: holding benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: added standing glargine to sliding scale for elevated
   fingersticks; glipizide held
   # fen: tube feeds. dobhoff to be placed today
   # proph: pantoprazole, heparin gtt
   # access: triple lumen, right radial line, picc
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status: full code
   disposition:
"
254,"chief complaint: reason for micu transfer: post-operative hypotension,
   remains intubated
   .
   chief complaint: vre bacteremia
   24 hour events:
 arterial line - start [**2150-2-11**] 10:00 pm
   -white cell transfusion without significant adverse events (received
   hydrocortisone 50 x 1)
   -pt with some hypotension overnight during transfusion resolved with
   awakening and lr boluses
   -pressures stabled out by 3-4am
   patient unable to provide history: sedated
   allergies:
   morphine
   nausea/vomiting
   last dose of antibiotics:
   piperacillin/tazobactam (zosyn) - [**2150-2-12**] 06:00 am
   infusions:
   other icu medications:
   pantoprazole (protonix) - [**2150-2-12**] 07:45 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  [**2150-2-12**] 07:57 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**52**] am
   tmax: 36.3
c (97.4
   tcurrent: 36.3
c (97.4
   hr: 96 (77 - 113) bpm
   bp: 97/60(72) {82/53(63) - 154/94(119)} mmhg
   rr: 18 (13 - 26) insp/min
   spo2: 99%
   heart rhythm: sr (sinus rhythm)
   wgt (current): 105.5 kg (admission): 105.5 kg
           total in:
                                                                  2,804 ml
                                                                  2,135 ml
   po:
           tf:
   ivf:
                                                                  2,339 ml
                                                                  1,726 ml
   blood products:
                                                                    375 ml
                                                                    259 ml
   total out:
                                                                     30 ml
                                                                      5 ml
   urine:
                                                                     30 ml
                                                                      5 ml
   ng:
   stool:
   drains:
   balance:
                                                                  2,774 ml
                                                                  2,130 ml
   respiratory support
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (set): 500 (500 - 500) ml
   vt (spontaneous): 579 (530 - 579) ml
   ps : 5 cmh2o
   rr (set): 14
   rr (spontaneous): 16
   peep: 5 cmh2o
   fio2: 40%
   rsbi: 30
   pip: 11 cmh2o
   spo2: 99%
   abg: 7.41/25/145/15/-6
   ve: 11 l/min
   pao2 / fio2: 363
   physical examination
   general: intubated, opens eyes to verbal stimulus, can squeeze fingers
   and barely wiggle toes on command
   heent: sclera anicteric, dried blood in op and nares. mmm
   neck: supple
   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
   gu: no foley
   ext: 1+ edema b/l warm, well perfused, rue dsg c/d/i. cap refill <3 sec
   bl.
   labs / radiology
   94 k/ul
   9.1 g/dl
   118 mg/dl
   2.8 mg/dl
   15 meq/l
   3.6 meq/l
   26 mg/dl
   101 meq/l
   135 meq/l
   26.0 %
   0.5 k/ul
        [image002.jpg]
                             [**2150-2-11**]  05:37 pm
                             [**2150-2-11**]  07:07 pm
                             [**2150-2-11**]  10:54 pm
                             [**2150-2-11**]  11:10 pm
                             [**2150-2-12**]  12:12 am
                             [**2150-2-12**]  02:20 am
                             [**2150-2-12**]  05:29 am
   wbc
   0.2
   0.1
   0.2
   0.5
   hct
   22.8
   22.0
   26.0
   27.0
   26.0
   plt
   89
   77
   84
   94
   cr
   2.7
   2.7
   2.8
   tco2
   18
   16
   glucose
   119
   124
   126
   118
   other labs: pt / ptt / inr:14.6/34.2/1.3, alt / ast:19/60, alk phos / t
   bili:126/1.2, differential-neuts:76.0 %, band:0.0 %, lymph:8.0 %,
   mono:16.0 %, eos:0.0 %, lactic acid:1.7 mmol/l, ldh:578 iu/l, ca++:7.9
   mg/dl, mg++:1.7 mg/dl, po4:4.1 mg/dl
   imaging: cxr ap [**2150-2-11**] wetread:
   low lung volumes limit ett tip 3.5 cm from carina bihilar opacification
   likley pulmonary edema but could be mulifocal pna d/[**initials (namepattern4) **] [**last name (namepattern4) 2391**] 7:45p
   gwlms
   microbiology: blood cultures of [**3-12**], [**2-5**], [**2-6**], [**2-7**], [**2-8**], [**2-9**] have
   all been positive with vre or enterococcus yet to be confirmed vre.
   tissue from or phlebitis cultures still pending.
   assessment and plan
 .h/o hypotension (not shock)
 .h/o renal failure, acute (acute renal failure, arf)
 .h/o pancytopenia
 bacteremia
   assessment and plan
   61 year old female with biphenotypic leukemia admitted with persistent
   neutropenia and high grade vre bacteremia attributed to line infection
   and septic thrombophlebitis now pod #0 s/p excision right basilic [**hospital 13196**]
   transferred from or intubated with transient hypotension.
   .
   # hypotension: resolved at present. most concerning for evolving sepsis
   given known bacteremia and immunocompromised status. cardiogenic,
   hypovolemic, or obstructive etiology less likely.
   - no need for bolus at present give pt is normotensive
   - if needed, would bolus with 1l d5 3amps bicarb as resuscitation fluid
   given renal failure metabolic acidosis and maintain map>65
   - changed sedation from propofol to dexmedetomidine to decrease
   hypotension, but weaning sedation nonetheless
   - maintain pivs, would like to avoid central access if possible given
   need for line holiday given high grade vre bacteremia
   - broad abx (dapto and zosyn) as below
   - if pressors/central line needed, will discuss placing hd catheter
   with vip port with renal since likely to need hd
   - if hd needed will need hd catheter placed, will d/w reanl
   # vre bacteremia: patient with high grade vre bacteremia but recent
   blood cx [**2-9**] ngtd and now has had removal of one source of infection
   (basilic vein) as well as picc. could also consider endocarditis as
   possibility but tte negative
   - continue daptomycin per id recommendations; continue zosyn for broad
   coverage and fever and neutropenia
   - appreciate id recommendations
   - consider adding linezolid if continues to have positive blood cx or
   increased mic to dapto
   - consider tee while intubated but unlikely to currently change
   management, will make sure to discuss with bmt and id
   # anuric arf: patient with rapidly progressive renal failure last 48
   hours, likely related to atn from hypotension as well as gentamycin (3
   doses [**date range (1) 120**]). uop 275cc last 24 hours, previously 850cc prior 24
   hours. nephrology following and medicatiosn redosed for creatinine
   clearance, may need cvvh next 24-72 hours if remains anuric/oliguric.
   - avoid nephrotoxic agents
   - appreciate renal recommendations
   - if hypotensive again, recommend maintaining renal perfusion and
   correct metaboli acidosis with boluses d5 with bicarb
   - renally dose meds, will discuss holding acyclovir with bmt
   # intubation: kept intubated overnight for white cell infusion. patient
   remained post-operatively intubated for unclear reasons. per
   anesthesia, had tachypnea pre-op but cxr relatively clear and without
   infiltrate other than possible pulmonary edema but difficult to
   interpret in setting of low lung volumes. oxygen saturations 100% on
   60%.
   - decrease fio2 to 40% and check abg
   - change to psv ventilation
   - short acting sedation to enable probable extubation in am
   - will wait to make sure no procedures need to be completed before
   extubation, will d/w consulting teams
   #) biphenotypic leukemia/pancytopenia: wbc improved from 0.2 to 0.5
   after infusion. patient is s/p hyper cvad x 2, mec and clofarabine and
   ara-c, now with persistent neutropenia and thrombocytopenia and
   decreased ability to clear infection and bacteremia.
   - monitor cbc w/diff after granulocyte infusion
   - maintain an active type and screen
   - transfuse for platelets<10,000 or any signs of bleeding and hct<24
   - touch base with renal and bmt if we should continue ppx with
   voriconazole and acyclovir
   - continue neupogen
   #) h/o positive ppd: continue prior regimen of moxifloxacin 400mg daily
   as per prior id recs
   # fen: npo, replete lytes, bolus 1l d5w with bicarb
   # ppx: pneumoboots and thrombocytopenia, ppi
   access: peripherals
   code:  full confirmed with patient and husband
   communication: [**name2 (ni) **]
   disposition: pending clinical improvement
   icu care
   nutrition:
   glycemic control: blood sugar well controlled
   lines:
   20 gauge - [**2150-2-11**] 04:55 pm
   22 gauge - [**2150-2-11**] 06:36 pm
   prophylaxis:
   dvt: boots
   stress ulcer: ppi
   vap: hob elevation, mouth care, daily wake up, rsbi
   comments:
   communication: icu consent signed 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: 61f aml/all dx [**11-10**], neg bmbx p/w diarrhea,
   vomitting and vre bacteremia in the setting of septic picc-related
   thrombophlebitis. developed epistaxis and gib on heparin, sent to or
   yesterday for clot extraction. bp improved overnight but remains
   anuric, art line placed, granulocyte infusion well tolerated.
   exam notable for tm 97.4 bp 130/70 hr 110 rr 18 with sat 99 on psv 5/5,
   uop 20cc since midnight. ill appearing. coarse bs b. rrr s1s2 2/6sm.
   soft +bs. rue dressing c/d/i. soft +bs. 2+ edema. labs notable for wbc
   0.2k, hct 26, k+ 3.6, cr 2.8. cxr with low volumes.
   agree with plan to manage post-op respiratory failure with sbt now and
   potential extubation as her mental status resolves and procedures are
   completed. bp improved somewhat with volume, continue broad abx
   coverage for vre sepsis / febrile neutropenia. arf is progressive, hold
   off on further volume loading, rd meds and d/w bmt re holding acyclovir
   and placing vip hd line. for all/aml - nad on bmbx but pancytopenic s/p
   granulocyte infusion, continue gcsf, brc transfusion, platelets for
   procedures. continue moxifloxacin for +ppd. remainder of plan as
   outlined above.
   patient is critically ill
   total time: 35 min
   ------ protected section addendum entered by:[**name (ni) 453**] [**last name (namepattern1) 775**], md
   on:[**2150-2-12**] 04:53 pm ------
"
255,"pt well known, who was recently admitted to [**hospital1 1**] for hypoxic and
   hypercarbic respiratory failure after being found unresponsive at home
   by her husband, treated for pna with vanco/levo/zosyn, s/p trach after
   prolonged wean, course c/b arf and drug fever, transferred to [**hospital1 664**]
   on [**2193-2-17**]. transferred back to [**hospital1 **] [**2-21**], in ed abd ct done showing
   diffuse colitis, t101. transfer to micu for mgt bacteremia and resp
   failure
    early this am, pt becoming tachycardic throughout night, now hr
   120-130
s sinus. received mult ivf bolus
 despite this. her lactate is
   now up to 2.5 and wbc to 30. also hct from 20 to 30 despite fluid
   resuscitation.
   to ir today for hd line placed, placed rij with out adverse events.  ct
   abdomen today indicative of large amounts of free air.  pt to or for
   surgery.
   husband, [**name (ni) 851**], [**name (ni) 1850**], was very upset.  lives two hours away, likely
   en route here now.  this rn [**name (ni) 1850**] sw as pt was very distraught on
   phone and in prior discussions indicated no support systems.  sw
   [**name (ni) 1850**] husband by phone.  please note there is an on call sw until
   9pm this evening, that should have been made aware of mr. [**known lastname **] and
   can be paged to see him.
   respiratory failure, chronic
   assessment:
   pt trached on ac 60%/550/14/15 peep, small amts of  tan-yellow
   secretions, overbreathing vent to 20-30
s. vbg
s worsening slightly.
   action:
   suctioned q4 for thick tan-yellow secretions, mdi
s, pulm toilet
   response:
   sats 96-99%, rr 23-30
   plan:
   continue mech vent, wean as tolerated. follow sats/ vbgs
   fever (hyperthermia, pyrexia, not fever of unknown origin)/sepsis
   assessment:
   lactate trending up 2.7. pt still febrile,
   action:
    tylenol given.  cont. to monitor. cont. on abx. cont. trending
   lactate. cont. ivf.
   response:
   worsening septic picture. t down to 101.  tachycardic, tachypnic this
   am. lactate trending up.
   plan:
   cont. to monitor.
   colitis, c-diff
   assessment:
   pt with ct showing diffuse colitis, peg clamped, bs hypoactive, c/o abd
   pain/nausea on admission. noted rebound tenderness on exam.  c-dff +
   results.  liquid golden, foul smelling stool.  noted hemoconcentration,
   despite multiple ivf bolus
   action:
   to ct, study indicative of large amounts of free air, to or for
   perforated bowel.  neo. gtt for low u/o and map.  and pt has become
   increasingly tachycardic.  vanco enemas, po as well continues on iv
   lasix.  tf on hold.
   response:
   c. diff +.stool  guiac negative; continue to hold tf, denies nausea.
   plan:
   or then tosicu. cont. abx therapy. supportive care.
   impaired skin integrity
   assessment:
   pt now on air bed, using assistive devices to turn pt more freq. noted
   new area on left (favors this side) mid back blistering since
   yesterday. allevyn dressing applied to blistering area.
   action:
   turning q2-4 now w/devices in place to assist.
   response:
   cont freq turns.
"
256,"chief complaint:  angioedema
   hpi:
   pt is an 85 y/o f with a h/o gave s/p argon treatment last on [**2150-3-11**],
   iron deficiency anemia, cirrhosis [**1-19**] hepc, portal htn/grade 1 varices
   but no hx of bleeding varices, cri (baseline cr = 1.2-1.5) who is
   transfered from [**hospital3 2546**] intubated s/p angioedema. the following
   history is obtained from her son as the patient is intubated. he states
   that she reported some mild abdominal pain and some irritation in her
   throat a day prior to admission to [**hospital3 2546**]. the following
   morning she called her son with complaints of oral swelling; son states
   that her speach was garbled. the son reports that the patient denies
   having had any sob, no wheezing, no hives. he called an abmulance who
   transported the pt to [**hospital3 2546**].
   .
   per omr, the patient present to [**hospital1 1**] pheresis unit on [**2150-4-10**] for
   blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications given and no adverse events; vitals on leaving
   the unit were 97.4 - 67 - 119/55. she has also been recently treated
   for a uti with bactrim started on [**2150-4-3**].
   .
   at st elizabeths', she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate in the ed and she
   was taken to the or. laryngeal edema was noted, but the et tube was
   passed successfully. she was then transfered to the ccu. she received
   hydroxyzine tid and her tongue swelling improved. sbt was attempted
   early on but failed likely secondary to sedation. per report, pt did
   have a cuff leak. family requested transfer to [**hospital1 1**] as pt receives all
   her care here.
   patient admitted from: transfer from other hospital
   history obtained from family / [**hospital 380**] medical records
   patient unable to provide history: language barrier
   allergies:
   nsaids
   please avoid du
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   home medications:
   felodipine - 5 mg tablet sustained release 24 hr - 3 tablet(s) by mouth
   once a day (2 tabs in a.m. and 1 tab in the p.m
   folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day
   furosemide [lasix] - 40 mg tablet - 1 tablet(s) by mouth once a day
   hydrocortisone acetate [anusol-hc] - 25 mg suppository - one rectally
   daily
   lactulose -  (prescribed by other provider) - 10 gram/15 ml solution -
   15 ml by mouth once a day for encephalopathy; goal of [**2-18**] bms qd
   metformin - 500 mg tablet - 2 (two) tablet(s) by mouth every morning
   and one tablet every evening.
   mupirocin - 2 % ointment - topical twice a day as needed for lesion or
   rash
   nadolol - 80 mg tablet - 1 (one) tablet(s) by mouth qam
   pantoprazole - 40 mg tablet, delayed release (e.c.) - one tablet(s) by
   mouth twice daily
   spironolactone [aldactone] - 50 mg tablet - one tablet(s) by mouth
   daily
   sucralfate - 1 gram tablet - 1 tablet(s) by mouth thre times per day
   zolpidem [ambien] - 5 mg tablet - 1/4-1 tablet(s) by mouth at bedtime
   as needed for insomnia
   calcium carbonate-vitamin d2 [oyster shell calcium-vit d3] - 500 mg-375
   unit tablet - 1 (one) tablet(s) by mouth twice a day
   cyanocobalamin - 500 mcg tablet - 1 tablet(s) by mouth once a day
   ferrous gluconate - 325 mg tablet - 1 tablet(s) by mouth 5 times a day
   pramoxine-menthol-petrolatum [sarna ultra] - 1 %-0.5 %-30 % cream -
   apply to affected areas one to two times per day
   past medical history:
   family history:
   social history:
   # gave - s/p argon treatment, last on last on [**2150-3-11**]
   # hepatitis c
   # cirrhosis
   - child's class a, portal htn, grade 1 varices
   - no h/o ascites, encephalopathy, variceal bleeding, synthetic
   function intact
   # dm type ii
   # htn
   # iron deficiency anemia
   # s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
   # hypercholesterolemia
   # osteopenia
   # insomnia
   no hx angioedema
   occupation:
   drugs:
   tobacco:
   alcohol:
   other: lives alone in [**location (un) 2471**] in [**hospital3 718**] complex. is widowed.
   has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
   holidays). worked in food business in sales.
   review of systems:
   flowsheet data as of [**2150-4-16**] 08:21 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 35.8
c (96.4
   tcurrent: 35.8
c (96.4
   hr: 84 (84 - 95) bpm
   bp: 119/53(69) {119/53(69) - 127/56(74)} mmhg
   rr: 19 (19 - 26) insp/min
   spo2: 96%
   heart rhythm: sr (sinus rhythm)
                  total in:
                  po:
                  tf:
   ivf:
   blood products:
   total out:
                                                                      0 ml
                                                                     50 ml
   urine:
   50 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    -50 ml
   respiratory
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (spontaneous): 398 (398 - 398) ml
   ps : 10 cmh2o
   rr (spontaneous): 25
   peep: 5 cmh2o
   fio2: 50%
   pip: 16 cmh2o
   spo2: 96%
   ve: 11.5 l/min
   physical examination
   gen: intubated awake alert with tube in place
   heent: ncat,oropharynx clear and without erythema or exudate, tongue is
   normal sized w/o any edema
   neck: supple, no lad, no appreciable jvd
   cv: rrr, normal s1s2, [**12-23**] holosystolic blowing murmur at apex.
   pulm: ctab, no w/r/r, good air movement bilaterally
   abd: soft, obese, ntnd, easily reduced umbilical hernia,
   normoactive bowel sounds, no organomegaly
   ext: warm and well perfused, full and symmetric distal pulses,
   no pedal edema
   neuro: awake, alert
   skin; no hives
   labs / radiology
   140
   1.1
   47
   22
   107
   5.5
   135
   32.5
   7.8
        [image002.jpg]
   assessment and plan:
   assessment and plan:  pt is an 85 y/o f with a h/o gave s/p argon
   treatment last on [**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc,
   portal htn/grade 1 varices but no hx of bleeding varices, cri (baseline
   cr = 1.2-1.5) who is transfered from [**hospital3 2546**] intubated s/p
   angioedema.
   .
   # angioedema: resoved. lack of hives, bronchospasm or hypotension
   suggests that this was not allergic angioedema but rather bradykinin
   related. c3 and c4 were low. c1 esterase inh pending, [**doctor first name **] neg per
   allergy consult at [**hospital3 5692**], non-allergic angioedema is due to
   completment depletion ([**1-19**] hereditary or carelated) or complement
   activation (infection or transfusion). the patient did have a
   transfusion recently which may be related. medications would also be
   high on the list of etiologies.  nsaids? [**last name (un) 284**]?
   - cont hydroxyzine from one more day
   - check cuff leak and extubate in am
   - hold all non-essential possible culprit meds: [**last name (un) 284**], felodipine, lasix,
   nadolol, bactrim
   - f/u complement studies at [**hospital3 2546**]
   - consider allergy consult
   - contact blood bank re risk of angioedema with transfusion as pt will
   need future transfuse and may be at risk for recurrent episode
   .
   # hx  cirrhosis:
   - cont lactulose
   .
   #cri: baseline 1.5, was elevated on admission to [**hospital3 5692**] to 1.7 now
   down to 1.1
   - monitor.
   icu care
   nutrition:
   glycemic control:
   lines:
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
   ------ protected section ------
   i have seen and examined the patient with the resident and agree with
   the assessment and plan with the following modifications/changes:
   85 year old with resolving angioedema transferred from osh.  remains
   intubated at this time and is hemodynamically stable.
   per son, swelling of tongue much improved.
   a:
   1)       angioedema
   2)       respiratory failure secondary to angioedema
   p:
   1)       review med records for report of grade view of airway
   2)       extubation in the am
   critically ill
   time spent: 30 minutes
   ------ protected section addendum entered by:[**name (ni) **] [**last name (namepattern1) 402**], md
   on:[**2150-4-17**] 10:40 am ------
"
257,"pt is an 85 y/o f who was transferred from [**hospital3 2546**] intubated
   s/p angioedema. the following history is obtained from her son as the
   patient is intubated. he states that she reported some mild abdominal
   pain and some irritation in her throat a day prior to admission to [**hospital 5701**]. the following morning she called her son with complaints
   of oral swelling; son states that her speach was garbled. the son
   reports that the patient denies having had any sob, no wheezing, no
   hives. he called ems.
   per omr, the patient presented to the [**hospital1 1**] pheresis unit on [**2150-4-10**]
   for a blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications and no adverse events. she has also been
   recently treated for a uti with bactrim started on [**2150-4-3**].
   at [**hospital3 3091**], she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate the pt so she was
   taken to the or. laryngeal edema was noted, but the et tube was passed
   successfully. sbt was attempted early on but failed likely secondary to
   sedation. per report, pt did have a cuff leak. family requested
   transfer to [**hospital1 1**] as pt receives all of her care here.
   airway, inability to protect (risk for aspiration, altered gag, airway
   clearance, cough)
   assessment:
   rec
d intubated and vented on ps-5, peep-5, with good o2 sats and a+
   cuff-leak, rr-[**2-10**], l/s rhonchi. has a positive gag. no edema or
   swelling noted. is a&ox3.
   action:
   was extubated and placed on 50% cool neb, and able to wean to 3l np.
   advancing diet as tolerated
   response:
   stable s/p extubation, but requiring freq nebs for wheezes, no distress
   or stidor noted. l/s have improved.  taking po
s well, no problems
   swallowing.
   [**name2 (ni) 149**]:
   continue to assess respir status, monitor o2 sats, observe for
   swelling, advance diet as tolerated.
   demographics
   attending md:
   [**location (un) **] [**doctor first name **] a.
   admit diagnosis:
   tongue swelling
   code status:
   full code
   height:
   admission weight:
   58.6 kg
   daily weight:
   allergies/reactions:
   nsaids
   please avoid du
   precautions:
   pmh:  anemia, diabetes - oral [**doctor last name **], gi bleed, hepatitis
   cv-pmh:  hypertension
   additional history: hep c cirrhosis, portal htn w/ grade i varices,
   ascites, encephalopathy, variceal bleeding, dm 2, right renal
   nephrectomy for renal cell ca (15 yrs ago), hypercholesterolemia,
   osteopenia, insomnia,
   surgery / procedure and date:
   latest vital signs and i/o
   non-invasive bp:
   s:122
   d:54
   temperature:
   98.7
   arterial bp:
   s:
   d:
   respiratory rate:
   22 insp/min
   heart rate:
   85 bpm
   heart rhythm:
   sr (sinus rhythm)
   o2 delivery device:
   nasal cannula
   o2 saturation:
   96% %
   o2 flow:
   3 l/min
   fio2 set:
   50% %
   24h total in:
   655 ml
   24h total out:
   415 ml
   pertinent lab results:
   sodium:
   143 meq/l
   [**2150-4-17**] 05:15 am
   potassium:
   4.3 meq/l
   [**2150-4-17**] 05:15 am
   chloride:
   112 meq/l
   [**2150-4-17**] 05:15 am
   co2:
   24 meq/l
   [**2150-4-17**] 05:15 am
   bun:
   27 mg/dl
   [**2150-4-17**] 05:15 am
   creatinine:
   1.1 mg/dl
   [**2150-4-17**] 05:15 am
   glucose:
   132 mg/dl
   [**2150-4-17**] 05:15 am
   hematocrit:
   31.4 %
   [**2150-4-17**] 05:15 am
   finger stick glucose:
   159
   [**2150-4-17**] 06:00 pm
   valuables / signature
   patient valuables: none
   other valuables:
   clothes:  sent home with:
   wallet / money:
   no money / wallet
   cash / credit cards sent home with:
   jewelry:
   transferred from: micu-7
   transferred to: [**hospital ward name 4126**]
   date & time of transfer:  [**2150-4-17**] 1830
"
258,"chief complaint:  angioedema
   hpi:
   pt is an 85 y/o f with a h/o gave s/p argon treatment last on [**2150-3-11**],
   iron deficiency anemia, cirrhosis [**1-19**] hepc, portal htn/grade 1 varices
   but no hx of bleeding varices, cri (baseline cr = 1.2-1.5) who is
   transfered from [**hospital3 2546**] intubated s/p angioedema. the following
   history is obtained from her son as the patient is intubated. he states
   that she reported some mild abdominal pain and some irritation in her
   throat a day prior to admission to [**hospital3 2546**]. the following
   morning she called her son with complaints of oral swelling; son states
   that her speach was garbled. the son reports that the patient denies
   having had any sob, no wheezing, no hives. he called an abmulance who
   transported the pt to [**hospital3 2546**].
   .
   per omr, the patient present to [**hospital1 1**] pheresis unit on [**2150-4-10**] for
   blood transfusion for chronic slow upper gi bleeding. she had no
   pretreatment medications given and no adverse events; vitals on leaving
   the unit were 97.4 - 67 - 119/55. she has also been recently treated
   for a uti with bactrim started on [**2150-4-3**].
   .
   at st elizabeths', she was hd stable but had a large, edematous tongue.
   she recevied decadron, epinephrine, benadryl, famotidine and
   hydroxazine in the ed. the ed was unable to intubate in the ed and she
   was taken to the or. laryngeal edema was noted, but the et tube was
   passed successfully. she was then transfered to the ccu. she received
   hydroxyzine tid and her tongue swelling improved. sbt was attempted
   early on but failed likely secondary to sedation. per report, pt did
   have a cuff leak. family requested transfer to [**hospital1 1**] as pt receives all
   her care here.
   patient admitted from: transfer from other hospital
   history obtained from family / [**hospital 380**] medical records
   patient unable to provide history: language barrier
   allergies:
   nsaids
   please avoid du
   last dose of antibiotics:
   infusions:
   other icu medications:
   other medications:
   home medications:
   felodipine - 5 mg tablet sustained release 24 hr - 3 tablet(s) by mouth
   once a day (2 tabs in a.m. and 1 tab in the p.m
   folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day
   furosemide [lasix] - 40 mg tablet - 1 tablet(s) by mouth once a day
   hydrocortisone acetate [anusol-hc] - 25 mg suppository - one rectally
   daily
   lactulose -  (prescribed by other provider) - 10 gram/15 ml solution -
   15 ml by mouth once a day for encephalopathy; goal of [**2-18**] bms qd
   metformin - 500 mg tablet - 2 (two) tablet(s) by mouth every morning
   and one tablet every evening.
   mupirocin - 2 % ointment - topical twice a day as needed for lesion or
   rash
   nadolol - 80 mg tablet - 1 (one) tablet(s) by mouth qam
   pantoprazole - 40 mg tablet, delayed release (e.c.) - one tablet(s) by
   mouth twice daily
   spironolactone [aldactone] - 50 mg tablet - one tablet(s) by mouth
   daily
   sucralfate - 1 gram tablet - 1 tablet(s) by mouth thre times per day
   zolpidem [ambien] - 5 mg tablet - 1/4-1 tablet(s) by mouth at bedtime
   as needed for insomnia
   calcium carbonate-vitamin d2 [oyster shell calcium-vit d3] - 500 mg-375
   unit tablet - 1 (one) tablet(s) by mouth twice a day
   cyanocobalamin - 500 mcg tablet - 1 tablet(s) by mouth once a day
   ferrous gluconate - 325 mg tablet - 1 tablet(s) by mouth 5 times a day
   pramoxine-menthol-petrolatum [sarna ultra] - 1 %-0.5 %-30 % cream -
   apply to affected areas one to two times per day
   past medical history:
   family history:
   social history:
   # gave - s/p argon treatment, last on last on [**2150-3-11**]
   # hepatitis c
   # cirrhosis
   - child's class a, portal htn, grade 1 varices
   - no h/o ascites, encephalopathy, variceal bleeding, synthetic
   function intact
   # dm type ii
   # htn
   # iron deficiency anemia
   # s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
   # hypercholesterolemia
   # osteopenia
   # insomnia
   no hx angioedema
   occupation:
   drugs:
   tobacco:
   alcohol:
   other: lives alone in [**location (un) 2471**] in [**hospital3 718**] complex. is widowed.
   has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
   holidays). worked in food business in sales.
   review of systems:
   flowsheet data as of [**2150-4-16**] 08:21 pm
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since 12 am
   tmax: 35.8
c (96.4
   tcurrent: 35.8
c (96.4
   hr: 84 (84 - 95) bpm
   bp: 119/53(69) {119/53(69) - 127/56(74)} mmhg
   rr: 19 (19 - 26) insp/min
   spo2: 96%
   heart rhythm: sr (sinus rhythm)
                  total in:
                  po:
                  tf:
   ivf:
   blood products:
   total out:
                                                                      0 ml
                                                                     50 ml
   urine:
   50 ml
   ng:
   stool:
   drains:
   balance:
                                                                      0 ml
                                                                    -50 ml
   respiratory
   o2 delivery device: endotracheal tube
   ventilator mode: cpap/psv
   vt (spontaneous): 398 (398 - 398) ml
   ps : 10 cmh2o
   rr (spontaneous): 25
   peep: 5 cmh2o
   fio2: 50%
   pip: 16 cmh2o
   spo2: 96%
   ve: 11.5 l/min
   physical examination
   gen: intubated awake alert with tube in place
   heent: ncat,oropharynx clear and without erythema or exudate, tongue is
   normal sized w/o any edema
   neck: supple, no lad, no appreciable jvd
   cv: rrr, normal s1s2, [**12-23**] holosystolic blowing murmur at apex.
   pulm: ctab, no w/r/r, good air movement bilaterally
   abd: soft, obese, ntnd, easily reduced umbilical hernia,
   normoactive bowel sounds, no organomegaly
   ext: warm and well perfused, full and symmetric distal pulses,
   no pedal edema
   neuro: awake, alert
   skin; no hives
   labs / radiology
   140
   1.1
   47
   22
   107
   5.5
   135
   32.5
   7.8
        [image002.jpg]
   assessment and plan:
   assessment and plan:  pt is an 85 y/o f with a h/o gave s/p argon
   treatment last on [**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc,
   portal htn/grade 1 varices but no hx of bleeding varices, cri (baseline
   cr = 1.2-1.5) who is transfered from [**hospital3 2546**] intubated s/p
   angioedema.
   .
   # angioedema: resoved. lack of hives, bronchospasm or hypotension
   suggests that this was not allergic angioedema but rather bradykinin
   related. c3 and c4 were low. c1 esterase inh pending, [**doctor first name **] neg per
   allergy consult at [**hospital3 5692**], non-allergic angioedema is due to
   completment depletion ([**1-19**] hereditary or carelated) or complement
   activation (infection or transfusion). the patient did have a
   transfusion recently which may be related. medications would also be
   high on the list of etiologies.  nsaids? [**last name (un) 284**]?
   - cont hydroxyzine from one more day
   - check cuff leak and extubate in am
   - hold all non-essential possible culprit meds: [**last name (un) 284**], felodipine, lasix,
   nadolol, bactrim
   - f/u complement studies at [**hospital3 2546**]
   - consider allergy consult
   - contact blood bank re risk of angioedema with transfusion as pt will
   need future transfuse and may be at risk for recurrent episode
   .
   # hx  cirrhosis:
   - cont lactulose
   .
   #cri: baseline 1.5, was elevated on admission to [**hospital3 5692**] to 1.7 now
   down to 1.1
   - monitor.
   icu care
   nutrition:
   glycemic control:
   lines:
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status:
   disposition:
"
259,"patient extubated on [**2149-8-19**] without any adverse events. kept
   overnight for observation as the family would like to make her comfort
   measures only and have her transported home to be with them. this case
   has been followed closely by social services and case management,
   arrangement were made in collaboration with family members for hospice
   care at home and for oxygen therapy as needed.
   this morning it is the consensus of the medical team that the client is
   stable enough to be transported home via ambulance in the company of
   family. she left the unit at approximately 1030, discharge paper work
   completed and necessary documents given. the grand daughter of patient
   did collect home medications from the [**company **] pharmacy prior to
   leaving.
"
260,"clinician:  resident
   patient became acutely hypotensive during morning rounds.  he consented
   to central venous and arterial line placements.  the patient was
   prepped and draped in a sterile fashion for a left subclavian central
   venous line.  the vein was canulated, but resistance was met when
   threading the catheter.  this was concerning for a possible left
   subclavian clot and the procedure was aborted.  the patient was then
   reprepped for a right femoral central line, which was successfully
   placed without events.  additionally, a left radial arterial line was
   placed under sterile conditions without adverse events.  a
   post-procedure cxr was obtained given multiple attempts made for a left
   subclavian line; no pneumothorax or hemothorax was present.
"
261,"micu nsg, 7a -7p
events:  pt had neg epg in am, to angiography for head and neck angiogram in pm.

neuro:  essentially unchanged.  alert, oriented x2. perl.  expressive aphasia, answering mostly yes,no, occ. word answers.  follows commands.  has not moved right arm or hand today.  lifts right leg only slightly.  lifts and holds left arm and leg.  no c/o pain.  medicated w midazolam and fentanyl at 1115 for epg, no adverse events.

cv:  bp 140-168/72-77 w no antihypertensive medications.  hr 76-80, nsr, no ectopy.  repleted k, mag, calcium.  inr 1.1.  tmax 99.4.
hct stable and increasing w blood products.  0900 hct 28.1, repeat sent at 1500, next one due at 2100, q 6h.  received 1upc at 1000.

resp:  99-100% o2 sat on ra.  ls clear.  rr 19-22.

gi:  egp negative.  +bs.  no stool, but staining melena, passing gas.  ng tube in place w sm, yellow residual, ob neg.  npo except for meds.

endo:  2 u reg ins. for fs 135 per riss.

social:  visited by aunt [**name (ni) **] - spokesperson.  with [**doctor first name **], social worker and [**name (ni) **], pt decided to allow knowledge of herself out to [**name (ni) **], [**name (ni) **] (aunts), and [**name (ni) 5525**], her neice.  others are to get information from them.
gu/flds:  uo very adeq at 40-180/hr, cl,yel urine.  pt + 1500 today, 2675 los.

plan:  to have colonoscopy in micu [**doctor first name **] am, approx 1100.  monitor hcts for further bleeding.
"
262,"nursing progress note
events: pt intubated at approx 1300 for increasing lack of airway protection with no adverse events.

neuro: pt now sedated on propofol for toleration of ett. when lightened, pt remains unresponsive. pt has [**last name (un) **] cough and gag. opens eyes spontaneously, but does not focus. perrla, 3mm, brisk. does not respond to verbal stimulus. pt postures with all extremeties to noxious stimuli. non-purposeful movement (posturing) in all extremeties. pt does not appear to be in pain.

cv: nsr/st, rare ectopy. pt very hyperdynamic with stimuli/coughing. hr 80-120, sbp 100-170's. +pp. lytes repleted as ordered.

resp: cmv 500x12/5/50. abg wnl. sats 98-100%. rr 20-low 30's with sx'ing. ls coarse bilaterally. pt sx'd several times for copious amts thick white secretions.

gi: abd soft, nt, ascites. awaiting vac dsg to be placed by trauma team. ngt to lis draining min amts bilious fluid. +bs. pt had one sm soft brown bm this shift totaling approx 2 [**1-19**] for today. pt received lactulose x2.

gu: foley draining adequate amts clear [**location (un) **] urine.

endo: riss, no coverage required.

id: tm 101.1. pt started on kefzol this morning. also receiving rifaximin.

skin: midline abd incision stapled and ota. lower portion has staples removed and awaiting vac dsg to be placed by trauma team. [**location (un) **] straps in place, wound draining copious amts serous fluid. also, small blister on coccyx.

social: social work involved in trying to track down possible family members in [**male first name (un) 3106**] for decision making.

plan: cont neuro checks q4hrs. light sedation for ett tolerance. pulm toilet. titrate lactulose to 3 lrge bms per day. frequent labs and repletions. awaiting pending cx results. follow up with sw on gaurdianship.
"
263,"admission date:  [**2155-7-12**]              discharge date:   [**2155-7-16**]

date of birth:  [**2097-9-7**]             sex:   m

service: medicine

allergies:
simvastatin / tape / hydrochlorothiazide / eptifibatide /
cellcept / [**year (4 digits) **]

attending:[**first name3 (lf) 14820**]
chief complaint:
transfered from [**hospital 18112**] hospital for inferior myocardial
infarction.

major surgical or invasive procedure:
cardiac catheterization
rca stent


history of present illness:
this is a 57 year old man, with a past medical history of cabg
and pfo closure in [**12-24**], s/p renal transplant secondary to
wegeners vasculitis, who was transferred from an outside
hospital for an inferior myocardial infarction.  pt was having
chest pain and an electrocardiogram showed st segment changes in
the inferior leads which was consistent with an inferior mi.
patinet underwent cardiac catheterization ([**2155-7-13**]) with
stenting for an inferior mi. he had some vagal symptoms towards
the end of the procedure and was treated with zophrin and
atropine.  pt was then transerred to the ccu.

past medical history:
-paroxysmal atrial fibrillation, not on coumadin
-esrd s/p living donor (sister) renal transplant in [**5-/2154**]
-cad:
   - s/p acute mi [**2143**] with palmaz lad and rca stents
   - s/p rotablation and hepacoat stent to the d1 in [**6-/2149**],
treated with brachytherapy for instent restenosis in [**10/2149**]
   - s/p taxus stent in rpl in [**10/2151**]
   - s/p two cypher stents placed in the rca [**10/2152**]
   - cath in [**7-24**] with 60-70% ostial stenosis of lad, moderate
diffuse disease of lcx, 60% proximal of rca with in stent
restenosis with a 70% in the pl branch taxus stent(for latest
cath, see pertinent results)
-denies h/o dm; however, sugars have been elevated in past
-chronic angina
-hypertension
-hypercholesterolemia
-wegener's granulomatosis (renal/pulmonary involvement)
diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, anca neg.
since (chronic proteinuria); now s/p renal transplant in [**5-/2154**]

-idiopathic pericarditis [**2150**]
-gerd
-anxiety, endorses dysthymic symptoms but not depression
-gout
-umbilical hernia repair
-restless leg syndrome
.
outpatient cardiologist:  [**first name4 (namepattern1) **] [**last name (namepattern1) **]
nephrologist:  dr. [**last name (stitle) 1366**]
transplant nephrologist:  [**doctor first name **] [**doctor last name **]
pcp: [**first name8 (namepattern2) 3788**] [**last name (namepattern1) **]
.
allergies:
[**last name (namepattern1) **]--rash
simvastatin--myalgia
tape--rash
hctz--unkown reaction

social history:
 social history is significant for the absence of current
tobacco use; quit 25 years ago. there is no history of alcohol
abuse; he endorses rare etoh. no illicit drugs. married with 3
children, lives w/ wife and youngest daughter.


family history:
there is no family history of premature coronary artery disease
or sudden death. mother had cva at 46. sister with scleroderma
and another sister with [**name (ni) 18109**].

physical exam:
vitals: vital signs stable, patient afebrile
gen: no acute distress
heent: mmm, perrl
neck: no jvd
heart: s1+, s2+ no murmurs.
lungs: clear to auscultation bilaterlly.
abd: soft, non tender, non distended, bowel sounds present
ex: no edema, distal pulses present bilarerally.
neuro: aaox3

pertinent results:
blood:
[**2155-7-16**] 06:05am blood wbc-8.2 rbc-3.70* hgb-10.2* hct-29.8*
mcv-81* mch-27.5 mchc-34.1 rdw-14.1 plt ct-129*

electrolytes:
[**2155-7-16**] 06:05am blood glucose-130* urean-22* creat-1.6* na-140
k-4.0 cl-106 hco3-25 angap-13

cardiac enzymes:
[**2155-7-14**] 05:30am blood ck(cpk)-987*
[**2155-7-13**] 05:15pm blood ck(cpk)-[**2153**]*
[**2155-7-13**] 06:19am blood ck(cpk)-2779*
[**2155-7-13**] 01:50am blood ck(cpk)-2132*
[**2155-7-14**] 05:30am blood ck-mb-76* mb indx-7.7* ctropnt-5.85*
[**2155-7-13**] 01:50am blood ck-mb-403* mb indx-18.9*
[**2155-7-16**] 06:05am blood calcium-8.3* phos-3.7 mg-1.9

transplant meds:
[**2155-7-16**] 06:05am blood tacrofk-8.2
[**2155-7-15**] 09:19am blood tacrofk-4.4*
[**2155-7-14**] 05:30am blood tacrofk-4.6*

blood gas:
[**2155-7-12**] 10:27pm blood type-art po2-116* pco2-33* ph-7.42
caltco2-22 base xs--1 intubat-not intuba

brief hospital course:
patient was admitted to ccu for medical management post
myocardial infarction and stent placement.  he remained stable.
he did develop an eight centimeter pseudoaneurysm and a-v
fistula on his left groin site.  [**month/day/year **] surgery was consulted
and said it was to small to intervene.  he will follow up with
surgery for another ultrasound to assess the size. he was seen
by transplant team for management of his transplant medications.
 renal was consulted for management of his wegeners
granulomatosa.  as patient had a stent placed and had a history
of an allergy to [**month/day/year **], he was desensitized to [**month/day/year **].  the
desensitization was successful without any adverse events.  ent
was consulted for epistaxis prophylaxis while on [**month/day/year **], patient
started on saline nasal spray.  he was transferred out of the
ccu to the floor and discharged on [**2155-7-16**].

problem [**name (ni) **]:

# cad/ischemia: history of cad (cabg in [**2154**]), pt had st
elevations on ecg in inferior leads with st elevation in v3r,
which are 90% sensitive for rv infarct. cath complicated by
vagal symptoms towards end of procedure treated with zofran and
atropine. pt. desensitized to [**year (4 digits) **] on [**2155-7-14**].
- continue [**last name (lf) **], [**first name3 (lf) **], statin
- patient monitored on telemetry
- as pt had rv infarct (by ekg, no right heart cath performed),
avoid nitroglycerin for chest pain as rv infarct patients are
preload dependent.
.
# pump: current echo lvef 35-40%, lv apical dyskinesis and lv
inferior/inferior-lateral hypokinesis. pt with some orthopnea.
- fluid status closely monitored.
- pt started on lasix 40 po.
.
# rhythm:  pt having runs of nsvt on telemetry. likely secondary
to hypokalemia, also possibly due to reperfusion. history of
paroxysmal a-fib, has  cardioversion.
- monitor on telemetry
- on metoprolol 50 [**hospital1 **] for rate control, titrate up to home dose
as bp tolerates
- will stop amiodarone as nsvt was peri mi and did not recur
.
# hypertension: it was noted in a prior note on omr that pt's
blood pressure should be managed with beta blocker, a small dose
of acei and nifedipine. if necessary nifedipine should be
titrated up as it is safe in the renal transplant setting.
- c/w bb and acei as bp tolerates.
- nitrates were held as blood pressure stable.  can be
re-assessed as outpatient.
- pt should have bp check by pcp or np within 1-2 weeks of d/c
.
# valves: +2 mr, mitral valve leaf thickening.  mild aortic
valve thickening.
.
# left femoral bruit: bruit over left groin where venous and
arterial access lines were pulled. systolic and diastolic bruit
likely due to av fistula. l groin u/s showing 8mm
pseudoaneurysm.
- per [**hospital1 1106**] surgery, pseudoaneurysm is to small to treat
(<2cm).  f/u with dr. [**last name (stitle) **] in [**last name (stitle) 1106**] clinic.
.
# wegeners granulomatosis: has been in remission for 10+ yrs.
stable.
- monitor respiratory status
- monitor hct
- follow ent recs re: epistaxis prevention:  saline nasal
flushes three times a day.
.
# renal transplant: end-stage renal disease secondary to
wegener's granulomatosis, received a living related renal
transplant from his sister on [**2154-5-14**]. baseline cr 1.7. pt.
back to baseline cr.
- continue tacrolimus and myfortic
- dose meds for crcl of 50.
.
# dm: sliding scale insulin.
.
# fen: cardiac/heart-healthy low salt diabetic diet
.
# prophylaxis: [**year (4 digits) **]
.
# code:  full

medications on admission:
1. allopurinol 100 mg tablet daily
2. atorvastatin 10mg daily
3. astelin 137 mcg ns
4. fluticasone 50 mcg ns
5. lisinopril 30mg daily
6. metoprolol 100mg sr 1.5 tabs daily
7. myfortic 360mg 2 tabs daily
8. nifedipine 90mg daily
9. protonix 40mg daily
10. actos 15mg daily
11. prednisone taper.
12. requip 3mg daily
13. zoloft 100mg daily
14. prograf 0.5mg daily
15. bactrim 400/80mg daily
16. aspirin 325 mg daily


discharge medications:
1. pioglitazone 15 mg tablet sig: one (1) tablet po twice a day.

2. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
3. atorvastatin 10 mg tablet sig: one (1) tablet po daily
(daily).
4. fluticasone 50 mcg/actuation spray, suspension sig: [**12-18**]
sprays nasal daily (daily).
5. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1)
tablet po daily (daily).
6. sertraline 100 mg tablet sig: one (1) tablet po daily
(daily).
7. mycophenolate sodium 360 mg tablet, delayed release (e.c.)
sig: two (2) tablet, delayed release (e.c.) po twice a day.
8. ropinirole 3 mg tablet sig: one (1) tablet po twice a day.
9. sodium chloride 0.65 % aerosol, spray sig: [**12-18**] sprays nasal
tid (3 times a day) 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. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily): please do not miss a dose, take for at least 1 year, do
not stop taking unless your cardiologist tells you to. .
disp:*90 tablet(s)* refills:*3*
12. astelin 137 mcg aerosol, spray sig: two (2) puffs nasal
twice a day.
13. toprol xl 100 mg tablet sustained release 24 hr sig: 1.5
tablet sustained release 24 hrs po once a day.
disp:*135 tablet sustained release 24 hr(s)* refills:*3*
14. furosemide 40 mg tablet sig: one (1) tablet po daily
(daily).
15. tacrolimus 1 mg capsule sig: 1.5 capsules po bid (2 times a
day).
16. lisinopril 30 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
non-st elevation myocardial infarction
acute on chronic systolic congestive heart failure
secondary diagnosis:
chronic renal insufficiency
wegenner's vasculitis
epistaxis


discharge condition:
stable


discharge instructions:
weigh yourself every morning before breakfast, call doctor if
weight > 3 lbs in 1 day or 6 pounds in 3 days.
adhere to 2 gm sodium/heart healthy diet.
.
you had an inferior myocardial infarction with 5 drug eluting
stents placed in your right coronary artery. you need to take
[**month/day (2) 4532**] every day for one year, do not miss [**first name (titles) 691**] [**last name (titles) 4319**] unless dr. [**doctor last name 11723**] tells you to. you were seen by pt who gave you a
activity prescription until you see dr.[**name (ni) 3733**].
.
stop taking your nifedipine.

while you were inpatient, you had [**name (ni) 4532**] desensitization. you
were started on a daily dose of [**name (ni) 4532**] after the
desensitization.  this medication should be taken daily, if at
any time 36 hours lapses between [**name (ni) 4319**] of [**name (ni) 4532**], the
desensitization process will have to be repeated.
.
you need repeat angiogram in 2 weeks, you should speak to your
cardiologist regarding this. you should also have a holter
monitor in 2 weeks that will monitor your heart rhythm and track
any irregular heart beats.

followup instructions:
primary care:
provider: [**first name11 (name pattern1) 198**] [**last name (namepattern4) 199**], m.d. phone: [**telephone/fax (1) 250**] date/time:
[**7-29**] at 4:20pm.
provider: [**first name11 (name pattern1) 198**] [**last name (namepattern4) 199**], m.d. phone: [**telephone/fax (1) 250**]
date/time:[**2155-11-4**] 1:00
cardiologist:
provider: [**first name4 (namepattern1) **] [**name initial (nameis) **], md phone: [**telephone/fax (1) 62**]. date/time:
[**7-22**] at 10:40am. [**hospital ward name 23**] clinical center, [**location (un) 436**].
[**location (un) **] follow-up for left femoral pseudoaneurysm:
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2155-8-13**] 8:00
provider: [**name10 (nameis) 251**] [**last name (namepattern4) 1490**], md phone:[**telephone/fax (1) 1237**]
date/time:[**2155-8-13**] 9:15



"
264,"admission date:  [**2164-7-13**]              discharge date:   [**2164-7-16**]

date of birth:  [**2089-3-5**]             sex:   f

service: medicine

allergies:
atenolol / diltiazem / lisinopril / verapamil

attending:[**first name3 (lf) 443**]
chief complaint:
sob, chest pain

major surgical or invasive procedure:
cardiac catherization


history of present illness:
ms. [**known lastname 18582**] is a 75 [**last name (un) **] with htn, hyperlipidemia, depression,
gerd, hypothyroidism and osetoporosis who was admitted today for
an elective cath.  she had been complaining of one year of
fatigue and sob.
.
she was taken to the cath lab where she had lad with 40%
stenosis after the diagonal. the proximal d1 had a 90% stenosis
in which a bms was placed. the pt had some cp on leaving the
cath lab which persisted and then worstened on [**hospital ward name 121**] 3. pt with
st elevations in i, avl and was sent for rpt cath
.
on repeat cath, she had restenosed the stent placed earlier in
the day so it was restented proximally and distally with 2 more
bms's. of note, she recieved a total of 465cc iv contrast.
.
on arrival in the icu, she has no complaints initially but then
c/o mild headache.
.
on ros, she denies any fevers, nausea, vomitting, pain, sob,
lightheadedness or any other sx.


past medical history:
gerd
h pylori [**2156**]
lower gi bleed r/t diverticulitis
polyps removed
chronic headaches
hypertension
osteoporosis
depression
intermittent blurry vision-unclear etiology
pneumonia
ep study [**2161**] d/t bradycardia
eye surgery for growth
hypothyroid
pernicious anemia


social history:
retired [**hospital1 18**] ekg tech. widow. lives alone. has
5 daughters. denies tobacco and etoh.

family history:
father died of an mi at age 52. mother died at age [**age over 90 **]


physical exam:
general: nad
heart: rrr, no m/r/g
pulm: ctab, no w/r/r
ext: no edema
neuro: grossly intact

pertinent results:
admission labs:
[**2164-7-13**] 04:06pm blood wbc-13.1* rbc-4.68 hgb-13.1 hct-38.8
mcv-83 mch-28.0 mchc-33.7 rdw-13.8 plt ct-308
[**2164-7-13**] 04:06pm blood pt-15.4* ptt-47.6* inr(pt)-1.4*
[**2164-7-13**] 04:06pm blood glucose-165* urean-12 creat-0.6 na-137
k-3.4 cl-99 hco3-25 angap-16
[**2164-7-13**] 04:06pm blood calcium-8.3* phos-4.9* mg-1.7
[**2164-7-14**] 06:04am blood triglyc-97 hdl-49 chol/hd-3.8 ldlcalc-120
.
cardiac enzymes:
[**2164-7-13**] 07:12pm blood ck-mb-33* mb indx-14.5*
[**2164-7-13**] 07:12pm blood ck(cpk)-228*
[**2164-7-14**] 06:04am blood ck-mb-42* mb indx-11.0*
[**2164-7-14**] 06:04am blood ck(cpk)-383*
[**2164-7-14**] 02:35pm blood ck-mb-24* mb indx-8.0* ctropnt-0.66*
[**2164-7-14**] 02:35pm blood ck(cpk)-300*
[**2164-7-15**] 05:35am blood ck-mb-8 ctropnt-0.53*
[**2164-7-15**] 05:35am blood ck(cpk)-118
[**2164-7-16**] 06:05am blood ck-mb-3 ctropnt-0.72*
[**2164-7-16**] 06:05am blood ck(cpk)-49
.
discharge labs:
[**2164-7-16**] 06:05am blood glucose-97 urean-12 creat-0.8 na-140
k-4.9 cl-102 hco3-30 angap-13
[**2164-7-16**] 06:05am blood calcium-9.3 phos-4.3 mg-2.1
.
[**2164-7-14**] echo:
the left atrium is dilated. there is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
distal septal, anterior and apical hypokinesis. the remaining
segments contract normally (lvef = 45%). 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 (1+) aortic regurgitation is seen. mild (1+)
mitral regurgitation is seen. there is mild pulmonary artery
systolic hypertension. there is no pericardial effusion.
impression: mild regional left ventricular systolic dysfunction,
c/w cad. mild mitral and aortic regurgitation.
compared with the prior study (images reviewed) of [**2164-7-13**],
the findings are similar.
.
[**2164-7-13**] echo:
there is mild symmetric left ventricular hypertrophy with normal
cavity size. there is regional left ventricular systolic
dysfunction. there is no pericardial effusion.
impression: no pericardial effusion identied.
.
[**2164-7-13**] 2nd cath:
comments:
1- limited selective coronary angiography of the lmca sysrtem
showed
acute occlusion of the entire d1 system. this vessel underwent
ptca and
stening with a 2.25x12 mm minivision bms 2 hours prior. the
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- the lmca, lad (known mid vessel lesion that was negative by
ffr
earlier), and lcx were unchanged.
3- successful emergent ptca and stenting of the d1 with two
additional
stents: a 2.0x8 mm distally overlapping and a 2.25x12 proximally

overlapping with the old (placed this am) 2.25x12 mm minivision
bms.
final angiography showed timi 3 flow thrroughout the d1 system
without
vresidual stenosis, dissection or distal emboli.
4- resting hemodynamic assessment showed stable hemodynamics
compared to
earlied rhc except for severe systemic arterial hypertension
(required
ntg gtt at doses as high as 200 mcg per min). the left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- bedside echocardiography showed absence of pericardial
effusion

final diagnosis:
1. acute closure of the d1, two hours after pci and stenting
2. [**name (ni) 18583**] ptca and stenting of the d1 with two additional
bms (one
distal and the second proximal to the earlier placed bms, all
overlapping).
3. ccu admission for observation
4. continue integrilin gtt for 18 hours
5. plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. asa 325 mg po indefinitely
7. 2d echocardiogram
8. global cardiovascular risk reduction strategies
.
[**2164-7-13**] 1st cath:
comments:
1- limited selective coronary angiography of the lmca sysrtem
showed
acute occlusion of the entire d1 system. this vessel underwent
ptca and
stening with a 2.25x12 mm minivision bms 2 hours prior. the
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- the lmca, lad (known mid vessel lesion that was negative by
ffr
earlier), and lcx were unchanged.
3- successful emergent ptca and stenting of the d1 with two
additional
stents: a 2.0x8 mm distally overlapping and a 2.25x12 proximally

overlapping with the old (placed this am) 2.25x12 mm minivision
bms.
final angiography showed timi 3 flow thrroughout the d1 system
without
vresidual stenosis, dissection or distal emboli.
4- resting hemodynamic assessment showed stable hemodynamics
compared to
earlied rhc except for severe systemic arterial hypertension
(required
ntg gtt at doses as high as 200 mcg per min). the left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- bedside echocardiography showed absence of pericardial
effusion

final diagnosis:
1. acute closure of the d1, two hours after pci and stenting
2. [**name (ni) 18583**] ptca and stenting of the d1 with two additional
bms (one
distal and the second proximal to the earlier placed bms, all
overlapping).
3. ccu admission for observation
4. continue integrilin gtt for 18 hours
5. plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. asa 325 mg po indefinitely
7. 2d echocardiogram
8. global cardiovascular risk reduction strategies


brief hospital course:
ms. [**known lastname 18582**] is a 75 [**last name (un) **] with htn, hyperlipidemia, depression,
gerd, hypothyroidism and osetoporosis who was admitted today for
an elective cath, had bms to 1st diag which thrombosed acutely
on the floor and had rpt stent x2
.
# cad: patient was chest pain free after 2nd catherization. she
was started on aspirin 235, plavix 75, and pravastatin 40mg po
qday. patient was hesitant to start new medications but was
counseled extensively that especially stopping aspirin and
plavix could lead to another mi. she was not started on a
beta-blocker given her history of complete heart block on
beta-blocker. she was not started on ace-i or [**last name (un) **] [**3-6**] h/o
adverse events and patient refusal to start those medications.
echo showed ef of 45% and regional systolic dysfunction c/w cad.
she will follow up with dr. [**last name (stitle) **].
.
# rhythm- patient was in sinus rhythm throughout
hospitalization.
.
# osteoporosis- cont home ca, vit d



medications on admission:
asa 81mg daily
calcium/ vit d 600/400 [**hospital1 **]
mvt daily


discharge medications:
1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
disp:*30 tablet, delayed release (e.c.)(s)* refills:*2*
2. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
3. multivitamin     tablet sig: one (1) tablet po daily (daily).

4. pravastatin 20 mg tablet sig: two (2) tablet po daily
(daily).
disp:*60 tablet(s)* refills:*2*
5. calcium 600 + d(3) 600-400 mg-unit tablet sig: one (1) tablet
po twice a day.


discharge disposition:
home

discharge diagnosis:
primary diagnosis:
stemi
.
secondary diagnosis:
gerd
osteoperosis


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
you were admitted for a cardiac catherization. after the
catherization you had a heart attack and you had additional
stents placed in your coronary arteries. we have started you on
several medications that you must take every day otherwise you
could have another heart attack. please follow up with your
cardiologist.
.
we have started you on the following medications:
1. aspirin 325mg by mouth every day
2. plavix 75mg by mouth every day
3. pravastatin 40mg by mouth every day

followup instructions:
provider: [**first name4 (namepattern1) **] [**last name (namepattern1) **] phone: [**telephone/fax (1) 7960**] date/time: [**2164-8-1**]
1:45pm



completed by:[**2164-7-17**]"
265,"admission date: [**2175-11-5**]        discharge date: [**2175-12-27**]

date of birth:  [**2147-8-13**]        sex:  f

service:  [**last name (un) **]


admission diagnosis:  respiratory distress.

history of present illness:  the patient is a 28-year-old
female with sle/lupus, nephritis, end-stage renal disease
status post cadaveric renal transplant [**2175-9-1**],
complicated by delayed graft function/atn, biopsy done
intraoperatively during reexploration post transplant for
bleeding requiring multiple transfusions. the patient has had
multiple admissions in the past since her transplant for
abdominal pain and dehydration. on [**2175-11-5**], the
patient was admitted for respiratory distress.

the patient was found to have agonal
breathing/unresponsiveness. at that time, fingersticks were
less than 20. the patient was treated with 1.5 amps of d50
but still not adequately awake. the patient was intubated in
the emergency room for airway protection. at that time, her
heart rate was in the 100s. systolic blood pressure was 90-
100.

the patient was transferred to the icu, and labs demonstrated
that the patient had a hematocrit of 14, sodium of 125,
potassium 8.3, chloride 95, bicarb 11, bun and creatinine of
37 and 6.6.

in the icu a line was placed, and a central line was placed.
the patient was transfused with 2 units of packed red blood
cells, 2 units of ffp, 1 unit of platelets and bicarb in the
setting of severe acidosis. the patient remained
hemodynamically stable.

past medical history:
1.  sle diagnosed in [**2166**] complicated by lupus/nephritis,
    anemia, serositis and ascites, currently in remission.
2.  end-stage renal disease on hemodialysis monday, wednesday
    and friday secondary to lupus.
3.  history of vsd status post corrective surgery at age 13.
4.  hypertension.
5.  itp.
6.  mssa endocarditis.
7.  [**year (4 digits) **] cell trait.
8.  status post left oophorectomy related to iud-associated
    infection.
9.  restrictive lung disease noted on pfts from [**2166**]. in [**2173**]
    chest ct was with diffuse ground glass opacities.
10. gerd in [**2172**].
11. history of domestic violence.
12. most recently is status post cadaveric renal on [**8-31**], [**2174**], complicated by delayed graft function.

allergies:  levaquin, cephalosporin, unasyn, vancomycin and
derivative, demerol and meperidine.

medications on admission:  prednisone 5 mg daily, bactrim ss
1 tablet daily, valcyte 450 mg every other day, __________
2.5 mg daily, nifedipine 90 mg sustained release daily,
protonix 40 mg daily, dronabinol 2.5 b.i.d., mirtazapine 15
mg q.h.s., mmf 500 mg b.i.d., nystatin suspension 5 ml
q.i.d., epogen injection 3000 units monday, wednesday and
friday, percocet [**12-11**] 5/325 mg tablets 1 tablet q.4-6 hours
p.r.n., labetalol 400 t.i.d., linezolid 600 q.12 for a total
of 7 days, reglan 5 mg q.i.d., sodium bicarb 650 mg tablets 4
tablets t.i.d., coumadin 5 mg 1 p.o. daily for a left
axillary thrombus, rapamune 6 mg once a day, the patient at
that time was on linezolid because of a gram-negative staph
urinary tract infection, and on coumadin for a non-occlusive
thrombus of left axillary vein that was documented on
[**2175-10-24**].

in the emergency room was intubated and sedation. ct of the
abdomen was performed demonstrating a large right-sided
hematoma displacing the transplanted kidney anteromedially
and inferiorly. the hematoma is larger compared to the cat
scan that was performed on [**2175-6-29**], but appears smaller
compared to the cat scan on [**2175-9-11**].

the transplanted kidney is barely discernable. the uv
catheter is noted in situ. a 3.8 cm heterogenous lesion,
likely arising from the uterus and probably a fibroid was
noted. there was also diffuse thickening of small bowel wall
with a differential of wide and intramural hemorrhage, and
there was massive ascites.

preoperative diagnosis:
1.  anemia.
2.  acute renal failure.
3.  hyperkalemia.
4.  metabolic acidosis.
5.  coagulopathy.
6.  sepsis.

the patient was rushed to the or where surgery was performed
on the morning of [**2175-11-6**], performed by dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **]. exploratory laparotomy and transplant nephrectomy
was performed due to a ruptured kidney.

a french [**doctor last name 406**] drain was brought out through a separate
incision and sutured in place with 3-0 nylon.

the patient remained intubated and was taken to the icu in
stable and satisfactory condition.

postoperatively the patient was febrile. the patient had a
right femoral arterial line and left triple lumen. cultures
were obtained on [**2175-11-7**], because the patient
became febrile which grew out pseudomonas.

the renal consulting team followed the patient closely.

the patient continued with hemodialysis monday, wednesday and
friday. cat scan was obtained postoperatively on [**2175-11-8**], to evaluate the abdomen and hematoma which demonstrated
interval removal of the transplant kidney with extravasation
of right extraperitoneal __________ . at the surgical site
remains an ill-defined collection consisting of residual
hemorrhage and gas and hyperdense perihepatic fluid probably
hemoperitoneum. there was free air present which may be
related to surgery. according to the radiologist, there was
nonspecific cecal thickening, new bibasilar consolidations
and new gallbladder distention.

the patient continued to be intubated. he was placed for tube
feeds, and tube feeds were started for nutrition. the patient
remained intubated. tube feeds were continued. the patient
was continued on antibiotics, linezolid day 16, zosyn day 13.

the patient was also continued on a fentanyl patch for pain
control.

at that time, [**2175-11-20**], she was assist control 40%,
peep of 10, 45 x 25.

infectious disease was consulted for ongoing fever despite
being on multiple antibiotics. the patient had a radial
peroneal abscess that was drained. infectious disease closely
followed the patient and made recommendations without
switching antibiotics.

on [**2175-11-14**], central line change was performed
complicated by a large left apical and basilar hemothorax.
chest tube was placed that evening. another chest x-ray was
performed demonstrating marked decrease of left-sided
pneumothorax, residual small left apical and basilar
pneumothorax.

the patient had another cat scan on [**2175-11-16**], because
of ongoing abdominal pain. the patient required another
catheter for drainage of collection. cat scan demonstrated 1)
interval improvement in bilateral basal consolidations, 2)
there was a collection along the right flank, decreased in
size compared to the prior study with catheter in adequate
position, 3) there was reduction of gallbladder distention,
4) stable small collection to the right of the uterus
consistent with resolving hematoma, 5) stable splenic
infarcts.

the patient hemodynamically stable. the patient did complete
a 7-day course for a possible mucocutaneous hsv. antibiotics
were changed to meropenem. linezolid and gentamicin were
discontinued.

tpn was discontinued. nepro tube feeds were started per
recommendations from nutrition.

the patient was slowly weaning from the vent. tube feeds were
advanced.

on [**2175-11-20**], the patient needed central venous
access, and there was successful placement of an 8.5 french
16 cm long four-lumen catheter via the left common femoral
vein. also the venogram demonstrated occlusion of the left ij
and the left subclavian vein with multiple collaterals, and
also the right ij was shown to be occluded on ultrasound
scan. therefore the left femoral line was in place and ready
to use for central access.

on [**2175-11-24**], the patient had a bronchoscopy to
evaluate and assess airway patency. using an endotracheal
tube, which was flexible, it was documented that her airway
was clear. there were no complications.

the patient continued with the dialysis 3 days a week. renal
continued to follow the patient.

on [**2175-11-30**], the patient had an open tracheostomy
performed by dr. [**last name (stitle) **] because of respiratory failure and
failure to wean off the ventilator status post tracheostomy
tube with a 7 french non-fenestrated tracheostomy tube. the
patient ventilated well, and the patient was transferred back
to the recovery room in stable condition.

on [**2175-12-2**], the patient had another cat scan
because of abdominal pain and persistent fever. the case was
discussed with dr. [**last name (stitle) 816**] who requested drainage of subhepatic
fluid collection.
1.  the size of the subhepatic fluid collection within an
    enhancing wall has decreased slightly since the prior
    study. this was drained with an 8 french pigtail catheter
    which was left in place.
2.  there was a jp drain in the right pericolic fluid
    collection which was in good position. the size of the
    fluid collection was essentially [**last name (stitle) 1506**] from the prior
    study of [**2175-11-23**].
3.  there was a stable appearance of a cystic collection deep
    within the pelvis to the right of the uterus not easily
    amendable to percutaneous drainage.
4.  there was anasarca with ascites.
5.  there was bilateral lower lobe consolidation which was
    [**year (4 digits) 1506**].
6.  there were splenic infarcts, which was [**year (4 digits) 1506**].

we continued to check her labs which included cbc,
electrolytes daily and were replaced as needed.

the patient was evaluated for rehab.

another cat scan was performed on [**12-22**] at 1 a.m.
because of abdominal pain, and was documented:
1.  persistent, although smaller multiloculated fluid
    collection along the right flank, status post removal of
    drainage catheter. the presence of infection cannot be
    excluded.
2.  there was a similar uterine mass.
3.  there was ascites and edema.
4.  improving bilateral lower lobe consolidations.
5.  continued splenic infarcts, not well appreciated on that
    particular study.

the patient continued on antibiotics for pseudomonas coverage
and vre bacteremia related to lines and questionable
abdominal fluid collections.

later that day on [**2175-12-22**], the patient had a ct-
guided abdominal drainage using ct fluoroscopic guidance. [**initials (namepattern4) **]
[**last name (namepattern4) 4300**] needle was advanced to the right flank collection.
approximately 40-50 ml of blood-tinged fluid was aspirated.
postprocedural films demonstrated that the right flank
collection appears in good position. the patient tolerated
the procedure well. there were no immediate complications.
the 8 french catheter remained in place after the ct was
completed.

on [**2175-12-12**], the patient was evaluated for a passy-
muir valve evaluation, and it was observed that she did
tolerate wearing the pmv for 20 minutes with no oxygen
desaturation and was able to speak with a clear voice and
intelligible speech; however, she then began to cough at the
end of the evaluator's exam suggesting either
dryness/irritation or possibility of aspiration secretions.

physical therapy and occupational therapy met with the
patient for evaluation and treatment and definitely felt that
the patient needed to go to rehab. the patient continued with
hemodialysis.

on [**2175-12-21**], the patient had a chest x-ray because of
ongoing fevers, and the radiologist documented the chest x-
ray report as a long-standing interstitial abnormality in the
right lower lobe present since [**5-19**]. this probably
represents irreversible changes of previous edema, pulmonary
hemorrhage, vascular congestion or interstitial lung disease,
not an acute process. top-normal heart size and dilatation of
pulmonary arteries and left atrium are long standing. there
are no findings to suggest further cardiovascular
decompensation or current enterothoracic infection. feeding
tube ends at the pylorus. tracheostomy tube in standard
placement. no pleural effusion.

pigtail catheter was removed on [**2174-12-21**], and
tracheostomy was downsized, and there were no adverse events
over night. she was afebrile with vital signs stable. p.o.
intake 640, tube feeds 710; does not void. the patient had jp
drainage of 35 cc.

infectious disease had recommended to continue tobramycin,
p.o. vancomycin and cipro until her follow-up appointment
with infectious disease on [**2176-1-9**]. at that time,
abdominal/pelvic ct will be obtained to assess fluid
collections to help define further duration of antibiotics.

on [**2175-12-22**], another cat scan was performed to
evaluate the abdominal collections after the drains have been
removed.

on [**2175-12-23**], pain service was consulted requires
multiple narcotics. the pain service had stated to continue
the fentanyl patch, to change her p.o. dilaudid regimen and
to discontinue her iv dilaudid.

currently the patient is on cipro for pseudomonas. the
patient is also on linezolid for enterococcus and history of
vre. the patient continues on vancomycin for prior c-diff.
she is also receiving tobramycin.

she has 2 pending cultures from blood cultures that were
obtained on [**2175-12-24**].

her labs on [**2175-12-26**], revealed the following: wbc
9.4, hematocrit 26.8, platelets 111; ptt 30.5, inr 1.1;
sodium 131, 3.6, 95, 28, bun and creatinine of 20 and 3.5,
glucose 88, calcium 9.6, phos 2.5, magnesium 0.7, albumin
2.6. the patient had a tobramycin level of 1.1 on [**2175-12-26**].

when the patient goes to rehab, the patient will need daily
cbc, chem10 at least once-a-week. the patient will need to
have a cbc with diff and a post dialysis tobramycin level.
those results need to be faxed to infectious disease [**telephone/fax (1) 18624**].

the patient has a follow-up appointment with dr. [**first name (stitle) 2505**] on
[**2176-1-9**], from infectious disease, [**telephone/fax (1) 457**]. this
appointment is for [**2176-1-9**], at 9 a.m. if you have
any questions or problems with the appointment please dr.[**name (ni) 18625**] office immediately. also the facility should make an
appointment with transplant surgery potentially on the same
day; please call [**telephone/fax (1) 673**].

discharge medications:  prednisone 5 mg daily, mucomyst
solution q.4-6 hours as needed, heparin 5000 units subcu
b.i.d., vancomycin 125, which is the oral liquid, q.6 hours,
prevacid 30 mg suspension 1 tablet daily, albuterol aerosol
puff inhalation 1-2 puffs q.6 hours, lopressor 4.5 b.i.d.,
fentanyl patch 100 mcg, please change every 72 hours,
__________  750 q.24 hours, colace 100 mg b.i.d., dilaudid 2
mg tablets 1-3 tablets q.2 hours p.r.n., linezolid 600 mg
q.12 hours, ativan 1 mg iv q.6 hours, tobramycin as needed,
the last dose was 140 mg, but please check level prior to
giving dose. if there are any questions in regards to the
tobramycin, call infectious disease at [**telephone/fax (1) 457**].

the patient is on tube feeds, nepro 3/4 strength, goal rate
of 40 cc/hr. please check residuals q.4 hours and hold tube
feeds for residuals greater than 100 ml. please flush with 50
cc of water q.8 hours. the patient should also receive
calorie counts and have a dietician following the patient.
the patient could be possibly transitioned from tube feeds to
a regular diet.

final diagnosis:  this is a 28-year-old woman with lupus
nephritis status post renal transplant on [**2175-9-1**],
with acute rejection and subsequent graft rupture.

secondary diagnosis:
1.  pseudomonas bacteremia.
2.  peritoneal abscess/necrotizing fascitis.
3.  left ij and left subclavian vein occlusion.
4.  left pneumothorax requiring chest tube placement.
5.
    respiratory failure requiring tracheostomy.
6.  intra-abdominal fluid collection status post drainage.



                        [**first name11 (name pattern1) **] [**last name (namepattern4) **], [**md number(1) 3432**]

dictated by:[**last name (namepattern1) 4835**]
medquist36
d:  [**2175-12-27**] 12:32:23
t:  [**2175-12-27**] 14:04:32
job#:  [**job number 18626**]
"
266,"admission date:  [**2198-6-19**]              discharge date:   [**2198-7-8**]

date of birth:  [**2120-8-11**]             sex:   m

service: urology

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1232**]
chief complaint:
angiosarcoma of bladder cancer

major surgical or invasive procedure:
radical cystoprostatectomy
ileal loop urinary diversion
regional node dissection
right internal jugular vein central line placement
swan-ganz catheter placement
arterial line placement
nasogastric tube placement

history of present illness:
mr. [**known lastname 19000**] is a 77-year-old male who was
diagnosed with prostate cancer in [**2189-11-8**] by abnormal dre.

he reports a psa of that time of 14. he received external beam
radiation therapy at [**hospital6 **]. he reports that his
psa post radiation was 0.3. he was followed periodically by psa
after radiation. his psa rise to about 11 in [**2193**]. he started
casodex and lupron [**4-8**]. he reports he was getting lupron every

other month. his lowest psa on hormonal treatment was 0.4 in
[**2197-2-6**]. his psa started to climb 1004 and reached 2.2 in 05/

05. he has been followed by dr. [**last name (stitle) 4749**] in [**hospital1 **].

the patient noted painless hematuria and clots beginning of
[**month (only) 958**]
he had a tur at [**hospital 1281**] hospital by dr. [**last name (stitle) **] where a bladder
tumor was noted. he has been seen by dr. [**last name (stitle) **] in evaluation
for a possible cystectomy and dr. [**last name (stitle) **] for medical oncologic

opinion of the angiosarcoma.
he reports he multiple negative ct scans and bone scans in the
past. most recently he had a bone scan in [**4-12**], which showed
increased tracer activity in l5-s1 region, likely representing
degenerative changes. ct chest, abdomen, and pelvis [**4-12**], shows

a infrarenal aortic aneurysm, measuring 4.2 x 4.8 cm, asymmetric

inferior bladder wall thickening, and multiple small bilateral
pulmonary nodules, the largest measuring 5 mm in the right
middle
lobe.
he presents for cystoprostatectomy.

past medical history:
prostate carcinoma
heartburn
asthma
appendectomy
no tuberculosis noted
copd: fev1 58%



social history:
mr. [**known lastname 19000**] is retired. he spent seven and a
half years in the russian army, then he went to college and was
an electrical engineer in a fairly high position. he lives in
[**location **]. he immigrated to the us about ten years ago. he has two
daughters and two grandsons who live in the area. he quit
smoking about 11 years ago. he smoked nonfiltered cigarettes for

a total of 100 pack years. he drinks vodka and bourbon once or
twice a week.


family history:
no family history of cancers. he has five
brothers, four of whom have died of heart attacks. his older
brother lives in [**name (ni) 6607**]. his mother died of a cva. his father
died at age 33 in [**2125**] from typhoid.


physical exam:
gen:  aaox3 nad
cv: s1 s2 rrr
chest: cta b/l
abd: pos bs soft nt/nd midline scar, uretostomy
extrem: no c/c/e

pertinent results:
[**2198-7-5**] 07:20am blood wbc-5.3 rbc-4.35* hgb-12.6* hct-39.1*
mcv-90 mch-29.0 mchc-32.2 rdw-15.6* plt ct-297
[**2198-7-4**] 07:00am blood wbc-4.0 rbc-4.21*# hgb-12.4*# hct-37.3*#
mcv-89 mch-29.4 mchc-33.1 rdw-15.1 plt ct-270
[**2198-7-3**] 07:25am blood wbc-3.8* rbc-3.24* hgb-9.8* hct-28.6*
mcv-88 mch-30.2 mchc-34.2 rdw-14.2 plt ct-211
[**2198-7-2**] 08:00am blood wbc-4.2 rbc-3.22* hgb-9.8* hct-29.0*
mcv-90 mch-30.3 mchc-33.6 rdw-14.2 plt ct-197
[**2198-7-1**] 03:23am blood wbc-3.3* rbc-3.15* hgb-9.4* hct-29.0*
mcv-92 mch-29.8 mchc-32.3 rdw-14.7 plt ct-170
[**2198-6-19**] 05:39pm blood wbc-6.8 rbc-3.27*# hgb-9.8*# hct-29.8*#
mcv-91 mch-29.8 mchc-32.8 rdw-14.1 plt ct-125*
[**2198-6-20**] 04:15am blood wbc-4.9 rbc-2.92* hgb-8.8* hct-26.1*
mcv-89 mch-30.3 mchc-33.9 rdw-14.1 plt ct-104*
[**2198-6-20**] 11:00am blood hct-31.6*
[**2198-6-20**] 03:57pm blood hct-31.3*
[**2198-6-21**] 03:45am blood wbc-7.4# rbc-3.47* hgb-10.7* hct-31.1*
mcv-90 mch-30.9 mchc-34.4 rdw-13.9 plt ct-104*
[**2198-6-21**] 08:29am blood wbc-6.7 rbc-3.48* hgb-10.8* hct-31.1*
mcv-89 mch-31.0 mchc-34.8 rdw-13.7 plt ct-105*
[**2198-6-21**] 04:21pm blood wbc-5.4 rbc-3.29* hgb-10.1* hct-29.4*
mcv-90 mch-30.8 mchc-34.4 rdw-13.9 plt ct-105*
[**2198-7-5**] 07:20am blood plt ct-297
[**2198-7-4**] 07:00am blood plt ct-270
[**2198-7-3**] 07:25am blood plt ct-211
[**2198-7-2**] 08:00am blood plt ct-197
[**2198-7-1**] 03:23am blood plt ct-170
[**2198-6-19**] 05:39pm blood pt-14.6* ptt-32.9 inr(pt)-1.4
[**2198-6-19**] 05:39pm blood plt ct-125*
[**2198-6-20**] 04:15am blood plt ct-104*
[**2198-6-21**] 03:45am blood plt ct-104*
[**2198-6-21**] 08:29am blood plt ct-105*
[**2198-7-6**] 09:00am blood glucose-97 urean-17 creat-1.3* na-142
k-3.7 cl-103 hco3-33* angap-10
[**2198-7-5**] 07:20am blood glucose-104 urean-14 creat-1.2 na-141
k-4.0 cl-102 hco3-32 angap-11
[**2198-7-4**] 07:00am blood glucose-105 urean-12 creat-1.0 na-144
k-3.6 cl-106 hco3-32 angap-10
[**2198-7-3**] 07:25am blood glucose-95 urean-14 creat-1.0 na-145
k-3.7 cl-108 hco3-29 angap-12
[**2198-6-19**] 05:39pm blood glucose-165* urean-17 creat-1.1 na-140
k-4.9 cl-112* hco3-23 angap-10
[**2198-6-20**] 04:15am blood glucose-133* urean-21* creat-1.6* na-135
k-4.4 cl-110* hco3-23 angap-6
[**2198-6-20**] 02:25pm blood glucose-124* urean-25* creat-2.8*# na-137
k-4.6 cl-110* hco3-21* angap-11
[**2198-6-20**] 08:00pm blood urean-28* creat-3.2* na-137 k-4.6 cl-111*
hco3-19* angap-12
[**2198-7-4**] 07:00am blood ck(cpk)-19*
[**2198-6-21**] 04:21pm blood alt-2 ast-24 alkphos-86 amylase-83
totbili-0.4
[**2198-6-21**] 03:45am blood alt-4 ast-28 ld(ldh)-208 ck(cpk)-619*
alkphos-59 totbili-0.5
[**2198-6-20**] 04:15am blood ck(cpk)-808*
[**2198-6-20**] 02:00am blood ck(cpk)-755*
[**2198-6-19**] 05:39pm blood ck(cpk)-160
[**2198-7-4**] 07:00am blood ck-mb-3 ctropnt-0.02*
[**2198-6-20**] 04:15am blood ck-mb-5 ctropnt-<0.01
[**2198-6-20**] 02:00am blood ck-mb-6
[**2198-6-19**] 05:39pm blood ck-mb-3 ctropnt-<0.01
[**2198-7-6**] 09:00am blood calcium-8.7 phos-3.4 mg-2.0
[**2198-7-5**] 07:20am blood phos-3.4 mg-1.9
[**2198-7-4**] 07:00am blood calcium-8.7 phos-3.3 mg-1.8
[**2198-7-3**] 07:25am blood calcium-8.4 phos-2.4* mg-1.7
[**2198-7-2**] 08:00am blood calcium-8.4 phos-2.0* mg-1.6
[**2198-6-19**] 05:39pm blood calcium-8.0* phos-4.9* mg-1.5*
[**2198-6-20**] 04:15am blood calcium-7.4* phos-2.9# mg-2.1
[**2198-6-20**] 02:25pm blood mg-2.1
[**2198-6-21**] 03:45am blood albumin-2.7* calcium-7.5* phos-5.3*#
mg-2.1
[**2198-6-21**] 08:29am blood calcium-7.4* phos-6.0* mg-2.2
[**2198-6-30**] 06:29pm blood type-art po2-122* pco2-35 ph-7.47*
calhco3-26 base xs-2
[**2198-6-30**] 03:38am blood type-art po2-75* pco2-43 ph-7.41
calhco3-28 base xs-1
[**2198-6-28**] 04:03am blood ph-7.42 comment-green top
[**2198-6-19**] 08:35am blood type-art po2-529* pco2-48* ph-7.39
calhco3-30 base xs-3
[**2198-6-19**] 10:19am blood type-art po2-212* pco2-45 ph-7.39
calhco3-28 base xs-2
[**2198-6-19**] 11:30am blood type-art po2-240* pco2-45 ph-7.38
calhco3-28 base xs-1
[**2198-6-19**] 12:30pm blood type-art rates-/10 tidal v-650 fio2-57
po2-239* pco2-41 ph-7.38 calhco3-25 base xs-0 intubat-intubated
vent-controlled
[**2198-6-19**] 02:11pm blood type-art po2-252* pco2-40 ph-7.41
calhco3-26 base xs-1
[**2198-6-19**] 03:54pm blood type-art ph-7.41
[**2198-6-30**] 06:29pm blood lactate-1.5
[**2198-6-30**] 03:38am blood glucose-108*
[**2198-6-27**] 05:12pm blood lactate-0.9
[**2198-6-27**] 03:31am blood glucose-152*
[**2198-6-25**] 03:18am blood glucose-86 lactate-1.2
[**2198-6-19**] 08:35am blood glucose-126* lactate-1.8 na-138 k-4.2
cl-104
[**2198-6-19**] 10:19am blood glucose-149* lactate-1.8 na-140 k-4.6
cl-105
[**2198-6-19**] 11:30am blood glucose-147* lactate-1.8 na-139 k-4.1
cl-109
[**2198-6-19**] 12:30pm blood glucose-153* lactate-2.4* na-137 k-4.6
cl-109
[**2198-6-19**] 02:11pm blood glucose-154* lactate-2.0
[**2198-6-30**] 03:38am blood o2 sat-96
[**2198-6-26**] 04:11pm blood o2 sat-90
[**2198-6-25**] 03:18am blood o2 sat-98
[**2198-6-22**] 11:27am blood o2 sat-97
[**2198-6-30**] 06:29pm blood freeca-1.20
[**2198-6-30**] 03:38am blood freeca-1.11*
[**2198-6-28**] 04:03am blood freeca-1.10*
[**2198-6-27**] 03:31am blood freeca-1.15

cxr - [**2198-7-5**]
indications: desaturation.

ap and lateral chest radiographs: comparison is made to [**2198-7-1**] and a
chest ct scan from [**2198-4-27**]. cardiac size is at the upper
limits of
normal. two rounded nodules are seen, one in each upper lobe.
the one in the
right measures 9 mm and the one in the left measures 13 mm.
these appear
different than on multiple prior studies. the patient has known
nodules on ct
scan. there are no consolidations. there is mild blunting of the
right cp
angle, likely reflecting a small effusion. overall, there is
improved
aeration of the left lower lobe.

impression: bilateral upper lobe nodules, more conspicuous than
on prior
studies. further evaluation with chest ct scanning is
recommended.

cxr - [**2198-7-1**]

there has been interval removal of the right ij line. there is
improved
aeration of both lower lobes. both cp angles are off the film.
there is no
focal infiltrate.

cxr - [**2198-6-22**]
findings: in comparison with the previous examination of the
same date, the
pulmonary artery catheter is again seen, now terminating within
the right
pulmonary artery and entering via a right internal jugular
approach. an
endotracheal tube terminates approximately 8.5 cm from the
carina. nasogastric
tube extends below the diaphragm and likely terminates in the
upper stomach.
there is interval improvement in pulmonary edema. probable small
bilateral
pleural effusions are incompletely evaluated due to exclusion of
the
costophrenic angles bilaterally. stable bibasilar atelectasis.

impression:

1. cardiomegaly and improving congestive heart failure.

2. bibasilar atelectasis and probable small bilateral pleural
effusions.


brief hospital course:
mr. [**known lastname 19000**] [**last name (titles) 1834**] a cystoprostatectomy on [**2198-6-19**] (please see
dictated operative report for details) without adverse events.
it was noted by surgeons that urine output was low throughout
the procedure. in the or he received 6,000cc of crystaloid, 2
units of packed red cells, 1000cc of hespan, and 750cc of 5%
albumin. estimated blood loss was 2,500cc.  given the large
fluid requirement and his history of copd, patient remained
intubated overnight.  he remained hemodynamically stable post
operatively. his urine output was variable with outputs 28-145cc
per hour and a total of 813 by midnight on operative day.  on
post-operative day 1 by 0600, his urine output progressively
decreased to a point where he was making < 5 cc per hour.  he
was given both normal saline and 2 units of prbcs with no kidney
response (24 hour total of 304 cc) and he remained in aneuric
failure despite receiving >5000cc of fluid over 24 hours.   he
was transferred to the intensive care unit from the
post-anesthesia care unit. his bun/cre also began to rise.
nephrology consult was obtained and the worry was that the
patient was in aneuric renal failure vs. outflow obstruction.
ct studies were obtained on [**6-21**] and revealed: 1. no evidence
for hydronephrosis or hydroureter. no evidence for urinoma. 2.
small amount of intraabdominal ascites as well as inflammatory
stranding along the pararenal fascia and within the right lower
quadrant at the site of the ureteroileal loop anastomosis. small
amount of intraabdominal free air. anasarca. these changes are
most likely secondary to recent postoperative state. 3. small
bilateral pleural effusions with bilateral lung base compressive
atelectasis. urinalysis was consistent with acute tubular
nephritis with aneuria, and creatinine continued to rise. he
remained intubated for ventilartory support.  he had minimal
response to lasix challanges. swan-ganz catheter was inserted
over existing right ij to monitor fluid status and cardiac
function. his creatinine and bun peaked at 6.4/49 respectively
on post operative day 2. he developed progressive non-anion gap
acidosis and bicarbonate infusion was started to control
acidemia.  at that point renal function began to return and
patient began to autodiurese with urine outputs in 3,000-4,000cc
range per 24 hours. he spiked fevers to 101.6 on post operative
day 6. blood, urine, sputum cultures were obtained and sputum
culture showed pseudomonas aureginosa presence. he was begun on
zosyn on [**2198-6-21**] and defervesced over the next 3 days. his bun
and creatinine progressively normalized, as did the acidemia. he
ramained intubated for ventilatory support.  with significan
autodiuresis, patient's sodium began to rise and free water
repletion was begun.  electrolytes were repleted as needed
throughout the stay.  propofol sedation was weaned and his
mental function slowly returned to [**location 213**].  he was extubated on
post-operative day 8. he continued to autodiurese. his mental
function slowly improved and he was transferred to the floor on
post-operative day 13.  after transfer to floor pulmonary was
consulted.  he was started on advair and standing
alb/ipratropium inhaler.  he was continued on zosyn.  he was
also diuresed with lasix which helped clear up his lungs.  his
pulmoary exam improved.  he was on 1:1 sitter which was stopped
and then started again and then stopped on [**7-5**].  he got
startled and slid back against the wall on [**7-4**] prompting the
sitter being restarted.  he made adequate urine output on the
floor and was seen and evaluated by pt who helped him ambulate.
his is/os were good on the floor and he tolerated his pos.  he
was screened for rehab and is in good condtion for discharge.


medications on admission:
advair
combivent
casodex 50 mg
protonix,
lupron every other month, last given [**2198-5-13**]


discharge medications:
1. albuterol sulfate 0.083 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for sob, wheezing.
disp:*30 inhalation* refills:*0*
2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every
4 to 6 hours) as needed.
disp:*30 tablet(s)* refills:*0*
3. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
q6h (every 6 hours) as needed for wheezing, copd.
disp:*10 inhalation* refills:*0*
4. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times
a day).
disp:*60 tablet(s)* refills:*0*
5. fluticasone-salmeterol 500-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
disp:*60 disk with device(s)* refills:*0*
6. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
disp:*30 injection* refills:*0*
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:*0*
8. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: one
(1) puff inhalation qid (4 times a day).
disp:*30 inhalation* refills:*2*
9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
disp:*60 capsule(s)* refills:*0*
10. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3
times a day).
disp:*135 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital 3915**] [**hospital **] rehab center

discharge diagnosis:
angiosarcoma of bladder


discharge condition:
good

discharge instructions:
discharge to rehab facility
need intructions and care for uroestomy
can shower
if have fever >101.4, intractable nausea, vomiting, severe pain
or trouble with your ostomy, please return.

followup instructions:
follow up with cardiology
follow up with pulmonology
follow up with dr. [**last name (stitle) **] (urology) - ([**telephone/fax (1) 4276**]



"
267,"admission date:  [**2104-3-29**]              discharge date:   [**2104-5-2**]

date of birth:  [**2043-11-1**]             sex:   f

service: medicine

allergies:
codeine / vicodin / percocet / compazine / percodan / tigan /
latex / betadine viscous gauze / protonix / surgical lubricant

attending:[**first name3 (lf) 943**]
chief complaint:
""severe all over body pain""


major surgical or invasive procedure:
- esophagogastroduodenoscopy


history of present illness:
60-year-old female with history of etoh/nash cirrhosis
complicated by ascites and encephalopathy (no known varices or
history of sbp) who presents with ""severe all over body pain"".
.
the patient was recently admitted for hypotension and
hyponatremia where she was found to have esbl uti and treated
with tobramycin/tetracycline. she was discharged to a nursing
home on [**2104-3-25**]. at the nursing home, the patient states that she
has not been taking her lactulose and has not had bowel
movements. she is confused and states she has ""all over body
pain"" although she is unable to describe it and unsure of if it
is different or more severe than her baseline chronic pain. she
presents to [**hospital1 18**] for further evaluation.
.
upon presentation to the ew, intial vitals were: t 98.2, hr 86,
bp 130/80, rr 18, sao2 97% ra. labs show inr 1.6, hct 27 (near
recent baseline), lfts okay. she is confused and has asterixis
on exam. she denies rectal. cxr with question of focal
infiltrate. kub with dilated loops of small bowel likely
secondary to ileus (although cannot rule out obstruction).
ultrasound with difficult anatomy and not enough ascites to
safely do diagnostic paracentesis at bedside. recommend
ultrasound guided paracentesis. she received lactulose and was
admitted for hepatic encephalopathy treatment.
.
currently, patient confused. yelling at nurses and very slow
with movement. she notes chills, nausea, right upper quadrant
discomfort and diffuse pain. she is unsure if this is different
than baseline. she is unsure of her last bowel movement and is
unsure if she is taking lactulose. she denies or does not know
about other ros.

past medical history:
1. cirrhosis: thought to be secondary to etoh use and fatty
liver disease
2. h/o pancreatitis
3. etoh abuse
4. cholelithiasis
5. obesity
6. hypothyroidism
7. venous insuffuciency
8. chronic lower extremity edema
9. spinal stenosis
10. reflex sympathetic dystrophy
11. hypokalemia
12. mitral regurgitation
13. neuropathy
14. bilateral hand weakness
15. osteoporosis
16. macrocytic anemia
17. thrombocytopenia
18. uterine fibroids
19. chronic renal insufficiency
20. ""tummy tuck""
21. chronic pain: on narcotics


social history:
lives with her roomate. is a former constable and volunteer
police officer. drinks 3-4 beers/day x 12 yrs. no h/o withdrawl
szs. no tobacco or illicit drug use. estranged from family. no
hcp, though patient believes that father or [**name2 (ni) 8317**] [**name (ni) **] could
be hcp.


family history:
aunt with cirrhosis. mother with alcoholism.

physical exam:
vs: t 98.2, bp 104/66, hr 86, rr 16, sao2 94% ra
general: yelling at nurses - ""no - i want to do it my own way"",
no apparent distress
heent: nc/at, perrl, eomi, sclerae anicteric, mmm, op clear
neck: supple
lungs: limited lung volumes, bibasilar crackles, no cough,
wheezes.
heart: rr, nl rate, i/vi murmur
abdomen: obese, soft, diffuse tenderness no rebound or guarding,
decreased bowel sounds
extremities: warm, le edema 2+
skin: stasis dermatitis bilateral lower extremities, multiple
ecchymotic lesions, rash right forearm
neuro - awake, a&ox2 (name and hospital, wrong day, month,
unsure of year) unwilling to participate in neuro examination,
very upset when asked to participate, emotionally labile. +
asterixis.

pertinent results:
labs on admission:
[**2104-3-29**] 06:54pm   comments-green top
[**2104-3-29**] 06:54pm   glucose-89 lactate-1.4 na+-131* k+-3.5
cl--97* tco2-26
[**2104-3-29**] 06:50pm   urea n-10 creat-1.0
[**2104-3-29**] 06:50pm   estgfr-using this
[**2104-3-29**] 06:50pm   alt(sgpt)-15 ast(sgot)-22 ld(ldh)-227 alk
phos-61 tot bili-1.9*
[**2104-3-29**] 06:50pm   lipase-14
[**2104-3-29**] 06:50pm   calcium-9.3 phosphate-3.9# magnesium-1.5*
[**2104-3-29**] 06:50pm   wbc-5.7 rbc-2.43* hgb-9.1* hct-27.0* mcv-111*
mch-37.7* mchc-33.9 rdw-16.1*
[**2104-3-29**] 06:50pm   neuts-62.6 lymphs-23.1 monos-8.5 eos-4.9*
basos-0.9
[**2104-3-29**] 06:50pm   plt count-148*
[**2104-3-29**] 06:50pm   pt-17.8* ptt-37.0* inr(pt)-1.6*

labs on discharge:
131  95  5
------------<98
3.1  31  0.8

microbiology:
[**2104-3-30**] 10:57 am urine      source: cvs.

                            **final report [**2104-3-31**]**

   urine culture (final [**2104-3-31**]):
      yeast.    >100,000 organisms/ml..

[**2104-4-3**] 3:23 pm urine      source: cvs.

                            **final report [**2104-4-6**]**

urine culture (final [**2104-4-6**]):
      enterococcus sp..    >100,000 organisms/ml..
      yeast.    >100,000 organisms/ml..

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             enterococcus sp.
                             |
ampicillin------------  =>32 r
linezolid-------------     1 s
nitrofurantoin--------    64 i
tetracycline----------  =>16 r
vancomycin------------  =>32 r

[**2104-4-17**] 11:03 am sputum      source: endotracheal.

                            **final report [**2104-4-22**]**

   gram stain (final [**2104-4-17**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2104-4-22**]):
      commensal respiratory flora absent.
      escherichia coli.    rare growth.
         warning! this isolate is an extended-spectrum
beta-lactamase
         (esbl) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. consider
infectious
         disease consultation for serious infections caused by
         esbl-producing species.
      yeast.    rare growth.

                              sensitivities: mic expressed in
mcg/ml

_________________________________________________________
                             escherichia coli
                             |
amikacin--------------   <=2 s
ampicillin------------  =>32 r
ampicillin/sulbactam--  =>32 r
cefazolin-------------  =>64 r
cefepime--------------       r
ceftazidime-----------       r
ceftriaxone-----------       r
ciprofloxacin---------   =>4 r
gentamicin------------  =>16 r
meropenem-------------<=0.25 s
tobramycin------------     8 i
trimethoprim/sulfa----  =>16 r

[**2104-4-29**] 9:39 am urine     no growth.

imaging:
- chest (pa & lat)	study date of [**2104-3-29**] 7:11 pm
impression: markedly limited study. question increased density
at the medial right lung base. this could represent
superimposition of normal structures crowded by significant
volume loss, however focal infiltrates cannot be entirely
excluded.

- portable abdomen	study date of [**2104-3-30**] 9:07 am
impression: two frontal views of the supine abdomen show
disproportionate
dilatation of the stomach and proximal small bowel with respect
to relatively mild gaseous dilatation of the colon, probably the
transverse. appearance is similar to [**3-29**]; small-bowel
obstruction must still be considered. no nasogastric tube is
seen despite severe gaseous distention of the stomach.
right lung base is elevated, probably a combination of
subpulmonic pleural
effusion and upward displacement of the diaphragm.

- ct abd & pelvis with contrast	study date of [**2104-3-30**] 2:56 pm
impression:
1. proximal small bowel dilatation measuring up to 3.6 cm with a
point of transition in the right lower quadrant. imaging
findings are consistent with partial versus complete obstruction
likely on the basis of adhesions.
2. findings of hepatic cirrhosis as on prior exams.
3. anterior abdominal wall hernia containing mesenteric fat and
fluid.

- lung scan	study date of [**2104-3-31**]
impression: underventilated triple match v/q defect with low
probability of pe.

- unilat up ext veins us	study date of [**2104-4-3**] 9:53 am
impression: no evidence of deep vein thrombosis in the right
arm.

- ct abd & pelvis with contrast	study date of [**2104-4-5**] 2:58 pm
impression:
1. stable mild dilatation of the proximal small bowel loops,
maximally measuring 3.6 cm. distal loops appear less distended,
with possible transition point in the right lower quadrant,
likely representing mild/partial small-bowel obstruction.
2. cirrhosis with moderate amount of abdominal and pelvic
ascites.

- ct head w/o contrast	study date of [**2104-4-16**] 6:30 pm
impression:
1. no acute intracranial hemorrhage or mass effect. if there is
continued
concern for parenchymal abnormalities, consider mr head if not
contra-indicated.
2. mild diffuse volume loss increased from [**2096**] ct head study.

- portable abdomen	study date of [**2104-4-20**] 9:38 pm
impression:
in comparison to [**2104-4-17**] exam, there is mild improvement of
ileus without
complete resolution.

- chest (portable ap)	study date of [**2104-4-25**] 8:38 am
findings: in comparison with the study of [**4-23**], the degree of
pulmonary
vascular congestion may have slightly improved. extensive
bilateral
atelectatic changes are again seen with blunting of the
costophrenic angles
consistent with pleural fluid. area of increased opacification
in the right
mid zone may merely represent atelectasis, though in the
appropriate clinical setting the possibility of pneumonia would
have to be considered.

brief hospital course:
summary statement:

ms. [**known lastname 28445**] is a 60 year old female with a provisional diagnosis
of etoh cirrhosis who presented from rehab after a brief
hospitalization for an mdr e.coli uti, new diagnosis of
cirrhosis, and hyponatremia with chronic pain who was found to
have an narcotic ileus who required tpn and then was transferred
to the micu for concern for prolonged epistaxis from presumably
ngt trauma who has remained encephalopathic with decompensated
cirrhosis, persistent ileus from administration from narcotics,
volume overload and hypoxia secondary to pulmonary edema and
atelectasis

prior to transfer to the micu:

1) narcotic ilues: prior to admission she presented with diffuse
abdominal pain, and dilated small loops of bowl on kub.
subsequent abdominal ct scans reveal potential transistion
points and partial small bowel obstruction.  she also developed
non-bloody bilious emesis necessitating ngt placement and small
bowel decompression.  surgery was consulted and a small bowel
follow through revealed and an ileus that was secondary to
prolonged narcotic use for a presumed diagnosis of rsd.  her
narcotics were then stopped, but her ileus persisted which
necessitated starting tpn, and subsequently her ileus resolved
after  methalynaloxone was administered.  her pain from rsd was
subsequently controlled with non-opioid analgesia including
tramadol and lyrica.  radiographs of the abdomin showed passing
of contrast from the small bowel to the colon and her nutrition
was transitioned from tpn to po.  she was tolerating po prior to
her transfer to the micu for epistaxis

2) decompensated cirrhosis:  she presented with peripherial
edema ascities without evidence of encephalopathy.  however, she
became mildly encephalopathic (grade i) with mild asterixis and
disorientation (date) as her ileus persisted.  she was given
lactulose enemas which helped resolve her confusion.  there was
also concern that she may have sbp, although she was never
febrile, and a a diagnostic paracentesis was negative.
subsequently however, she underwent a therapeutic paracentesis
to help remove ascites (3l removed) to improve her respiratory
mechanics in addition to her ileus.  she remained mildly
encephalopathic until her transfer to the micu.

2) volume overload:  she developed volume overload secondary to
decompensated cirrhosis and portal hypertension, ascities, and
the administration tpn in addition to iv medications and
antibiotics.  she was given albumin and prbc to maintain her map
to help diuresis with aldactone and lasix.  due to her uti, and
concern for delerium, a foley was note placed to monitor uop.
her weights were followed to monitor her fluid balance.

3) nutrition: due to her inability to tolerate po and narcotic
ileus.  she was started on tpn for several days.  she also
required additional potassium repletion due to diuresis for
volume overload.

4) hyponatremia: she developed hypervolemic hyponatremia due to
decompensated cirrhosis.  her hyponatremia resolved after the
administration of diurectics and free water restriction.

5) enterococcus/yeast uti.  upon admission she was noted to have
inflammation on her ua in addition to persistent yeast in her
urine and vre.  she was treated empirically for seven days for a
complicated uti with linezolid and fluconazole.  subsequent
urine cultures were negative for persisent yeast or vre.

6) mdr e.coli uti: upon admission she was completing a course of
tobramycin for an esbl uti, please see previous discharge
summary for sensitivities.

7) anemia: the patient remained anemic on presentation and
required multiple prbc transfusions for volume due to
hypotension secondary to decreased intravascular volume.  prior
to her transfer to the micu she did not have evidence of active
bleeding.

micu course: patient transferred to micu given concern for
hematemesis and upper gi bleed.  was electively intubated for
egd on [**4-16**].  egd did not reveal presence of varices, but did
show barrett's and gastropathy.  patient continued on famotidine
for gi ppx.  there was no recurrence of hematemesis, and hct
remained stable.  patient did develop hypotension while
intubated, likely multifactorial secondary to her underlying
cirrhosis and to sedating medications.  was briefly on pressors,
but quickly weaned off once extubated.  was successfully
extubated [**2104-4-17**].  patient developed recurrent ileus while in
icu; ngt kept to continuous low wall suction and patient kept
npo.  course notable for persistent ams, and patient was given
lactulose enemas while npo.  no evidence of infection, as
patient afebrile without leukocytosis.  diagnostic para [**4-16**]
negative for sbp.

post micu course

# encephalopathy: the patient's encephalopathy continued after
she was transferred from the micu to the floor. she was aao x 1
with asterixis. she was treated heavily with lactulose po/pr,
and began to put out an appropriate amount of stool, but without
resolution of her encephalopathy. an infectious work-up with
blood, urine, and chest x-ray was negative. opioid medications,
which were given to her in the icu, were avoided on the floor.
the patient's encephalopathy cleared on [**2104-4-24**], when she was
aaox3, and was following commands, but with occasional
asterixis. she no longer required restraints, and had not been
using the olanzapine which was written for her prn for
agitation. her encephalopathy was felt likely secondary to
lingering opioid medication, and not to hepatic encephalopathy
given her appropriate output of stool.

# epistaxis: upon transfer back from the icu, the patient did
not have any signs of epistaxis, and did not require any
transfusion.

# ileus: the patient had an ileus that was noted on abdominal
x-ray upon return from the icu, which was felt likely secondary
to opioid medication. the patient was made npo, and started on
metoclopromide. a few days later the patient's gi motility
started to return, and her diet was gradually advanced, and her
medications were returned to po. opioid medication was again
thought to play the largest role in the patient's ileus.
metoclopromide was discontinued on patient's discharge.

# tachypnea: the patient was noted on the floor for tachypnea
during her stay, with a normal abg and normal o2 sats. her
tachypnea was felt to be secondary to abdominal ascities with
ateletasis and an element of volume overload. she was treated on
the floor with iv lasix, and ultimately her o2 requirements were
removed. the patient was started on a dose of 40 mg lasix po bid
and her home dose of spironolactone (50 mg daily). she was
discharged on her home dose of 40 mg lasix daily and a new dose
of 100 mg spironolactone daily without tachypnea.

# decompensated cirrhosis: underlying etoh cirrhosis. no history
of varices or sbp; egd from [**4-16**] confirmed patient does not have
varices, and diagnostic para [**4-16**] not suggestive of sbp. the
patient was continued on lactulose and rifaximin.

# hypernatremia/hyponatremia: the patient transiently became
hypernatemic with na of 154 after diuresis, which resolved with
free water administration. on discharge she was hyponatremic
without end organ signs likely secondary to diuresis.

# nutrition: given resolving ileus and multiple bm, the patient
was discharged on regular diet low salt/heart healthy diet

# pain: the patient's chronic leg and back pain had previously
been treated with opiod medication, but her hospital course was
complicated by several adverse events secondary to opioid
medication (ileus, encephalopathy). her morphine doses were
discontinued, and the patient was started in house on standing
tylenol for pain control.

# history of restless legs: the patient previously had been on
mirapex 1mg qhs for restless legs.  this was stopped while in
the hospital, but may be restarted as needed.

medications on admission:
1. alendronate 70 mg po qweekly
2. morphine 30 mg po q12h
3. morphine 15 mg po q6h prn
4. omeprazole 20 mg po daily
5. potassium chloride 20 meq po bid
6. mirapex 1 mg po qhs
7. trazodone 300 mg po qhs
8. hydroxyzine hcl 25 mg po q6h prn
9. lactulose 30ml po tid
10. phenazopyridine 100 mg po tid prn
11. triamcinolone acetonide 0.1 % cream topical [**hospital1 **]
12. lidocaine 5 %(700 mg/patch) adhesive patch daily
13. zofran 8 mg po qid prn
14. calcium citrate + d 630-400 mg-unit po bid
15. vitamin d-3 1,000 unit po daily
16. cyanocobalamin (vitamin b-12) 1,000 mcg po daily
17. docusate sodium 100 mg po bid
18. centrum silver po daily
19. furosemide 40 mg po daily
20. spironolactone 50 mg po daily
21. rifaximin 550 mg po bid
22. tetracycline 500 mg po qid last day [**2104-3-31**]
23. azithromycin 250mg daily (started at rehab)
24. albuterol nebulizer (started at rehab)

discharge medications:
1. alendronate 70 mg tablet sig: one (1) tablet po once a week.

2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
3. potassium chloride 10 meq capsule, extended release sig: two
(2) capsule, extended release po twice a day.
4. trazodone 300 mg tablet sig: one (1) tablet po at bedtime as
needed for insomnia.
5. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po every six
(6) hours as needed for itching.
6. lactulose 10 gram/15 ml solution sig: thirty (30) ml po three
times a day.
7. phenazopyridine 100 mg tablet sig: one (1) tablet po three
times a day as needed for pain.
8. triamcinolone acetonide 0.1 % cream sig: one (1) application
to affected areas topical twice a day.
9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) patch topical once a day.
10. zofran 8 mg tablet sig: one (1) tablet po four times a day
as needed for nausea.
11. calcium 600 with vitamin d3 600 mg(1,500mg) -400 unit
capsule sig: one (1) capsule po twice a day.
12. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet,
chewable po once a day.
13. cyanocobalamin (vitamin b-12) 1,000 mcg tablet sig: one (1)
tablet po once a day.
14. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day.
15. centrum silver     tablet sig: one (1) tablet po once a day.

16. furosemide 40 mg tablet sig: one (1) tablet po once a day.
17. rifaximin 550 mg tablet sig: one (1) tablet po twice a day.

18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1) puff inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
19. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler
sig: one (1) puff inhalation every four (4) hours as needed for
shortness of breath or wheezing.
disp:*1 inhaler* refills:*3*
20. acetaminophen 500 mg capsule sig: one (1) capsule po every
six (6) hours.
disp:*120 capsule(s)* refills:*0*
21. artificial tears(glycerin-peg) 1-0.3 % drops sig: one (1)
drop to both eyes ophthalmic prn as needed for dry eye.
disp:*1 tube* refills:*0*
22. spironolactone 100 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*0*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
primary diagnosis:
- [**female first name (un) 564**] and vre cystitis
- opioid-induced ileus
- hepatic encephalopathy
secondary diagnosis:
- etoh cirrhosis


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:
ms. [**known lastname 28445**], it was a pleasure taking care of you in the
hospital. you were admitted to the hospital with diffuse body
pain. you were found to have an infection in your bladder, and
we treated you with the appropriate antibiotics. however, your
hospital course was complicated by a slow moving gi tract that
likely happened because of the high dose of narcotics which you
normally take. we confirmed that you did not have an obstruction
in your abdomen, and gave you some medications to help your gut
move along. during that time when you were not eating, we were
giving your nutrition through your veins. also during your
hospital stay, you had started vomiting some blood; we took you
to the icu were we put a breathing tube down your throat and
also looked at your stomach lining, where we did not see any
bleeding. we believe that your vomiting of blood may have been
blood which dripped into your stomach from your nose.

unfortunately, when you were intubated, we needed to give you
more doses of narcotics, which caused your gi tract to slow down
again. your gut motility improved, but you still remained a
little bit confused, which improved once the narcotics had
worked their way out of your system.

when you leave the hospital:
- stop morphine 30 mg every 12 hours
- stop morphine 15 mg every 6 hours as needed for pain
- stop tetracycline 500 mg four times a day
- stop azithromycin 250 mg every day
- stop mirapex 1mg before bedtime
- start ipratropium bromide inhaler 1 puff inhalation every four
(4) hours as needed for shortness of breath or wheezing
- start acetaminophen 500 mg every 6 hours
- start artificial tears(glycerin-peg)  1-0.3 % drops: use one
(1) drop to both eyes as needed for dry eyes
- increase your dose of spironolactone to 100 mg daily
(previously you had been taking 50 mg daily)

we did not make any other changes to your medications, so please
continue to take them as you normally have been.

followup instructions:
when you leave the hospital, please have your rehab facility
make the following appointments for you:

- make an appointment to see your primary care doctor, dr. [**first name (stitle) 1022**],
one week after your discharge from rehab by calling [**telephone/fax (1) 250**]

department: liver center
when: wednesday [**2104-5-7**] at 10:00 am
with: [**first name11 (name pattern1) **] [**last name (namepattern1) 7128**], md [**telephone/fax (1) 2422**]
building: lm [**hospital unit name **] [**location (un) 858**]
campus: west     best parking: [**hospital ward name **] garage



"
268,"admission date:  [**2170-6-12**]              discharge date:   [**2170-6-15**]

date of birth:  [**2105-8-24**]             sex:   m

service: medicine

allergies:
penicillins

attending:[**first name3 (lf) 2901**]
chief complaint:
chest pain

major surgical or invasive procedure:
left heart catheterization


history of present illness:
mr. [**known lastname 5066**] is a 54 y/o m with a history of cad s/p bms to
lad in [**2158**], htn, dm2 who presented with sudden onset chest
pain/indigestion approximately 1 hour prior to presentation to
the ed. patient reports burning chest pain that felt like
indigestion radiating to his left arm and up his neck. he was
watching television during the onset of his symptoms. he took
his home omeprazole with no relief. he called ems and who noted
ste in anterolateral leads. he was brought to the ambulance and
had an episode of v-fib, which responded to one shock. he
reverted to nsr after and was loaded with 150mg of amiodarone.
he was also given a aspirin 81mg.
.
when he arrived to the ed initial vitals were  pulse: 106 rr:
25, bp: 130/76, o2sat: 95%, o2flow: ra. a code stemi was called
and he was taken to the cath lab which revealed significant lad
disease primarily in-stent restenosis of his previous bms and a
more distal occlusion that was felt to be the culprit lesion. in
the ed he was given aspirin 325mg, plavix 600mg, and started on
a heparin and amiodarone drip. ekg showed ste in v1-v4 and
pathological q waves in ii, iii and avf.
.
on arrival to the floor, patient the patient was comfortable and
in no acute distress. he did note having continued indigestion
however he states that the sensation was different than what he
was experiencing previously. 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:
1. cardiac risk factors: + diabetes, + dyslipidemia, +
hypertension
2. cardiac history:
-cabg: n/a
-percutaneous coronary interventions: bms to lad [**2158**]
-pacing/icd: n/a
3. other past medical history:
ulcerative colitis
pud
osa not on cpap
asthma


social history:
he is a retired navy consultant.
-tobacco history: denies
-etoh: denies
-illicit drugs: denies

family history:
he states that his mother has angina but had never had an
intervention. his sister has struggled with arthritis and
multiple cancers.
no family history of early mi, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

physical exam:
admission exam:
general: comfortbale and 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.
cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3
or s4.
lungs: ctab, no crackles, wheezes or rhonchi.
abdomen: soft, ntnd. no hsm or tenderness.
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:
98-99.5 74-98 109-162/57-82 rr 18 93-98% ra
gen: comfortable, nad, nt/nd
heent: sclera anicteric, perrla. conjunctive pink without
cyanosis or pallor. no xanthelasma.
neck: supple, jvp of 7
cardiac: normal s1, s2. no murmurs, rubs, or gallops, difficult
due to adiposity.
lungs: good air entry bilaterally, no rales, rhonchi, or
wheezes.
abdomen: soft, non-tender, non-distended, normal bowel sounds.
no organomegaly.
extremities: edema present to one hands-breadth below knee
skin: no stasis ulcers, dermatitis, scars. abundant skin lesions
on back.
pulses: right and left dps and pts 2+

pertinent results:
[**2170-6-15**] 06:57am blood wbc-7.5 rbc-3.39* hgb-9.9* hct-30.4*
mcv-90 mch-29.2 mchc-32.6 rdw-14.8 plt ct-244
[**2170-6-12**] 03:30am blood wbc-12.4* rbc-4.10* hgb-11.9* hct-36.6*
mcv-89 mch-29.0 mchc-32.4 rdw-15.1 plt ct-225
[**2170-6-15**] 06:57am blood plt ct-244
[**2170-6-15**] 06:57am blood pt-14.3* ptt-73.5* inr(pt)-1.3*
[**2170-6-12**] 03:30am blood pt-12.2 ptt-150* inr(pt)-1.1
[**2170-6-12**] 03:30am blood plt ct-225
[**2170-6-12**] 03:30am blood fibrino-426*
[**2170-6-15**] 06:57am blood glucose-166* urean-10 creat-0.7 na-142
k-4.1 cl-105 hco3-28 angap-13
[**2170-6-12**] 09:08am blood glucose-221* urean-18 creat-0.8 na-139
k-3.5 cl-99 hco3-28 angap-16
[**2170-6-13**] 02:45am blood alt-28 ast-59* ld(ldh)-472* alkphos-79
totbili-0.2
[**2170-6-14**] 06:59am blood alt-22 ast-29
[**2170-6-14**] 09:24pm blood ck(cpk)-172
[**2170-6-14**] 09:24pm blood ck-mb-3 ctropnt-1.32*
[**2170-6-12**] 09:08am blood ck-mb-53*
[**2170-6-12**] 03:30am blood ck-mb-11* mb indx-2.9 ctropnt-0.90*
[**2170-6-15**] 06:57am blood calcium-8.3* phos-2.0* mg-2.2
[**2170-6-12**] 09:08am blood calcium-7.6* phos-2.0* mg-1.1*
[**2170-6-12**] 03:30am blood %hba1c-7.1* eag-157*
[**2170-6-12**] 03:30am blood triglyc-102 hdl-35 chol/hd-2.8 ldlcalc-44
[**2170-6-12**] 03:30am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2170-6-12**] 03:46am blood glucose-246* lactate-4.2* na-140 k-2.9*
cl-99 calhco3-27
[**2170-6-12**] 03:46am blood hgb-11.6* calchct-35 o2 sat-94 cohgb-2
methgb-0
[**2170-6-12**] 03:21pm blood freeca-1.03*
[**2170-6-13**] 02:09pm blood aldosterone-pnd
[**2170-6-13**] 02:09pm blood renin-pnd
indications for catheterization:
coronary artery disease, canadian heart class iv,  unstable.
prior ptca
[**2158-12-4**].

procedure:
percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

hemodynamics results body surface area:  2.58 m2
  hemoglobin: 11.9 gms %
  entry
**pressures
aorta {s/d/m} 112/74/86
**cardiac output
heart rate {beats/min} 103
rhythm sinus




**ptca results
  lad

ptca comments:
primary pci was delayed because of severe torutosity in the
right upper
extremity and inability to seat the guide appropriately. we
initially
gained access via the right radial artery. however, because of
severe
tortuosity in the right axilla and because of a short ascending
aorta,
we were unable to engage the left main coronary artery. because
of this,
we then gained access in the right femoral artery. a 6f sheath
was
inserted. initial angiography revealed a 70% stenosis in the
proximal
lad, a 70% stenosis in the proximal portion of the prior mid lad
stents
and a 95% stenosis in the mid to distal edge of the prior mid
lad
stents. we planned to treat all of these lesions with ptca and
stenting.
bivalirudin was administered for anticoagulation, and a
therapeutic act
was confirmed. a 6f xblad 3.5 guide provided adequate support. a

prowater wire crossed the lesions with mdoerate difficulty.  we
then
predilated the distal lesion with a 2.25 x 12 mm sprinter legend
rx
balloon at 10 atm three times. this led to a short dissection
and no
reflow in the distal lad. we therefore attempted to rapidly
deliver a
2.25 x 18 mm resolute rx stent, but we were not able to deliver
due to
tortuosity. we therefore elected to change for a stiffer wire. a
2.25 x
15 mm sprinter balloon was advanced to the distal lad, and the
prowater
wire was removed. a choice pt extra support wire was advanced to
the
distal lad, and the distal lad was again predilated with the
2.25 x 15
mm sprinter balloon at 12 atm. we were then able to deliver a
2.25 x 14
mm resolute stent to the distal lesion and deployed it at 13
atm. we
then delivered a 2.75 x 22 mm resolute to the more proximal
portion of
the prior stents and deployed it at 16 atm. the proximal portion
of
the new stents was postdilated with a 3.0 x 15 mm nc quantum
apex mr
balloon at 16 atm. the mid portion of the newly deployed stents
was
postdilated with a 2.75 x 12 mm nc quantum apex balloon at 18
atm. we
then direct stented the more proximal lad lesion with a 3.5 x 15
mm
resolute stent at 16 atm. final angiography revealed no residual

stenosis, no evidence of dissection and timi 3 flow. right
femoral
angigoraphy revealed an arteriotomy site appropriate for
closure, and a
6f perclose was deployed with adequate hemostasis.


technical factors:
total time (lidocaine to test complete) = 1 hour 54 minutes.
arterial time = 1 hour 53 minutes.
fluoro time = 35 minutes.
effective equivalent dose index (mgy) = 6634 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 440 ml

premedications:
          midazolam 0.5 mg iv
          fentanyl 25 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          diltiazem (ia) 500mcg
          nitroglycerine (ia) 200mcg
           potassium 40meq
          amiodarone (iv) 1mg/min
          bivalrudin 100mg ivb f/b 238mg/hr
          fentanyl 100mcg
          midazolam 1.5mg
          nicardipine 1000mcg
cardiac cath supplies used:
          - [**doctor last name **], prowater 300cm
          - [**company **], magic torque 260cm
          - [**company **], choice pt extra support 300cm
          2.25mm [**company **], sprinter 12mm
          2.25mm [**company **], sprinter 15mm
          - [**company **], nc apex 15/3.0
          - [**company **], nc apex 12/2.75
          6fr cordis, xblad 3.5
          6fr [**doctor last name **], perclose proglide
          - [**company **], resolute 15/3.5
          - [**company **], resolute 15/3.5
          - allegiance, custom sterile pack
          - merit, left heart kit
          6fr terumo, glidesheath
          - [**doctor last name **], priority pack 20/30
          - terumo, tr band large


comments:
1. selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel cad. the lmca had no
angiographically-apparent disease. the lad had 70% proximal
stenosis
prior to the old mid-lad stent. there was also 95% stenosis at
the
distal end of the old mid-lad stent. the lcx had 80% stenosis in
the om1
branch. the dominant rca had no angiographically apparent
disease.
2. limited resting hemodynamics revealed normal systemic
arterial
pressures with a measured central aortic pressure of 112/67/84.
3. left ventriculography was deferred.
4. successful ptca and stenting of the mid to distal lad with
overlapping 2.25 x 14 mm (distal) and 2.75 x 22 mm resolute dess

postdilated to 2.75 mm in the mid portion and 3.0 mm proximally
(see
ptca comments).
5. successful direct stenting of the more proximal lad with a
3.5 x 15
mm resolute des (see ptca comments).
6. successful rfa perclose (see ptca comments).

final diagnosis:
1. two vessel cad with lad stenosis (culprit).
2. successful pci of the mid to distal lad with overlapping 2.25
x 14 mm
(distal) and 2.75 x 22 mm (proximal) resolute dess postdilated
to 2.75
mm in the overlapping segment and 3.0 mm in the proximal
segment.
3. successful pci of the proximal lad with a 3.5 x 15 mm
resolute des.
4. successful rfa perclose.
.
i, dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **],
was physically present during the entire procedure and in
compliance with the cms regulations.
.
[**hospital1 18**] attending of record: [**last name (lf) **],[**first name3 (lf) **] e.
referring physician: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].
fellow: [**last name (lf) **],[**first name3 (lf) **]
[**last name (lf) **],[**first name3 (lf) **] b.
invasive attending staff: [**last name (lf) **],[**first name3 (lf) **] e.
electronically signed by: [**last name (lf) **],[**first name3 (lf) **] on fri [**2170-6-15**] 10:23
am
[**medical record number 28546**] m  64  [**2105-8-24**]
.
cardiovascular report ecg study date of [**2170-6-12**]  3:14:42 am
.
sinus tachycardia. left axis deviation. acute anterolateral wall
myocardial infarction. possible inferior wall myocardial
infarction. compared to the previous tracing of [**2159-6-21**] the
acute infarction is new.
.
echo [**2170-6-12**]
conclusions
the left atrium is mildly dilated. left ventricular wall
thicknesses and cavity size are normal. there is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior wall, septum and apex. the remaining segments contract
normally (lvef = 25%). no masses or thrombi are seen in the left
ventricle. right ventricular chamber size is normal with focal
hypokinesis of the apical free wall. the aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. no
aortic regurgitation is seen. the mitral valve leaflets are
mildly thickened. trivial mitral regurgitation is seen. 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.
.
impression: extensive regional left ventricular systolic
dysfunction, c/w proximal lad disease. no lv thrombus seen.
.
compared with the report of the resting portion of the prior
stress study (images unavailable for review) of [**2162-11-16**],
regional lv wall motion abnormalities are new.
.
findings were discussed with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] at 1120 hours
on the day of the study.
  electronically signed by [**first name8 (namepattern2) **] [**last name (namepattern1) 171**], md, interpreting
physician [**last name (namepattern4) **] [**2170-6-12**] 11:22
.
.
ekg study date of [**2170-6-12**]  7:54:28 pm
.
sinus rhythm. left axis deviation. there are q waves in the
anterior leads
with st segment elevation and terminal t wave inversion
extending into the
anterolateral leads. there are tiny r waves in the inferior
leads consistent
with probable infarction. there are additional non-specific st-t
wave changes.
compared to the previous tracing of the same day st segment
elevation in the
anterior leads has increased. clinical correlation is suggested.

tracing #3



brief hospital course:
active issues:
# stemi with reduced ef:
mr. [**known lastname 5066**] presented to the ed one hour after the onset of
sudden, severe, burning chest pain that radiated up his neck and
to his left arm. he perceived the chest pain to be indigestion
and took an antacid to no relief. he called ems, who documented
st elevation inthe anterolateral leads. during transport, mr.
[**known lastname 5066**] had an episode of ventricular fibrillation, which
responded to one shock. he reverted to normal sinus rhythm and
was administered amiodarone and aspirin.

in the ed, ecg demonstrated ste in v1-v4 and pathological q
waves in ii, iii and avf. mr. [**known lastname 5066**] was taken straight for
cardiac catheterization, which revealed significant lad disease
- primarily in-stent restenosis of his in situ bare metal stent
and a more distal 95% stenosis. three drug-eluting stents were
placed in the proximal and distal lad with good angiographic
results.

post-stemi echocardiography demonstrated an ejection fraction of
25%, which is a marked deterioration from previous studies
(ef=60%). moreover, there was newly diagnosed apical, anterior,
and septal akinesis. based on these findings, the team decided
that mr. [**known lastname 5066**] would benefit from the initiation of
coumadin therapy for thrombus prevention.

during mr. [**known lastname 28547**] stay, an electrophysiology consult
advised us to schedule mr. [**known lastname 5066**] for electrophysiology
follow-up as an outpatient in 40 days' time to assess his need
for an icd. they felt that he would not benefit from
anti-arrhythmic therapy or an external defibrillating device in
the interim.

recovery, first in the ccu and subsequently on the cardiology
[**hospital1 **], was speedy. mr. [**known lastname 5066**] required some potassium
supplementation, and several changes were made to his
medications. during his hospitalization, mr. [**known lastname 5066**] [**last name (titles) 28548**]d nifedipine 30mg once daily, irbesartan 150mg once
daily, metoprolol tartrate 100mg twice daily, and
hydrochlorothiazide 25mg once daily, and was commenced on
coumadin 3mg once daily, clopidogrel 75mg once daily, losartan
25mg once daily, metoprolol succinate 200mg once daily,
eplerenone 25mg once daily. his other medications remain
unchanged.

#inactive issues
1. ulcerative colitis: appears to be doing well with no recent
flares. continue dicyclomine as needed and sulfazaline 1000mg
tid

2. diabetes mellitus: the patient was switched from his oral
medications to insulin while in house with good results.

#transitional issues
1. mr. [**known lastname 5066**] has commenced coumadin prophylaxis. he
received his first dose (5mg) on [**2170-6-13**], and was discharged on
3mg once daily. his inr is to be checked by a visiting nurse on
[**2170-6-16**], and he is scheduled to attend your clinic on [**2170-6-19**].
he has been instructed to take 3mg once daily at 4pm until he
attends your clinic or is linked in with your coumadin service.
we defer any dose adjustments that he may require to you. i have
already contact[**name (ni) **] a nurse in your office with this information.

(2) given the fact that mr. [**known lastname 5066**] required potassium
supplementation a few times during his hospital stay, we
recommend that his serum electrolytes be checked in the short
term, possibly alongside his inr. we commenced him on
eplerenone, which may help in avoiding hypokalemia.

(3) outpatient appointments have been arranged with dr. [**first name8 (namepattern2) **]
[**last name (namepattern1) **] (cardiac services [**2170-6-18**]) and dr. [**last name (stitle) **] [**name (stitle) 1911**]
(cardiac services, electrophysiology [**2170-7-26**]).

(4) mr. [**known lastname 5066**] has expressed interest in cardiac rehab
services in [**location (un) 745**]. i informed him that he should contact the
center of his choice, which would correspond with your office to
arrange for an official referral. he also expressed concern at
having missed a recent appointment with a dietician, which he
would like to have rescheduled through your office.


medications on admission:
1. omeprazole 20 mg oral capsule, delayed release(e.c.) take 1
capsule 30 min before first meal of day
2. sitagliptin (januvia) 100 mg oral tablet take one tablet
daily
3. metformin 750 mg oral tablet extended release 24 hr take 1
tablet three times a day
4. sitagliptin (januvia) 100 mg oral tablet 1 tab po qd
5. fluticasone (flonase) 50 mcg/actuation nasal spray,
suspension 1 spray in each nostril twice a day
6. glipizide 10 mg oral tablet extended rel 24 hr take 1 tablet
twice daily
7. sulfasalazine 500 mg oral tablet 2 tablets (1000mg) three
times daily
8. atorvastatin 80 mg oral tablet take one tablet daily
9. irbesartan (avapro) 150 mg oral tablet take 1 tablet daily
10. loratadine 10 mg oral tablet 1 tablet daily as needed.
11. epinephrine (epipen) 0.3 mg/0.3 ml intramuscular pen
injector use as needed and seek medical advice
12. hydrochlorothiazide 25 mg oral tablet 1 tablet daily
13. nifedipine er 30 mg 24 hr tab 30 mg oral tr24 take 1 tablet
daily
14. dicyclomine 20 mg tab take 1 tablet by mouth 4 times a day
as needed
15. one touch ultra test strips (blood sugar diagnostic) use as
directed 2 times daily
16. lancets use [**hospital1 **] prn
17. metoprolol 100 mg tab (metoprolol tartrate) 1 tablet twice
daily
18. baby aspirin oral (aspirin) none entered

discharge medications:
1. omeprazole 20 mg po daily
2. losartan potassium 25 mg po daily
please hold for sbp<100
please start [**2170-6-15**]
rx *losartan 25 mg 1 tablet(s) by mouth daily disp #*30 tablet
refills:*3
3. nitroglycerin sl 0.3 mg sl prn chest pain
rx *nitrostat 0.3 mg 1 tablet sublingually every 15 minutes as
needed for chest pain not to exceed three pills disp #*30 tablet
refills:*3
4. eplerenone 25 mg po daily
rx *eplerenone 25 mg 1 tablet(s) by mouth daily disp #*30 tablet
refills:*3
5. metoprolol succinate xl 200 mg po daily
start in am on [**6-15**]
rx *metoprolol succinate 200 mg 1 tablet(s) by mouth daily disp
#*30 tablet refills:*3
6. clopidogrel 75 mg po daily
rx *clopidogrel 75 mg 1 tablet(s) by mouth daily disp #*30
tablet refills:*3
7. atorvastatin 80 mg po daily
please stop this drug if you develop muscle weakness or pain or
if your urine gets very dark.
8. aspirin 81 mg po daily
9. sulfasalazine_ 1000 mg po tid
10. januvia *nf* (sitagliptin) 100 mg oral daily
11. metformin xr (glucophage xr) 750 mg po tid
do not crush
12. fluticasone *nf* 50 mcg/actuation nu [**hospital1 **]
1 spray each nostril twice daily
13. glipizide xl 10 mg po bid
14. loratadine *nf* 10 mg oral qday:prn asthma
15. epipen *nf* (epinephrine) 0.3 mg/0.3 ml injection once:prn
anaphylaxis
use as needed and seek medical advice immediately
16. dicyclomine 20 mg po tid:prn bowel irritation
please do not take this medication until you see your physician,
[**last name (namepattern4) **]. [**last name (stitle) 28549**], on [**6-19**].
17. one touch ultra test *nf* (blood sugar diagnostic)
miscellaneous [**hospital1 **]
use as directed two times daily
18. lancets *nf*    miscellaneous [**hospital1 **]
use as directed twice daily
19. warfarin 3 mg po daily16
rx *warfarin 1 mg 3 tablet(s) by mouth daily disp #*30 tablet
refills:*3
20. outpatient lab work
please draw blood for an inr on [**2170-6-16**] and fax the result to
dr. [**last name (stitle) 28549**] at [**telephone/fax (1) 6808**]
21. outpatient lab work
please draw blood on [**2170-6-22**] and send it for serum sodium,
potassium, chloride, bicarbonate/co2, bun, creatinine, calcium,
magnesium, and phosphate. please fax the results to dr. [**last name (stitle) 28549**]
at [**telephone/fax (1) 6808**]


discharge disposition:
home with service

facility:
[**company 1519**]

discharge diagnosis:
primary diagnosis: anterolateral st segment myocardial
infarction (heart attack to the front wall of your heart)
secondary diagnosis: apical akinesis of the left ventricle


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
dear mr. [**known lastname 5066**],

it was a pleasure taking care of you while you were hospitalized
at the [**hospital1 **]. as you know, you were admitted to
the hospital because of your chest pain. on the way, the
emergency medical technicians had to shock you because of an
irregular heart rhythm, which reverted to normal subsequently.
when you got to the hospital, we confirmed that you indeed had a
heart attack and performed a procedure called a left heart
catheterization where a wire was threaded into the arteries that
supply your heart. we found that the area where you already had
a stent placed in [**2158**] was narrowed and there was a very severe
narrowing farther along the artery. the newly diagnosed
narrowing was fixed with a drug-eluting stent. this should help
prevent the re-narrowing that occurred at the site of the bare
metal stent you received in [**2158**].

please keep in mind two important points:
1. you must take plavix for at least 6 months to one year based
on the placement of your drug-eluting stent. you must not miss
any doses because if you do, you will run the risk of having a
sudden and severe blockage of the new stent that could give you
another severe heart attack.

2. because of the location of your heart attack, part of your
heart is not moving properly. this can cause blood to be
stagnant inside of the heart and clot, which can lead to strokes
or other adverse events. as a result, you will need to start a
blood thinner called coumadin for at least a few months. if your
heart regains some of its lost function, you may be able to stop
blood thinners, but this is a discussion that needs to be
undertaken in several months in conjunction with your
cardiologist. until you see dr. [**last name (stitle) 28549**], you should take 3mg of
coumadin by mouth each afternoon at 4pm.

you were brought to the cardiac care unit after your procedure
where you did well. you were transferred to the non-intensive
care cardiology floor shortly thereafter where your course
continued to be unremarkable.

you have several follow-up appointments listed below. please
keep all of them; each is extremely important. also, please
discuss cardiac rehabilitation with your cardiologist and
primary care provider next [**name9 (pre) 766**] and tuesday, respectively.

start:
coumadin 3mg by mouth once daily (on [**8-16**], and [**6-17**]). you
will have blood tests drawn on the 14th and 15th that will
dictate your dose on [**6-18**] and thereafter. you must go to [**hospital1 2292**] in [**location (un) **], [**university/college **], or [**location (un) 38**] to have these labs
drawn. they will be submitted electronically to dr.[**name (ni) 28550**]
office, where he and his team can decide the appropriate
coumadin dose.
plavix 75mg by mouth once daily
losartan 25mg by mouth once daily
metoprolol succinate (xl) 200mg by mouth once daily
eplerenone 25mg by mouth once daily

stop:
nifedipine er 30 daily
irbesartan 150 daily
metoprolol tartrate 100mg twice daily
hydrochlorothiazide 25mg daily


followup instructions:
department: cardiac services
when: monday [**2170-6-18**] at 4:20 pm
with: [**first name11 (name pattern1) **] [**last name (namepattern4) 1523**], md [**telephone/fax (1) 62**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

name: [**last name (lf) **],[**first name3 (lf) **] j
location: [**location (un) 2274**]-[**location **]
address: 291 independence dr, [**location **],[**numeric identifier 1700**]
phone: [**telephone/fax (1) 28551**]
appt:  [**6-19**] at 2:20pm

department: cardiac services
when: friday [**2170-7-13**] at 10:00 am
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

department: cardiac services
when: thursday [**2170-7-26**] at 1 pm
with: [**name6 (md) 1918**] [**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


                             [**first name11 (name pattern1) **] [**last name (namepattern1) 2908**] md, [**md number(3) 2909**]

"
269,"admission date:  [**2180-6-3**]              discharge date:   [**2180-6-12**]

date of birth:  [**2134-3-21**]             sex:   f

service: medicine

allergies:
vancomycin

attending:[**first name3 (lf) 759**]
chief complaint:
fever, sputum production, shortness of breath, stomach pain

major surgical or invasive procedure:
none

history of present illness:
mrs. [**known lastname **] is a 46-year-old with a history of intracranial
hemorrhage secondary to avm s/p evacuation in [**2179-8-27**],
complicated by hydrocephalus requiring vp shunt, brought in from
[**hospital3 2558**] nursing home. she has a tracheostomy and peg. she
has undergone rehabilitation at [**hospital3 **] [**hospital1 8**] and
[**location (un) 1036**] [**location (un) 620**]. during her time at [**location (un) 1036**], she was
hospitalized at [**hospital1 18**] [**location (un) 620**] and found to have a mucous plug
with sputum culture positive for mrsa, as well as e. faecalis
urinary tract infection (sensitive to linezolid, vancomycin, and
furantoin) treated with nitrofurantoin x 6 days. she was
transferred from [**location (un) 1036**] to [**hospital3 2558**] on [**2180-5-30**]. per a
[**hospital3 2558**] employee who spoke with the patient's respiratory
therapist, the patient was noted to have increasingly voluminous
secretions requiring increasingly frequent sunctioning (every
four hours -> every two hours -> every hour -> every 30
minutes). she was febrile to 101.2 with a heart rate in the
120s.
.
in the [**hospital1 18**] ed, vs were hr 126, bp 90/68, rr 26, o2 99% on ?
o2. she was thought to have suprapubic tenderness on exam. chest
x-ray revealed no acute intrathoracic process. urinalysis was
leukocyte- and nitrite-positive with many bacteria. sputum
gram-stain and culture, blood culture, and urine culture went
sent. she received cefepime 2g iv x 1 and linezolid 600mg iv x 1
for possible healthcare-associated pneumonia and urinary tract
infection, plus acetaminophen and fluids.
.
on the floor she is noted to be hypotensive to 82/palp and is
triggered in the setting of losing her iv access. she is
admitted to the micu for closer monitoring. in the micu she
denies complaints.
.
 in the micu pt received fluid boluses (6.5l total) to treat
hypotension, but did not receive pressors. linezolid and
cefepime were continued [**12-29**] vanc allergy. cxr revealed
questionable pneumonia with retrocardiac opacity vs atelectasis,
and current abx should treat for any hap as well. on hospital
day 3, pt's hypotension stabilized, with sbps in the 100s. at
time of txfr, sputum culture taken is growing gnr, which will
need to be followed. urine cx revealed e. coli sensitive to
cefepime. pt's lactate trended down with condition improvement.
pt was transferred to the floor.
.
on the floor, pt remained stable, with sbps in the 100s.
midodrine was added to pt's regimen, with resumption of normal
blood pressures in the 110s to 120s. pt remained afebrile on the
floor, with no adverse events. cefepime and linezolid were
continued. pt was restarted on her normal cycled tube feeding
regimen from continuous feeds, which she tolerated well.
.
review of systems:
(+) per hpi; she has had ongoing hyperthermia thought to a
""central fever""/reset thermostat, though she was afebrile on
discharge from [**location (un) 1036**] (t 98.0); husband also notes that she
has complained of intermittent headache recently; she is
constipated at baseline
(-) denies sinus tenderness, rhinorrhea or congestion. denied
chest pain or tightness, palpitations. denied arthralgias or
myalgias

past medical history:
intracranial hemorrhage in [**2179-8-27**]
s/p vp shunt
enterococcus faecalis uti ([**2-4**])
mucous plug ([**2-4**])
mrsa colonized
situational depression

social history:
cared for by husband, who is her guardian. currently [**name2 (ni) 546**] at
[**hospital3 2558**] ([**location (un) **]), a nursing facility, but has spent
the last ~9 months at [**hospital3 **] [**hospital1 8**] and [**location (un) 1036**]
[**location (un) 620**]. [**university/college **] grad [**first name8 (namepattern2) **] [**doctor first name **] note.


family history:
non-contributory

physical exam:
on admission:
vs: t 97.3, bp 95/60, hr 79, rr 24, spo2 100% on 50%
ga: somnolent and uncommunicative
heent: perrl. eyes with strabismus. oropharynx exam limited but
there are visible secretions. no lad. trach with visible
secretions.
cards: faint s1 and s2, no mrg, pulses full but faint
pulm: diffusely rhonchorous breath sounds with scattered
background wheezes
abd: soft, deep palpation did not elicit grimace
extremities: wwp
skin: warm with no rashes, peg site clean and non-draining
neuro/psych: strabisus as above. cn iv-xii, ue/le strength,
coordination, reflexes, and gait not assessed.

on discharge:
vs: t 98.8, bp 116/75, hr 82, rr 24, spo2 99% on 35% humidified
through trach mask
ga: alert and responsive.
heent: eyes with strabismus, left anisocoria. oropharynx without
lesions. no lad. trach clean and well-cushined with no leaking
secretions.
cards: normal s1 and s2, no mrg, pulses 2+
pulm: good air entry b/l throughout. transmitted upper airway
sounds from trach heard throughout.
abd: soft, non-tender, non-distended.
extremities: wwp 2+ pt/dp pulses
skin: warm with no rashes, peg site clean and non-draining
neuro/psych: strabisus as above, left anisocoria unchanged
during course on floors.


pertinent results:
admission labs:

discharge labs:

studies:
cxr [**2180-6-3**]:
impression: no acute intrathoracic process.

ct abd/pelvis:
impression:
mild amount of subcutaneous air in the anterior abdominal wall
inferiorly is likely related to injections.
trace pelvic free fluid, could be physiologic (if patient
pre-menopausal), or could relate to vp shunt.

micro:
blood cx [**2180-6-3**]: pending
urine cx [**2180-6-3**]: pending
sputum cx [**2180-6-3**]:
[**2180-6-3**] 11:45 am sputum

   gram stain (final [**2180-6-3**]):
      >25 pmns and <10 epithelial cells/100x field.
      3+  (5-10 per 1000x field):   gram negative diplococci.
      2+   (1-5 per 1000x field):   gram negative rod(s).
      1+    (<1 per 1000x field):   gram positive cocci.
                                    in pairs and in short
chains.
      1+    (<1 per 1000x field):   gram positive rod(s).

   respiratory culture (preliminary):

[**2180-6-8**] 06:15am blood wbc-8.8 rbc-3.24* hgb-10.0* hct-30.7*
mcv-95 mch-30.9 mchc-32.6 rdw-14.9 plt ct-378
[**2180-6-7**] 05:55am blood wbc-7.5 rbc-3.19* hgb-9.8* hct-30.3*
mcv-95 mch-30.8 mchc-32.4 rdw-14.6 plt ct-333
[**2180-6-6**] 06:14am blood hct-30.9*
[**2180-6-6**] 04:02am blood wbc-7.4 rbc-2.68* hgb-8.2* hct-24.9*
mcv-93 mch-30.8 mchc-33.1 rdw-14.5 plt ct-322
[**2180-6-5**] 05:46am blood wbc-8.0 rbc-3.20* hgb-9.9* hct-29.8*
mcv-93 mch-30.8 mchc-33.1 rdw-14.4 plt ct-264
[**2180-6-4**] 04:25am blood wbc-7.1# rbc-2.98*# hgb-9.2*# hct-28.0*#
mcv-94 mch-30.9 mchc-32.9 rdw-14.4 plt ct-280
[**2180-6-3**] 11:12am blood wbc-16.8* rbc-4.34 hgb-13.3 hct-39.0
mcv-90 mch-30.6 mchc-34.0 rdw-14.5 plt ct-421
[**2180-6-3**] 11:12am blood neuts-82.2* lymphs-10.4* monos-5.8
eos-0.7 baso-0.8
[**2180-6-8**] 06:15am blood plt ct-378
[**2180-6-5**] 05:46am blood pt-11.1 ptt-26.3 inr(pt)-0.9
[**2180-6-8**] 06:15am blood glucose-117* urean-6 creat-0.4 na-137
k-4.0 cl-98 hco3-32 angap-11
[**2180-6-7**] 05:55am blood glucose-103* urean-4* creat-0.3* na-138
k-3.9 cl-101 hco3-30 angap-11
[**2180-6-6**] 04:02am blood glucose-87 urean-6 creat-0.4 na-141 k-3.8
cl-107 hco3-27 angap-11
[**2180-6-5**] 05:46am blood glucose-139* urean-6 creat-0.4 na-136
k-4.0 cl-105 hco3-24 angap-11
[**2180-6-4**] 04:25am blood glucose-117* urean-11 creat-0.4 na-137
k-3.9 cl-108 hco3-22 angap-11
[**2180-6-3**] 11:12am blood glucose-128* urean-19 creat-0.7 na-132*
k-5.1 cl-95* hco3-20* angap-22*
[**2180-6-7**] 05:55am blood alt-74* ast-50* alkphos-78 totbili-0.1
[**2180-6-5**] 05:46am blood alt-33 ast-22 ld(ldh)-242 alkphos-69
totbili-0.1
[**2180-6-3**] 11:12am blood alt-53* ast-38 ld(ldh)-309* alkphos-98
amylase-47 totbili-0.2
[**2180-6-7**] 05:55am blood lipase-24
[**2180-6-5**] 05:46am blood lipase-29
[**2180-6-3**] 11:12am blood lipase-42
[**2180-6-8**] 06:15am blood calcium-9.0 phos-3.2 mg-2.4
[**2180-6-7**] 05:55am blood albumin-3.2* calcium-8.7 phos-3.6 mg-2.4
[**2180-6-6**] 04:02am blood calcium-8.5 phos-3.4 mg-2.3
[**2180-6-5**] 05:46am blood calcium-8.4 phos-2.8 mg-2.2 iron-20*
[**2180-6-4**] 04:25am blood calcium-7.9* phos-3.1 mg-2.2
[**2180-6-3**] 11:12am blood albumin-4.3 calcium-9.5 phos-3.1 mg-2.8*
[**2180-6-5**] 05:46am blood caltibc-218* ferritn-290* trf-168*
[**2180-6-4**] 04:56am blood type-[**last name (un) **] po2-76* pco2-43 ph-7.37
caltco2-26 base xs-0
[**2180-6-4**] 04:56am blood lactate-1.2
[**2180-6-3**] 11:21am blood lactate-2.3*

brief hospital course:
pt is a 46 yo f w pmh of avm intracerebral bleed c/b cerebral
edema in [**2178**] requiring a trach and peg who presents with
increased respiratory secretions, increased lethargy,
hypotension and fever concerning for severe sepsis. she was
transferred to the micu for hypotension and closer monitoring.
she was treated with linezolid and cefepime. cultures were sent
and showed e coli in the urine sensitive to cefepime.

# severe sepsis: patient's vitals in the ed were temp 102, hr
126, rr 26, with a wbc count of [**numeric identifier 2686**]. patient met all 4
criteria for sirs. patient also has a ua concerning for uti. pt
also has a trach aspirate growing moraxella from an osh and a
sputum culture pending here; however, clear lungs, lack of
increased sputum or o2 requirement here, lack of infiltrate
makes hap unlikely. ct abdomen unrevealing. pt was bolused with
ivf's and hypotension resolved. she would become intermittently
hypotensive 1-2x/day throughout her micu course thought to be
secondary to autonomic dysfunction secondary to her stroke.
sepsis was thought to be resolved, and the hypotension would
quickly recover on its own or with small fluid bolus. she was
started on linezolid given history of vanc allergy & vre
positive per report, in addition to cefepime to cover for gnr's
on [**2180-6-3**] for day 1. c. diff was ordered; however, pt was not
stooling while in the micu. kub was sent and revealed
constipation. she remained hemodynamically stable with no
pressor requirement while in the micu. cultures were sent and
showed e coli in the urine sensitive to cefepime.
outpatient issues:
-- continue cefepime next 4 days to complete 14d course,
midodrine

# abdominal pain: unclear origin but most likely [**12-29**] uti,
possible pyelonephritis. lfts showed only mildly elevated alt.
ct abd unrevealing. abdomen remained soft. vp peritonitis
considered, but only minimal ascites on imaging in addition to
benign abdomen on exam. kub revealed constipation and she
improved with suppositories and laxatives. once on floor s/p
micu stay, pt no longer complained of abdominal pain.

# anion gap acidosis: likely [**12-29**] lacate. lactate downtrended and
acidosis resolved.

# anemia: normocytic, previous baseline ~ 30-32. likely dry on
admission, and hct fell to 28, likely dilutional in setting of
volume resuscitation. patients hematocrit monitored daily. hcts
remained stable.
 .
# hypotension. per report patient with baseline sbps in
90s-100s. in micu patient received a total of 6.5l in 500cc
boluses to maintain pressures. with treatment of infection sbps
stabilized to 100s. decision made to start patient on standing
midodrine to treat possible component of autonimic dysfunction
secondary to known intracranial pathology.

# s/p intracerebral bleed: baseline neuro status according to
husband. on trach and peg. has [**2-29**] r sided strength, left sided
weakness. no acute issues.

# depression: wellbutrin held on linezolid due to initial
concern for serotonin syndrome. patient continued on ambien.


medications on admission:
-jevity tube feeds @ 85 cc/hr via ng tube at 8pm off at 6am
-azocranberry 150 mg ng [**hospital1 **]
-lactulose 15 ml ng [**hospital1 **]
-ritalin 2.5 mg ng daily
-clonidine 0.1 mg ng [**hospital1 **]
-vitamin b complex 1 tab ng daily
-lovanox 40 mg subq daily
-zantac 150 mg/10 ml syrup ng daily
-senna 2 tabs ng daily
-wellbutrin 100 mg ng daily
-ambien 5 mg ng qhs
-tylenol 650 mg ng q4h prn:pain, fever
-simethicone 80 mg ng qid prn:gas pain
-acetylcysteine [mucomyst] 600 mg neb [**hospital1 **]

discharge medications:
1. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2
times a day): [**month (only) 116**] decrease by half if pt has more than 2 bowel
movements per day.
2. b complex vitamins capsule sig: one (1) cap po daily (daily).

3. ranitidine hcl 15 mg/ml syrup sig: one [**age over 90 1230**]y (150) mg
po daily (daily).
4. senna 8.6 mg tablet sig: two (2) tablet po daily (daily).
5. acetaminophen 500 mg tablet sig: one (1) tablet po q4h (every
4 hours) as needed for pain.
6. simethicone 80 mg tablet, chewable sig: one (1) tablet,
chewable po qid (4 times a day) as needed for gas pain.
7. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
8. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid
(4 times a day) as needed for thrush.
9. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1)
tablet, sublingual sublingual qid (4 times a day).
10. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2
times a day).
11. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po
daily (daily) as needed for constipation.
12. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a
day). disp:*180 tablet(s)* refills:*2*
13. cefepime 2 gram recon soln sig: one (1) recon soln injection
q12h (every 12 hours): for the next four days through [**2180-6-16**].
14. lovenox 40 mg/0.4 ml syringe sig: one (1) subcutaneous once
a day.
15. bisacodyl 5 mg tablet sig: 1-2 tablets po once a day as
needed: for constipation. tablet(s)
16. mucomyst neb sig: 600mg twice a day: give acetylcysteine
600mg neb [**hospital1 **].


discharge disposition:
extended care

facility:
[**hospital3 2558**] - [**location (un) **]

discharge diagnosis:
urosepsis

discharge condition:
level of consciousness: alert and interactive, though
neurologically limited.
activity status: bedbound.
mental status: confused - sometimes.


discharge instructions:
dear ms. [**known lastname **]: it was a pleasure participating in your care at
[**hospital1 69**]. you were treated here for
urosepsis, which is a severe infection of the bladder. you need
4 more days of antibiotics through your veins. you were also
treated for a likely infection of your lungs, you already
completed antibiotics for that. you should continue your
medications as you had previously, and take the antibiotics as
prescribed in the medicine list.
.
changes to your medication:
start: to treat infection, please take your cefepime twice per
day for the next 4 days.
start: please continue your bowel regimen (laxatives) as
prescribed on the medication sheet to avoid constipation and
belly pain.
start: to treat low blood pressure please take the midodrine as
prescribed on your medication sheet.

stop: ritalin 2.5mg daily, you did not seem to need this. you
are now getting midodrine.
stop: clonidine, your blood pressures were low during this
admission.
hold: wellbutrin 100mg daily. you can discuss with your rehab
doctor when you resume this medication.
to avoid future urinary tract infections, you should have your
diapers changed very regularly. your institution may want to
straight-cath collect urine every 4 hours if diaper changes are
not frequent enough.

followup instructions:
please follow up with the doctors at rehab this week.



completed by:[**2180-6-12**]"
270,"admission date:  [**2118-10-14**]              discharge date:   [**2118-10-25**]

date of birth:  [**2068-6-1**]             sex:   m

service: [**hospital unit name 196**]

allergies:
vancomycin

attending:[**first name3 (lf) 4765**]
chief complaint:
dizziness

major surgical or invasive procedure:
cardiac catheterization with stent placement
intubation
urinary tract infection


history of present illness:
50yo man with h/o cad s/p imi and rca stent in [**2-13**], also with
h/o hypercholesterol, [**date range **], etoh, who p/t an osh hospital with
nstemi (st depressions in ii, iii, avf), bradycardic and
nauseated. he was transferred to [**hospital1 18**] emergently for cardiac
cath.

past medical history:
cad s/p imi and rca stent in [**2-13**]
hypercholesterol
[**date range **]
etoh

social history:
lives with his wife and daughter in [**name (ni) 28117**], ma, though wife
has avoided him recently because of his etoh use and depression.

etoh: significant increase in use x 6mths since his mother died
[**name2 (ni) **]: none
drugs: none

family history:
cad, with mi <55 in several relatives

physical exam:
vitals: t100.3, hr 100(paced), rr24 (vent), o2 sat 100% on 50%
fio2
gen: middle-aged man lying in bed, sleeping, awoken to voice
skin: warm and dry; no perspiration, no groin hematoma, no flank
hematoma; right groin with no bleeding
heent: normal size pupils, perrl, mmm, no oral bleeding, poor
dentition with missing teeth
cv: normal s1 s2, no g/r/m
lungs: bibasilar rales, no w/r, no egoph, no tact frem
abd: +bowel sounds, soft, nt/nd, no hsm, no masses palpated
ext: 2+ dp pulses b/l, feet warm and well perfused; no le edema
neuro: a+ox3

pertinent results:
[**2118-10-14**] 10:00pm blood wbc-16.4*# rbc-3.20* hgb-11.4* hct-33.0*
mcv-103*# mch-35.4* mchc-34.5 rdw-11.6 plt ct-221
[**2118-10-15**] 12:30am blood wbc-25.8*# rbc-3.83* hgb-13.3* hct-37.6*
mcv-98 mch-34.7* mchc-35.4* rdw-12.0 plt ct-362#
[**2118-10-23**] 12:15pm blood wbc-13.6* rbc-4.08* hgb-13.3* hct-38.2*
mcv-94 mch-32.5* mchc-34.8 rdw-13.8 plt ct-442*
[**2118-10-25**] 11:24am blood wbc-14.8* rbc-4.01* hgb-13.1* hct-37.1*
mcv-93 mch-32.7* mchc-35.3* rdw-14.0 plt ct-616*
[**2118-10-18**] 11:09pm blood neuts-77.8* lymphs-10.3* monos-5.2
eos-6.2* baso-0.5
[**2118-10-14**] 10:00pm blood pt-18.2* ptt-150.0* inr(pt)-2.1
[**2118-10-14**] 10:00pm blood plt ct-221
[**2118-10-15**] 12:30am blood pt-15.8* ptt-138.5* inr(pt)-1.6
[**2118-10-15**] 12:30am blood plt ct-362#
[**2118-10-22**] 06:01am blood plt ct-319
[**2118-10-23**] 12:15pm blood pt-13.9* ptt-25.4 inr(pt)-1.2
[**2118-10-23**] 12:15pm blood plt ct-442*
[**2118-10-25**] 11:24am blood plt ct-616*
[**2118-10-17**] 12:08pm blood fibrino-567* d-dimer-1370*
[**2118-10-17**] 12:08pm blood fdp-0-10
[**2118-10-14**] 10:00pm blood glucose-406* urean-8 creat-0.7 na-133
k-3.5 cl-104 hco3-13* angap-20
[**2118-10-15**] 12:30am blood glucose-229* urean-8 creat-0.9 na-135
k-4.1 cl-106 hco3-14* angap-19
[**2118-10-22**] 06:01am blood glucose-96 urean-11 creat-0.7 na-141
k-3.7 cl-101 hco3-31* angap-13
[**2118-10-23**] 12:15pm blood glucose-83 urean-11 creat-0.8 na-145
k-3.6 cl-107 hco3-24 angap-18
[**2118-10-24**] 06:45am blood glucose-95 urean-18 creat-0.8 na-145
k-4.7 cl-109* hco3-28 angap-13
[**2118-10-14**] 10:00pm blood ck(cpk)-69
[**2118-10-15**] 12:30am blood ck(cpk)-512*
[**2118-10-15**] 03:56am blood alt-33 ast-150* ld(ldh)-506* alkphos-82
totbili-0.6
[**2118-10-15**] 04:17am blood alt-25 ast-53* ld(ldh)-259* ck(cpk)-1355*
alkphos-85 totbili-0.6
[**2118-10-15**] 04:55pm blood ck(cpk)-6653*
[**2118-10-16**] 12:10am blood ck(cpk)-6893*
[**2118-10-16**] 07:27am blood alt-35 ast-144* ld(ldh)-428*
ck(cpk)-6313* alkphos-73 totbili-0.6
[**2118-10-19**] 04:24am blood ck(cpk)-3207*
[**2118-10-22**] 06:01am blood alt-50* ast-48* ck(cpk)-581* alkphos-167*
totbili-0.5
[**2118-10-23**] 12:15pm blood ggt-227*
[**2118-10-14**] 10:00pm blood ck-mb-5
[**2118-10-15**] 12:30am blood ck-mb-19* mb indx-3.7 ctropnt-0.28*
[**2118-10-15**] 04:17am blood ck-mb-44* mb indx-3.2 ctropnt-1.19*
[**2118-10-15**] 04:55pm blood ck-mb-45* mb indx-0.7 ctropnt-1.17*
[**2118-10-14**] 10:00pm blood calcium-3.5* phos-2.5* mg-1.7
[**2118-10-15**] 12:30am blood calcium-6.1* phos-1.8* mg-1.9
[**2118-10-15**] 03:56am blood calcium-8.1* phos-3.3 mg-1.9
[**2118-10-15**] 04:17am blood albumin-3.3* calcium-8.1* phos-1.9*
mg-2.5
[**2118-10-23**] 12:15pm blood calcium-8.7 phos-3.8 mg-2.3
[**2118-10-24**] 06:45am blood calcium-8.8 phos-3.7 mg-2.3
[**2118-10-17**] 04:35pm blood hapto-53
[**2118-10-15**] 08:35am blood %hba1c-5.0
[**2118-10-17**] 12:08pm blood triglyc-99
[**2118-10-16**] 07:27am blood tsh-0.090*
[**2118-10-16**] 07:27am blood free t4-1.0
[**2118-10-16**] 07:27am blood cortsol-29.8*
[**2118-10-14**] 10:13pm blood type-art tidal v-700 peep-5 o2-100
po2-304* pco2-41 ph-7.19* calhco3-16* base xs--11 aado2-390 req
o2-67 -assist/con intubat-intubated
[**2118-10-15**] 12:51am blood type-art temp-34.4 tidal v-600 o2-100
po2-191* pco2-31* ph-7.25* calhco3-14* base xs--12 aado2-509 req
o2-83 intubat-intubated vent-imv
[**2118-10-15**] 04:19am blood type-art po2-280* pco2-34* ph-7.46*
calhco3-25 base xs-1
[**2118-10-15**] 06:51am blood type-art o2-80 po2-291* pco2-30* ph-7.48*
calhco3-23 base xs-0 aado2-264 req o2-50 intubat-intubated
[**2118-10-15**] 01:45pm blood type-art temp-39.3 rates-22/ tidal v-650
peep-5 o2-50 po2-168* pco2-37 ph-7.46* calhco3-27 base xs-3
intubat-intubated
[**2118-10-17**] 04:13pm blood type-art temp-36.8 rates-/24 tidal v-430
peep-5 o2-40 po2-132* pco2-43 ph-7.45 calhco3-31* base xs-5
intubat-intubated vent-spontaneou
[**2118-10-20**] 06:03am blood type-art po2-142* pco2-44 ph-7.45
calhco3-32* base xs-6
[**2118-10-20**] 01:05pm blood type-art temp-36.8 po2-104 pco2-39
ph-7.46* calhco3-29 base xs-3
[**2118-10-15**] 12:51am blood lactate-7.3*
[**2118-10-15**] 12:51am blood freeca-0.83*
[**2118-10-19**] 09:19pm blood freeca-1.13

brief hospital course:
upon arrival to the cath lab the pt was slurring his speech,
nauseated and smelled of etoh. while his disorientation
prohibited the pt from making an informed decision about the
cath, the concern for acute mi and the apparent life threatening
nature of the event compelled the cardiac team to proceed with
the cath.

during the cath, the pt was found to be in bradycardic afib with
[**last name (lf) 46360**], [**first name3 (lf) **] two attempts at cardioversion were attempted without
success.  the pt was intubated at this time for airway
protection in the setting of repetitive vomitting. an attempt
was made to cross a lesion in the patient's om1 branch with a
graphix wire, at which time the patient went into vfib. over the
next 30-40 minutes, the pt received cpr intermittently, iv
lidocaine, amiodarone bolus x 300mg and iv drip, iv epinephrine,
defribrillation at 360j x 20 attempts. because of severe
bradycardia after cardioversion, a temporary pacing cath was
placed, with initial rate set at 100bpm. after stabilized in
this manner, the om1 branch was stented open. an attempt
thereafter to decrease his pacer rate to 60bpm resulted in
recurrent vfib. a second pacer wire was placed to reposition,
and then first pacer wire removed. finally, an iabp was placed
with sbp around 130mmhg thereafter, and the patient was
transferred to the ccu for further care.

1. cardio
a. coronaries: as above, pt had stent placed to his om1 branch
in the cath lab, with good post-cath flow and no evid of
dissection. pt was cont on asa, plavix, lipitor. also given
aggrastat x 2d post cath. was on heparin for iabp, which was
stopped after the iabp was removed.
b. pump: pt was transferred to the unit on pressors and iabp on
am on [**2118-10-15**]. iabp was d/c on pm of [**2118-10-16**].  dopamine was
titrated off over the course of several days as his blood
pressure tolerated.  tte revealed lvef 40%; hk of the inferior
free wall. started on metoprolol and captopril, switched over to
lisinopril prior to d/c.
c. rhythm: as noted, pt had recurrent vfib in cath lab, then had
5 episodes of vfib overnight while in the ccu during his first
night, all reverted to paced rhythm at 100bpm once shocked with
pacing pads at 360j x once.  pt was felt to be moving and
dislodging the pacing wires, leading to his vfib, so his
sedation was increased and thereafter he did not have any
further vfib. was initially on an amio drip and a lido drip from
cath lab. lido was weaned off on [**10-16**], with amio weaned off [**10-17**].
pt had his pm turned off, with normal sinus at 70bpm but
occassional drops to 35bpm with no [**month/day (4) 46360**].  pacer was d/c'd after
several days with no adverse events, no requirement for external
pacing. ep felt that pt's arrythmias were [**3-14**] acute ischemia now
resolved and that he would not benefit from an aicd.

2. pulm: pt extubated from cath lab, extubated on [**10-21**]; pt was
given a course of flagyl and levaquin x 10d for possible asp
pna.

3. renal: lytes were repleted qd

4. id: pt had rll atelectasis vs pna on initial cxr, was started
on abx; blood cultures with 1/2 anaerobic bottles growing gpc in
pairs/chains; started on abx on [**10-16**] -- was on vanc for 3d, zosyn
for 7d, ceftriaxone, ceftaz and flagyl; continued flagyl and
levaquin x 10d for possible asp pna.

5. gi: pt had sanguinous heme+ ogt drainage initially, gi
consult was sought. gi advised to follow hct, protonix [**hospital1 **] and
conservative management given the patient's anticoagulated
state. pt's ogt drainage resolved spontaneously after several
days.

6. heme: pt had platelet and hct drop initially, both of unclear
etiologies, which resolved; hit ab test was negative, plt drop
may have been related to prbc transfusions; hemolysis and dic
w/u negative, no source of bleeding other than initial ugib
found. pt received a total of 6 units over the course of this
hospitalization. hct was trending up and greater than 30 upon
discharge.

7. neuro/psych: pt was thought to be likely to have anoxic brain
injury vs. etoh dementia initially, though this did not seem to
be the case. he had no gross neuro deficits, was briefly on a
ciwa scale but did not show signs of etoh withdrawal. psych
evaluated, recommended outpatient f/u for patient's depression
and etoh use, which was set up for the pt prior to his d/c.

medications on admission:
asa
plavix
enalapril
lopressor
lipitor
ativan
paxil

discharge medications:
1. metoprolol succinate 50 mg tablet sustained release 24hr sig:
one (1) tablet sustained release 24hr po qd (once a day).
disp:*30 tablet sustained release 24hr(s)* refills:*2*
2. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every
24 hours) for 7 days.
disp:*7 tablet(s)* refills:*0*
3. multivitamin     capsule sig: one (1) cap po qd (once a day).
disp:*30 cap(s)* refills:*2*
4. lisinopril 5 mg tablet sig: 0.5 tablet po qd (once a day).
disp:*15 tablet(s)* refills:*2*
5. thiamine hcl 100 mg tablet sig: one (1) tablet po qd (once a
day).
disp:*30 tablet(s)* refills:*2*
6. folic acid 1 mg tablet sig: one (1) tablet po qd (once a
day).
disp:*30 tablet(s)* refills:*2*
7. atorvastatin calcium 80 mg tablet sig: one (1) tablet po once
a day.
disp:*30 tablet(s)* refills:*2*
8. aspirin, buffered 325 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*
9. pantoprazole sodium 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*
10. docusate sodium 100 mg capsule sig: one (1) capsule po once
a day as needed for constipation.
disp:*30 capsule(s)* refills:*0*
11. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd
(once a day).
disp:*30 tablet(s)* refills:*2*


discharge disposition:
home

discharge diagnosis:
myocardial infarction (nstemi)
ventricular fibrillation
urinary tract infection


discharge condition:
stable

discharge instructions:
please take all medications as prescribed and attend all
appointments made for you. you will also need to schedule an
appointment with your primary care doctor, dr. [**last name (stitle) 27542**], by
calling ([**telephone/fax (1) 29515**] and with your cardiologist, dr. [**last name (stitle) 11493**], by
calling ([**telephone/fax (1) 29810**]. you should ask for appointments within
the next two weeks if at all possible.  you should mention to
the secretaries that you have just been discharged from the
hospital after having a myocardial infarction (heart attack)
that was complicated by ventricular fibrillation (a dangerous
disorganized electrical activity in the heart).  you should
mention that your doctor in the hospital wanted you to be seen
as soon as possible as an outpatient to follow up on the
medications that you were started on during your admission.

you have been set up for an appointment at [**hospital1 **], [**last name (namepattern1) 46361**] in [**hospital1 1559**], [**numeric identifier 46362**] this thursday, [**10-27**] at 1pm for
assistance in avoiding the health problems associated with
alcohol use.  while this is voluntary, we feel that it is very
important to your well being and the best way you can stay
healthy in the weeks and months ahead.  drinking for you is
particularly risky given your heart condition, and may have been
a factor in your recent heart attack.

you were admitted to this hospital on [**2118-10-14**] with a myocardial
infarction and are being discharged on [**2118-10-25**] having been
treated for this health problem as well as several complications
that have arrisen during the course of your hospitalization.
while you do not require physical therapy at this time, it is
important that you return to work only once you feel comfortable
to do so.  this may take up to a week depending on how quickly
your body recovers.

if you have any symptoms of chest pain, shortness of breath, or
any other complaints that concern you please return the er for
evaluation.

followup instructions:
please make appointments to see your primary care doctor as well
as your cardiologist:
dr. [**last name (stitle) 27542**] ([**telephone/fax (1) 29515**]
dr. [**last name (stitle) 11493**] ([**telephone/fax (1) 29810**]



"
271,"admission date:  [**2154-3-6**]     discharge date:  [**2154-3-10**]

date of birth:   [**2092-4-14**]     sex:  m

service:

history of present illness:  the patient has a long standing
history of hearing loss in the right side.  evaluation of
this hearing loss by his primary care physician led to an
mri, which revealed a right sided 1.6 cm acoustic neuroma.
he was evaluated by dr. [**last name (stitle) 3878**] in [**hospital **] clinic and the choice
of management was reviewed with the patient.  it was decided
that he would undergo a trans-labyrinthine excision of the
acoustic neuroma.

past medical history:  significant for hypertension and
hypercholesterolemia.

past surgical history:  he is status post left herniorrhaphy.

medications:  cardizem cd 360 mg po q.d., lipitor 5 mg po
q.d., hydrochlorothiazide 25 po q.d.

allergies:  no known drug allergies.

hospital course:  the patient was admitted on [**3-6**] and
underwent an uncomplicated right sided trans-labyrinthine
excision of his right acoustic neuroma.  preservation of the
facial nerve was verified with the use of nerve stimulation
at the end of the case.  the patient tolerated the procedure
well and was recovered in the intensive care unit overnight
without any adverse events.

on postop day one the patient was transferred to the floor.
the remainder of his hospital course was uneventful.
initially he had a mild nystagmus, as well as sensation of
dizziness and mild nausea.  after the ensuing couple of days
the patient's symptoms diminished.  the neurosurgery service
continued to follow the patient.  physical therapy was
consulted to assist the patient with ambulation.

on the day of discharge the patient was doing well, remained
afebrile.  he had adequate oral intake and no dizziness.  he
was discharged to home in stable condition with instructions
to contact dr.[**name2 (ni) 37129**] office to make his follow up
appointments.

discharge medications:  percocet one to two tabs po q 3 to 4
hours prn pain.  colace 100 mg po b.i.d., cardizem cd 360 mg
po q.d., lipitor 5 mg po q.d., hydrochlorothiazide 25 mg po
q.d.

discharge diagnosis:
right acoustic neuroma status post trans-labyrinthine
resection.

condition at discharge:  stable.






                          [**first name11 (name pattern1) **] [**last name (namepattern4) **], m.d.  [**md number(1) 37130**]

dictated by:[**last name (namepattern1) 3801**]

medquist36

d:  [**2154-3-9**]  15:42
t:  [**2154-3-13**]  05:56
job#:  [**job number **]
"
272,"admission date:  [**2109-4-21**]       discharge date:  [**2109-5-3**]

date of birth:   [**2046-6-13**]       sex:  f

service:  acove
history of present illness:  the patient is a 62 year-old
female admitted to the acove service on [**2109-4-21**] after transfer
from the medical intensive care unit.  the patient was initially
admitted to an outside hospital on [**4-16**] for a right total hip
replacement.  postoperatively, the patient was anticoagulated
with lovenox and coumadin secondary to thromboembolic concerns
given her history of deep venous thrombosis, pulmonary embolus
and known anticardiolipin antibody positive.  on postop day
number two several adverse events occurred including the patient
spiking a temperature to greater then 101, having an elevated
white blood cell and an inr, which was noted to be
supratherapeutic.  her creatinine also increased from a baseline
of 1.4 to 3.8 and the patient had become anuric and acidotic.  on
postoperative day number three the patient became transiently
hypotensive and an infection workup was instituted.  at that time
she was given stress dose steroids.  further anticoagulation was
held and the renal team was consulted.  subsequently the patient
was transferred to the [**hospital1 69**] on
postoperative day number four for further management.  prior
to transfer she was given bicarbonate and transfused 3 units
of packed red blood cells.

on the 30th the patient was directly admitted to the intensive
care unit.  at that time she was evaluated by the renal service
who felt that her physiology, urine and phena represented acute
atn and as such hemodialysis was not indicated.  the patient also
had antibiotics tapered to levaquin for treatment of an e-coli
urinary tract infection.  on the 27th the patient was noted to
have a hematocrit drop from 28 to 22 and abdominal pelvic ct
demonstrated a right hip thigh hematoma.  as such the patient was
taken to the operating room by orthopedics dr. [**first name8 (namepattern2) **] [**name (stitle) 1022**] for
exploration and evacuation of the expanding hematoma.  the
patient was transfused 5 units of packed red cells at that time.
she was also noted to hve neurological deficits in the right leg.
it is not clear as to the timing of these deficits.

past medical history:  1.  right hip avascular necrosis
diagnosed by mri with subsequent total hip replacement as
described in the history of present illness.  2.  history of
prior deep venous thrombosis and pulmonary embolism last
approximately five years prior to admission.  3.  systemic
lupus erythematosus.  4.  sjogren.  5.  chronic renal
insufficiency.  6.  peripheral vascular disease.  7.
coronary artery disease status post myocardial infarction,
status post percutaneous transluminal coronary angioplasty.
8.  known anticardiolipin antibody positive.  9.  anemia
thought secondary to chronic renal insufficiency.  10.  total
abdominal hysterectomy.  11.  history of benign prostatic
biopsy.

medications on transfer:  1.  synthroid .125.  2.  protonix
40 mg po q day.  3.  prednisone 60 mg po q day.  4.  sodium
bicarb [**2056**] mg t.i.d.  5.  amphojel 30 cc q.d.  6.  zocor 5
mg po q day.  7.  epogen 3000 units one time per week.  8.
colace 100 mg po b.i.d.  9.  percocet prn.  10.  iron sulfate
325 mg po b.i.d.  11. levaquin 250 mg po q.o.d.  12.  lovenox
30 mg subq b.i.d.  13.  regular insulin sliding scale.  14.
lactulose prn.

allergies:  the patient has reported allergies to penicillin,
sulfa, codeine and imuran.

social history:  the patient lives with her husband.  she has
a remote history of both tobacco and ethanol use
unquantitative.

hospital course on the acove service:  given the patient's renal
failure the decision was made in consultation with the renal
service to hold her lovenox and change over to heparin as there
is little data as to the clearance of lovenox in acute renal
failure and as such could not be appropriately dosed.  during the
transition period to heparin, which was done without a bolus the
patient was again noted to have increasing girth of her right
thigh and an 8 point hematocrit drop.  as such repeat ct scan of
the thigh was done, which showed reaccumulation of the hematoma.
the patient was again evaluated by orthopedics in this setting,
however, since there was no progression of her neurologic
deficits and there was no neurovascular compromise of the leg the
decision was made not to intervene at this time.  instead
anticoagulation was held until the patient was stabilized and the
patient was transfused a total of 3 units of packed red blood
cells.  during this time the patient was also evaluated by the
neurology service for her right sided deficits.  on further
evaluation it was determined that the patient that the patient
has a history of spondylolithiasis. however, this could not
account for all of her symptoms.

consultation with both orthopedics and neurology suggests the
possibility of damage of the nerve at time of initial surgery, as
her nerve was noted to be very superficial in the operative
report during the second operation at the [**hospital1 190**] for evacuation.  it also possible that some
compression of the nerve occurred with her initial hematoma.
after the patient was hemodynamically stable her renal function
was noted to return to baseline and her creatinine fell to 1.1.
as such it was felt that it was safe to reinstitute lovenox in
this patient and to slowly load coumadin.  it was verified with
her primary care physician that indeed the patient is
anticardiolipin antibody positive and as such will require
long term anticoagulation with a goal inr of approximately 3.5.
in this setting coumadin was again started.  on both lovenox and
coumadin the patient was hemodynamically stable with no further
evidence of bleeding for greater then 48 hours.  given the
patient's neurologic deficits evaluation by physical therapy
revealed that the patient would benefit from a rehab facility and
the patient was discharged on hip precautions for three months to
rehab.

discharge medications:  1.  synthroid 0.125 mg po q day.  2.
zocor 5 mg po q.d.  3.  iron sulfate 325 mg po b.i.d.  4.
colace 100 mg po b.i.d.  5.  tylenol 500 mg po q 6.  6.
oxycontin 10 mg po q 12.  7.  aspirin 81 mg po q day.  8.
prednisone 5 mg po q day, which is her baseline dose.  9.
metoprolol 75 mg po t.i.d.  10.  captopril 25 mg po t.i.d.
11.  oxycodone 5 mg po q 6 prn.  12.  lovenox 30 mg subq q 12
until therapeutic inr is met.  13.  coumadin 5 mg po q.h.s.
with goal inr of approximately 3.5.  14.  multivitamin one
tab po q day.

the patient is to be on hip precautions for three months
including no hip flexion with internal rotation.  the patient
is to follow up with dr. [**first name8 (namepattern2) **] [**name (stitle) 1022**] of [**location (un) 86**] orthopedics,
[**telephone/fax (1) 36310**].  at this time emg will be deferred as the patient
is to be anticoagulated and as such the risk of the procedure
would out weigh the benefits of the information gained.  the
patient was discharged to rehab in stable condition.

discharge diagnoses:
1.  status post right total hip replacement with subsequent
hematoma and evacuation with reaccumulation.
2.  anticardiolipin antibody positive.
3.  atn now resolved.

secondary diagnoses:
1.  hypothyroidism.
2.  sjogren.
3.  systemic lupus erythematosus.
4.  right avn.






                            [**name6 (md) **] [**name8 (md) **], m.d.  [**md number(1) 4446**]

dictated by:[**last name (namepattern1) 9348**]
medquist36

d:  [**2109-5-3**]  07:28
t:  [**2109-5-3**]  08:25
job#:  [**job number 42109**]
"
273,"admission date:  [**2154-12-2**]              discharge date:   [**2155-1-1**]

date of birth:  [**2097-7-11**]             sex:   m

service: surgery

allergies:
lisinopril

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
[**2154-12-2**]:
1. takedown fundoplication from previous mark iv thoracotomy.
2. paraesophageal hernia repair.
3. roux-en-y gastric bypass, open.
4. open cholecystectomy.
5. [**last name (un) **] gastrostomy tube.

[**2154-12-10**]:
1.  central line placement

[**2154-12-10**]:
1. exploratory laparotomy and irrigation of abdominal cavity.
2. placement of drains x3.
3. placement of chest tube, right

[**2154-12-13**]:
1 right-sided pigtail catheter placement


history of present illness:
[**known firstname **] has class iii morbid obesity with weight as of [**2154-4-1**]
304.4 pounds.  his initial screen weight on [**2154-3-20**] was 302.7
pounds and more recent weight recorded through his primary care
office was 293.5 pounds.  his height is 70 inches and his bmi is
42.2. his previous weight loss efforts have included 6 months of
optifast in [**2142**] losing 60 pounds that he maintained for 6
months, 12 weeks [**first name8 (namepattern2) 1446**] [**last name (namepattern1) **] in [**2141**] losing 20 pounds, 26 weeks
of weight watchers in [**2140**] losing 30 pounds and he lost about 25
pounds with 16 weeks of nutrisystem in [**2129**] that he maintained
for about 10 years.  he has not taken prescription weight loss
medications or used over-the-counter ephedra-containing appetite
suppressants/herbal supplements.  his weight at age 21 and was
172 pounds with his lowest adult weight 160 pounds and his
highest weight was 304.4 pounds on [**2154-4-1**].  he weight 281.6
pound in [**10/2147**], 293.4 pounds in [**3-/2149**] and 261 pounds one year
ago.  he states he has been struggling with weight since the age
of 40 and cites as factors contributing to his excess weight
large portions, inconsistent meal pattern, too many saturated
fats, emotional and stressful eating as well as lack of exercise
regimen.  her activity he does walk one hour one to two times
per week.  he denied history of eating disorders and has no
diagnosis of depression however has had anxiety/mood issues that
are weight related, has not seen a therapist nor has he been
hospitalized for mental health issues and he is currently on no
psychotropic medications.


past medical history:
pmh: morbid obesity, fatty liver, sleep apnea, diabetes type ii,
hypertension, severe esophagitis and reflux, mild congestive
heart failure

psh: [**last name (un) 13989**] mark iv in [**2130**], pilonidal cyst, appendectomy in
[**2142**], laminectomy, and abdominoplasty

social history:
he denied tobacco or recreational drug usage, has one to two
glasses of wine twice per week, drinks both caffeinated and
carbonated beverages.  he works as
coo at [**state 350**] biologics and has a very hectic schedule
traveling mostly domestically, lives with his spouse age 48 who
is a professor of business, he has no children

family history:
his family history is noted for father deceased age 73 secondary
to congestive heart failure, copd and thyroid disorder; mother
living in her mid 80s with heart disease s/p cabg x 4, valve
replacement, hypertension, diabetes and overweight; has two
brothers and two sisters living with younger sister borderline
hypertension and one brother with hypertension and a younger
brother with diabetes.

physical exam:
vs: t97.7 hr 95 bp 121/76 rr 20 02 95% ra

constitutional: nad
neuro: alert and oriented to person, place and time
cardiac: rrr, nl s1,s2
lungs: cta bilaterally
abdomen: soft, non-tender to palpation, no rebound
tenderness/guarding
wounds: abd midline incision, open to air, intact, no periwound
erythema, no drainage; jp insertion site without erythema or
drainage; g-tube insertion
ext: no edema


pertinent results:
[**2154-12-2**] ecg: normal sinus rhythm with a-v conduction delay and
left bundle-branch block with secondary st-t wave abnormalities.
compared to the previous tracing of [**2152-10-27**] no diagnostic
interval change

[**2154-12-3**] ecg: sinus rhythm. atrio-ventricular conduction delay.
left atrial abnormality.  left bundle-branch block. compared to
the previous tracing of [**2154-12-2**] the findings are similar

[**2154-12-3**] cxr: impression: ap chest compared to [**7-27**]:
lung volumes are lower and there is a mild-to-moderate degree of
subsegmental atelectasis at both lung bases. upper lungs are
clear. moderate cardiomegaly is stable and there is no good
evidence of pulmonary edema. small left pleural effusion may be
present. no pneumothorax. nasogastric tube passes below the
diaphragm and out of view. likely an epidural catheter
projecting over the midline but course indeterminate \

[**2154-12-4**]:
cta chest w&w/o c&recons, non-; ct abd & pelvis with contrast:
impression:
1. pulmonary embolism in the right superior lobar segmental
artery.
2. bilateral pleural effusions, greater on the right than the
left.
3. small right lower lobe consolidation, likely atelectasis,
although in the proper clinical setting could represent
aspiration or pneumonia.
4. post-surgical air within the mediastinum.
5. small amount of fluid in the lesser sac, likely
postoperative.
6. normal postoperative appearance of roux-en-y without evidence
of leaks or adjacent fluid collections.

[**2154-12-6**]:
unilat up ext veins us right: impression: superficial
thrombophlebitis of the right cephalic vein

[**2154-12-6**]:
bilat lower ext veins: impression: no evidence of lower
extremity dvt

[**2154-12-9**]:
echo: suboptimal image quality. borderline left ventricular
cavity enlargement with extensive systolic dysfunction c/w
multivessel cad or other diffuse process. pulmonary artery
hypertension. compared with the prior study (images reviewed) of
[**2154-4-23**], left ventricular dysfunction is more pronounced c/w
interim ischemia.

[**2154-12-9**]:
ecg: sinus tachycardia with first degree a-v delay. frequent
ventricular premature beats. intraventricular conduction delay
of the left bundle-branch block type. compared to the previous
tracing of [**2154-12-3**] the rate is faster and ventricular ectopy is
new.

[**2154-12-9**]:
chest (portable ap): there is no evidence of pneumothorax on the
current radiograph. bibasilar areas of atelectasis are unchanged
associated with small amount of pleural effusion. infectious
process in the lung bases, in particularly on the right, cannot
be excluded

[**2154-12-9**]:
chest port. line placement: the right internal jugular line tip
is at the level of superior svc. within the limitations of this
extremely lordotic and limited radiograph, no evidence of
complications demonstrated. left upper mediastinal drain is
partially imaged.

[**2154-12-9**]:
ct chest w/contrast; ct abdomen w/contrast: impression:
1. a large collection from the distal esophagus into the upper
mid abdomen
that contains gas bubbles and debris within it, compatible with
an abscess, which is most probably secondary to a leak.
2. enlarging lesser sac fluid collection as described.
3. small fluid collection just anterior to the first part of the
duodenum.
4. small right pneumothorax.
5. right pleural effusion with secondary atelectasis.

[**2154-12-9**]: bas/ugi air/sbft: impression: leak at the
gastrojejunal anastomosis

[**2154-12-11**]: echo: impression:severe global left ventricular
systolic dysfunction with potential regionality

[**2154-12-12**]: echo: impression: mild to moderate global left
ventricular systoilc dysfunction. mild mitral regurgitaiton.
mild pulmonary hypertension. compared with the prior study
(images reviewed) of [**2154-12-11**], biventricular systolic function
has improved.

[**2154-12-13**]: chest port. line placement
new left ij catheter tip is at the confluence of the
brachiocephalic veins.  there is no evident pneumothorax. new
right basal pleural catheter is in place. right pleural effusion
has decreased. there are no other interval changes.

[**2154-12-14**]: ct chest w/contrast; ct abd & pelvis with contrast:
impression: 1. several fluid loculations in the right hemithorax
with complete collapse of the right lower lobe.
2. fluid in the mid abdomen adjacent to the gastroesophageal
junction has
decreased in size since recent washout.
3. poorly defined fluid collection posterior to the stomach has
slightly
increased in size and is not in continuity with any of the
surgical drains.

[**2154-12-16**]: ecg: sinus rhythm. p-r interval prolongation. consider
left atrial abnormality. intraventricular conduction delay of
left bundle-branch block type. since the previous tracing the
rate is somewhat slower. left atrial abnormality pattern is more
recognizable

[**2154-12-18**]: cxr:
findings: orogastric tube ends approximately just below the
level of the
preliminary reportcarina. left internal jugular line terminates
at the mid svc. right chest preliminary reporttube ending at mid
thorax and right basal pigtail catheter present, unchanged
preliminary reportin position. low lung volumes and
mild-to-moderate right pleural effusion preliminary
reportassociated with right lower lung atelectasis is similar.
no pneumothorax.  preliminary reportheart size, mediastinal and
hilar contours are unchanged. no consolidation or preliminary
reportpleural effusion on the left side.

[**2154-12-22**]: chest (portable ap)
impression: ap chest compared to [**12-22**], 4:39 a.m.:
moderate right pleural effusion is smaller. i see only one right
pleural
drain, pigtail catheter unchanged in position at the base of the
right
hemithorax. previous pulmonary edema and mediastinal vascular
engorgement
have also improved. heart size is normal. left lung is clear. no

pneumothorax. left jugular line ends in the upper svc.
nasogastric tube ends just inferior to the level of the left
main bronchus in the upper esophagus

[**2154-12-22**]: chest port. line placement:
a left subclavian picc line is present -- the tip lies at the
svc/ra junction. no pneumothorax is detected. an additional tube
which appears to terminate in the mid mediastinum apparently
represents an enteric tube with tip near the left mainstem
bronchus and sideport near the thoracic inlet. the picc line and
enteric tube findings were discussed by radiology resident, dr.
[**last name (stitle) **] with the iv nurse, [**first name8 (namepattern2) **] [**doctor last name 7830**], at 9:30 a.m. on
[**2154-12-23**].
there is lordotic positioning. the cardiomediastinal silhouette
is probably unchanged. again seen is opacity at the right lung
base likely representing a combination of pleural fluid and
right base collapse and/or consolidation.  there is a small left
effusion, with some patchy retrocardiac density, also probably
unchanged. tube overlying the right lung base on [**2154-12-22**] film
is not visualized on the current film. no pneumothorax is
detected.

[**2154-12-30**]: ugi sgl contrast w/ kub:
impression: no evidence of anastomotic leak or obstruction at
the
gastrojejunostomy.


brief hospital course:
the patient presented to pre-op on [**2154-12-2**]. pt was
evaluated by anaesthesia and taken to the operating room where
he underwent a takedown fundoplication from previous mark iv
thoracotomy, paraesophageal hernia repair, roux-en-y gastric
bypass, open, open cholecystectomy and [**last name (un) **] gastrostomy tube
placement. there were no adverse events in the operating room;
please see the operative note for details.

patient was extubated and taken to the pacu. it should be noted
that patient required an insulin drip intra-operatively to
control persistently high blood glucose levels, which was
continued in the pacu and eventually replaced on post-operative
day 1 with an insulin sliding scale while on the floor at the
direction of [**last name (un) **] who was consulted for diabetes management.
also while in the pacu, the patient was experiencing mild chest
pain. cardiology was consulted and the patient received
nitroglycerin, pr aspirin and metoprolol. no ekg changes were
observed. once stable, the patient was transferred to the
inpatient surgery [**hospital1 **] for further observation.

on pod 1, the patient's oxygen saturation levels dropped to
below 85% after maintaing sats in the 90s on 3l nc, the patient
triggered on the floor and required 5l of continuous oxygen via
face mask to maintain >90% oxygen saturation. the patient denied
shortness of breath, chest pain, palpitations, headache at this
point. a stat cxr was ordered and revealed mild-to-moderate
degree of subsegmental atelectasis at both lung bases with no
evidence of pneumothorax. ekg was unchanged from previous study.
with the lack of any clinical symptoms, volume overload was
suspected as the most likely culprit for the dropping o2 sats.
the patient was continued on 5l face mask overnight. on pod 2,
he was given a dose of lasix and a ct scan was ordered.
following the lasix dose, the patient was weaned from the
facemask to 3l nc, however, the chest ct revealed a right
segmental pulmonary embolism.  subsequently, a heparin gtt was
initiated to maintain ptt 60-80 and eventually transitioned to
therapeutic lovenox.  the patient continued to deny sob or cp
and was weaned from supplemental oxygen and maintained on room
air.

he remained stable on the floor until he reported severe
abdominal pain, chest pain, fever and tachycardia following an
episode of coughing on pod7.  he was subsequently transferred to
the sicu where he was noted to be febrile, tachycardic,
tachypneic and diaphoretic with a stable bp.  also, given
bandemia empiric broad spectrum intravenous antibiotics were
intiated.  a central line was also placed at this time.  an abd/
chest ct and ugi series was suggestive of a large collection
from the distal esophagus into the upper mid abdomen containing
gas bubbles and debris, compatible with an abscess, likely
secondary to leak; also a small right sided pneumothorax was
noted.  given the findings, the patient returned to the
operating room where he underwent an exploratory laparotomy and
irrigation of abdominal cavity, placement of drains x3 and
placement of a right-sided chest tube.  post-operatively, the
patient remained intubated and was transferred back into the
sicu.

neuro: the patient was initially alert and oriented
post-operatively; pain was initially managed with an epidural.
on pod 2, due to findings of a right-sided pulmonary embolism
requiring anticoagulation via heparing gtt, the epidural was
d/c'd and pca was started for pain control.  on pod4, the pain
regimen was transitioned to oral roxicet.  however, on pod7, the
patient was transferred to the sicu and was taken to the
operating room.  post-operatively he remained intubated and
sedated with fentanyl and versed until pod 15/9.  following
extubation, pain was controlled with prn iv hydromorphone and
transitioned to an oral regimen of liquid oxycodone.

cv: vital signs were routinely monitored. the chest pain the
patient experienced immediately post-operatively subsided by pod
1 and did not recur until the patient required transfer to the
icu on pod7 as described above.  an ekg remained unchanged
showing left bundle branch block, a troponin x 1 was negative
and an echo revealed ef 20-25% likely related to demand ischemia
per report. cardiology re-evaluated the patient and felt was
mildly fluid overloaded but that his decompensation was related
to possible anastomotic leak and was not ischemic in nature.
recommendations included gentle diuresis once clinically stable
and daily electrolyte monitoring.  a repeat echo cardiogram was
performed on pod [**8-24**] and [**9-24**] with progressively improved
systolic function (ef 35-40%).  intravenous lasix was resumed on
pod [**10-26**] with goal of negative 1liter daily until shortly before
leaving the icu on pod 20/13. he remained hemodynamically stable
while on the floor and remained on telemetry for monitoring.

pulmonary: on pod2, following an acute desaturation, a right
segmental pe was identified on cta as described above.  he
remained stable from a pulmonary standpoint with a heparing gtt
for anticoagulation until pod7.  on pod7, the patient returned
to the operating room (as described above) and remained
intubated post-operatively.  a chest tube was placed
intra-operatively due to findings of a small pneumothorax
following central line placement. on pod [**10-26**], the patient
underwent thoracentesis with pigtail catheter placement by
interventional pulmonary with drainage of 100 cc purulent fluid.
 an abdominal ct obtained the following day indicated several
fluid loculations in the right hemithorax with complete collapse
of the right lower lobe. on pod 13/6, the patient underwent
bronchoscopy with evidence of mucus plug or excessive
secretions. he was gradually weaned from the ventilator and
extubated on pod 16/9; he was maintained on cpap overnight for
known osa for the remainder of the hospitalization.  the chest
tube output gradually decreased and was removed on pod 14/7.
the pigtail catheter output also decreased gradually and was
removed on pod 20/13. he was on room air and was noted to have
no desaturation on ambulation on pod 21/14. as he was able to
ambulate more and no longer experienced epsiodes of desaturation
and was ambulating on room air without difficulty by pod 25/18.

gi/gu/fen: the patient was initially kept npo, however, his diet
was gradually advanced beginning on pod1 following a negative
abd ct scan and subsequent removal of the ngt.  his diet was
progressively advanced to a stage 3 diet, which was well
tolerated until the episode of coughing with severe abdominal
pain (described above) occured on pod7.  at this time he was
made npo.  a repeat abd ct and ugi series were performed and
indicative of a large collection from the distal esophagus into
the upper mid abdomen most likely from an anastamotic leak at
the ge anastamosis; as described above, the patient was
subsequently taken back to the operating room for an abdominal
washout and placement of 2 additional jp drains.  as the
patient's diet was unable to be advanced, tpn was initiated on
pod [**11-26**]. after ugi study and subsequent methylene blue test
showed no evidence of leak he was started on trophic tube feeds
at 10cc/hr on pod 19/12.  this was advanced slowly and
eventually reached goal rate on pod 26/19. tpn was weaned as the
tf rate increased and eventually disconitnued on pod 24/17.
following a repeat methylene blue dye test (pod 22/15) in
conjuction with minimal drain output, the ngt and jp #2 were
removed on pod 23/16 followed by jp#1 on pod 24/17 as drain
input did not increase.  on pod 28/21, a repeat ugi series
suggested no leak, therefore, the diet was advanced to stage 1,
which was well tolerated.  on pod 29/22, following removal of jp
#3 and a negative repeat methylene blue dye test, the diet was
advanced to stage 3 and tube feedings were discontinued.  the
patient tolerated the diet advancement well.  he will remain on
this diet until outpatient follow-up with dr. [**last name (stitle) **].

id: patient was noted to have low grade fevers in the immediate
post op course and was found to have positive blood cultures,
growing g+ cocci in pairs and clusters on pod [**7-23**] and was
started on vanc/zosyn/fluc. id was consulted and transitioned
him to vanc/[**last name (un) **]/fluc on pod [**8-24**]. his wbc peaked at 12.6 on pod
[**9-24**]. there was concern for hap but his mini bal and sputum were
negative. repeat blood cultures afterwards had no growth. he had
pleural fluid sampled on pod [**9-24**] that grew veillonella species
on placment of a right sided pigtail that returned 100cc of
purulent drainage on insertion. the following day his ct scan
showed that he had a loculated enhancing pleural effusion. he
underwent a bronch on pod [**10-26**] and was weaned to extubation on
pod 13/6. his antibiotics were narrowed to unasyn on pod 17/10
and remained afebrile and without a leukocytosis afterwards.
unasyn was discontinued on pod 29/22 following a negative ugi
series.  the patient subsequently remained afebrile without
leukocytosis.  he was started on nystatin swuch and spit for
presumed thrush on pod 20/13. after the ngt was removed he had
no further issues with pain in his throat.

heme: he required one unit transfusions on pod [**7-23**], pod [**11-26**],
and pod 14/7. otherwise his hematocrit remained stable.

endo: immediately post-operatively, he maintained on an insulin
gtt as described above.  post-operatively, blood sugars were
controlled with a regular insulin sliding scale.  once on a
stage 3 diet, the patient did not require insulin coverage.

prophylaxis: he was maintained on subcutaneous heparin until he
was found to have a pulmonary embolism as mentioned above, at
which point he was transitioned to a heparin drip, with goal ptt
of 60-80. he was maintained on this until 23/16 when he was
tranistioned to lovenox. hematology recommended 1 mg/kg
therapeutic dosing with anticoagulation for 6 months.  a factor
xa was therapeutic at the time of discharge.  the patient will
follow-up with hematology in [**3-3**].  additionally, wore pneumatic
boots throughout this hospitalization.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received extensive discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
acyclovir 400 mg daily prn
albuterol ih prn
amlodipine 10 mg daily
chlorthalidone 25 mg daily
fluticasone 50 mcg 2 sprays [**hospital1 **]
losartan 100 mg daily
metformin 1000 mg [**hospital1 **]
metoprolol succinate 50 mg daily
pantoprazole 40 mg daily
potassium kcl 10 meq daily
sildenafil 100 mg daily prn
simvastatin 20 mg daily
vitamin d3 1000 units daily
mvi w/ minerals 1 tablet daily


discharge medications:
1. enoxaparin 120 mg/0.8 ml syringe [**hospital1 **]: one (1) syringe
subcutaneous [**hospital1 **] (2 times a day).
disp:*60 syringe* refills:*2*
2. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1)
tablet,rapid dissolve, dr [**last name (stitle) **] once a day.
disp:*30 tablet,rapid dissolve, dr(s)* refills:*0*
3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler [**last name (stitle) **]:
1-2 puffs inhalation every six (6) hours as needed for shortness
of breath or wheezing.
4. insulin regular human 100 unit/ml solution [**last name (stitle) **]: 2-10 units
injection four times a day as needed for refer to sliding scale:
sliding scale:101-150-0 units; 151-200-0 units; 201-250-2
units;251-300-4 units;301-350-6 units;351-400-8 units; >400-10
units.
disp:*1 vial* refills:*2*
5. oxycodone 5 mg/5 ml solution [**last name (stitle) **]: [**5-1**] ml po every 4-6 hours
as needed for pain: administer via g-tube; flush w/ 30 ml water
before and after administration.
disp:*300 ml* refills:*0*
6. docusate sodium 50 mg/5 ml liquid [**month/year (2) **]: ten (10) ml po bid (2
times a day) as needed for constipation: administer via g-tube;
flush w/ 30 ml water before and after administration.
disp:*300 ml* refills:*0*
7. lorazepam 0.5 mg tablet [**month/year (2) **]: one (1) tablet po every twelve
(12) hours as needed for anxiety: sublingual; do not combine
with oxycodone.
disp:*10 tablet(s)* refills:*0*
8. insulin syringe-needle u-100 1 ml 25 x 1  syringe [**month/year (2) **]: one
(1) syringe miscellaneous four times a day as needed for refer
to sliding scale.
disp:*1 box* refills:*2*
9. multivitamin with minerals     tablet [**month/year (2) **]: one (1) tablet po
once a day: chewable only; no gummy.


discharge disposition:
home with service

facility:
[**hospital3 **] [**doctor last name **]

discharge diagnosis:
1. sepsis.
2. pneumothorax.
3. gastrointestinal leak.
4. recurrent hiatal hernia with obstruction.
5. cholelithiasis.
6. obesity.
7. fatty liver.
8. type 2 diabetes.
9. severe reflux esophagitis.
10. sleep apnea.


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
100.7, chills, chest pain, shortness of breath, severe abdominal
pain, pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.

diet: stage 3 diet; do not self-advance

medication instructions:
you will be starting some new medications:
1.  lovenox: 120 mcg subcutaneous injection, twice daily
2.  lorazepam sublingual: 0.5 mg twice daily as needed for
anxiety.  do not take with oxycodone.
3.  prevacid sublingual: 30 mg tablet daily.  this medication is
being prescribed in place of pantoprazole (protonix) as
pantoprazole cannot be crushed.
4.  regular insulin sliding scale: please check your blood
sugars four times daily and adhere to the provided sliding scale
to determine dosage of insulin.  your will not require insulin
if your blood sugar is less than 200 mg/dl.
1.  you are being discharged on medications to treat the pain
(liquid oxycodone) from your operation. this medications will
make you drowsy and impair your ability to drive a motor vehicle
or operate machinery safely. you must refrain from such
activities while taking these medications. also, do not combine
with lorazepam (ativan).
2. you should begin taking a complete multivitamin with
minerals, crushed and administered via your g-tube. no gummy
vitamins.
5. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-6**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


followup instructions:
department: orthopedics
when: tuesday [**2155-1-7**] at 9:40 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: orthopedics
when: tuesday [**2155-1-7**] at 10:00 am
with: hand clinic [**telephone/fax (1) 3009**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 551**]
campus: east     best parking: [**hospital ward name 23**] garage

department: [**last name (un) **] diabetes center
when: tuesday [**2155-1-7**] at 0830 am
with: [**first name8 (namepattern2) **] [**doctor last name **], n.p. [**telephone/fax (1) 2384**]

department: bariatric surgery
when: wednesday [**2155-1-15**] at 4:00 pm
with: [**first name8 (namepattern2) **] [**last name (namepattern1) **], rd [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: bariatric surgery
when: wednesday [**2155-1-15**] at 4:30 pm
with: [**first name4 (namepattern1) **] [**last name (namepattern1) **], md [**telephone/fax (1) 305**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) **]
campus: east     best parking: [**hospital ward name 23**] garage

department: [**hospital3 249**]
when: friday [**2155-1-31**] at 10:20 am
with: [**first name11 (name pattern1) 569**] [**last name (namepattern4) 12637**], m.d. [**telephone/fax (1) 250**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 895**]
campus: east     best parking: [**hospital ward name 23**] garage

department: hematology/oncology
when: friday [**2155-2-28**] at 10:30 am
with: [**first name4 (namepattern1) 569**] [**last name (namepattern1) **], 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: friday [**2155-2-28**] at 10:30 am
with: [**first name8 (namepattern2) 25**] [**last name (namepattern1) **], md [**telephone/fax (1) 22**]
building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**]
campus: east     best parking: [**hospital ward name 23**] garage



completed by:[**2155-1-1**]"
274,"admission date:  [**2130-10-16**]       discharge date:  [**2130-10-24**]


service:  ccu

history of present illness:  this is an 83-year-old white
male with history of coronary artery disease status post
coronary artery bypass graft times three vessels in [**2121**], end
stage renal disease on hemodialysis three times a week,
diabetes mellitus and hypertension transferred from [**hospital 1474**]
hospital for cardiac catheterization.

the patient initially presented to [**hospital 1474**] hospital with
complaints of increased dyspnea on exertion, weakness and
dizziness.  in the emergency department their he was found to
have new ekg changes, new t wave depressions in v2 through v3
and more depressed t wave depressions in v4 through v6 and
atrial fibrillation.  the patient was ruled out for mi by
serial enzymes, although he did have an initial ck mb index
of 3.2 and had an echocardiogram which showed lv enlargement
with akinesis of the inferior and posterior walls.  also with
hypokinesis of other lv walls and ejection fraction of 30%,
mitral tricuspid regurgitation with a pulmonary artery
systolic pressure of 45 mg of mercury, mild mr with
significant left atrial enlargement.  patient then had a
persantine mibi which showed a small lateral wall ischemia
and small inferior wall infarct.

decision was then made to transfer to [**hospital1 190**] for cardiac catheterization.  cardiac
catheterization showed a pulmonary capillary wedge pressure
of 22 mg of mercury, right atrial pressure of 25 mg of
mercury, pa pressure of 46/17, right ventricular pressure
48/9.  a totally occluded lad with positive collateral flow,
70% stenosis of the left circumflex.  the svg to om graft was
totally occluded.  svg to dm graft was patent and lima to lad
graft was patent.  overall severe three vessel disease.  two
out three grafts had moderately decreased left ventricular
ejection fraction of 40%, moderate mitral regurgitation and
moderately diffuse hypokinesis.

during the procedure, the patient became hypertensive with a
210/110 and intravenous prior to nitroglycerin was started.
patient also had flash pulmonary edema after a
................. load of about 500 cc and was electively
intubated for increased shortness of breath and agitation.
the patient was then transferred to the ccu for nipride wean
and extubation.

medications on transfer:
1.  tylenol p.r.n.
2.  ambien p.r.n.
3.  metoprolol 25 mg p.o. b.i.d.
4.  captopril 6.25 mg p.o. t.i.d.
5.  ec-asa 325 mg p.o. q.d.
6.  coumadin 5 mg h.s. then 2 mg h.s.
7.  nitroglycerin drip 0.052.2 mcg per kilogram per minute.
8.  nephrocaps one cap p.o. q.d.
9.  regular insulin sliding scale.
10. glipizide xl 10 mg p.o. q.d.
11. propofol drip.

past medical history:
1.  coronary artery disease status post coronary artery
bypass graft for three vessels in [**2121**].
2.  end stage renal disease on hemodialysis on tuesday,
thursday and saturday.
3.  hypertension.
4.  diabetes mellitus.
5.  anemia.
6.  prostate ca.
7.  new onset atrial fibrillation.

social history:  not obtainable.

family history:  not obtainable.

initial ekg showed atrial fibrillation at 65 beats per
minute, normal axis, qrs mildly elongated, left ventricular
hypertrophy by voltage, t wave inversions in v2 through v5,
st depressions in i and l, unchanged from outside hospital
ekgs.

physical examination:  vital signs with a temperature of 97.6
f, blood pressure 106/45, heart rate 68.  pulmonary artery
pressure 37/11.  in general elderly, sedated, intubated male
lying still in bed.  head, eyes, ears, nose and throat:
normocephalic, atraumatic.  pupils are 2 mm bilaterally,
equal, round, reactive to light.  endotracheal tube in place.
neck:  no jugular venous distention.  cardiovascular:  iv/vi
systolic murmur loudest at the apex radiating to the axilla
into the back, irregular.  pulmonary:  loud bronchial sounds
bilaterally.  abdomen:  soft, nondistended with normal
abdominal bowel sounds, no hepatosplenomegaly.  positive
abdominal bruit.  extremities:  warm, no edema, no hematoma
at right groin.  neuro:  patient sedated.  withdraws from
touching of feet.

initial laboratory results:  white blood cell count of 5.7,
hematocrit 32.7, platelets 134.  differential was 72.4%
neutrophils, 18.2% lymphocytes, 8.2% monocytes, 1.0%
eosinophils, 0.2% basophil.  inr was 1.3. potassium 5.5,
calcium 8.3, magnesium 2.7, phosphorus was 9.7.

abg done was 7.45, 73 and 345 on 100% oxygen.

initial assessment:  this is an 83-year-old male with history
of coronary artery disease, diabetes mellitus, end stage
renal disease on hemodialysis transferred from outside
hospital for cardiac catheterization secondary to abnormal p
mibi with dyspnea and hypertension in cath lab.  started on
nipride and nitroglycerin drips, intubated and electively
transferred to ccu for extubation and drip weaning.

hospital course:
1.  cardiac:  patient is being kept on the nitroglycerin drip
throughout the entire course when he was on the ventilator
and it was discontinued once he had been weaned.  the patient
was started on imdur 50 mg p.o. q.d. for approximately six
hours prior to stopping the nitroglycerin drip with no ill
effects.

patient was noted to have a moderately decreased left
ventricular ejection fraction of 30 to 40%.  the patient was
started on an ace inhibitor and was gradually titrated up,
however two days into ace inhibitor therapy with captopril,
the patient developed an erythematous rash which was
pruritic.  at this point, it was assumed that the rash was
secondary to the sulfur group of the captopril and patient
was switched to lisinopril 40 p.o. q.d. with eventual
clearing of rash and no other ill effects.

the patient was switched over from nitroglycerin drip to
imdur with no ill effects.  patient remained moderately
hypertensive throughout the hospital course with blood
pressures up to 160 mg of mercury systolic were tolerated as
this patient is on hemodialysis.

2.  rhythm:  patient was noted to have new onset atrial
fibrillation.  patient was maintained on telemetry and had
frequent episodes of nonsustained ventricular tachycardia as
well as ventricular tachycardia throughout the first two days
of hospitalization with gradual clearing of these.  the
patient was tried on a beta blocker and pr prolongation was
noted.  at this point, the beta blocker was discontinued and
patient had a pacemaker placed so that he would be able to
tolerate amiodarone therapy.

patient had a dual chamber rate responsive pacemaker placed
and was started on amiodarone loading 400 mg p.o. b.i.d.  at
pacemaker placement, the patient received a dose of
vancomycin.  the patient tolerated the pacemaker placement
and was kept on telemetry for 24 hours after pacemaker was
placed with no adverse events noted.

the patient was also restarted on coumadin for
anticoagulation after pacemaker placement.  the decision of
how long to continue coumadin will be left up to the pcp.
[**name10 (nameis) **] patient's amiodarone loading should be 400 mg p.o. b.i.d.
times one week then 400 mg p.o. q.d. times one week and then
200 mg p.o. q.d.  the patient should be seen at [**hospital **]
clinic in one week.

3.  coronaries:  patient with status post coronary artery
bypass graft in [**2121**], lima to lad, svg to lpda, and svg to om
which is totally occluded, 70% stenotic lesion in mid
circumflex.  patient was started on lipitor 10 mg p.o. q.d.
and was kept on aspirin throughout hospital course.  the
patient should continue to take these two drugs indefinitely.


4.  pulmonary:  patient had an initial weaning trial
approximately 12 hours after admission to the ccu.  the
patient became tachypneic as he was initially weaned from the
ventilator and it was decided to rest him for another day.
the patient was switched over to pressure support and
successfully weaned on hospital day #2.  the patient
initially required oxygen, but soon was able to tolerate room
air with o2 saturations of 95% and above.  there were no
further pulmonary issues in the hospital course.

5.  renal:  patient was continued on hemodialysis throughout
hospital course and initially started on amphojel and phos-lo
as patient had increased phosphorus on presentation.
eventually, amphojel was able to be discontinued after four
hospital days as per renal's recommendation.  patient to
continue hemodialysis as an outpatient on tuesdays, thursdays
and sundays.

6.  endocrine:  the patient was noted to become hypoglycemic
with blood sugars as low as 48.  patient had his glipizide
discontinued and had some hypoglycemia for one day after
discontinuation and subsequently high blood sugars of 160s to
200s while continuing regular insulin sliding scale.  it was
decided to reinitiate glipizide at a lower dose of 2.5 mg
q.d. and further watch for hypoglycemia as an outpatient.

7.  dermatologic:  patient developed an erythematous
maculopapular and some areas ................ pruritic rash
over the trunk and upper thighs and back on day #2 of
captopril.  a dermatology consult was called and a skin
biopsy was performed.  the patient was switched from
captopril to lisinopril.  skin biopsy confirmed a lymphocytic
infiltrate with rare eosinophils, focal rbc extravasation
consistent with systemic hypersensitivity reaction, no
leukocytoclastic vasculitis was seen.

the patient's rash eventually cleared, although not
completely after lisinopril was initiated.  the patient was
given sarna lotion, [**doctor first name **] and benadryl p.r.n. for itching
with moderate effect.

8.  prophylaxis:  patient received aspirin, lipitor, coumadin
and protonix for gi prophylaxis during hospital course.

discharge diagnosis:
1.  new onset atrial fibrillation status post dual chamber
pacemaker placement, initiation of amiodarone therapy.
2.  coronary artery disease.
3.  end stage renal disease on hemodialysis tuesday, thursday
and saturday.
4.  hypertension.
5.  diabetes mellitus type 2.
6.  anemia.
7.  prostate ca.

discharge medications:
1.  warfarin 2 mg p.o. q.h.s.
2.  amiodarone 400 mg p.o. b.i.d. times seven days started
[**2130-10-23**] then 400 mg p.o. q.d. times seven days then
200 mg p.o. q.d.
3.  lisinopril 40 mg p.o. q.d.
4.  imdur 60 mg p.o. q.d.
5.  lipitor 10 mg p.o. q.h.s.
6.  enteric coated aspirin 325 mg p.o. q.d.
7.  benadryl 25 mg p.o. q. six hours p.r.n.
8.  docusate 100 mg p.o. b.i.d.
9.  [**doctor first name **] 60 mg p.o. b.i.d.
10. sarna tp p.r.n.
11. phos-lo three caps p.o. t.i.d.
12. [**doctor last name **] two tabs p.o. b.i.d. p.r.n.

condition on discharge:  good.

discharge status:  to short term rehab.  patient to follow up
with own cardiologist to arrange pulmonary function test as
patient is now being started on amiodarone and also to follow
up tsh and lfts.




                            [**first name11 (name pattern1) **] [**last name (namepattern4) 1008**], m.d.  [**md number(1) 1009**]

dictated by:[**name8 (md) 45172**]
medquist36

d:  [**2130-10-24**]  16:26
t:  [**2130-10-24**]  14:35
job#:  [**job number 45173**]
"
275,"admission date:  [**2176-10-29**]              discharge date:   [**2176-11-5**]

date of birth:  [**2136-3-10**]             sex:   f

service: surgery

allergies:
nsaids

attending:[**first name3 (lf) 301**]
chief complaint:
morbid obesity

major surgical or invasive procedure:
1. laparoscopic repair of paraesophageal hernia.
2. placement of laparoscopic adjustable band and port device.


history of present illness:
[**known firstname 45779**] has class iii morbid obesity with weight of 276.2
pounds as of [**2176-9-10**] (her initial screen weight on [**2176-8-8**] was
280 pounds), height of 64 inches and bmi of 47.4.  her previous
weight loss efforts have included weight watchers, the salad
diet, the south beach diet, the [**doctor last name 1729**] diet, over-the-counter
ephedra-containing ma [**doctor last name **], slim-fast, prescription weight loss
medication and pancreatic lipase inhibitor orlistat (xenical),
and [**first name8 (namepattern2) 1446**] [**last name (namepattern1) **].  her weight and age 21 was 140-145 pounds with
her lowest adult weight 130 pounds at age 20 and her highest
weight 281.7 pounds on [**2176-8-19**].  she weighed 140-145 pounds 10
years ago and 165 pounds 5 years ago.  she states she developed
significant [**last name 4977**] problem in childhood and cites as factors
contributing to her excess weight genetics, large portions,
grazing, late night eating, too many carbohydrates in saturated
fats, stress, compulsive eating and emotional eating as well as
lack of exercise regimen.  her current activity includes
swimming 30 minutes 2-3 times per week and walking 10-15 minutes
twice per week.  she denied anorexia, bulimia, diuretic or
laxative abuse but stated she does have binge eating without
purging.  she has significant psychological history of
depression/bipolar disorder/anxiety and suicide attempts
admitted to [**hospital 1191**] hospital in [**location (un) 10059**] x 2 in [**2171**] for drug
overdose and lithium toxicity with auditory hallucinations,
followed by psychiatrist and a therapist and is currently on
psychotropic medications (paroxetine, abilify and lorazepam).


past medical history:
pmh: copd, fatty liver, htn, hl, hypothyroidism,gerd, bipolar
disorder, iron deficiency anemia, renal insufficiency,
nephrogenic diabetes insipidus

psh:  wisdom teeth, breast implants, precervical cancer surgery


social history:
she smoked one pack per day of cigarettes for 25 years quit
[**2176-7-29**], no
recreational drugs, no alcohol and does drink both carbonated
and caffeinated beverages. two daughters age 20 and age 21 who
had been in dss group homes and in [**doctor last name **] homes.  she is
divorced and is on disability, used to work in cosmetic sales,
lives alone but does have supportive friends.


family history:
her family history is noted for both parents living father with
history of stroke, mother with heart disease, hyperlipidemia,
asthma, thyroid disorder; sister living with heart disease and
thyroid disorder; multiple family members with mental illness

physical exam:
vs: t 98 hr 80 bp 120/78 rr 20 o2 99%ra

constitutional: nad
neuro: alert and oriented to person, place and time; affect flat
cardiac: rrr, nl s1,s2, no mrg
lungs: cta b
abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
wounds: abdominal lap sites with steri-strips, no periwound
erythema/ induration, mild periwound ecchymosis
ext: 2+ dp pulses

pertinent results:
labs:
[**2176-11-5**] 10:09am blood wbc-8.4 rbc-3.77* hgb-9.7* hct-30.8*
mcv-82 mch-25.7* mchc-31.5 rdw-16.0* plt ct-207
[**2176-11-5**] 06:27am blood glucose-90 urean-24* creat-1.5* na-146*
k-3.7 cl-108 hco3-26 angap-16
[**2176-11-5**] 10:09am blood glucose-124* urean-22* creat-1.5* na-143
k-4.1 cl-106 hco3-27 angap-14
[**2176-11-5**] 10:09am blood calcium-9.7 phos-3.3 mg-2.2
[**2176-11-4**] 02:05am blood glucose-100 urean-21* creat-1.4* na-143
k-4.0 cl-107 hco3-23 angap-17
[**2176-11-4**] 04:05pm blood na-139 k-3.9 cl-103
[**2176-11-4**] 08:39pm blood na-141 k-3.7 cl-105
[**2176-11-3**] 04:04am blood glucose-102* urean-19 creat-1.6* na-149*
k-3.9 cl-112* hco3-26 angap-15
[**2176-11-2**] 12:31am blood glucose-102* urean-15 creat-1.7* na-155*
k-4.1 cl-119* hco3-23 angap-17
[**2176-11-2**] 04:44am blood na-158* k-4.0 cl-121*
[**2176-11-2**] 12:31am blood glucose-102* urean-15 creat-1.7* na-155*
k-4.1 cl-119* hco3-23 angap-17
[**2176-11-2**] 04:44am blood na-158* k-4.0 cl-121*
[**2176-11-2**] 07:58am blood glucose-147* urean-17 creat-1.8* na-159*
k-4.4 cl-122* hco3-28 angap-13
[**2176-11-2**] 12:28pm blood glucose-95 urean-19 creat-1.8* na-154*
k-4.5 cl-117* hco3-26 angap-16
[**2176-11-2**] 04:15pm blood glucose-101* urean-18 creat-1.6* na-149*
k-4.0 cl-113* hco3-25 angap-15
[**2176-11-2**] 08:25pm blood glucose-105* urean-19 creat-1.6* na-150*
k-4.2 cl-114* hco3-26 angap-14
[**2176-11-1**] 09:27am blood na-159* cl-122*
[**2176-11-1**] 09:48am blood glucose-139* urean-15 creat-2.0* na-159*
k-3.9 cl-123* hco3-26 angap-14
[**2176-11-1**] 12:05pm blood na-156* k-3.5 cl-120*
[**2176-11-1**] 02:10pm blood na-154* k-3.9 cl-120*
[**2176-11-1**] 10:10pm blood na-152* k-3.5 cl-116*
[**2176-11-1**] 01:25am blood glucose-128* urean-15 creat-2.1* na-168*
k-3.9 cl-131* hco3-26 angap-15
[**2176-10-31**] 08:50am blood glucose-136* urean-15 creat-1.9* na-167*
k-3.7 cl-129* hco3-27 angap-15
[**2176-10-31**] 10:50am blood glucose-100 urean-15 creat-1.9* na-167*
k-4.5 cl-132* hco3-23 angap-17
[**2176-10-31**] 04:02pm blood na-164* k-3.6 cl-128*
[**2176-10-31**] 08:50am blood calcium-10.7* phos-2.5*# mg-2.6
[**2176-10-31**] 10:50am blood osmolal-346*
[**2176-11-4**] 02:05am blood osmolal-304
[**2176-10-31**] 10:50am blood tsh-0.71
[**2176-10-31**] 10:50am blood t4-13.1*
[**2176-10-31**] 05:31pm blood na-163*
[**2176-10-31**] 08:36pm blood na-159*
[**2176-10-31**] 11:32pm blood na-163*
[**2176-11-1**] 04:50am blood na-163*
[**2176-11-1**] 04:12pm blood na-154*
[**2176-11-1**] 06:40pm blood na-154*
[**2176-11-1**] 08:48pm blood na-153*
[**2176-11-3**] 12:29am blood na-148*
[**2176-11-3**] 09:08am blood na-145
[**2176-11-3**] 12:32pm blood na-146*
[**2176-11-3**] 04:38pm blood na-143 k-4.4
[**2176-11-3**] 08:36pm blood na-144
[**2176-11-4**] 06:33am blood na-144
[**2176-11-4**] 11:58am blood na-144

imaging:
[**2176-10-30**]: ugi sgl contrast w/ kub:
impression: appropriate lap band position, patent stoma, no
evidence of leak.

[**2176-10-31**] ecg:
sinus tachycardia. low precordial lead voltage. st-t wave
changes in the
anterolateral leads which raise the question of active
anterolateral ischemic process. followup and clinical
correlation are suggested. no previous tracing available for
comparison

[**2176-11-1**]: chest (portable ap):
impression: no pneumothorax, hematoma, or other sequela of
procedural
complication identified. bibasilar atelectasis.

[**2176-11-1**]:
chest port. line placement:
impression: new right picc terminating within the right atrium,
4.5-5.0 cm
beyond the cavoatrial junction.


brief hospital course:
the patient presented to pre-op on [**2175-10-30**]. pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic adjustable gastric band placement. there were no
adverse events in the operating room; please see the operative
note for details. pt was extubated, taken to the pacu until
stable, then transferred to the [**hospital1 **] for observation.

neuro: the patient became intermittently agitated beginning on
pod1, pulling at her ngt, iv lines and threatening to leave
against medical advice and complaining of thirst.  psychiatry
was consulted, however, the patient declined visitation; the
patient's home psychiatric medication regimen was resumed at
this time.  overnight on pod2, the pt became progressively
disoriented, again attempting to leave against medical advice
and lacked insight into all aspects of her hospitalization and
expected post-operative recovery.  psychiatry was re-consulted
as the patient appeared to lack any capacity for decision
making.  at this time, electrolytes had been checked and the
serum sodium was noted to be 167 making a metabolic cause for
the patient's disorientation more likely; upon reviewing the
sodium level, psychiatry felt her mental status changes were
more likely the result hypernatremia induced delerium related to
diabetes insipidus.  after normalization of serum sodium levels,
the patient remained alert and oriented x 3 without any further
issues regarding agitation or insight into her care.
cv: the patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.  of note, the
patient's innopran xl was changed to regular release propranolol
as all medications must be crushed.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially on bariatric stage 1 diet, which
was well tolerated despite patient consuming more liquid than
ordered.  an upper gi study was performed on pod 1 which
revealed appropriate band position without evidence of
obstruction.  her diet was further advanced to stage 2 and then
3 due to the patient's extreme thirst and dietary
non-compliance; the patient tolerated this level of intake well.
 additionally, on pod2, the patient was noted to be
hypernatremic with a serum sodium level of 167.  renal was
consulted and felt this was due to diabetes insipidus related to
prior lithium use; [**name8 (md) **] rn at the patient's pcp's office confirmed
this was a known diagnosis.  the patient was identified as
having a free water deficit of approximately 10 liters; lr was
discontinued, d5w initiated, fluid intake liberalized and the
patient was transferred to the tsicu for q 3-4 hour serum sodium
monitoring.  while in the tsicu, the patient's hypernatremia
gradually resolved over the course of 4 days with resolution of
her delerium; she was transferred back to the general surgical
[**hospital1 **] on pod6.  her serum sodium remained between 141-146; renal
felt it was safe for discharge to home with liberal fluid
intake, a stage 3 diet and a repeat serum sodium level within 1
week.  both the patient's pcp and nephrologist were contact[**name (ni) **]
and follow-up appointments were made for the patient.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a
liberalized stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled.  the patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan including
follow-up with her pcp tomorrow and her nephrologist on [**11-25**], [**2175**].


medications on admission:
aripiprazole 15 mg daily
paroxetine 10 mg daily
perphenazine 32 mg q hs
propranolol xl 160 mg daily
levothyroxine 88 mcg daily
zolpidem 10 mg daily
omeprazole 40 mg [**hospital1 **]
lorazepam 1 mg qid
diphenhydramine 25 mg daily

discharge medications:
1. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po twice a
day as needed for constipation.
disp:*250 ml* refills:*0*
2. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls
po q4h (every 4 hours) as needed for pain.
disp:*100 ml(s)* refills:*0*
3. aripiprazole 15 mg tablet sig: one (1) tablet po once a day:
please crush.
4. paroxetine hcl 10 mg tablet sig: one (1) tablet po once a
day: please crush.
5. perphenazine 8 mg tablet sig: four (4) tablet po qhs (once a
day (at bedtime)).
6. propranolol 40 mg tablet sig: two (2) tablet po bid (2 times
a day).
disp:*120 tablet(s)* refills:*0*
7. levothyroxine 88 mcg tablet sig: one (1) tablet po daily
(daily).
8. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime):
please crush.
9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day: open capsule,
sprinkle contents onto applesauce, swallow whole.  do not chew
beads.
10. lorazepam 1 mg tablet sig: one (1) tablet po four times a
day: please crush.


discharge disposition:
home

discharge diagnosis:
1. gastroesophageal reflux with paraesophageal hernia.
2. obesity.
3. fatty liver.
4. diabetes insipidus
5. hypernatremia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
discharge instructions: please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, nausea or vomiting,
difficulty drinking fluids, severe abdominal bloating, inability
to eat or drink, foul smelling or colorful drainage from your
incisions, redness or swelling around your incisions, confusion,
headache, weakness, increased thirst or any other symptoms which
are concerning to you.

diet: stay on stage iii diet until your follow up appointment.
do not self advance diet, do not drink out of a straw or chew
gum.  please drink fluids freely and contact dr. [**last name (stitle) 15645**] office
or report to the emergency department immediately if you are
unable to tolerate liquids.

medication instructions:
resume your home medications except for the following changes:
1.  please stop innopran xl (propranolol) as this medication
cannot be crushed.  a new prescription for propranolol (regular
release) has been provided to you as you may crush this
medication.  please notify your primary care provider of this
change.
2.  please stop amiloride per our nephrologist.
crush all pills.
you will be starting some new medications:
1.  you are being discharged on medications to treat the pain
from your operation. these medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. you must refrain from such activities while
taking these medications.
2. you should begin taking a chewable complete multivitamin with
minerals. no gummy vitamins.
3. you should take a stool softener, colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. you must not use nsaids (non-steroidal anti-inflammatory
drugs) examples are ibuprofen, motrin, aleve, nuprin and
naproxen. these agents will cause bleeding and ulcers in your
digestive system.

activity:
no heavy lifting of items [**10-12**] pounds for 6 weeks. you may
resume moderate exercise at your discretion, no abdominal
exercises.

wound care:
you may shower, no tub baths or swimming.
if there is clear drainage from your incisions, cover with
clean, dry gauze.
your steri-strips will fall off on their own. please remove any
remaining strips 7-10 days after surgery.
please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.



completed by:[**2176-11-5**]"
276,"admission date:  [**2197-4-26**]       discharge date:  [**2197-5-6**]

date of birth:   [**2130-3-5**]       sex:  m

service:  card-[**last name (un) **]

history of present illness:   this is a 67 year old male who
presented to his primary care provider with [**name initial (pre) **] chief complaint
of progressive dyspnea on exertion over the past 18 months.
the patient's wife reported that the patient has become
progressively more and more dyspneic upon walking up a flight
of stairs and has episodes every day that resolve with rest.
the patient denied ever experiencing any chest pain in
association with these episodes.  the patient subsequently
underwent a stress test in [**2197-3-28**], which was stopped
after six minutes and 34 seconds of the [**doctor first name **] protocol
secondary to shortness of breath.  the patient did not
experience any chest pain during this test.

the patient's ekg at this time demonstrated [**street address(2) 49111**] depressions in leads ii, iii, avf and v5 through
6 during the last stage of exercise.  in the recovery room,
the patient developed [**street address(2) 49112**] depressions
in leads i, ii, iii, avf and v1 through v6, with t wave
inversions which persisted until 12 minutes after exercise.

imaging studies demonstrated moderate reversible anterior and
septal wall defects.  the patient's ejection fraction was
estimated to be 43%.  the patient was subsequently referred
to [**hospital1 69**] for an outpatient
cardiac catheterization to evaluate heart function.

the catheterization took place on [**2197-4-26**], and
demonstrated 80% distal stenosis of the left main coronary
artery and 80% occlusion of the left anterior descending.
ejection fraction was noted to be 49%.  the patient was
subsequently admitted to the [**hospital unit name 196**] service under the direction
of dr. [**first name (stitle) **] k. w. ho, on [**2197-4-26**] for further
evaluation and management.

past medical history:
1.  hypertension.
2.  hypercholesterolemia.
3.  penile cancer status post resection.
4.  crohn's disease status post resection.
5.  chronic cough.

home medications:
1.  aspirin.
2.  pravachol.
3.  b12.
4.  atenolol.

allergies:   no known drug allergies.

social history:   the patient lives with his wife and works
as a cashier.  the patient has a remote history of smoking
cigarettes which he quit approximately 15 years ago.  he
drinks one to two alcoholic drinks per week.  no intravenous
drug use history.

hospital course:   the patient was admitted to the [**hospital unit name 196**]
service on [**2197-4-26**], under the direction of dr. [**last name (stitle) **].  a
cardiothoracic surgery consultation was obtained upon
admission; following an extensive discussion with the patient
and his family regarding the relative risks and benefits of
surgery, the patient agreed to undergo coronary artery bypass
graft on [**2197-4-27**].

on [**2197-4-27**], the patient underwent a coronary artery
bypass graft times three.  anastomoses included left internal
mammary artery to left anterior descending; saphenous vein
graft to diagonal; and saphenous vein graft to obtuse
marginal.  the patient tolerated the procedure well and had a
bypass time of 79 minutes and a cross clamp time o4 44
minutes.  the patient's pericardium was left open;
intraoperative lines placed included a right radial and right
internal jugular line; both ventricular and atrial wires were
placed; mediastinal and left pleural tubes were placed.

the patient was subsequently transferred from the operating
room to the cardiac surgery recovery unit, intubated, for
further evaluation and management.  on transfer, the
patient's mean arterial pressure was 80; his central venous
pressure was 6; his pad was 13 and his [**doctor first name 1052**] was 17.  the
patient was atrially paced at a rate of 88 beats per minute.

active drips on transfer included neo-synephrine and
propofol.  following arrival in the csru, the patient was
successfully weaned and extubated.  his postoperative
hematocrit was noted to be 36.1.  in the csru, the patient
progressed well clinically.  he was advanced successfully to
oral medications without adverse events and was successfully
weaned from pressor drips.  the patient's chest tubes were
successfully removed without complication as were his pacer
wires, after which point he was cleared for transfer to the
floor on postoperative day number four.

the patient was subsequently admitted to the cardiothoracic
service under the direction of dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 70**].
postoperatively, the patient's clinical course was
uneventful.  the patient was evaluated by physical therapy
who deemed him an appropriate candidate for eventual
discharge to home following completion of the acute medical
care.

the patient was noted to develop atrial fibrillation
refractory to medical therapy, after which point he was begun
on a coumadin anti-coagulation pathway.  as the patient was
progressively dosed with coumadin for a therapeutic inr of
over 2.0, the patient was noted to be successfully
transitioned to a full regular diet and his pain was
controlled adequately with oral pain medications.  the
patient was noted to be independently ambulatory and was
noted to be independently productive of adequate amounts of
urine for the duration of his stay.

by postoperative day number eight, the patient was noted to
be afebrile and stable.  his incisions were noted to be
healing well with steri-strips intact and no evidence of
cellulitis or purulent drainage.  the patient was noted to be
fully tolerant of a regular diet and his pain was well
controlled.

following a final inr [**location (un) 1131**] of 2.3, the patient was cleared
for discharge to home on postoperative day number 9, [**2197-5-6**], with instructions for follow-up.

condition on discharge:   the patient is to be discharged
home with instructions for follow-up.

discharge status:   stable.

discharge medications:
1.  colace 100 mg p.o. twice a day.
2.  amiodarone 400 mg p.o. q. day times 14 days, followed by
200 mg p.o. q. day times four weeks.
3.  vicodin one to two tablets p.o. q. four to six hours
p.r.n.
4.  pravastatin 80 mg p.o. q. day.
5.  coumadin 5 mg p.o. q. day times four days, with the
patient's dose to be titrated thereafter by his primary care
physician, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **].

discharge instructions:
1.  the patient is to maintain his incisions clean and dry at
all times.
2.  the patient may shower but should pat-dry incisions
afterwards; no bathing or swimming until further notice.
3.  the patient is to resume a cardiac diet.
4.  the patient has been instructed to limit physical
activities; no heavy exertion.
5.  no driving while taking prescription pain medications.
6.  the patient is to have his coumadin dosage schedule
managed by his primary care provider, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **]; the
patient is to receive biweekly blood draws on mondays and
thursdays beginning [**2197-5-8**], and is to call dr. [**last name (stitle) **]
with his results following each blood draw for subsequent
modification of his coumadin dosing schedule for a target inr
of 2.0.
7.  the patient is to have additional primary care physician
[**name9 (pre) 702**] as needed.
8.  the patient is to follow-up with dr. [**first name4 (namepattern1) 919**] [**last name (namepattern1) 911**] in
cardiology within three to four weeks.
9.  the patient is to follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 70**] six
weeks following discharge.

the patient is to call to schedule all appointments.



                            [**first name11 (name pattern1) **] [**initials (namepattern4) **] [**last name (namepattern4) **], m.d.  [**md number(1) 75**]

dictated by:[**last name (namepattern1) 1053**]
medquist36

d:  [**2197-5-6**]  15:39
t:  [**2197-5-6**]  16:08
job#:  [**job number 49113**]
"
277,"admission date:  [**2125-2-9**]              discharge date:   [**2125-2-18**]

date of birth:  [**2058-2-22**]             sex:   f

service: medicine

allergies:
ace inhibitors

attending:[**first name3 (lf) 69838**]
chief complaint:
hematuria

major surgical or invasive procedure:
trans-urethral resection of bladder


history of present illness:
66 y.o. female with cad s/p mi and bm stent, chf, s/p mechanical
avr on coumadin and recently discovered bladder tumor who was
transferred from [**hospital 8125**] hospital with hematuria. patient developed
hematuria on [**1-17**], which prompted her to go to the
hospital. at that time, she was felt to have a uti and was
treated wtih tetracyclin. additionally a ct abdomen showed a
bladder tumor, that as of yet has not been biopsied. after
completing antibiotics, the hematuria cleared and the patient
was doing well, being followed by dr. [**last name (stitle) 770**] for eventual plans
to biopsy the tumor. on [**2-7**], patient noticed blood in her
urine, but says it was minimal. she spoke to her urologist who
reassured her but told her to continue to monitor the symptoms.
on the following day, she developed clots and by the day of
admission, [**2-9**], felt as though she was ""hemorrhaging"". prior to
this, she was asymptomatic, but on the day of presentation,
reports feeling dizzy without chest pain or palpitations. she
additionally denies f/c, n/v but does endorse some mild back
pain and dysuria.
.
patient initially presented to [**hospital 8125**] hospital with her
complaints, but was then transferred to [**hospital1 18**] because her
urologist was here. in the ed, labs revealed an inr of 4.3 and a
strongly positive ua and wbc of 21 with 84% neutrophils, no
bands. she was afebrile and hemodynamically stable. urology was
consulted and placed a 22 french foley and hand irrigated many
clots from the bladder, after which the urine remained pink.
patient's cardiologist, dr. [**last name (stitle) **], saw the patient in the ed and
recommended holding her asa and coumadin for now. patient was
given ceftriaxone empirically for the uti and was then admitted
to the medicine team for continued management of her hematuria.



past medical history:
bladder tumor
chf (ef 40-45% in 10/'[**23**])
cad s/p mi and stents to lcx [**8-5**]
carotid stenosis
hypertension
hypercholesterolemia
s/p hysterectomy


social history:
former smoker, but stopped in [**2124-7-29**]. denies alcohol
or illicit drug use. patient lives in [**hospital3 **] and works in real
estate.

family history:
non-contributory

physical exam:
physical exam:
t: 96.9, bp: 110/60, p: 83, rr: 18, o2 sats: 94% ra
gen: awake, alert, nad
heent: nc/at; perrla, eomi; op clear, nonerythematous
neck: supple, no lad, no jvd
cv: s1, s2 nl, no m/r/g appreciated, though valvular click was
ausculated
resp: ctab
abd: soft, tender to palpation in suprapubic area, nd, + bs
back: no flank tenderness
gu: normal female genitalia with foley in place, draining frank
blood
ext: no c/c/e
neuro: grossly intact


pertinent results:
=================
  admission labs
=================

wbc-21.3*# rbc-3.53* hgb-8.9*# hct-28.0* mcv-79*# mch-25.2*#
mchc-31.7 rdw-14.6 plt ct-458*
neuts-84.2* lymphs-10.8* monos-3.9 eos-1.0 baso-0.1
pt-39.4* ptt-37.2* inr(pt)-4.3*
glucose-114* urean-17 creat-0.7 na-136 k-4.6 cl-97 hco3-28
angap-16

===============
  radiology
===============

chest (pa & lat)  [**2125-2-10**] 3:07 pm
median sternotomy wire and mitral valve annuloplasty again
noted. the lungs are grossly clear. cardiac contour within
normal limits. aortic arch is calcified. aorta is ectatic.
impression:
1. no active disease in the chest.
2. ectatic aorta.

ct pelvis w&w/o c   [**2125-2-11**] 11:15 am
findings: there is a large intraluminal filling defect within
the urinary bladder, predominantly on the right, slightly
adherent to the wall, measuring 6 x 5.5 x 5.3 cm. this filling
defect is heterogeneous in appearance and has irregular margins.
it is also directly related to the right ureterovesical
junction. there is a foley catheter within the urinary bladder
as well as foci of air. there is no evidence of significant
retroperitoneal lymphadenopathy. there is no evidence of
hydronephrosis. multiple small foci of hypodensity within the
right renal parenchyma, most likely representing small cysts.
the bilateral adrenal glands are unremarkable. the spleen, the
liver and the pancreas are unremarkable. there is evidence of
cholelithiasis. there is no evidence of free fluid or free air.
the bowel appears unremarkable. there is a thoracoabdominal
aortic aneurysm, measuring 4.4 cm in maximum diameter at the
inlet to the abdomen, after which it tapers to 2.5 cm at the
level of the sma.
bilateral lung bases are unremarkable.
there are no suspicious bony lesions.
impression:
1. large filling defect within the urinary bladder, which is
heterogeneous, measuring 6 cm in maximal diameter. differential
diagnosis includes a bladder tumor versus a blood clot given
that the patient has been on coumadin

================
 microbiology
================

urine culture (final [**2125-2-14**]):    no growth.

=================
 discharge labs
=================

wbc-13.3* rbc-3.60* hgb-9.5* hct-29.8* mcv-83 mch-26.2*
mchc-31.8 rdw-16.4* plt ct-420
pt-17.9* ptt-125.2* inr(pt)-1.6*
glucose-102 urean-10 creat-0.8 na-139 k-4.3 cl-99 hco3-29
angap-15
calcium-8.8 phos-3.2 mg-2.0

brief hospital course:
66 y.o. female with known bladder tumor and mechanical mitral
valve, presenting with gross hematuria, now with stable hct, s/p
transurethral tumor resection
.
# hematuria / bladder tumor: although culprit for hematuria was
a known tumor, intervention was not possible upon admission
secondary to anticoagulation. patient has mechanical valve at
the mitral position, for which she is anticoagulated with
coumadin. patient required a single transfusion of 2 units of
pbrc after warfarin was stopped. continuous bladder irrigation
was initiated and inr was allowed to drift down without reversal
due to increased risk of adverse events in setting of mechanical
valve.
patient was started on heparin drip when inr reached 2.5 and
urology performed trans-urethral bladder tumor resection once
inr reached 1.5.
tissue sent to pathology, this however is pending at the time of
discharge. patient will follow up with dr [**last name (stitle) 770**] for further
management.

# mechanical mitral valve: as above, patient with ([**hospital3 **])
valve in place. after procedure was performed patient was
re-startedd on heparin drip and transitioned to lovenox. she was
discharged on a lovenox to coumadin drip and asked to have inr
checked at her primary care provider, [**name10 (nameis) **] request of her
cardiologist. patient given script for [**name10 (nameis) **] work. defer further
management to primary care physician.

# uti: history of vre uti in the past. this admission, patient
had infection with streptococcus species. she will complete 10
day course of [**last name (lf) **], [**first name3 (lf) **] require two more doses as outpatient.
.
# cad: patient is s/p mi with bare metal stent [**8-5**]. we
re-started aspirin at time of discharge, and continued beta
blocker and statin during entire admission.
.
# chronic systolic heart failure: ef 40-45% on [**9-4**], following
mvr. patient remained well compensated during this admission and
no changes in medication regimen were made.
.
# carotid artery stenosis: per ultrasound ([**2124-9-6**]) 80-99%
right ica stenosis, with no significant left ica stenosis. no
neurological symptoms during this presentation.
.
# fen: patient tolerated a cardiac/heart-healthy diet
.
# code: patient remained full code during this admission.


medications on admission:
lipitor 20 mg po qd
lasix 80 mg po bid
potassium
coumadin 5mg mwf, 2.5mg tuthsasu
asa 81 mg po qd
toprol xl 50 mg po qd
digoxin 125 mcg
advair


discharge medications:
1. atorvastatin 20 mg tablet sig: one (1) tablet po daily
(daily).
2. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a
day).
3. metoprolol succinate 50 mg tablet sustained release 24 hr
sig: one (1) tablet sustained release 24 hr po daily (daily).
4. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily).

5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig:
one (1) disk with device inhalation [**hospital1 **] (2 times a day).
6. lovenox 80 mg/0.8 ml syringe sig: one (1) syringe (80 mg)
subcutaneous twice a day: until your doctor asks you to stop.
[**hospital1 **]:*28 syryinges* refills:*0*
7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
8. warfarin 5 mg tablet sig: one (1) tablet po at bedtime:
please note, dose will be modified by your primary care
physician.
[**name initial (nameis) **]:*30 tablet(s)* refills:*0*
9. ciprofloxacin 250 mg tablet sig: one (1) tablet po q12h
(every 12 hours) for 2 days.
[**name initial (nameis) **]:*4 tablet(s)* refills:*0*
10. percocet 5-325 mg tablet sig: one (1) tablet po every six
(6) hours as needed for pain for 7 days.
[**name initial (nameis) **]:*28 tablet(s)* refills:*0*
11. outpatient [**name initial (nameis) **] work
please have cbc and pt/ptt/inr drawn on [**2-21**]


discharge disposition:
home

discharge diagnosis:
primay:
mechanical mitral valve
hematuria
bladder tumor


discharge condition:
hemodynamically stable, afebrile


discharge instructions:
you were admitted to the hospital because you were having
bleeding from your bladder and required a different type of
anticoagulation that would allow for a surgery to find the cause
of your bleeding. you underwent the procedure and tolerated it
well. the results of the tissue analysis will not availabe for a
few days, your primary care doctor will need to follow this up.

you will need to follow up with your primary care doctor and
take all medications as prescribed. you will also need to give
yourself lovenox injections twice daily until your inr (level of
coumadin) is at a good range.

if you experience any chest pain, nausea, vomiting, diarrhea, or
any other symptom that concerns you, please seek medical
attention immediatly.

followup instructions:
please make schedule a follow up appointment with your primary
care physician [**name initial (pre) 176**] 1 week. you will need to have your
coumadin level checked in his office on [**2-21**].

[**last name (lf) **],[**first name3 (lf) **] h [**telephone/fax (1) 57926**]


                             [**first name4 (namepattern1) **] [**last name (namepattern1) **] md [**md number(2) 69841**]

"
278,"admission date:  [**2103-6-23**]              discharge date:   [**2103-7-8**]

date of birth:  [**2035-8-7**]             sex:   m

service: medicine

allergies:
azilect

attending:[**first name3 (lf) 2763**]
chief complaint:
hypoxia

major surgical or invasive procedure:
intubation, trach, peg

history of present illness:
67yom with parkinson's disease, bipolar disorder, htn,
dyslipidemia, right vertebral artery aneurysm who presents for
hypoxia.
.
per ed report and per the patient's sister's report (who spoke
directly to the nurses who were taking care of the patient
today), the patient was in his usual state of health at [**hospital 100**]
rehab and had just eaten breakfast and was waiting to be wheeled
to his room for his routine nap. the nurse turned away to finish
feeding another patient and turned back to see the patient with
emesis coming out of his nose and mouth. the patient was
unresponsive during this episode and was rapidly suctioned.
however, he was hypoxic and ems was called who found the patient
to be hypoxic en route to the ed and bag masked and ventilated
for initial apnea, per report. he was lethargic en route and
transferred to the [**hospital1 18**] ed for further evaluation. there was no
reports of fevers or symptoms preceeding the event, but the
sister states that the patient does not typically complain of
symptoms even when he feels unwell. the patient's sister reports
the patient has never had difficulties with swallowing or
eating, and has never had an aspiration episode in the past.
.
in the ed, initial vs: 99.6 (rectal) 67 132/94 91% nrb
the patient was reportedly not responsive to commands and had
coarse rales diffusely. he was given vanc/levofloxacin/flagyl in
the ed and intubated for hypoxia. ekg showed sinus rhythm at
62bpm without evidence of acute ischemia. cxr was obtained which
showed possible rml infiltrate. cta chest was obtained to r/o pe
which instead showed evidence of aspiration pneumonia. ct head
showed enlargement of the patient's known right vertebral artery
aneurysm, and neurology and neurosurgery were consulted out of
concern that the intracranial aneurysm could be contributing to
his symptoms. neurosurgery recommended mri head/neck and
neurology planned to have the stroke consult see him in the am
pending mri/mra results. he was transferred to the micu for
further management. transfer vitals were: 84 109/68 19 100% tv
500 peep 8 rr 20 fio2 100
.
on arrival to the micu, the patient was minimally responsive to
pain off sedation after having received paralytics. he went to
for the mri/mra during which time his respiratory rate increased
and sedation was initiated with propofol boluses, then a low
dose gtt. he became fully responsive to commands and his
respiratory rate and blood pressures increased on cmv/ac.


past medical history:
- htn
- hyperlipidemia
- bipolar disorder
- parkinson's disease (pet in [**2094**] consistant with diagnosis)
- gastropathy
- unruptured right vertebral artery aneurysm (cta from an
outside facility was reviewed; right vertebral artery aneurysm,
longest dimension 9-10 mm located intradurally in the region of
the right vertebral artery. he could not becertain whether the
aneurysm involved the pica origin, but most likely it seemed to
be separate from it.)
- depression
- degenerative arthritis/multilevel spondylosis
- knee oa, s/p tka


social history:
- tobacco: denies
- etoh: denies
- illicit drugs: denies
non-ambulatory at baseline. lives at nursing home, [**hospital 100**] rehab
since [**2099**]. retired ph.d. psychologist.


family history:
father with ""ataxia"" and prostate cancer. mother with breast
cancer.  pt denies family cardiac history.

physical exam:
vs: 100.1 80 130/75 100% on cmv fio2 100% tv 6000 peep 5
gen: intubated, not following commands, no acute distress
heent: perrl, sclera anicteric, mmm
cv: soft heart sounds, rrr, normal s1/s2, no m/r/g
resp: equal bs b/l, rhonchi and coarse crackles at rlb, no
wheezes
abd: soft, nt/nd, +bs, no masses or hepatosplenomegaly
ext: wwp, no c/c/e, 2+ dp pulses b/l
skin: no rashes/no jaundice/no splinters
neuro: corneal reflexes b/l, rare spontaneous non-purposeful
movements of right finger.


pertinent results:
[**2103-6-23**] 10:55am blood wbc-10.6 rbc-4.82 hgb-14.5 hct-40.5
mcv-84 mch-30.2 mchc-35.9* rdw-13.5 plt ct-213
[**2103-6-23**] 10:40pm blood neuts-39* bands-39* lymphs-5* monos-2
eos-1 baso-0 atyps-3* metas-11* myelos-0
[**2103-6-23**] 10:55am blood pt-13.0 ptt-22.9 inr(pt)-1.1
[**2103-6-23**] 10:55am blood fibrino-334
[**2103-6-23**] 10:55am blood glucose-119* urean-24* creat-1.1 na-140
k-5.7* cl-104 hco3-20* angap-22*
[**2103-6-23**] 10:40pm blood alt-12 ast-15 ck(cpk)-111 alkphos-38*
totbili-0.5
[**2103-6-23**] 10:55am blood lipase-37
[**2103-6-23**] 10:55am blood ctropnt-<0.01
[**2103-6-23**] 10:40pm blood ck-mb-4 ctropnt-<0.01
[**2103-6-24**] 04:14am blood ck-mb-4 ctropnt-<0.01
[**2103-6-23**] 10:55am blood calcium-8.5 phos-4.8* mg-2.5
[**2103-6-23**] 10:55am blood triglyc-136
[**2103-6-28**] 06:20am blood vanco-13.6
[**2103-6-23**] 10:55am blood asa-neg ethanol-neg acetmnp-6*
bnzodzp-neg barbitr-neg tricycl-neg
[**2103-6-23**] 12:12pm blood type-art rates-16/ tidal v-500 peep-8
fio2-100 po2-436* pco2-56* ph-7.27* caltco2-27 base xs--1
aado2-233 req o2-46 -assist/con intubat-intubated
[**2103-6-23**] 11:41am blood lactate-2.9*
[**2103-6-23**] 11:48pm blood lactate-2.3*
[**2103-6-24**] 04:34am blood lactate-2.7*
[**2103-6-24**] 03:23pm blood lactate-1.6
[**2103-7-4**] 04:49pm blood lactate-1.4
[**2103-6-24**] 03:23pm blood freeca-1.14

reports:

cxr ap [**2103-6-23**]
impression:
1. standard position of endotracheal tube.
2. nasogastric tube extends below level of diaphragm, but
inferior aspect not well seen. consider repeat if desire to
confirm that it terminates in the stomach.
3. low lung volumes with mild bibasilar atelectasis.

ct head [**2103-6-23**]
1. interval increased size of a right-sided vertebral artery
aneurysm with
increased mass effect upon the brainstem. cta should be
considered for
further evaluation.
2. parenchymal atrophy and small vessel ischemic disease. no
other acute
findings.

cta chest [**2103-6-23**]
1. bibasilar, and perihilar opacities with peribronchial
thickening may
reflect aspiration pneumonia. hilar lymph nodes may be reactive.

2. no pulmonary embolism.
3. ng tube tip at the ge junction and should be further advanced
to achieve gastric positioning.

mra head/neck [**2103-6-23**]
impression: right vertebral artery aneurysm at the v3 segment,
apparently
partially thrombosed, the carotid bifurcations and the left
vertebral artery are grossly normal.

cta head w and w/o contrast [**2103-7-7**] (prelim read!) - (final
report dictation confirms preliminary findings.)
1. right vertebral artery aneurysm measuring smaller on cta than
routine head ct - likely secondary to differences in technique.
difficult to measure on non-contrast images due to artifact.
continues to demonstrate compression on the brainstem.
reconstructions pending at this time.
2. no evidence for other aneurysm, vascular malformation or
proximal large
arterial occlusion.
3. new fluid in mastoid air cells bilaterally, may be secondary
to recent
intubation and supine positioning. clinical correlation
recommended.

micro
[**2103-7-6**] sputum gram stain-final; respiratory
culture-preliminary inpatient
[**2103-7-4**] blood culture blood culture, routine-pending
inpatient
[**2103-7-4**] blood culture blood culture, routine-pending
inpatient
[**2103-7-4**] urine urine culture-final inpatient
[**2103-7-3**] stool clostridium difficile toxin a & b
test-final inpatient - negative
[**2103-7-2**] rapid respiratory viral screen & culture
respiratory viral culture-final; respiratory viral antigen
screen-final inpatient
[**2103-7-2**] bronchial washings gram stain-final;
respiratory culture-final {stenotrophomonas (xanthomonas)
maltophilia, gram negative rod #2, yeast}; immunoflourescent
test for pneumocystis jirovecii
(carinii)-final; fungal culture-preliminary {yeast} inpatient
+
   gram stain (final [**2103-7-2**]):
      2+   (1-5 per 1000x field):   polymorphonuclear
leukocytes.
      no microorganisms seen.
      smear reviewed; results confirmed.

   respiratory culture (final [**2103-7-4**]):
      commensal respiratory flora absent.
      due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      stenotrophomonas (xanthomonas) maltophilia.
         10,000-100,000 organisms/ml..
         identification and sensitivities performed on culture #
324-8468n
         ([**2103-6-27**]).
      gram negative rod #2.    rare growth.
      yeast.    10,000-100,000 organisms/ml..

[**2103-7-2**] stool clostridium difficile toxin a & b
test-final inpatient - negative
[**2103-7-1**] urine urine culture-final inpatient
[**2103-6-30**] blood culture blood culture, routine-final
inpatient
[**2103-6-30**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification} inpatient

   gram stain (final [**2103-6-30**]):
      >25 pmns and <10 epithelial cells/100x field.
      no microorganisms seen.

   respiratory culture (final [**2103-7-3**]):
      commensal respiratory flora absent.
      stenotrophomonas (xanthomonas) maltophilia.    sparse
growth.
         identification and sensitivities performed on culture #
324-8468n
         ([**2103-6-27**]).
      [**female first name (un) **] albicans, presumptive identification.    sparse
growth.
         identification performed on culture # 324-8468n
([**2103-6-27**]).

[**2103-6-29**] blood culture blood culture, routine-final
inpatient
[**2103-6-28**] blood culture blood culture, routine-final
inpatient
[**2103-6-28**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification} inpatient
[**2103-6-28**] urine urine culture-final inpatient
[**2103-6-28**] blood culture blood culture, routine-final
inpatient
[**2103-6-27**] sputum gram stain-final; respiratory
culture-final {stenotrophomonas (xanthomonas) maltophilia,
[**female first name (un) **] albicans, presumptive identification, serratia species}
inpatient
[**2103-6-26**] blood culture blood culture, routine-final
inpatient
[**2103-6-24**] sputum gram stain-final; respiratory
culture-final {yeast} inpatient
[**2103-6-24**] blood culture blood culture, routine-final
inpatient
[**2103-6-23**] sputum gram stain-final; respiratory
culture-final inpatient
[**2103-6-23**] mrsa screen mrsa screen-final inpatient
[**2103-6-23**] urine urine culture-final emergency [**hospital1 **]
[**2103-6-23**] blood culture blood culture, routine-final
emergency [**hospital1 **]
[**2103-6-23**] blood culture blood culture, routine-final
emergency [**hospital1 **]

discharge labs:
na 143
k 4.3
cl 108
bun 26
bun 9
cr 0.5
gluc 94
ca 8.5
mg 2
phos 3.7

wbc 5.5
hct 31 (stable)
plt 243

brief hospital course:
67yom with parkinsonism & cognitive impairment with known r
vertebral aneurysm (prior eval by [**doctor last name **] in [**2099**]). pt admitted
after syncopal episode after which he was unresponive, apneic.

#. hypoxic respiratory distress: per report, the patient's
episode of coughing while eating, hypoxia, and subsequent loss
of consciousness is consistent with aspiration pneumonia. he was
intubated for his hypoxemic respiratory failure. his chest
imaging, and purulent sputum from endotracheal tube all confirm
this diagnosis. patient was treated with an 8 day course of
vanc/cefepime/flagyl from [**2103-6-23**] until [**2103-7-1**] for
health-care-associated pneumonia. given that he had
stenotrophamonas growing in his sputum sensitive to bactrim, he
was started on bactrim 40 ml po/ng qid d1=[**6-29**] for a long 2-week
course, last dose to be given on [**2103-7-13**]. given his baseline
parkinson's disease, likely icu myopathy, and generalized
weakness, the patient was unable to be weaned from the
ventilator successfully. he was extubated on [**2103-7-2**] but had to
be emergently reextubated the same day for acute respiratory
failure. a trach and peg was placed on [**2103-7-6**] without
complication and he was successfully weaned off of the
ventilator on [**2103-7-8**], currently satting in the mid-high 90s on
50% fio2 trach mask. he would benefit from continued antibiotics
and pulmonary rehabilitation/chest pt. blood and repeat sputum
cultures remained negative.

#. loss of consciousness: given the limited history, it is
unclear whether the patient had loss of consciousness following
or preceeding the emesis and aspiration event. cardiac enzymes
negative x2. neurologic work up revealed slightly larger known
vertebral artery aneurysm (more on this below) thought not to be
related to his current presentation per neurology and
neurosurgery consultation. this was thought to be related to his
hypoxic respiratory failure per above. the patient remained
sedated throughout the admission and on day of discharge.

#. vertebral artery aneurysm: patient with known right vertebral
artery aneurysm, currently 14x12mm as compated to 11x9mm in
[**2101-8-6**]. neurosurgery was consulted and did not recommend
acute treatment of the aneurysm, but recommended mri brain, mra
head and neck. neurology stroke consult was also recommended
given the as stroke is a possibility given this limited history
and exam. repeat cta head/neck revealed a slightly smaller
aneurysm. these findings were discussed with neurosurgery on day
of discharge and a follow up appointment with neurosurgery
should be arranged [**telephone/fax (1) 1669**] within 4-8 weeks.

#. fever: patient persisted to have multiple low grade fevers
for several days all thoughout his icu course (tmax in 24 hours
100.5 last evening [**2103-7-7**]) and 100 this morning [**2103-7-8**]. a large
number of blood, urine, stool, and sputum cultures were drawn
and only positive for stenotrophomonas (xanthomonas) maltophilia
per above and negative for c diff x 2 over the course of [**7-15**]
days. yeast grew in the sputum as well that was thought to be
nonpathologic. the patient developed an acne-like rash on his
backside thought to be secondary to diaphoresis, however,
drug-hypersensitivity secondary to bactrim was considered but
felt to be unlikely. eosinophil count remained normal on day of
discharge. his picc line was also pulled as a potential source
of infection on day of discharge. his fever was therefore
thought to be secondary to stenotrophomonas infection of the
lungs. monitoring of the rash by [**hospital 100**] rehab staff would be
appropriate as well.

#. elevated lactate: patient with lactate of 2.9 on initial
presentation, likely secondary to volume depletion and
hypovolemia. this cleared after ivf.

#. parkinson's disease: continued home sinemet 25/100mg 0.5 tab
at 5pm, 8pm, 1.5 tabs at 8am, 12pm, 2pm

#. bipolar disorder: stable. continued home seroquel 50mg [**hospital1 **],
hold seroquel 25mg q6h prn given patient is intubated, continued
neurontin 100mg daily, continued valproic acid 250mg tid with no
adverse events.

#. hypertension: bp stable, no evidence of shock or hypotension.
held lisinopril , metoprolol 25mg [**hospital1 **], held klonipin 0.5mg tid
as patient sedated and intubated, can be restarted at rehab.

#. dyslipidemia: continued simvastatin 20mg qhs

#. depression: continued cymbalta 40mg [**hospital1 **] per home regimen

#. prophylaxis: patient continued on heparin subcutaneous 5,000
units tid. ppi and chlorhexadine were discontinued upon
discharge as he became vent independent today.
lidoderm patch for chronic pain was continued.
senna/colace/miralax. ppi.

#. contact: sister [**name (ni) **] - [**name (ni) **] [**name (ni) **] [**telephone/fax (1) 74952**] (home),
[**telephone/fax (1) 74953**] (cell). sister [**name (ni) 382**], poa) - [**name (ni) **] [**last name (namepattern1) **]
[**telephone/fax (1) 74954**] (home), [**telephone/fax (1) 74955**] (cell).

#. code status: after extensive family meetings, patient was
deemed dnr but not dni. ambulance services refused to accept dnr
order, despite md signature, demanded hcp signature,
unfortunately, she was not available for signature, therefore
she remained full code for transport. he would return to dnr
status upon arrival to [**hospital 100**] rehab.


medications on admission:
- lisinopril 40mg qhs
- lopressor 25mg [**hospital1 **]
- simvastatin 20mg qhs
- seroquel 25mg q6h prn
- seroquel 50mg [**hospital1 **]
- sinemet 25/100mg 0.5 tab at 5pm, 8pm, 1.5 tabs at 8am, 12pm,
2pm
- valproic acid 250mg tid
- lidoderm patch
- tylenol 1gm q8h prn pain
- vitamin d 1000 units daily
- klonipin 0.5mg tid
- cymbalta 40mg [**hospital1 **]
- neurontin 100mg daily
- nitro tp 0.2mcg/day
- miralax 17g [**hospital1 **]
- dulcolax 5mg qday prn
.


discharge medications:
1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid
(2 times a day).
2. simvastatin 10 mg tablet sig: two (2) tablet po daily
(daily).
3. quetiapine 25 mg tablet sig: two (2) tablet po bid (2 times a
day).
4. quetiapine 25 mg tablet sig: one (1) tablet po q6h (every 6
hours) as needed for agitation.
5. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po
tid (3 times a day).
6. carbidopa-levodopa 25-100 mg tablet sig: 0.5 tablet po q 5pm,
8pm ().
7. valproic acid (as sodium salt) 250 mg/5 ml syrup sig: five
(5) ml (250 mg) po q8h (every 8 hours).
8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig:
one (1) adhesive patch, medicated topical daily (daily).
9. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain, fever.
10. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1)
tablet po daily (daily).
11. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times
a day).
12. duloxetine 20 mg capsule, delayed release(e.c.) sig: two (2)
capsule, delayed release(e.c.) po bid (2 times a day).
13. gabapentin 250 mg/5 ml solution sig: 100 mg (2 ml)  po daily
(daily).
14. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day): ok to hold if pt is able to
ambulate tid.
15. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: [**1-7**]
drops ophthalmic prn (as needed) as needed for dry, red eyes.
16. sulfamethoxazole-trimethoprim 200-40 mg/5 ml suspension sig:
forty (40) ml po qid (4 times a day) for 5 days: take through
[**7-13**].
17. erythromycin 5 mg/gram (0.5 %) ointment sig: one (1)
ophthalmic [**hospital1 **] (2 times a day) for 2 days.
18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for
nebulization sig: one (1)  inhalation q6h (every 6 hours) as
needed for wheezing, shortness of breath.
19. ipratropium bromide 0.02 % solution sig: one (1)  inhalation
qid (4 times a day) as needed for wheezing, shortness of breath.

20. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a
day) as needed for constipation.
21. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2)
tablet, delayed release (e.c.) po daily (daily) as needed for
constipation.
22. docusate sodium 50 mg/5 ml liquid sig: one (1)  po bid (2
times a day).
23. polyethylene glycol 3350 17 gram/dose powder sig: one (1)
po daily (daily) as needed for constipation.


discharge disposition:
extended care

facility:
[**hospital6 459**] for the aged - macu

discharge diagnosis:
primary: aspiration pneumonia, respiratory failure, altered
mental status
.
secondary: conjunctivitis, parkinson's, bipolar, loss of
conciousness, verterbral artery anuerysm


discharge condition:
mental status: confused - always.
level of consciousness: lethargic but arousable.
activity status: bedbound.


discharge instructions:
you were admitted to the hospital for hypoxic respiratory
distress thought to be due to aspiration pneumonia.  you were
treated with antibiotics and you improved, however you were
unable to be weaned from the ventilator, therefore a
tracheostomy was performed and a peg tube was placed for
nutrition.  additionally while in the hospital you were treated
for conjunctivitis and followed for your vertebral artery
anuerysm which was stable.  your home psychiatric and
parkinson's medications were continued.
.
the following changes were made to your medications:
-start bactrim, continue taking through [**7-13**]
-stop lisinopril and nitroglycerin pathc, this can be restarted
if you are hypertensive, however it was discontinued during the
admission because your pressures were well controlled
-start sc heparin for dvt prophylaxis
-start erythromycin eye ointment and moisturizing eye drops
-start albuterol and ipratroprium nebs as needed for shortness
of breath
-start senna and docusate for constipation

followup instructions:
please follow up with your rehab physician.  [**name10 (nameis) 357**] schedule
follow up with neurosurgery in [**4-13**] weeks by calling:
[**telephone/fax (1) 1669**].


                             [**name6 (md) **] [**name8 (md) **] md [**md number(2) 2764**]

completed by:[**2103-7-8**]"
279,"admission date:  [**2131-8-2**]              discharge date:   [**2131-8-21**]

date of birth:  [**2067-11-7**]             sex:   m

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 2297**]
chief complaint:
reason for admission: seizures


major surgical or invasive procedure:
none.

history of present illness:
mr. [**known lastname 916**] is a 63yo male with pmh significant for seizures,
atrial fibrillation, and s/p cabg who is being transferred from
osh for management of seizures. per patient's wife, on tuesday
the patient complained of seeing spots in his eyes. on wednesday
night/early morning the patient complained of seeing spots
again. at approximately 4am mr. [**known lastname 916**] attempted to go the
bathroom but fell on the floor at which time his wife woke up
and found her husband seizing. she called 911 and the patient
was brought to [**hospital 1562**] hospital. initial vitals in ed were t
100.4 bp 182/66 ar 128 rr 14 o2 sat 96% ra. in the ed he had
another generalized tonic clonic seizure. he was given keppra
via the ngt. he was intubated for airway protection. per osh
records, the intubation was difficult and required help of
anesthesiologist. ct scan of head and c spine were unrevealing.

.
he was then transferred to the icu for closer management. in the
icu the patient spiked a temperature to 102 and he was given
rocephin and clindamycin for suspected aspiration pneumonia. on
[**8-2**] at 3am patient went into 15-30 minutes of status
epilepticus. he was loaded with dilantin 500mg iv x1. and placed
on benzos. ventilation settings at this time were: simv tv 600
rr 10 fio2 60% ps 15 peep 5. he was then transferred to [**hospital1 18**]
for further management.
.
per patient's wife, he was diagnosed with seizures 1 year ago
when he had a seizure at home and presented to [**hospital1 2025**]. found to
have cva which was thought to be cause of seizure. he was
started on keppra. he has not had a seizure since then but has
complained of seeing spots occasionally. she is followed closely
by her neurologist and saw him 1 month ago.
.
no recent fevers, chills, chest pain, sob, dizziness, or
dysuria. per wife, the patient has good and bad days but had
been feeling well prior to this admission.


past medical history:
1)cad s/p cabg 9 years ago
2)seizure disorder-last seizure 1 year ago
3)atrial fibrillation on anticoagulation
4)ulcerative colitis


social history:
patient lives with wife in [**hospital3 **]. currently retired. no
history of tobacco, alcohol, or ivda.

family history:
nothing relevant, per wife

physical exam:
vitals t 102.4 bp 159/114 ar 103 rr 14
vent settings: ac fi02 1.0 tv 600 rr 14 peep 5
gen: patient sedated, responsive to sternal rub
heent: ett in place
heart: irregularly, irregular. +systolic murmur
lungs: course breath sounds anteriorly
abdomen: obese, soft, nt/nd, decreased bss
extremities: no edema, 2+ dp/pt pulses bilaterally


pertinent results:
[**2131-8-2**] 05:30pm   pt-24.6* ptt-43.6* inr(pt)-2.5*
[**2131-8-2**] 05:30pm   plt count-259
[**2131-8-2**] 05:30pm   wbc-5.7 rbc-3.38* hgb-12.9* hct-37.5*
mcv-111* mch-38.3* mchc-34.6 rdw-16.1*
[**2131-8-2**] 05:30pm   tsh-0.39
[**2131-8-2**] 05:30pm   albumin-3.1* calcium-8.1* phosphate-3.1
magnesium-2.4
[**2131-8-2**] 05:30pm   ck-mb-6 ctropnt-0.10*
[**2131-8-2**] 05:30pm   lipase-12
[**2131-8-2**] 05:30pm   alt(sgpt)-25 ast(sgot)-27 ld(ldh)-312*
ck(cpk)-187* alk phos-47 amylase-174* tot bili-1.5
[**2131-8-2**] 05:30pm   glucose-124* urea n-14 creat-1.2 sodium-143
potassium-3.9 chloride-111* total co2-21* anion gap-15
[**2131-8-2**] 06:11pm urine  uric acid-few
[**2131-8-2**] 06:11pm urine  rbc-[**5-13**]* wbc-[**2-5**] bacteria-few
yeast-none epi-0-2
[**2131-8-2**] 06:11pm urine  blood-lg nitrite-neg protein-tr
glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0
leuk-neg
[**2131-8-2**] 06:11pm urine  color-amber appear-clear sp [**last name (un) 155**]-1.028
[**2131-8-2**] 09:51pm   phenytoin-4.5*
[**2131-8-2**] 09:51pm   digoxin-0.9
[**2131-8-2**] 10:51pm   type-art temp-38.2 rates-14/0 tidal vol-600
peep-5 o2-60 po2-133* pco2-43 ph-7.36 total co2-25 base xs--1
-assist/con intubated-intubated
[**2131-8-3**] 03:22am blood wbc-5.0 rbc-3.24* hgb-12.3* hct-34.8*
mcv-107* mch-38.0* mchc-35.4* rdw-17.3* plt ct-223
[**2131-8-4**] 03:14am blood wbc-4.5 rbc-2.98* hgb-11.3* hct-32.0*
mcv-107* mch-38.1* mchc-35.4* rdw-16.8* plt ct-209
[**2131-8-3**] 03:22am blood glucose-115* urean-12 creat-1.2 na-143
k-4.0 cl-113* hco3-21* angap-13
[**2131-8-3**] 03:44pm blood glucose-119* urean-10 creat-1.0 na-143
k-3.7 cl-111* hco3-21* angap-15
[**2131-8-4**] 03:14am blood glucose-119* urean-8 creat-0.9 na-143
k-3.6 cl-110* hco3-21* angap-16
[**2131-8-5**] 03:01am blood glucose-92 urean-5* creat-0.8 na-146*
k-3.2* cl-111* hco3-25 angap-13
[**2131-8-5**] 03:01am blood lipase-75*
[**2131-8-3**] 03:22am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-pos barbitr-neg tricycl-neg

[**hospital 93**] medical condition:
63 year old man with sob, hypoxia
reason for this examination:
r/o dvt
shortness of breath and hypoxia. question dvt.

grayscale and doppler son[**name (ni) 1417**] were performed of the ij,
subclavian and axillary veins on the left and of the ij on the
right. there was diminished compressibility in the left cephalic
vein compatible with acute thrombosis. there was normal
compressibility, flow, and augmentation in the other vessels.

impression: superficial venous thrombus noted in the cephalic
vein. no dvt.

[**hospital 93**] medical condition:
63 year old man with sob, hypoxia
reason for this examination:
r/o dvts
indication: rule out dvt.

[**doctor last name **] scale and doppler son[**name (ni) 1417**] of bilateral common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins was performed. there is normal compressibility, color
flow, and augmentation.

impression: no evidence of right or left leg dvt.

the study and the report were reviewed by the staff radiologist.
dr. [**first name4 (namepattern1) 19115**] [**last name (namepattern1) **]
dr. [**first name11 (name pattern1) 8711**] [**initial (namepattern1) **] [**last name (namepattern4) **]
approved: fri [**2131-8-17**] 8:37 am

brief hospital course:
hd#1 ([**2131-8-2**]):  patient arrived in the [**hospital1 18**] micu-6 the
afternoon of [**2131-8-2**] intubated, sedated and in stable condition
with ngt in place.  on arrival active patient medications
included keppra 1000 mg [**hospital1 **] and sedation with fentanyl 50 mcg/hr
and midazolam 4 mg/hr.  all other home medications were intially
held.  given suspicion for meningitis in the setting of seizure
+ fevers patient was given one dose of ceftriaxone 2 gm iv with
infectious disease consent required for further treatment.
also, a history suspicious for patient was sent for urgent mra
of head & neck and mr of head which showed:  1)no enhancing
lesions.  chronic infarct in left parieto-occipital lesion, and
2)50% narrowing of right proximal ica.  left ica origin
atheroma.""  patient was initially seen on unit by neurology who
recommended continuation of keppra, eeg to evaluate for seizure
activity, echo for new murmur + fever, lp when inr < 1.5, and an
increase in versed drip with consideration of dilantin load if
patient seized again.  suctioning from ett showed brownish-grey
aspirate and ua that day showed no organisms.  patient remained
febrile throughout first day in micu.
.
hd#2 ([**2131-8-3**]):  patient received tylenol for fever overnight
and had echo and eeg in the morning.  echo showed no signs of
valvular vegetations and eeg showed no signs of an epileptiform
focus.  in the setting of seizure + fevers meningitis remained
at the top of our differential diagnosis and an lp was arranged.
 prior to admission patient had taken coumadin for his atrial
fibrillation and on transfer to micu initial inr was 2.5,
patient was initially given 3 units of ffp with following
inr=1.7.  transfusion of two more units of ffp resulted in no
change in inr so plan for lp was aborted.  during the day
patient became very anxious, became tachycardic to the 140s,
began demonstrating tremor in his lower extremities bilaterally
and started pulling against his restraints.  his fentanyl was
incresaed to 75 mg/hr and versed was increased to 5.0 mcg/hr.
he was also bolused with dilantin 1000 mg iv once since patient
was also displaying tremor in le bilaterally while sedated.
patient remained tachycardic to the 120s-130s depsite the
increase in sedation and diltiazem 60 mg po qid was started with
diltiazem 5 mg iv for immediate control.  to empirically cover
aspiration pneumonia vancomycin & flagyl were started and id
approval for ceftriaxone therapy (to cover pneumococcus) was
obtained.  ampicillin was also started to cover listeria
monocytogenes and acyclovir was started due to concern for hsv
encephalitis after blood drawn for hsv pcr.  temperature spiked
to 101 at 18:00 with repeat panculture including mini-bal which
showed 1+ pmns and oropharyngeal flora.  ett was advanced 1 cm
after cxr showed approx 5 cm above the carina.  patient remained
npo.
.
hd#3 ([**2131-8-4**]):  patient remained febrile and began having
episodes of loose stools.  patient with long history of
ulcerative colitis, but stool sample sent for c.diff toxin which
was negative.  restarted on 6-mercaptopurine for uc.  lp was
re-attempted prior to which patient received an additional 5
units of ffp with following inr=1.3.  following lp tube feedings
were intiated and changed later in the day to include fiber with
a goal of 90 cc/hr.  urine output was noted to be poor, patient
putting out approximately 15 cc/hr.  two fluid boluses of 500 cc
were given with no effect.
.
hd#4 ([**2131-8-5**]):  patient remained febrile, with attempts to wean
sedation aborted due to increased patient anxiety/agitation.  in
light of negative blood/csf/urine cultures acyclovir, ampicillin
and ceftriaxone were discontinued.  mr. [**known lastname 916**] continued to take
vancomycin for [**8-4**] sputum culture that grew 2+ g(+) cocci in
pairs and clusters and flagyl for empiric tx of c.diff diarrhea
despite negative stool toxin screens.  ct of chest with contrast
showed:  1)bilateral pleural effusions with associated
atelectasis & consolidation, left>right, 2)2 small pulmonary
nodules in rul ~4 cm in diameter, 3)airspace disease in the lul,
and 4)coronary artery and mitral annulus calcifications.
.
hd#5 ([**2131-8-6**]):  patient continued to be febrile, reaching
temperature of 102 degrees overnight.  also continued to have
loose stools with output of 2l, flagyl discontinued due to
multiple negative c.diff toxin screens.  however, stool was
re-sent for c.diff a&b toxins and banana flakes were added to
tube feeds to bulk-up stools.  plan for gi consult the following
day.  urine output continued to be poor, patient was given
one-time dose of lasix iv 40 mg with transient increase in uop.
patient was placed on trial of pressure support starting @ 13:00
and continuing on throughout the night without adverse events.
sedation was gradually weaned with fentanyl decreased from 75
mcg/hr to 60 mcg/hr and versed at 4.0 mg/hr.  patient continued
to have episodes of anxiety throughout the day for which he was
given lorazepam 1 mg iv for breakthrough relief.  picc line was
place in right arm in the a.m.  zosyn 4.5 mg iv q8h was started
to empirically cover g(-) organisms causing pneumonia
.
hd#6 ([**2131-8-7**]):  no high fever spikes, but patient ran low-grade
fever of 100.5.  per cxr, pna not progressing/worsening.
azithromycin 500 mg po bid added to cover atypical causes of pna
(mycoplasma/chlamydia/etc).  gi consulted for increased, watery
stool output (patient has h/o uc treated with 6-mp, requested
consult to determine any additional management
options/symptomatic relief).  no recommendations per gi, cannot
determine at this time if current stooling is any change from
baseline.  per neurology, keppra dose was increased to 1250 mg
po bid (from 1000 mg).  patient on coumadin as outpatient for
a.fib, held on admission to perform lp.  heparin ggt restarted
for dvt prophylaxis.  given another single dose of lasix 40 mg
iv to removed third-spaced fluid, net -850 cc at end of day with
los fluid net +8.6l.  diltiazem ggt titrated up to 10 u/hr to
maintain hr<100 bpm.  overnight, patient became agitated on
cpap+ps, ac restarted briefly for a few hours and placed back on
pressure support.
.
hd#7 ([**2131-8-8**]):  patient placed back on pressure support with ps
15/peep 8 (increased from [**11-7**]).  arterial line placed in right
arm without complications.  abg showed 7.44/33/102/23.  dosed
again with lasix 40 mg iv to removed fluid that had third spaced
into tissues/pleural space.  continued vanc/zosyn/azithro.
again spiked temperature to 101.5 degrees at mid-day and was
pancultured.  patient also became tachycardic with hr increase
to 130s-140s, diltiazem drip increased to 10 mg/hr.  began
having apneic episodes on pressure support and was placed back
on ac at 20:00.  sedation weaned to versed 3.0 mg/hr and
fentanyl 25 mcg/hr.  lost last piv access, patient only with
arterial line and right picc line.  k 3.2, corrected.  tube
feeds held due to continued high gastric residuals.  during late
afternoon/evening patient was dosed once again with lasix 20 mg
iv with repeat cr 1.8.
.
hd#8 ([**2131-8-9**]):  cr this a.m. 2.0.  urine sent for urine lytes
(na, bun, creatinine), urine eosinophils, microscopic analysis.
likely due to hypovolemia secondary to diuresis.  lasix held
today, monitoring cr for improvement of [**last name (un) **].  throacic
ultrasound performed to look for possible empyema/loculated
plueral effusions and did not reveal any significant fluid
collection that would benefit from throacentesis.  patient
remained on ac vent overnight, risbi in the a.m. 103, mid-day
abg on ac 7/46/36/106.  decided to give patient spontaneous
breathing trial.  patient maintained own ventilation for 30 min
at which time respirations were ~40/min, sao2 92% and patient
having difficulty breathing.  trial was stopped and patient put
back on pressure support with ps 5/peep 0.  id consulted for
further work-up of fuo.  recommended checking borellia and
ehrlichia serologies and inspecting peripheral smear of blood
for parasites (babesiosis) if spiked temp again.  also
recommended changing azithromycin to doxycycline if spiked temp
again.  later in evening patient spiked temp to 102.5 and id
recs were instituted.
.
hd#9 ([**2131-8-10**]):  renal consulted for decline in renal fxn and
proposed atn vs. prerenal azotemia vs. ain, though most likely
non-oliguric atn.  recommended increase in free water intake as
patient was also hypernatremic and renally dosing medications.
renal us showed no evidency of hydronephrosis.  had ct of
head/sinuses which showed no acute sinusitis with mild mucosal
thickening and non-contrast ct of chest & abdomen which showed:
1.  bilateral pleural effusions with associated atelectasis and
consolidation, greater on the left than the right.  this is
stable from prior exam. 2.  stable pulmonary nodules in the
upper lobe. 3.  stable extensive coronary artery and aortic
calcifications. 4.  no discrete focus of infection is identified
although this study is limited by lack of contrast. 5.  anasarca
of the body wall in abdomen and pelvis.
.
hd#10 ([**2131-8-11**]):  stopped diltiazem gtt & started esmolol gtt to
control hr & bp.  sedation weaned and discontinued and patient
extubated, after which patient was tachypneic but abgs looked
good.  id recommended further checking cmv serologies, patient
spiked temp to 101 and blood was cultured again for anaerobic
bacteria and fungus.
.
hd#11 ([**2131-8-12**]):  patient continued tx with iv vancomycin (dosed
by levels) and renally-dosed zosyn.  received 1 gm vanc when
afternoon levels 13.5.  attempted to wean esmolol gtt, could not
maintain adequate control of hr & bp.  stopped drip and gave
metoprolol 25 mg po tid, soon increased to 75 mg po tid with
additional dosing of diltiazem 10 mg iv once to control rate.
patient then started on diltiazem 30 mg po qid in addition to
metoprolol 75 mg po tid to control rate, though patient
continued to be tachycardic and htnive throughout day.
metroprolol increased to 100 mg po tid and diltiazem increased
to 60 mg po qid.  overnight patient remained confused, likely
residual effect of multiple heavy sedatives, and attempted to
climb out of bed and required one-time doses of ativan &
zyprexa.  patient will require one-on-one sitter upon tx to
floor.  patient had tee which showed no vegetations and severely
deformed aortic valve.  d/c'd doxycycline per id recs and had
repeat cxr due to increased airway secretions and concern over
?aspiration while taking a.m. medications.  order placed for
speech & swallow eval, post-poned until tomorrow due to patient
having brief episode of tachypnea and sats down to 92% requiring
non-rebreating mask.  per renal, adjusted dose of keppra
according to gfr, approved by neuro and will be seen by their
service tomorrow.  na noted to be 149 and given 1l d5w over 24
hours.
.
hd#12 ([**2131-8-13**]):  patient not seen by neuro.  patient continued
to be hypernatremic and was given 1l d5w @ 200 cc/hr and another
at 125 cc/hr.  metoprolol was increased to 100 mg po tid and
diltiazem was increased to 60 mg po qid to control heart rate.
per nursing that morning, patient had questionable episode of
aspiration while taking morning medications.  repeat cxr showed
marginal worsening infiltrates in the rml.  later that night
patient dropped sats to 85% and given cpap for 30 minutes with
improvement.  he had several hours of respiratory stability but
eventually re-developed tachypnea (50) and hypoxemia (7.48/36/61
on nrb) followed by an episode of hypotension and was
re-intubated.  the rest of hospital summary will be in
problem-based format:
.
1)hypoxic respiratory failure: patient intubated @ osh in
setting of status epilepticus in order to protect airway.
initially struggling against ventilator requiring increases in
sedation, suctioning of ett showing brownish-[**doctor last name 352**] sputum. now
weaning sedation with vent on cpap+ps as patient tolerates,
decreased sputum production. arterial line placed [**2131-8-8**], d/ced
by pt on [**8-11**]. pt extubated [**8-11**], required supplemental o2 via nc
and hiflow nrb over following days & developed tachypnea and
hypoxia early morning of [**8-15**] requiring re-intubation. [**8-15**] leni
and l ueni show no dvt, ct chest same day showing new bilat ll
consolidation concerning for aspiration, bridging
small-to-moderate pleural effusions and new hydrostatic
pulmonary edema. bnp 30,173 on [**8-15**]. serial cardiac enzymes r/o
mi.
-rested overnight on psv, good sbt this a.m. and extubated
without complications. ngt placed prior to extubation for tube
feedings due to recent h/o aspiration.
-continue suppl. 02, wean as tolerated to maintain sa02 >90%.
chest pt. patient oob with assist to chair.
-thoracic us [**8-16**] showed ~1.6 ml of pleural fluid, ip unable to
tap effusions.
-aspriation pna most likely culprit, cont iv vanc/zosyn renal
dosing. concern for developing lung abscess. currently on day
13/14 of zosyn regimen, will extend until chest can be re-imaged
and abscess confirmed/ruled-out.
-continue lasix gtt with goal of net negative 1l fluid balance
today. if patient auto-diureses may stop gtt and begin scheduled
regimen.
-daily cxr
-pt to evaluate for rehab.
.
2)fevers: patient presents with fevers since he was admitted to
osh. likely cause of new onset seizures. possible sources of
infection include lll infiltrate. no report of productive cough,
dysuria, other symptoms at home. still unclear source. tee done,
blood and urine negative to date, cdiff negative, csf negative.
lack of leukocytosis may be due to uc tx with 6-mp. [**8-4**], [**8-5**],
[**8-6**] c.diff screens negative.
[**8-4**] blood culture showing not growth. [**8-11**] non-contrast ct of
head/chest/abdomen for eval of possible sinusitis and
surveillance of occult focus of infection =>no infectious
source. pt continues to spike temps nightly. [**2131-8-13**] tee shows
not evidence of endocarditis and a severely deformed aortic
valve. -lyme, -hsv, c.diff toxin b negative. relatively afebrile
[**8-12**] through [**8-14**] but spiked temp to 102 degrees am of [**8-15**],
resolved to low-grade temp ~100.5 by [**8-20**]. negative
ehrlichia/coxiella/legionella bal culture.
- tylenol prn for fever
- continue broad coverage of pna. zosyn renally dosed to 2.25 gm
iv q6 hours, back on scheduled vanc 750 mg iv daily, follow vanc
levels
- check routine vanc levels.
- f/u [**8-15**] and [**8-17**] blood cultures as well as [**8-11**] fungal/afb
cultures. c.diff rechecked and negative [**8-17**].
- f/u additional id recs, appreciate input,
.
3)acute kidney injury: cr stable now. likely due to
hypovolemia/prerenal azotemia secondary to lasix diuresis. urine
lytes show no eosinophiluria, fena and feuria indicate intrinsic
renal etiology of [**last name (un) **].
- cr stable, monitor daily
- renal consult, appreciate recs
- dose medications for patient's creatinine
- continue lasix gtt, stop if cr >2.5. [**month (only) 116**] start schuled iv
lasix this pm.
.
4)hypernatremia: increased to 149 [**2131-8-14**] & decreased to 139
with d5w supplementation. morning of [**8-15**] found to be 155 but
patient sedated after reintubation and difficult to assess for
mental status changes. patient with good uop.
-na now wnl
-ngt placed prior to extubation and tube feedings stopped. [**month (only) 116**]
gently re-start tube feedings this pm. d/c free water boluses.
-continue lasix gtt and monitor uop.
-daily chem7.
.
5)atrial fibrillation: patient remains in atrial fibrillation;
confirmed by ekg on admission to osh and [**hospital1 18**]. previously on
coumadin for a.fib.
- on heparin drip at 1400 u/hr. holding coumadin 5 mg po daily.

- [**2131-8-9**] shows severe as with valve diameter of 0.8 cm2. patient
will need aggressive rate control to decrease stress to heart.
- continue metoprolol 100 mg tid, po diltiazem increased at 90
mg po qid.
.
6)seizure disorder (requiring intubation): patient was diagnosed
with seizure disorder 1 year ago in setting of cva. now presents
with recurrent seizures despite being on keppra. differential
for seizures include infection, stroke, metabolic
encephalopathy, drugs, head trauma, tumors, etc. most likely
infection since patient has been febrile. concerned about
meningitis as a possible etiology though ruled out by negative
lp. [**2131-8-3**] mra head/neck and mr of head show no new enhancing
lesions. same day echo for new murmur showed no vegetations and
eeg showed no epileptiform focus.
- infectious etiology continues to be at top of differential,
but pneumonia only foci identified thus far.
- keppra renally-dosed to 750 mg po bid, approved by neuro.
- iv ativan if patient becomes symptomatic for seizures
.
7)ulcerative colitis: patient on mercaptopurine as outpatient.
per wife, patient has history of cramping and loose stools on a
regular basis.
- continue mercaptopurine 75 mg po daily. 400 cc stool op
yesterday.
- per gi consult, no evidence current stool op is change from
baseline.
- banana flakes added to tube feeds if having loose stools.
.
8)cad s/p cabg: no complaint of recent sob or chest pain during
this admission.
- continuing home statin, on oral beta blocker and ccb for rate
& pressure control.
.
9)fen:
- speech & swallow evaluation shows okay to take pre-thickened
nectar feeds, however will initially feed via ngt s/p
extubation.
- repeat speech & swallow study in the am
- restart nutren full-strength tube feedings tonight at 10 cc/hr
with goal of 45 cc/hr, advance as tolerated and checking
residuals q6 hours
.
10)access: right picc line placed [**2131-8-6**]. arterial line placed
[**2131-8-15**] in rue and pivx1 (20g).
.
11)prophylaxis: iv heparin, ppi.
.
12)code: full (verified with wife
.
13)dispo:  c/o to floor bed.
.
final instructions to accepting team:
1)  monitor na
2)  follow mental status for return to baseline.  will likely
need 1:1 sitter due to increased pm agitation, pulling ngt,
well-controlled with iv ativan.
3)  continue iv zosyn (day 14) due to concern for ? lung
abscess.  per id okay to d/c vanc (18 day course total)
4)  follow-up 9/12 & [**8-17**] blood cultures, [**8-11**] fungal/afb culture
5)  wean 02, continue chest pt and
6)  speech & swallow to perform video swallow eval once mental
status improves
7)  screen for rehab
8)  f/u pt/ot consult on day of transfer, oob with assistance.

medications on admission:
digoxin
diltiazem 240mg po daily
lasisx 40mg po daily
isordil
coumadin
omeprazole
purinethol 75mg po daily
keppra 750mg po daily


discharge medications:
keppra 750 mg po bid
diltiazem 90 mg po qid
metoprolol 100 mg po tid
asa 81 mg po daily
lasix 40 mg iv bid
zosyn 2.25 gm iv q6 hours (day 14/16)
protonix 40 mg iv daily
mercaptopurine 75 mg po daily
ativan 1 mg iv prn agitation

discharge disposition:
extended care

facility:
[**hospital3 105**] northeast - [**location (un) 701**]

discharge diagnosis:
recurrent seizures/status epilepticus of unknown etiology
requiring intubation complicated by aspiration pneumonia and
recurrent fevers.

discharge condition:
stable, mental status not returned to baseline.

discharge instructions:
please keep all scheduled medical appointments.  call a
physician or go to the emergency room if experiencing the
following symptoms:  chest pain, shortness of breath, change in
mental status/increased confusion, fever greater than 102
degrees, recurrent seizures or loss of consciousness, onset of
weakness or loss of sensation or any other concerning symptoms.

followup instructions:
please call your neurologist and primary care provider within
two weeks of leaving rehabilitation to set up an appointment.
please also have your primary care provider refer you to a
cardiologist or see your pre-existing cardiologist to evaluate a
valvular abnormality that was noted during your hospital stay.


"
280,"admission date:  [**2188-4-28**]              discharge date:   [**2188-5-2**]

date of birth:  [**2141-6-25**]             sex:   m

service: medicine

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 1899**]
chief complaint:
s/p cardiac arrest

major surgical or invasive procedure:
cardiac catheterization with no intervention
endotracheal intubation


history of present illness:
46 y/o man with etoh abuse and no other significan pmhx who
became uncousious while at the bar, received cpr and presented
to slh where he was found to have vfib arrest s/p shock x1 and
transferred to [**hospital1 18**] for further care.
.
pt. was in usoh until saturday night when he awoke from sleep
and was c/o of chest pain.  he felt it was [**2-13**] gerd and this
apparently improved with repositioning.  when he awoke, he was
not himself (usually drinks with his brother in am, but this
time did not due to not feeling well).  he felt malaised all
day, no frank cp complaints.  he then arrived at the bar around
6pm, ordered a beer, was talking with friends and then  suddenly
was noted by bystanders not to respond appropriately/confused.
seconds later he fell backwards, eyes rolled up, no shaking or
urinary incontinence.  cpr was started within 1 minute b/c the
patient was apneic, cpr was for ~ 5 minutes, by time ambulance
arrived, patient had a pulse.
.
he was apparently given narcan and became ""awake"" (per ems
reports) though unclear if he followed commands.    apparently
upon arrival to slh he became unresponsive and was found to be
in vfib arrest.  he received 150mg of amiodarone, 1 shock and
had return of pulse within 1 minute of the arrest. s/p shock was
confused but moving all extremities. earliest bp noted is
187/105 at [**2107**]. was then intubaed and received asa 325mg,
amiodarone gtt.  ekg sr, tachy, ste v1 3mm and avr 1mm, std i,
avl, v2-6.  started on heparin gtt.  ekg then nsr, < 1mm ste v1
and avr; ste iii, avf < 1mm; std i, avl, v4-6 of < 1mm.
underwent ct h/n with concern for ich, thus heparin gtt was
stopped.  transferred to [**hospital1 18**] for possible cath.  of note, had
a ""posturing"" episode, treated with 2mg of versed w/ resolution.
 labs at osh notable for ck 257, mb 2.4, mbi 0.9%, troponin 0.14
(0 - 0.3), + urine cannabinoids, wbc 15k, k 3.2, ast 52, alt of
39, etoh of 107,  and ... ""+pregnancy test""
.
vs in ed arrival were 97 157/93 30.  pt. was bucking the vent
and moving all extremities.  he was started on
propofol/midazolam/fentanyl.  ekg showed sr, ste v1 4mm, avr
<1mm and iii/avf < 1mm; std i, avl, v4-6. labs in the ed notable
for troponin of 0.28 and wbc of 14k. ct head was repeated and
was negative for ich.  he received amiodarone 1mg/min iv gtt,
heparin gtt, clopidogrel 600 mg, atorvastatin 80mg.  tte showed
no sign. wma and low/normal ef.  repeat ekg: sr, nl axis, ste v1
as above but not elsewhere and no std.  cooling not initiated
given spontaneous movements and mouthing of words.  patient
transferred to ccu for further care.
.
in ccu, vs were 84 124/84 26 on ac 50%fio2, 500/5/22.  sedated,
intubated.
.
unable to obtain ros but per girlfriend: has been c/o of
intermittent chest pressure since [**month (only) **], started on ppi with
some improvement.
.
no 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. no
recent fevers, chills or rigors. all of the other review of
systems were negative.
.
.


past medical history:
1. cardiac risk factors: -diabetes, -dyslipidemia, -hypertension

2. cardiac history:
-cabg:  none
-percutaneous coronary interventions:  none
-pacing/icd: none
3. other past medical history:
.


social history:
landscaping, cuts trees.  lives near [**location (un) 5503**] with
girlfriend.
-tobacco history:  1.5ppd x since teens.
-etoh: 6-8 per day, has had withdrawal sx in past, no dts or
seizures.
-illicit drugs:  marijuana, daily. no ivdu, no cocaine.

family history:
fa - mi at 60s. cancer - burkitt's lymphoma.
mo - healthy
2 brothers - etoh abuse
1 sister - etoh abuse
no sudden cardiac death; otherwise non-contributory.

physical exam:
neuro: intubated, off sedation:
opens eyes to command, sticks tongue out, squeezes both hands
symmetrically and moves feet b/l.  nods for yes and shakes for
no.
cns: l 3->2mm, r 2.5->1.5mm, eomi no nystagmus, face symmetric,
+ gag, + corneals.
motor: normal tone, symmetric movements, ues are ag at least.
no clonus.  toes down b/l.  dtrs deferred.
.
heent: ncat. in collar. no xanthalesma.
neck: in collar.
cardiac: pmi located in 5th intercostal space.
rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4.
lungs: cta laterally.
abdomen: soft, ntnd. no hsm or tenderness. no abdominal bruits.

extremities: no c/c/e. no femoral bruits.
skin: no stasis dermatitis, ulcers, scars, or xanthomas.
pulses:
right: carotid 2+ dp 1+ pt 1+
left: carotid 2+ dp 2+ pt 2+

pertinent results:
i. labs

a. admission

[**2188-4-28**] 12:00am blood wbc-14.0* rbc-4.83 hgb-15.9 hct-44.3
mcv-92 mch-32.9* mchc-35.8* rdw-13.2 plt ct-220
[**2188-4-28**] 06:04am blood neuts-86.0* lymphs-10.0* monos-3.1
eos-0.4 baso-0.6
[**2188-4-28**] 12:00am blood pt-11.7 ptt-21.7* inr(pt)-1.0
[**2188-4-28**] 12:00am blood fibrino-331
[**2188-4-28**] 12:00am blood urean-8 creat-0.6
[**2188-4-28**] 12:00am blood alt-45* ast-74* ld(ldh)-318*
ck(cpk)-[**2139**]* alkphos-86 totbili-0.5
[**2188-4-28**] 12:00am blood albumin-4.0 calcium-7.7* phos-2.8 mg-1.8
[**2188-5-2**] 07:30am blood vitb12-773
[**2188-4-28**] 06:04am blood %hba1c-5.6 eag-114
[**2188-4-28**] 06:04am blood triglyc-90 hdl-67 chol/hd-2.7 ldlcalc-97
[**2188-4-28**] 12:00am blood asa-neg ethanol-neg acetmnp-neg
bnzodzp-neg barbitr-neg tricycl-neg
[**2188-4-28**] 12:08am blood glucose-115* lactate-1.7 na-137 k-4.1
cl-105 calhco3-19*

b. cardiac biomarkers
[**2188-4-28**] 12:00am blood ck-mb-19* mb indx-1.0
[**2188-4-28**] 12:00am blood ctropnt-0.28*
[**2188-4-28**] 06:04am blood ck-mb-133* mb indx-4.6 ctropnt-0.86*
[**2188-4-28**] 12:15pm blood ck-mb-214* mb indx-7.6* ctropnt-1.04*
[**2188-4-28**] 07:51pm blood ck-mb-157* ctropnt-1.26*
[**2188-4-29**] 04:10am blood ck-mb-96* mb indx-5.4 ctropnt-1.51*
[**2188-4-29**] 02:21pm blood ck-mb-58* mb indx-5.1 ctropnt-1.13*
[**2188-4-30**] 12:14am blood ck-mb-23* mb indx-4.1 ctropnt-1.11*
[**2188-4-30**] 06:08am blood ck-mb-17* mb indx-4.0 ctropnt-1.23*

c. discharge
[**2188-5-2**] 07:30am blood wbc-9.3 rbc-4.69 hgb-14.8 hct-43.2 mcv-92
mch-31.5 mchc-34.2 rdw-13.2 plt ct-314
[**2188-5-2**] 07:30am blood glucose-101* urean-14 creat-0.9 na-137
k-4.1 cl-99 hco3-27 angap-15
[**2188-4-30**] 06:08am blood alt-49* ast-60* ck(cpk)-424*
[**2188-5-2**] 07:30am blood calcium-9.4 phos-4.1# mg-1.9

d. urinary

[**2188-4-28**] 12:00am urine color-straw appear-clear sp [**last name (un) **]-1.009
[**2188-4-28**] 12:00am urine blood-neg nitrite-neg protein-neg
glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg
[**2188-4-30**] 03:00pm urine hours-random urean-1489 creat-190 na-43
k-53 cl-57
[**2188-4-30**] 03:00pm urine osmolal-911
[**2188-4-28**] 12:00am urine bnzodzp-pos barbitr-neg opiates-neg
cocaine-neg amphetm-neg mthdone-neg

ii. cardiology

a. c. cath ([**2188-4-29**]) ** prelim report **
brief history:   46 year old male with history of etoh and
tobacco abuse
with recent cardiac arrest at a bar after several days of chest
discomfort.

indications for catheterization:

procedure:
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

left ventriculography:

**arteriography results	morphology	% stenosis	collat. from
**right coronary
1) proximal rca	 	normal	 	 	 	
2) mid rca	 	discrete	100	 	 	
2a) acute marginal	 	normal	 	 	 	
3) distal rca	 	normal	 	 	 	
4) r-pda	 	normal	 	 	 	
4a) r-post-lat	 	normal	 	 	 	
4b) r-lv	 	normal	 	 	 	

**arteriography results	morphology	% stenosis	collat. from
**left coronary
5) left main	 	normal	 	 	 	
6) proximal lad	 	discrete	20	 	 	
6a) septal-1	 	normal	 	 	 	
7) mid-lad	 	normal	 	 	 	
8) distal lad	 	normal	 	 	 	
9) diagonal-1	 	discrete	40	 	 	
10) diagonal-2	 	normal	 	 	 	
11) intermedius	 	normal	 	 	 	
12) proximal cx	 	normal	 	 	 	
13) mid cx	 	normal	 	 	 	
13a) distal cx	 	normal	 	 	 	
14) obtuse marginal-1	 	normal	 	 	 	
15) obtuse marginal-2	 	normal	 	 	 	
16) obtuse marginal-3	 	normal	 	 	 	
17) left pda	 	normal	 	 	 	
17a) posterior lv	 	normal	 	 	 	

technical factors:
total time (lidocaine to test complete) = 0 hour33 minutes.
arterial time = 0 hour33 minutes.
fluoro time = 10 minutes.
irp dose = 354 mgy.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 130 ml
premedications:
          midazolam 1 mg iv
          fentanyl 100 mcg iv
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          lidocaine 5ml subq
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - merit, left heart kit


comments:
1. selective coronary angiography of this left dominant system
reveale
single vessel coronary artery disease. the lm was free from
angiographic
disease. the lad had a short segment of myocardial bridge
proximally
with 20% focal disease; the single diagonal branch takes off
relatively
proximally and has 40% tubular proximal disease; the distal lad
filled the distal rpda retrogradely. the lcx is a hyperdominant
vessel
giving rise to 4 om branches. the av groove lcx is a well
developed
vessel; the om3 and om4 also supply bridging collaterals to the
distal
rpda; well developed atrial branch is also noted. the rca is a
non-dominant vessel occluded proximally with a ""peaked""
appearance
suggestive of recent occlusion; the occlusion is past the
takeoff of the
conus branch and just beyond the sinus node and a small rv
branch; the
distal rpda reconsituted via collateral with the lad (mostly)
and the
om3-4. sided filling pressure lvedp of 19mmhg. there was mild
aortic
stensosis with a peak-to-peak gradient of 30mmhg. there was
severely
elevated systemic arterial pressure of 186/104mmhg.
3. left ventriculography revealed mitral regurgitaion, and lvef
of 60%
and somewhat sluggish inferior wall.

final diagnosis:
1. single vessel cad with total occlusion of the proximal rca.
2. mild disease in the d1 and mid lad with myocardial bridge in
the
proximal-mid lad.
3. elevated lvedp consistent with mild-moderate diastolic
dysfunction.
4. normal lvef without mr.
5. medical therapy.
6. mild aortic stenosis.

b. tte ([**2188-4-28**])
conclusions
the left atrium and right atrium are normal in cavity size. left
ventricular wall thicknesses and cavity size are normal. due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. overall left ventricular systolic
function is low normal (lvef 50-55%). right ventricular chamber
size is normal. free wall motion could not be assessed, but may
be hypokinetic. the aortic sinus is normal in diameter. the
aortic valve leaflets may be mildly thickened. mild aortic
regurgitation is suggested. the mitral valve leaflets are
structurally normal. at least mild (1+) mitral regurgitation is
seen. there is no pericardial effusion.

impression: technicaly suboptimal study. normal biventricular
cavity size with low normal global left ventricular systolic
function. ? mild aortic regurgitation. at least mild mitral
regurgitation.
if clinincally indicated, a follow-up study by laboratory
personnel/son[**name (ni) 930**] is suggested.

c. tte ([**2188-4-28**])
the left atrium and right atrium are normal in cavity 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 are mildly thickened (?#) but mobile. an increased
velocity is detected across the valve which likely represents
high output, though cannot fully exclude mild aortic stenosis.
very mild (1+) aortic regurgitation is seen. the mitral valve
leaflets are structurally normal. there is no mitral valve
prolapse. mild (1+) mitral regurgitation is seen. the estimated
pulmonary artery systolic pressure is normal. there is an
anterior space which most likely represents a prominent fat pad.

impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. possible
mild aortic valve stenosis (vs. high output). mild mitral
regurgitation with normal valve morphology. very mild aortic
regurgitation.

clinical implications:
based on [**2184**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

d. ecg (admission on [**2188-4-27**])
cardiology report	ecg	study date of [**2188-4-27**]  11:58:20 pm

normal sinus rhythm. st segment elevation most marked in lead v1
but also seen
in leads iii and avf. j point depression seen in lead v2 and
non-specific
st-t wave abnormalities. cannot exclude acute myocardial
infarction. suggest
clinical correlation and repeat tracing.
tracing #1

read by:	[**last name (lf) 10516**],[**first name3 (lf) **]
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
92	154	72	[**telephone/fax (2) 88644**]	74

e. ecg  ([**4-29**])
cardiology report	ecg	study date of [**2188-4-29**]  8:01:56 pm

sinus tachycardia. st-t wave configuration may be due to early
repolarization
pattern. clinical correlation is suggested. since the previous
tracing of same
date sinus tachycardia is now present.

read by:	[**last name (lf) **],[**first name3 (lf) 177**] w.
 	intervals	axes
rate	pr	qrs	qt/qtc	p	qrs	t
101	136	78	332/403	62	-13	26

iii. radiology

a. cxr
history: cpr after cardiac arrest, to assess for rib fractures.

findings: in comparison with the earlier study of this date,
there is no
definite evidence of rib fracture. if this is a serious clinical
concern, a
dedicated rib series could be obtained. central fullness of
pulmonary vessels
persists. no evidence of acute focal pneumonia or pneumothorax.

the study and the report were reviewed by the staff radiologist.



brief hospital course:
46-year-old male with alcohol abuse and no other significant
past medical history became unconscious at a bar with resultant
cpr for ventricular fibrillation arrest. he was taken to an osh
where he was thought to have ventricular fibrillation arrest s/p
shock x1 and transferred to [**hospital1 18**] for further care with cardiac
cath showing recent rca occlusion suggestive of ischemic
mechanism for arrest and aortic stenosis. hospital course
complicated by femoral groin site bleed, alcohol withdrawal,
severe systemic hypertension, and encephalopathy.

# one vessel coronary artery disease with cardiac arrest
the patient arrived intubated for airway protection in setting
of cardiac arrest.   etiology of cardiac arrest may be related
to rca occlusion; however, complete data are not available
especially from ems to state whether or not this was a true
cardiac arrest as no rhythm strips are available from ems. the
osh documented ventricular fibrillation; however, only one strip
available in the chart and per electrophysiology review,
uncertain if represents such arrest. no further work-up for
abnormal heart rhythm was advised by ep. initial ecg on
admission showed st-elevation in v1, iii, and avf with j-point
depression in v2 and non-specific st-t abnormalities. cardiac
biomarkers peaked with troponint peak of 1.51 and ck-mb 214 and
trended down with some component likely attributable to cpr and
electrical shock during resuscitation. therapeutic hypothermia
was not initiated in the [**hospital1 18**] emergency department as mental
status was not impaired. he was started on empiric treatment for
acs including nitroglycerin infusion secondary to high systemic
hypertension in setting of alcohol withdrawal and underwent c.
cath showing one-vessel coronary artery disease with peaked
appearance of rca suggestive of recent occlusion. there was no
intervention performed as there appeared to be collaterals to
pda and right-sided vessels from lcx, the lesion appeared to be
acute-on-chronic with lcx-dominant anatomy, and rca did not
supply a significant amount of myocardium at baseline lvef > 55
%)

after extubation, patient reported several day history of chest
discomfort supporting likely possible ischemic etiology of
arrest.

cardiac cath was complicated by left femoral groin site bleed
secondary to patient leg movement despite instructions. pressure
was held for 20 minutes. bedside us did not indicate
pseudoaneurysm. on discharge, there was a soft hematoma
measuring at least 2 cm x 2 cm around the area with no femoral
bruit.

the patient continued to report severe chest pain consistent
with msk etiologies especially in setting of recent cpr with
serial ecgs and cardiac biomarkers not suggestive of acute
ischemic event. his pain was treated with oxycodone. cxr was not
suggestive of rib fractures.

he remained in nsr throughout hospitalization.

labs indicated a1c 5.6 and cholesterol panel of total
cholesterol 182, tg 90, hdl 67, ldl 97.

he was discharged on aspirin 325 mg po qd, atorvastatin 80 mg po
qd, clopidogrel 75 mg po qd, lisinopril 10 mg po qd, and
metoprolol succinate 50 mg po qd.

he will follow-up with cardiology after discharge for aggressive
medical optimization.

# mild aortic stenosis
patient endorses family history of aortic stenosis with possible
bicuspid valve in family member. c. cath indicated peak-to-peak
gradient of 30 mmhg suggestive of mild aortic stenosis.

he will follow-up with cardiology as above.

# probable peripheral vascular disease
patient reported symptoms of claudication and exam significant
for disparate pulses notably in femoral area. he will follow-up
with cardiology for further evaluation.

# alcohol abuse with alcohol withdrawal and tobacco abuse
the patient was actively drinking about [**6-18**] drinks per day. it
is uncertain what ""a drink"" constitutes for the patient, so his
effective alcohol intake may be much higher than 6-8 days. he
was given a banana bag and nutritional supplementation in
addition to other supportive measures. he has had withdrawal
symptoms in the past without a history of seizures or dts. he
also has concurrent substance abuse with marijuana. urine tox
was negative for other substances such as cocaine. he was placed
on a ciwa scale and treated for withdrawal. he had not seizures
or adverse events related to alcohol withdrawal during
hospitalization. social work was consulted and discussed
substance abuse. patient plans to schedule outpatient evaluation
including mental health appointment for treatment of anxiety
symptoms.

# transaminitis
admission lfts significant for alt 45, ast 74 and cpk in [**2177**]
supporting a potential muscular etiology in setting of cpr and
electrical shocks. lfts trended down to alt 49, ast 60 with no
disturbances in synthetic markers such as tbili or inr. given
concurrent alcohol abuse, it is uncertain if another process
such as a primary liver process is contributing somewhat to
elevation. repeat lfts and ck are advised at pcp [**last name (namepattern4) 702**].

he was discharged on a multivitamin, folate, and thiamine.

# acute toxic-metabolic encephalopathy
the patient seemed to be inattentive. occupational therapy
evaluation noted severe short term memory deficits, decreased
safety awareness, and issues with functional mobility and
balance. his function was below baseline level and required
verbal cues to be safe. [**hospital 6266**] rehab secondary to
impulsiveness, cognitive impairments, and poor insight was
recommended. exam was significant for positive romberg,
nystagmus, and ataxia. given concern for wernicke's
encephalopathy, neurology was consulted with impression of
subtle cerebellar deficits and mild ataxia on finger to nose.
these findings were thought to be due to combination of
pre-existing cerebellar atrophy secondary to alcohol abuse as
well as possible mild anoxic brain injury due to cardiac arrest.
it was also thought that the component of inattentiveness may be
secondary to resolving encephalopathy due to alcohol withdrawal.
wernicke's encephalopathy was unlikely given that he lacked
ophthalmoplegia.

overall, it was felt that the patient will likely improve over
time.

he should follow-up in the cognitive neurology clinic if
cognition remains problem[**name (ni) 115**] in [**2-14**] weeks.

he was discharged home with 24-hour supervision by family.


code: full

comm:
[**name (ni) **] [**telephone/fax (1) 88645**], [**name2 (ni) **]iend.
father - hcp - [**name (ni) 25368**] [**name (ni) 88646**] - [**telephone/fax (1) 88647**], cell [**telephone/fax (1) 88648**].

medications on admission:
prilosec


discharge medications:
1. aspirin 325 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. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr
transdermal daily (daily) for 6 weeks.
disp:*30 patch 24 hr(s)* refills:*2*
4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
6. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*2*
8. metoprolol succinate 50 mg tablet extended release 24 hr sig:
one (1) tablet extended release 24 hr po once a day.
disp:*30 tablet extended release 24 hr(s)* refills:*2*
9. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po once a day.
10. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet
sublingual every 5 minutes for total of 3 tablets as needed for
chest pain.
disp:*25 tablets* refills:*0*


discharge disposition:
home with service

facility:
[**hospital **] home health care

discharge diagnosis:
non st elevation myocardial infarction s/p cardiac arrest
coronary artery disease
peripheral artery disease
aortic stenosis
alcohol abuse
tobacco abuse


discharge condition:
mental status: confused sometimes
level of consciousness: alert and interactive.
activity status: ambulatory - gait unsteady, needs supervision


discharge instructions:
you had chest pain and collapsed in a bar. you were unresponsive
but it is unclear why. you were defibrillated and brought to [**hospital6 84784**], then transferred to [**hospital1 18**]. a cardiac
catheterization showed that you have blockages in your heart
arteries but they did not appear to cause your collapse. we did
not place any stents at this time. an electrophysiology doctor
team saw you here and did not think that you need to have any
further workup for an irregular heart rhythm. you did have a
heart attack and we started many new medicines to help your
heart recover from the heart attack. it is very important that
you take these medicines every day and go to the scheduled
doctor's appointments. you also need to stop drinking and
smoking to prevent another similar incident and to help the
medicines work. a neurology team evaluated you and thought that
your forgetfulness and unsteadiness is due to your collapse and
possible lack of oxygen to your brain. they do not think that
more tests are necessary and they feel that you will improve
gradually.
.
start taking the following medicines:
1. aspirin 325 mg daily to prevent another heart attack
2. plavix 75 mg daily to prevent another hear attack
3. atorvastatin 80 mg daily to prevent further blockages in your
arteries.
4. metoprolol 50 mg daily to slow your heart rate and prevent
another heart attack
5. lisinopril 10 mg daily to lower your blood pressure
6. nitroglycerin under your tongue as directed for chest pain
7. folic acid 1 mg daily and thiamine 100 mg daily for
nutritional reasons as you were drinking heavily
8. nicotine patch one daily to help you quit smoking.

followup instructions:
primary care:
[**hospital3 **] primary care
[**street address(2) 74742**]
[**location (un) 5503**], [**numeric identifier 88649**]
phone:  ([**telephone/fax (1) 68439**]
fax: ([**telephone/fax (1) 88650**]
the office will call you with an appt for next week

department: cardiac services
when: thursday [**2188-6-5**] at 11:40 am
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(3) 1905**]

"
281,"admission date:  [**2189-1-2**]              discharge date:   [**2189-1-21**]

date of birth:  [**2116-1-21**]             sex:   f

service: cardiothoracic

allergies:
iodine; iodine containing / lipitor / codeine

attending:[**first name3 (lf) 165**]
chief complaint:
transfer from an outside hospital for non st elevation
myocardial infarction, congestive heart failure exacerbation

major surgical or invasive procedure:
cardiac catheterization without pci
coronary artery bypass grafts x 4
(lima-lad,svg-dg1,svg-om,svg-rca)& mitral valve repair (28mm
[**company 1543**] annuloplasty ring)- [**1-14**]
left heart catheterization, coronary angiography- [**1-4**]


history of present illness:
this is a 72-year-old female with a past medical history
significant for hypertension, diabetes, smoking, cad s/p mi x3
most recently in [**10-25**] complicated by cardiogenic shock, s/p rca
stenting x2 and lcx stenting x2, chf with ef of 40%, mr,
pulmonary hypertension, and pvd s/p lower extremity stenting
transfered from an osh for nstemi and chf exacerbation.

in brief, she was discharged from [**hospital1 18**] on [**2188-11-11**] after a
prolonged hospitalization notable for a nstemi with stenting of
the lcx and hemodynamic compromise requiring a iabp. she did
well after discharge with improvement of her sob and mobility.
she and her husband went on vacation during which time she
developed doe, the cp mostly a night with no correlation to
activity. her cp responded consistently to 1 to 2 ntg. she began
to notice orthopnea and pnd as well as ankle edema. she had
nausea and sob associated with her cp but not sweats or
dizziness. on [**2189-1-1**] she had a bacon and cheese omelet for
breakfast and clam chowder and [**location (un) 20935**] steak with french fries
for lunch. that afternoon she began to have persistent cp and
sob with associated nausea not relieved by ntg x3q5 minutes. ems
was called and she was admitted to [**hospital 67742**] medical center in
[**location (un) **], n.h. where she was found to be atrial fibrillation and
pulmonary edema with and an admission probnp of 5814.4. a
central line was placed and emergent cardioversion was
performed. she initially was hypotensive but stablized post
cardioversion. ekg revealed st depression in the lateral leads.
her tni trended 1.17, 3.03, 8.9 consistent with an nstemi. she
was maintained on a heparin drip with aggressive diuresis. proir
to transfer she had been on and off nitroglycerin drip. she has
chest pressure whenever it was shut off but she was hypertensive
when the nitro is increased. by report from the osh she was
wheezing on admission. her blood sugar on admission to the osh
was 515 and she was briefly on an insulin drip with improvement
of her sugars. there is also a question of whether she missed a
dose of her beta-block dose prior to her admission. she was
transferred to [**hospital1 18**] for further management.
.

she developed 7/10 chest pain with no ecg changes. she was
continued on heparin drip and ntg drip was restarted with
resolution of her cp.

she had recurrent chest pain w/ ekg chnages and was taken for an
emergent coronary srtery bypass graft and mv repair om [**2188-1-14**].

past medical history:
coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis


social history:
heavy smoker up to 2 ppd for 50 years, quit in [**10-25**]. denies
etoh or ivdu. pt is a retired x-ray technician. she lives with
her husband and two grandchildren in [**name (ni) 67740**], she is the
caregiver for her sister with [**name (ni) 309**] body dementia and her husband
as well as her two grandchildren.

family history:
no family history of cad or premature death, dm, htn, hld.
mother with pd. sister with [**name (ni) 309**] body dementia. sister with lung
ca.

physical exam:
admission:
gen: obese elderly lady in nad. oriented x3. mood, affect
appropriate.
heent: ncat. sclera anicteric. perrl, eomi. dry mm. no pallor or
cyanosis of the oral mucosa. no xanthalesma. no cervical or
axillary lad. neck supple with jvp of 10 cm. no carotid bruits
cv: pmi difficult to assess. rr, normal s1, s2. no m/r/g. no
thrills, lifts. no s3 or s4.
pulm: no chest wall deformities, scoliosis or kyphosis. resp
were unlabored, no accessory muscle use. poor air movement.
diffuse mile crackles greater in the bases with scattered
wheezes.
abd: bs+, soft, ntnd. no hsm or tenderness. gas on percussion.
limbs: no c/c/e. no stasis dermatitis, ulcers, scars, or
xanthomas.
pulses:
right: carotid 2+ radial 2+ dp 1+
left: carotid 2+ radial 2+ dp 2+


pertinent results:
[**2189-1-18**] 03:52am blood wbc-17.3* rbc-3.53* hgb-10.8*# hct-30.9*
mcv-87 mch-30.6 mchc-35.0 rdw-14.3 plt ct-191
[**2189-1-19**] 04:28am blood wbc-14.4*
[**2189-1-19**] 04:28am blood glucose-57* urean-28* creat-1.2* k-3.8

[**hospital1 18**] echocardiography report

[**known lastname **], [**known firstname **]       [**hospital1 18**] [**numeric identifier 67743**] (complete)
done [**2189-1-14**] at 10:54:24 am      final
referring physician     [**name9 (pre) **] information
[**name9 (pre) **], [**first name3 (lf) **]
division of cardiothoracic [**doctor first name **]
[**first name (titles) **] [**last name (titles) **]
[**hospital unit name 4081**]
[**location (un) 86**], [**numeric identifier 718**]  status: inpatient dob: [**2116-1-21**]
age (years): 72 f  hgt (in): 65
bp (mm hg): 123/67  wgt (lb): 230
hr (bpm): 67  bsa (m2): 2.10 m2
indication: intraoperative tee for cabg procedure and mitral
valve repair. chest pain. congestive heart failure. left
ventricular function. mitral valve disease. myocardial
infarction. preoperative assessment. right ventricular function.

icd-9 codes: 428.0, 786.05, 786.51, 440.0, 424.0
test information
date/time: [**2189-1-14**] at 10:54    interpret md: [**name6 (md) 1509**] [**name8 (md) 1510**],
md
test type: tee (complete) son[**name (ni) 930**]: [**last name (namepattern5) 9958**], md
doppler: full doppler and color doppler test location:
anesthesia west or cardiac
contrast: none tech quality: adequate
tape #: 2009aw2-: machine: [**doctor last name 11422**] 3d
echocardiographic measurements
results  measurements  normal range
left atrium - long axis dimension:  *5.0 cm  <= 4.0 cm
left ventricle - septal wall thickness:  1.0 cm  0.6 - 1.1 cm
left ventricle - inferolateral thickness:  1.0 cm  0.6 - 1.1 cm

left ventricle - diastolic dimension:  *6.0 cm  <= 5.6 cm
left ventricle - ejection fraction:  35%  >= 55%
aorta - annulus:  2.0 cm  <= 3.0 cm
aorta - sinus level:  2.7 cm  <= 3.6 cm
aorta - sinotubular ridge:  2.5 cm  <= 3.0 cm
aorta - ascending:  3.3 cm  <= 3.4 cm
aorta - arch:  2.3 cm  <= 3.0 cm
aorta - descending thoracic:  2.4 cm  <= 2.5 cm
aortic valve - peak velocity:  0.8 m/sec  <= 2.0 m/sec
mitral valve - peak velocity:  1.2 m/sec
mitral valve - mean gradient:  1 mm hg
mitral valve - pressure half time:  53 ms
mitral valve - mva (p [**12-19**] t):  4.2 cm2
mitral valve - e wave:  0.9 m/sec
mitral valve - a wave:  0.5 m/sec
mitral valve - e/a ratio:  1.80
mitral valve - e wave deceleration time:  *127 ms  140-250 ms

findings
left atrium: moderate la enlargement. no mass/thrombus in the [**name prefix (prefixes) **]
[**last name (prefixes) **] laa. all four pulmonary veins identified and enter the left
atrium.

right atrium/interatrial septum: a catheter or pacing wire is
seen in the ra and extending into the rv. no asd by 2d or color
doppler.

left ventricle: wall thickness and cavity dimensions were
obtained from 2d images. normal lv wall thickness. moderately
dilated lv cavity. moderate-severe regional left ventricular
systolic dysfunction. moderately depressed lvef. [intrinsic lv
systolic function likely depressed given the severity of
valvular regurgitation.]

right ventricle: normal rv systolic function.

aorta: normal diameter of aorta at the sinus, ascending and arch
levels. simple atheroma in aortic arch. normal descending aorta
diameter. complex (>4mm) atheroma in the descending thoracic
aorta.

aortic valve: normal aortic valve leaflets (3). no as. no ar.

mitral valve: mildly thickened mitral valve leaflets. no ms.
moderate to severe (3+) mr. [**name13 (stitle) 15110**] to the eccentric mr jet, its
severity may be underestimated (coanda effect).

tricuspid valve: physiologic tr.

pulmonic valve/pulmonary artery: physiologic (normal) pr.

pericardium: no pericardial effusion.

general comments: a tee was performed in the location listed
above. i certify i was present in compliance with hcfa
regulations. the patient was under general anesthesia throughout
the procedure. no tee related complications. the patient appears
to be in sinus rhythm. frequent ventricular premature beats.
patient.

regional left ventricular wall motion:





     n = normal, h = hypokinetic, a = akinetic, d = dyskinetic
conclusions
pre-bypass: the left atrium is moderately dilated. no
mass/thrombus is seen in the left atrium or left atrial
appendage. no atrial septal defect is seen by 2d or color
doppler. left ventricular wall thicknesses are normal. the left
ventricular cavity is moderately dilated. there is moderate to
severe regional left ventricular systolic dysfunction with
hypokinesis of the apex, apical portions of the inferior and
lateral walls as well as the mid portions of the inferior,
inferolateral and inferoseptal walls. overall left ventricular
systolic function is moderately depressed (lvef= 35 %). the
diameters of aorta at the sinus, ascending and arch levels are
normal. there are simple atheroma in the aortic arch. there are
complex (>4mm) atheroma in the descending thoracic aorta. the
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. no aortic
regurgitation is seen. the mitral valve leaflets are mildly
thickened. moderate to severe (3+) mitral regurgitation is seen.
due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (coanda effect). there is no
pericardial effusion.

dr. [**last name (stitle) **] was notified in person of the results in the
operating room.

post bypass

patient is av paced and receiving an infusion of epinephrine,
milrinone and phenylephrine. lvef is 40%. rv function is
unchanged. annuloplasty ring seen in the mitral position. mild
mitral regurgitation seen between the p2 and p3 scallops. dr
[**first name (stitle) **] aware. mean gradient across the mitral valve is 2 mm hg.
aorta intact post decannulation.
  i certify that i was present for this procedure in compliance
with hcfa regulations.

electronically signed by [**name6 (md) 1509**] [**name8 (md) 1510**], md, interpreting
physician [**last name (namepattern4) **] [**2189-1-14**] 16:03

[**known lastname **],[**known firstname **] m [**medical record number 67744**] f  72  [**2116-1-21**]

cardiology report c.cath study date of [**2189-1-6**]



brief history:   72 year old female with coronary artery disease
and
prior mi, status post pci of her lcx and rca, peripheral
vascular
disease, and mitral regurgitation who was recently admitted to
an
outside hospital with congestive heart failure and a non-st
elevation
mi. she is now transferred for cardiac catheterization.

indications for catheterization:
coronary artery disease

procedure:
right heart catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 french pulmonary wedge pressure
catheter,
advanced to the pcw position through an 8 french introducing
sheath.
cardiac output was measured by the fick method.
left heart catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 french angled pigtail catheter,
advanced
to the left ventricle through a 5 french introducing sheath.
coronary angiography: was performed in multiple projections
using a 5
french jl4 and a 5 french jr4 catheter, with manual contrast
injections.
left ventriculography: was performed in the 30 degrees [**doctor last name **]
projection,
using 39 ml of contrast injected at 13 ml/sec, through the
angled
pigtail catheter.
conscious sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

hemodynamics results body surface area:  2.13 m2
  hemoglobin: 10.3 gms %
  fick
**pressures
right atrium {a/v/m} 15/14/9
right ventricle {s/ed} 54/15
pulmonary artery {s/d/m} 54/28/45
pulmonary wedge {a/v/m} 36/41/33
left ventricle {s/ed} 135/36
aorta {s/d/m} 135/54/84
**cardiac output
heart rate {beats/min} 80
rhythm n
o2 cons. ind {ml/min/m2} 125
a-v o2 difference {ml/ltr} 46
card. op/ind fick {l/mn/m2} 5.8/2.7
**resistances
systemic vasc. resistance 1035
pulmonary vasc. resistance 166

**% saturation data (nl)
pa main 94
ao 61

other hemodynamic data:      the oxygen consumption was assumed.



left ventriculography:
volumetric data:
          lv ejection fraction (nl 50%-80%).                40
qualitative wall motion:
[**doctor last name **]:
          1. antero basal -    normal
          2. antero lateral -  normal
          3. apical -          normal
          4. inferior -        hypokinetic
          5. postero basal -   normal
other findings:
mitral valve showed the following abnormalities.
          1. regurgitation [**2-18**]+.
aortic valve was normal.


**arteriography results morphology % stenosis collat. from
**right coronary
1) proximal rca   discrete 70
2) mid rca   normal
2a) acute marginal   normal
3) distal rca   normal
4) r-pda   normal
4a) r-post-lat   normal
4b) r-lv   normal

**arteriography results morphology % stenosis collat. from
**left coronary
5) left main   discrete 30
6) proximal lad   normal
6a) septal-1   normal
7) mid-lad   discrete 60
8) distal lad   normal
9) diagonal-1   discrete 60
10) diagonal-2   normal
12) proximal cx   discrete 90
13) mid cx   discrete 99


technical factors:
total time (lidocaine to test complete) = 34 minutes.
arterial time = 18 minutes.
fluoro time = 6.0 minutes.
contrast injected:
          non-ionic low osmolar (isovue, optiray...), vol 94 ml
premedications:
          [**month/day (3) **] 325 mg p.o.
anesthesia:
          1% lidocaine subq.
anticoagulation:
other medication:
          fentanyl 25mcg
          furosemide 60mg iv
          nahc03 75ml/hr
          midazolam 0.5mg
cardiac cath supplies used:
          - allegiance, custom sterile pack
          - [**company **], left heart kit
          - [**company **], right heart kit
          5fr [**company **], multipack
          7fr [**company **], pulmonary wedge pressure catheter


comments:
1. selective coronary angiography of this right dominant system
revealed
three vessel disease.  the lmca had a 30% ostial stenosis.  the
lad had
a 60% mid-vessel lesion involving a major diagonal branch.  the
lcx had
a 95% proximal isr and a long 99% isr in the mid and distal
vessel.  the
rca had a 70% proximal isr.
2. resting hemodynamics revealed a severely elevated left heart
filling
pressure with a mean pcwp of 33mmhg.  there was moderate
pulmonary
artery hypertension with a mean pa of 45mmhg.  the cardiac index
was
preserved at 2.7l/min/m2.
3. left venticulography revealed an estimated lvef of 40% with
severe
inferior hypokinesis.  there was severe [**2-18**]+ mitral
regurgitation.

final diagnosis:
1. three vessel coronary artery disease.
2. severe mitral regurgitation.
3. moderate systolic and severe diastolic ventricular
dysfunction.
4. moderate pulmonary hypertension.

attending physician: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].
referring physician: [**name10 (nameis) **],[**first name4 (namepattern1) **] [**last name (namepattern1) 975**]
cardiology fellow: [**last name (lf) **],[**first name3 (lf) **] m.
attending staff: [**last name (lf) **],[**first name3 (lf) **] e.


carotid ultra sound
impression: right ica 60-69% stenosis. left ica 40-59% stenosis.
both have
bulky plaque. antegrade vertebral flow bilaterally. the right
has been
stable since [**2185**]. the left has evidence of mild progression on
today's
study.


brief hospital course:
[**hospital1 1516**] cardiology service brief hospital course:
this is a 72-year-old female with a past medical history
significant for hypertension, diabetes, smoking, cad s/p mi x3
most recently in [**10-25**] complicated by cardiogenic shock, s/p rca
stending x2 and lcx stenting x2, systolic chf with ef of 40%,
pulmonary hypertension, and pvd s/p lower extremity stenting
transfered from an osh for nstemi and chf exacerbation. on her
second day of hospitalization she developed flash pulmonary
edema. given she was in sinus when she flashed there was concern
for ischemic mr. [**first name (titles) **] [**last name (titles) 1834**] cath on [**2189-1-6**] and was found to
have 3vd (lad and isr of lcx and rca) and servere mr. [**first name (titles) **] [**last name (titles) 67745**]s were taken and cardiac [**doctor first name **] referral was made. pt
agreed to cabg. she had egd-colonoscopy to rule out possible
sources of gib which was negative. also developed worsening of
cri, but improved with holding lasix and [**doctor first name 21177**]. developed
recurrent cp with ecg changes and was ultimately sent to ct
surgery for emergent cabg the day following her egd-[**last name (un) **].
.
#. cad: pt s/p mix4 (the latest nstemi this admission) and found
to have 3vd at cath + mr. [**first name (titles) **] [**last name (titles) **] 325mg po daily. held
plavix 75mg po daily for cabg washout but had recent bms to the
lcx in [**10-25**]. continued metoprolol 37.5mg po bid in place of
toprolxl 75mg daily. holding statins for now given history of
adverse events to these and excellent cholesterol panel. lipid
panel: cholest 147, triglyc 134, hdl 60, ldlcalc 60. cath on
[**2189-1-6**] showed severe mr with angio showing that lad with 60%
mid-vessel lesion involving a major diagonal branch, lcx with
95% proximal isr and a long 99% isr in the mid and distal
vessel, and rca with 70% proximal isr. last dose of plavix was
on [**2189-1-6**]. had cp [**2-24**] with ecg changes on the am of [**2189-1-13**]
during bowel prep. resolved completely with ntgx1. again had cp
[**5-27**] overnight 1/27-28/09 resolved after ntg x2. triggered for
cp x2 in <24hrs with 3vd. sent emergently to cabg on the morning
of [**2189-1-13**] for recurrent cp.
.
#. pump: pt with chf with known ef of 40%. pt continues to be in
sinus (chf preivously exacerbated by afib s/p cardioversion).
however, on [**2189-1-4**] pt triggered for sob, hypoxia to high 80s on
room air. pt's exam showed acute worsening of fluid status
concerning for flash pulmonary edema. also concern for ischemic
mr. [**first name (titles) **] [**last name (titles) 21177**] at 5mg po daily ([**12-19**] home dose). lisopril was
held the am of transfer to ct surgery to improve renal function.
continued metoprolol as above. will consider spironolactone for
naturesis in the future. echo on [**2189-1-6**] showed ef of 40%,
systolic dysfunction with akinesis of the inferolateral wall and
hypokinesis of the inferior and anterolateral walls, and severe
unchanged mr. initially on lasix drip, but discontinued lasix iv
and started lasix 80mg po bid. was retaining some additional
fluid so increased lasix to 100mg po bid. this was held on the
day of transfer to ct surgery.
.
#. rhythm: nsr, s/p afib on admission to osh with cardioversion
into sinus.
.
#. renal insufficiency: pt with mild elevation of cr to 1.8 from
lasix, [**date range 21177**], hypovolemia, and bowel prep. held lasix and
lisopril the am of transfer to ct surgery.
.
admission to cardiac surgery post-op. [**2189-1-14**]

pt was taken to the or on [**2189-1-14**] for cabg x4 - lima-lad; svg to
d1, om, rca and mv repair.  please see operative note for
details. the patient arrived to the cardiac icu on milrinone,
epi, neo, propofol and insulin drips. she was readily weaned
from milrinone and epi and extubated on pod#1. chest tubes and
wires were removed. the patient was begun on betablocker and
diuresis and transferred to the floor for ongoing management and
rehab.
patient's insulin [**date range 4319**] were adjusted to achieve glucose
control.
rehab screening was recommended by physical therapy.
postoperative course was uneventful and the patient was
discharged to rehab on pod 6.

medications on admission:
insulin nph 36u [**hospital1 **] and humalog 4u [**hospital1 **]
toprol xl 75mg po daily
lisinorpil 10mg po daily
prilosec 20mg po bid
advil 200mg po daily
[**hospital1 **] 325mg po daily
plavix 75mg po daily
hctz 25mg po daily
iron
colace


discharge medications:
1. clopidogrel 75 mg tablet sig: one (1) tablet po daily
(daily).
2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day.
3. insulin nph human recomb 300 unit/3 ml insulin pen sig:
thirty six (36) units subcutaneous twice a day.
4. insulin lispro 100 unit/ml insulin pen sig: four (4) units
subcutaneous twice a day.
5. atrovent hfa 17 mcg/actuation aerosol sig: one (1) puff
inhalation four times a day.
disp:*2 inhaler* refills:*5*
6. xopenex hfa 45 mcg/actuation hfa aerosol inhaler sig: one (1)
puff inhalation four times a day.
disp:*2 inhalers* refills:*5*
7. [**hospital1 **] 10 mg tablet sig: one (1) tablet po once a day.
8. metolazone 5 mg tablet sig: two (2) tablet po daily (daily).

9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
10. simvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
disp:*30 tablet(s)* refills:*2*
11. heparin (porcine) 5,000 unit/ml solution sig: one (1)
injection tid (3 times a day).
12. albuterol 90 mcg/actuation aerosol sig: two (2) puff
inhalation q6h (every 6 hours) as needed.
13. ipratropium bromide 17 mcg/actuation aerosol sig: two (2)
puff inhalation qid (4 times a day).
14. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po daily (daily).
15. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po
q4h (every 4 hours) as needed for pain.
16. amiodarone 200 mg tablet sig: two (2) tablet po once a day:
2 daily for 7 days then one daily for one month.
disp:*45 tablet(s)* refills:*0*
17. metoprolol succinate 25 mg tablet sustained release 24 hr
sig: three (3) tablet sustained release 24 hr po daily (daily).

18. potassium chloride 20 meq tab sust.rel. particle/crystal
sig: one (1) tab sust.rel. particle/crystal po twice a day.
disp:*60 tab sust.rel. particle/crystal(s)* refills:*2*


discharge disposition:
extended care

facility:
[**hospital1 700**] - [**location (un) 701**]

discharge diagnosis:
coronary artery disease with unstable angina
chronic systolic heart failure
mitral regurgitatiuon
obesity
insulin dependent diabetes mellitus
s/p coronary angioplasty
pulmonary hypertension
hypertension
peripheral vascular disease-s/p stenting lower extremities
s/p cholecystectomy
s/p appendectomy
s/p psoas abcess
gastritis


discharge condition:
good


discharge instructions:
shower daily, no baths or swimming
no driving for 4 weeks and off all narcotics
no lotions, creams or powders to incisions
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain gretaer than 2 pounds a day or 5 pounds a
week
take all medications as directed


followup instructions:
dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] in 2 weeks
dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3314**] in [**12-19**] weeks ([**telephone/fax (1) 3183**])
dr. [**first name (stitle) **] in 4 weeks
wound clinic in 2 weeks
please call for appointments


                             [**name6 (md) **] [**name8 (md) **] md [**md number(2) 173**]

completed by:[**2189-1-20**]"
282,"admission date:  [**2150-4-16**]              discharge date:   [**2150-4-21**]


service: medicine

allergies:
nsaids / bactrim

attending:[**first name3 (lf) 358**]
chief complaint:
angioedema

major surgical or invasive procedure:
intubation

history of present illness:
pt is an 85 y/o f with a h/o gave s/p argon treatment last on
[**2150-3-11**], iron deficiency anemia, cirrhosis [**1-19**] hepc, portal
htn/grade 1 varices but no hx of bleeding varices, cri (baseline
cr = 1.2-1.5) who is transfered from [**hospital3 **] intubated
s/p angioedema. by report the pt has some mild abdominal pain
and some irritation in her throat a day prior to admission to
[**hospital3 **]. the following morning she called her son with
complaints of oral swelling; son states that her speach was
garbled. the son reports that the patient denies having had any
sob, no wheezing, no hives. he called an abmulance who
transported the pt to [**hospital3 **].
.
per omr, the patient present to [**hospital1 18**] pheresis unit on [**2150-4-10**]
for blood transfusion for chronic slow upper gi bleeding. she
had no pretreatment medications given and no adverse events;
vitals on leaving the unit were 97.4 - 67 - 119/55. she has also
been recently treated for a uti with bactrim started on [**2150-4-3**].

.
at st elizabeths', she was hd stable but had a large, edematous
tongue. she recevied decadron, epinephrine, benadryl, famotidine
and hydroxazine in the ed. the ed was unable to intubate and she
was taken to the or. laryngeal edema was noted, but the et tube
was passed successfully. she was then transfered to the ccu. she
received hydroxazine tid and her tongue swelling improved. sbt
was attempted early on but failed likely secondary to sedation.
per report, pt did have a cuff leak. family requested transfer
to [**hospital1 18**] as pt receives all her care here.
.
on arrival in the micu she passed an sbt and was successfully
extubated. she did well throughout the day but continued to have
an o2 requirement. by the time of transfer to the floor she was
on 2l of nc o2 satting 94%. on the floor she is alert and
oriented. she does not know what caused her swelling. she denies
new pills, new medications, or new foods. she feels well and has
no sob, itching, or complaints.
.


past medical history:
# gave - s/p argon treatment, last on last on [**2150-3-11**]
# hepatitis c
# cirrhosis
- child's class a, portal htn, grade 1 varices
- no h/o ascites, encephalopathy, variceal bleeding, synthetic
function intact
# dm type ii
# htn
# iron deficiency anemia
# s/p r radial nephrectomy for renal cell ca [**55**] yrs ago
# hypercholesterolemia
# osteopenia
# insomnia
# angioedema [**3-26**] possibly due to bactrim but as yet not proven

social history:
lives alone in [**location (un) 583**] in [**hospital3 4634**] complex. is widowed.
has 2 sons who live nearby.  no tob in >45 yrs, occ etoh (at
holidays). worked in food business in sales.


family history:
no family history of allergic diseases

physical exam:
gen: pleasant elderly lady in nad, speaking comfortably, no
cyanosis, jaundice, or dyspnea
vs: 99.4 124/58 82 18 94% on 2l nc
heent: mmm, no op lesions, tongue nl size, neck supple, no lad
or thyromegaly
cv: rr, nl s1 s2 no s3 s4 mrg
pulm: roncherous breath sounds with scattered wheezes and
crackles 1/4 up the lung fields
abd: bs+, nt, ventral hernia, gas on percussion, no masses or
hsm, no fluid wave, + collaterals and angiomata
limsb: no le edema, + clubbing
neuro: perrla, eomi, moving all limbs, reflexes 2+ of the biceps
and petellar tendons.


pertinent results:
admission labs:
[**2150-4-17**] 05:15am blood wbc-7.4 rbc-3.41* hgb-10.2* hct-31.4*
mcv-92 mch-29.9 mchc-32.5 rdw-16.7* plt ct-139*
[**2150-4-17**] 05:15am blood glucose-132* urean-27* creat-1.1 na-143
k-4.3 cl-112* hco3-24 angap-11
[**2150-4-18**] 08:30am blood alt-112* ast-59* ld(ldh)-203 alkphos-99
totbili-1.7*
[**2150-4-17**] 05:15am blood calcium-8.6 phos-2.8 mg-2.4
.
discharge labs:
[**2150-4-21**] 05:50am blood wbc-5.0 rbc-3.13* hgb-9.6* hct-28.4*
mcv-91 mch-30.7 mchc-33.8 rdw-16.9* plt ct-200
[**2150-4-21**] 05:50am blood glucose-91 urean-34* creat-1.4* na-137
k-3.9 cl-103 hco3-24 angap-14
[**2150-4-20**] 05:40am blood alt-55* ast-34 ld(ldh)-182 alkphos-83
totbili-1.3
[**2150-4-20**] 05:40am blood albumin-2.6* calcium-8.3* phos-3.5 mg-2.0

brief hospital course:
85f with a h/o gave s/p argon laser treatment last on [**2150-3-11**],
iron deficiency anemia due to chronic ugib, cirrhosis [**1-19**] hcv,
portal htn with grade 1 varices but no history variceal
bleeding, cri (baseline cr = 1.2-1.5) who is s/p prolonged
intubatation for angioedema of unknown etiology - possibly due
to bactrim. she is doing very well on s/p extubation at this
point. all antihistamines have been discontinued at this point.
she was progressively be restarted on her home meds.
.
# angioedema: resoved. lack of hives, bronchospasm or
hypotension suggests that this was not allergic angioedema but
rather bradykinin related. c3 and c4 were low. c1 esterase
inhibitor pending, [**doctor first name **] neg. per allergy consult at [**hospital 7302**] prior to transfer, non-allergic angioedema
is due to complement depletion (either hereditary or ca related)
or complement activation (infection or transfusion). the patient
did have a transfusion recently which may be related.
medications would also be high on the list of etiologies. common
offenders are nsaids and aceis, but arbs have also been
implicated.  it was discovered that the pt was taking bactrim
when the reaction leading to her admission. this is a possible
offender and has been added to her allergy list. restarted home
meds one by one. all but felodipine have been restarted. had
hives and itching the day prior to discharge which did not
generalize and seemed more of a contact dermatitis on the l arm.
no new medications were started so it is unclear what initiated
this. responded to hydroxyzine x1. also of note, the patient
refused to shower or be washed down this admission which may
contribute to her itchiness.
.
# chronic ugib: received regular blood transfusions as an
outpatient for any hct < 30. in the past she only needed them
infrequently but her transfusion requirements have increased
lately. transfused prior to discharge. [**month (only) 116**] need outpatient
follow up with gi (dr [**first name8 (namepattern2) 1158**] [**last name (namepattern1) 679**] has been recommended by her
outpatient gastroenterologist [**first name4 (namepattern1) 2127**] [**last name (namepattern1) 10113**]).
.
# wheezes and ronchi: related to angioedema and volume overload
most likely. resolved with diuresis and nebulizers.
.
# hx hcv complicated by cirrhosis. no evidence of encephalopathy
now, but is at risk. continued lactulose. continued
spironolactone [aldactone] - 50 mg daily. continue furosemide
[lasix] - 40 mg daily. continue nadolol - 80 mg daily as ppx
against variceal bleeding.
.
# htn: holding home ccb as normotensive. on nadolol as above.
.
# cri: baseline 1.5, was elevated on admission to [**hospital3 5097**] to
1.7. at baseline on discharge.
.
# diabetes: iss in house. discharged on metformin.

medications on admission:
home medications:
felodipine - 10 mg qam and 5 mg qpm
folic acid - 1 mg daily
furosemide [lasix] - 40 mg daily
hydrocortisone acetate [anusol-hc] - 25 mg daily
lactulose 10 gram/15 ml daily
metformin - 1000 mg qam and 500 mg qpm
mupirocin - 2 % ointment [**hospital1 **]
nadolol - 80 mg daily
pantoprazole - 40 mg [**hospital1 **]
spironolactone [aldactone] - 50 mg daily
sucralfate - 1 g tid
zolpidem - 5 mg tablet - [**12-21**] qhs prn
calcium carbonate-vitamin d2 - 500 mg-375 unit [**hospital1 **]
cyanocobalamin - 500 mcg daily
ferrous gluconate - 325 mg 5 times a day
sarna ultra [**hospital1 **]


discharge medications:
1. calcium 500 with d 500 mg(1,250mg) -400 unit tablet sig: one
(1) tablet po twice a day.
disp:*60 tablet(s)* refills:*11*
2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*11*
3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
4. anusol-hc 25 mg suppository sig: one (1) suppository rectal
once a day.
disp:*30 suppositories* refills:*6*
5. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po once a
day.
disp:*450 ml(s)* refills:*11*
6. metformin 500 mg tablet sig: two (2) tablet po qam.
disp:*60 tablet(s)* refills:*5*
7. metformin 500 mg tablet sig: one (1) tablet po qpm.
disp:*30 tablet(s)* refills:*5*
8. nadolol 80 mg tablet sig: one (1) tablet po daily (daily).
disp:*30 tablet(s)* refills:*5*
9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q12h (every 12 hours).
disp:*60 tablet, delayed release (e.c.)(s)* refills:*5*
10. spironolactone 50 mg tablet sig: one (1) tablet po once a
day.
disp:*30 tablet(s)* refills:*5*
11. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime)
as needed for insomnia.
disp:*30 tablet(s)* refills:*0*
12. b-12 dots 500 mcg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*11*
13. ferrous gluconate 325 mg tablet sig: one (1) tablet po five
times a day.
disp:*150 tablet(s)* refills:*11*


discharge disposition:
home

discharge diagnosis:
angioedema

discharge condition:
stable vital signs, at baseline

discharge instructions:
you were admitted at [**first name8 (namepattern2) 1495**] [**hospital **] hospital with angioedema,
or swelling in your mouth and throat. you had a breathing tube
placed for this. you were then transfered to [**hospital1 771**] where you had the breathing tube taken
out. you improved clinically and were discharged to home.
.
please continue to take your medications as ordered. because you
had a likely medication reaction that led to your angioedema you
should throw out your old medications. do not take any
supplements. here is your updated medication list list:
1. stop taking felodipine for now
2. calcium + vitamin d twice daily
3. vitamin b12 daily
4. folic acid daily
5. furosimide 40mg daily
6. anusol daily as needed for hemorrhoids
7. metformin 1000mg (2 pills) in the morining and 500mg (1 pill)
in the evening
8. lactulose 15ml daily to 3 bowel movements per day
9. nadolol 80mg daily
10. pantoprazole (protonix) 40mg twice daily
11. spironolactone 50mg daily
12. zolpidem (ambien) 5mg at night as needed for insomnia
13. iron 5 times daily
.
please attend your follow up appointments.
.
please call your doctor or come to the emergency room if you
experience swelling of you face or tongue, chest pain,
palpitations, shortness of breath, wheezing, bleeding, or other
concerning symptoms.

followup instructions:
md: [**name6 (md) 10160**] [**name8 (md) 10161**], np
specialty: priamry care
date and time: [**last name (lf) 766**], [**5-4**] at 4pm
location: [**hospital3 **]
phone number: [**telephone/fax (1) 250**]
special instructions if applicable: booked with russain
interpreter


completed by:[**2150-4-22**]"
283,"unit no:  [**numeric identifier 97681**]
admission date: [**2162-2-15**]
discharge date: [**2162-2-24**]
sex:
service:


history of present illness:  this is an 81-year-old female
with a history of recent cabg with avr, chf, protein s
deficiency who presented from [**hospital3 **] in the
morning on [**2162-2-14**] with fever and respiratory distress.  she
was felt at [**hospital1 **] to be in chf versus pneumonia and was
given levofloxacin, ceftriaxone, and lasix.  they were unable
to contact her proxy and thus sent her to ems, as her oxygen
saturation decreased to 90 percent on nonrebreather.

in the ambulance, she was given morphine and bipap was
attempted, but her saturations decreased and she was
intubated in the field.

past medical history:  recent cad, status post cabg and avr
in [**11-26**] complicated postoperatively by multiple recurrent
episodes of congestive heart failure versus pulmonary disease
of unclear etiology.

protein s deficiency with recurrent dvts and pes.

schizophrenia.

chronic renal insufficiency with creatinine ranging between
1.3 to 1.5.

chf with an ef of 25 percent by echo in [**11-26**].

copd.

dementia.

history of mrsa.

medications on admission:
1. singulair 10 mg by mouth every day.
2. coumadin.
3. colace 100 mg by mouth two times a day.
4. aricept 10 mg at bedtime.
5. aspirin 81 mg a day.
6. [**doctor first name **] 60 mg a day.
7. protonix 40 mg a day.
8. advair 100/50 mcg.
9. prednisone 5 mg every other day.
10.      celexa.
11.      zyprexa 2.5 mg at bedtime.
12.      toprol xl 100 mg two times a day.
13.      neurontin two times a day.
14.      magnesium gluconate 1 g three times a day.
15.      lasix 60 mg two times a day.
16.      ceftriaxone 1 g.
17.      levofloxacin 500 mg.


allergies:  no known drug allergies.

social history:  the patient quit tobacco several years ago,
lived in [**hospital3 **] prior to her hospitalization in
[**month (only) 1096**]; however, after her operation in [**month (only) 1096**] had a
prolonged hospital course with multiple attempts of
extubation and difficulties with this resulting in severely
deconditioned patient and need for [**hospital3 **]
afterwards.  she has been in there since her discharge in
[**month (only) 404**].  her husband lives in a nursing home.

physical examination:  notable for temperature of 102.6,
blood pressure of 100/39, and assist control 16/450 with 5
peep.  lungs with bilateral coarse rales and rhonchi with
mechanical ventilation in all lung fields.  neurological
examination, the patient opens eyes to voice.  cranial nerves
ii through xii intact, withdraws all 4 extremities to
peripheral painful stimuli, and toes are upgoing on the
right.

laboratory data:  notable labs on admission were white count
of 7.8 with left shift, hematocrit of 27.1, inr of 1.6, and
creatinine of 1.2.

abg 7.28, 67, 341 on ac 14/400.

radiographic studies:  chest x-ray with pulmonary
interstitial edema consistent with chf and left pleural
effusion.

hospital course:  the patient was admitted to the intensive
care unit for further care.  problem list at this time
included respiratory distress, congestive heart failure,
pneumonia, anemia, fever.  in addition, in the emergency
room, she had a left internal jugular line placed, which on
chest x-ray was noted to be cannulating the carotid.  this
was removed, ffp was given, and pressure was held for 1 hour
with no adverse events on follow-up cat scan of the neck.
the patient was noted to have a left-sided pneumothorax,
which in comparison to cat scan from her hospitalization in
[**12-27**] seemed to be there at that time also.

respiratory distress.  the patient was intubated in the
field.  she initially was diuresed and a repeat
echocardiogram demonstrated an ef of 25 percent again with an
lv aneurysm.

she also continued to spike a fever and levofloxacin and
flagyl were started.  on [**2162-2-17**], she continued to have
fevers and bronchoscopy was performed.  during her previous
admission, she had much difficulty being extubated and
bronchoscopy at that time had revealed tracheomalacia and the
patient was given a tracheal and left main stem bronchial
stent, which made it then easy for her to be extubated.  on
the repeat bronchoscopy on [**2162-2-17**], the stents were found to
be in place, and the patient was found to have no further
problems with her tracheomalacia.  however, she continued to
have difficulty with weaning off her vent and with continuous
fevers.

a cat scan of the chest on [**2162-2-19**] demonstrated increased
cervical lymphadenopathy, a small stable pneumothorax,
hydropneumothorax, and left lower lobe consolidation.  two
days later, the bal returned with mrsa positivity, which she
has had in the past.  although this is likely a colonizer,
vancomycin was started in addition to levofloxacin and flagyl
on [**1-/2087**].

in addition, lenis were ordered, which were negative for dvt.

on [**2-23**], the patient was able to tolerate pressure support
in the morning and thus was extubated later in the day on to
bipap.  she eventually was able to tolerate being off of the
bipap overnight, but then had recurrent respiratory distress
in the morning of [**2-24**].  at this time, she refused strongly
and clearly bipap and re-intubation.  she was able to state
back her understanding that she was going to die and
understood that we would make her as comfortable as possible.
she was allowed to discuss this with her family who agreed to
honor her wishes.

the patient's daughter [**name (ni) **] [**name (ni) 30864**] was her proxy and also
went in and spoke to her mother and confirmed that her
mother's wishes were to be cmo.

on [**2162-2-24**], the patient was given iv morphine and made as
comfortable as possible and passed soon after.

a postmortem was declined by the family.

in addition to the above hospital course, there were multiple
other problems that contributed very little to her final
outcome such as a minor gi bleed with hematocrit of 27
requiring 2 units of packed red blood cells, worsening
chronic renal insufficiency up to 1.4 to 1.5 that improved
with hydration, and agitation, anxiety that was treated with
her outpatient psychiatric medications.

discharge diagnoses:  multifocal pneumonia.

congestive heart failure.

chronic pneumothorax.

gastrointestinal bleeding.

anemia.

respiratory distress.

discharge medications:  none.


                        [**first name11 (name pattern1) **] [**last name (namepattern1) **], [**md number(1) 18138**]

dictated by:[**last name (namepattern1) 46369**]
medquist36
d:  [**2162-6-7**] 12:26:33
t:  [**2162-6-8**] 01:45:35
job#:  [**job number 97682**]



"
284,"admission date:  [**2121-12-7**]              discharge date:   [**2121-12-12**]

date of birth:  [**2041-5-16**]             sex:   f

service: medicine

allergies:
penicillins / sulfa (sulfonamide antibiotics) / lidocaine

attending:[**first name3 (lf) 2387**]
chief complaint:
acute mental status change

major surgical or invasive procedure:
chest tube placement
right internal jugular central venous line placement


history of present illness:
80 year-old lady with history of dementia presents as
transfer to medicine service. the patient was admitted to the
cv-icu on the night of [**2121-12-7**] because she had a central line
placed in her left subclavian artery at an outside hospital.
this was complicated by a left-sided hemopneumothorax for which
a
chest tube was placed at the outside hospital. the only other
active medical issues upon transfer was the patient's recurrent
acute on chronic renal failure and a recurrent uti.  the patient
had an inr of 4.3 and hct of 23 upon transfer to [**hospital1 18**].  the
goal
upon admission to the vascular service was to transfuse her and
correct her inr.  the subclavian line would be pulled at the
bedside [**2121-12-8**].


past medical history:
a fib, dementia, htn, hypercholesterolemia, s/p cva with
hemiparesis, anxiety disorder, depression, frequent utis, pna,
rib fractures, s/p r hip fracture, hydronephrosis, congenital
upj
obstruction

[**doctor first name **] hx: s/p r total hip replacement x 2


social history:
lives at [**hospital1 11851**] nh; no etoh, dnr/dni


family history:
noncontributory

physical exam:
transfer exam

vs: t 94.7 (ax), hr 73, bp 108/53, rr 20, 94% 3l
gen: anxious, communicates with groans
neck: supple, no bruits
lungs: rhonchi b/l, wheezes b/l, no air leak on chest tube
cv: irregularly irregular, nl s1 and s2
abd: soft, nt, nd
ext: l arm without any sign of ischemia, no c/c/e of le, right
foot slightly cooler than left, 2+ radial and 1+ ulnar on left
vasc:
     fem     [**doctor last name **]     pt     dp
r    2+      2+      d      d
l    2+      2+      d      2+

discharge exam
vs 97/97.2 155/70 70 20 98%ra
gen: nad
heent: mmm, op clear, neck supple
cv: irregular s1+s2, no m/r/g
lungs: ctab anteriorly
abd: s/nt/nd +bs
ext: no c/c/e
neuro: oriented x1 (person). continues to have echolalia
although improved from yesterday.

pertinent results:
[**2121-12-12**] 07:35am blood wbc-10.1 rbc-3.55* hgb-10.5* hct-30.3*
mcv-85 mch-29.5 mchc-34.6 rdw-15.1 plt ct-277
[**2121-12-11**] 07:00am blood wbc-10.2 rbc-3.43* hgb-10.1* hct-28.5*
mcv-83 mch-29.4 mchc-35.4* rdw-15.1 plt ct-306
[**2121-12-10**] 07:07am blood wbc-12.1* rbc-3.84*# hgb-11.4*#
hct-32.2*# mcv-84 mch-29.6 mchc-35.3* rdw-15.4 plt ct-360
[**2121-12-9**] 02:08am blood wbc-8.9 rbc-2.92* hgb-8.6* hct-24.5*
mcv-84 mch-29.3 mchc-34.9 rdw-15.1 plt ct-274
[**2121-12-8**] 04:18pm blood hct-24.8*
[**2121-12-8**] 04:58am blood wbc-9.8 rbc-3.26* hgb-9.7* hct-27.6*
mcv-85 mch-29.9 mchc-35.3* rdw-14.9 plt ct-261
[**2121-12-7**] 08:46pm blood wbc-8.8 rbc-3.09* hgb-8.9* hct-26.3*
mcv-85 mch-28.8 mchc-33.8 rdw-15.1 plt ct-286
[**2121-12-7**] 08:46pm blood neuts-84.6* lymphs-14.6* monos-0.6* eos-0
baso-0.1
[**2121-12-7**] 08:46pm blood hypochr-normal anisocy-normal poiklo-1+
macrocy-normal microcy-normal polychr-1+ ovalocy-1+
schisto-occasional tear dr[**last name (stitle) **]1+
[**2121-12-12**] 07:35am blood plt ct-277
[**2121-12-12**] 07:35am blood pt-13.2 ptt-24.6 inr(pt)-1.1
[**2121-12-12**] 07:35am blood glucose-87 urean-44* creat-1.1 na-148*
k-3.3 cl-113* hco3-27 angap-11
[**2121-12-12**] 07:35am blood calcium-8.1* phos-2.4* mg-1.5*
[**2121-12-10**] 07:07am blood vitb12-1495*
[**2121-12-10**] 07:07am blood tsh-1.2
[**2121-12-7**] 09:20pm blood type-[**last name (un) **] po2-42* pco2-53* ph-7.24*
caltco2-24 base xs--5

cth
1. no evidence of acute intracranial hemorrhage. hypoattenuation
involving
the left basal ganglia extending into the corona radiata may
represent sequela
of previously stated remote cva, however, interposed acute
component cannot be
entirely excluded. mri may be obtained for further evaluation to
exclude
underlying acute component as discussed with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]
at the time of
dictation.

2. minimal sinus disease as described above.

3. right subinsular cortical infarct, old.

note added at attending review: the changes noted above
involving the left
thalamus, caudate body, internal capsule and periventricular
white matter
appear to reflect old infarction, perhaps with old hemorrhage.
there is no
evidence of recent infarction. however, in the setting of
chronic infarction further ischemic injury in the same
distribution can be difficult to detect with non contrast ct.

cxr ([**2121-12-10**])
probable persistent tiny left apical pneumothorax although
difficult to discern from overlying rib shadows.


brief hospital course:
80 year old female with af, dementia, hlp, cva with residual
hemiparesis, anxiety/depression, and congenital upj obstruction
transferred from osh for left subclavian arterial line placement
and presumed uti.

1. uti:patient has history of frequent utis with multiple
admissions in the past year to osh.  she also currently has a
chronic indwelling fc, increasing her risk of uti.  she has been
treated with iv ciprofloxacin since being admitted to the osh.
repeated urine cultures during admission were contaminated.
patient was initially treated with ciprofloxacin, but given past
history of e.coli resistant to quinolones. urinalysis at outside
hospital performed without urine culture.  patient was converted
to ceftriaxone, which she tolerated well even with reported
history of pcn allergy.  on discharge, she was coverted to
cefpodoxime and instructed to complete a total of 7 days on
ceftriaxone/cefpodoxime.

2. anemia: patient was transfused a total of 2u prbc during
admission at [**hospital1 18**]. although unclear, it appears as if she was
also transfused 2u prbc at osh. on discharge, her hct was
stable.

3. left subclavian arterial line placement: upon transfer,
subclavian arterial line was removed and a chest tube was placed
on the left for her hemopneumothorax.  on hospital day 3 her
chest tube was removed without adverse events.  of note, a
follow-up cxr after chest tube removal demonstrated a small
residual pneumonthorax.

4. acute mental status change: most likely multifactorial due to
uti, hospitalization, and medications including morphine and
ativan that the patient received while in the icu.  the patient
at [**hospital1 11851**] has also been receiving remeron, ativan, and
trazadone, which were discontinued. the patient appeared to have
mild improvement in her delirium during her admission. of note,
a non-contrast ct head was performed during her admission that
did not demonstrate an acute intracranial process.

5. acute on chronic renal failure: likely secondary to
intravascular volume depletion.  patient received ivf during her
admisison and on discharge, her creatinine was at baseline at
1.1.

6. afib: patient was initially admitted on atenolol 100 mg po
bid. given her acute on chronic renal failure, she was
transitioned to metoprolol 50 mg po bid.  after her hematocrit
was stabilized, she was restarted on coumadin.  she will need to
have her inr monitored with a goal of [**2-9**].

7. hypertension: beta blocker changed to metoprolol as above.
amlodipine 5 mg daily was added for additional blood pressure
control.

8. steroids: the patient was admitted to [**hospital1 18**] one prednisone,
which was continued during her admission. on discharge, she was
instructed to continue with 10 mg daily prednisone.  although
unclear as to the reason for her steroid use, it appears as if
she was on a scheduled taper at [**hospital1 11851**] of prednisone.  she
was instructed on discharge to follow-up with her physician at
[**name9 (pre) 11851**] or her pcp with regard to prednisone taper.

medications on admission:
coumadin 2 qd, lasix 40 qd, mvi 1 qd, kdur 20
meq qd, atenolol 100 [**hospital1 **], remeron 30 qhs, prednisone 10 qd,
cipro
500 [**hospital1 **] (started [**12-5**]), forastor probiotic 250 [**hospital1 **], tylenol 650
q 4 prn, dulcolax prn, mom prn, trazodone 25 qhs prn, ativan 0.5
mg q4 prn, duonebs prn


discharge medications:
1. vantin 200 mg tablet sig: one (1) tablet po twice a day for 5
days.
disp:*10 tablet(s)* refills:*0*
2. metoprolol tartrate 100 mg tablet sig: one (1) tablet po once
a day.
3. norvasc 5 mg tablet sig: one (1) tablet po once a day.
4. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4
pm.
5. lasix 40 mg tablet sig: one (1) tablet po once a day.
6. multiple vitamin     tablet sig: one (1) tablet po once a
day.
7. prednisone 10 mg tablet sig: one (1) tablet po once a day.
8. duoneb 0.5-2.5 mg/3 ml solution for nebulization sig: one (1)
 inhalation every six (6) hours as needed for shortness of
breath or wheezing.
9. dulcolax 5 mg tablet, delayed release (e.c.) sig: one (1)
tablet, delayed release (e.c.) po once a day as needed for
constipation.
10. acetaminophen 325 mg tablet sig: one (1) tablet po q6h
(every 6 hours) as needed for pain.


discharge disposition:
extended care

facility:
[**hospital 11851**] healthcare - [**location (un) 620**]

discharge diagnosis:
primary
- uti
- anemia

secondary
a fib, dementia, htn, hypercholesterolemia, s/p cva with
hemiparesis, anxiety disorder, depression, frequent utis, pna,
rib fractures, s/p r hip fracture, hydronephrosis, congenital
upj
obstruction


discharge condition:
patient was discharged in stable condition.


discharge instructions:
1. you were admitted for a urinary tract infection, which was
treated with antibiotics. you will need to continue these
antibiotics as an outpatient. the instructions for this
medication are:
cefpodoxime 200 mg by mouth twice daily for 5 days (stop on
[**2121-12-17**])

2. you were also admitted for a subclavian arterial line
placement. you received a blood transfusion while admitted. on
discharge your hematocrit was stable.

3. unless otherwise indicated, please resume all of your
medications as take prior to admission. it is very important
that you take your medications as prescribed.  you were admitted
on prednisone, which was continued during your admission. you
will need to follow-up with your pcp or [**name9 (pre) 11851**] physician with
regard to prednisone taper.

4. you will need to have you inr checked on monday, [**12-15**] with a
goal inr of [**2-9**]. you will need to have regular inr checks with
your coumadin adjusted as necessary by your doctor [**first name (titles) **] [**last name (titles) 11851**].

5. it is very important that you make all of your doctor's
appointments.

6. if you develop chest pain, shortness of breath, or other
concerning symptoms, please call your pcp or go to your local
emergency department immediately.

followup instructions:
please follow-up with your pcp [**last name (namepattern4) **] 2 weeks. you can schedule an
appointment by calling [**telephone/fax (1) 6019**].



completed by:[**2121-12-13**]"
285,"admission date:  [**2147-4-8**]              discharge date:   [**2147-4-16**]

date of birth:  [**2069-5-24**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**last name (namepattern1) 1838**]
chief complaint:
episodes of speech difficulty (dysarthria and non-fluency) and
left arm numbness

major surgical or invasive procedure:
-[**2147-4-11**] cerebral angiogram
-[**2147-4-14**] neurointervnetional embolization of right parietal avm


history of present illness:
the pt is a 77yo rh male with pmhx of htn, hl and niddm who
presents because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech. the patient was at his
baseline until wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of l hand numbness over seconds.  he felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather ""it was dead"".  he rubbed his
hand and the sensation didn't go away.  within 30 seconds he
noticed that his l face was drooping also and he also had a
numbness sensation around his mouth on the left side ""that felt
like novocaine"".  he felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  his wife drove him to [**hospital3 **] where
he was admitted and had an ekg notable for afib with rbbb, an
unremarkable nchct but a cta that showed a likely pial av
fistula in the r parietal [**hospital3 3630**] measuring ~ 4.5cm.  he was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

however, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
l hand, mostly the 4th and 5gh digits.  he again had almost
immediate l facial drooping with l facial numbness most notable
around his mouth in addition to some mildly slurred speech.  he
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just ""slurred"".  no associated
weakness/tingling/ha/visual sx.  he was then taken back to
[**hospital1 **], where they immediately sent him to [**hospital1 18**] as
they felt he needed to see neurosurgery. while here in the [**name (ni) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. he was initially evaluated by
neurosurgery in the ed who felt that his presentation could be
c/w tias rather than the av
fistula in his r parietal [**last name (lf) 3630**], [**first name3 (lf) **] neurology was called to
evaluate the patient further.

on neuro ros, the pt reports l hand and l face numbness.  denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. denies difficulties producing or comprehending
speech.  denies focal weakness, parasthesiae. no bowel or
bladder incontinence or retention. denies difficulty with gait.

on general review of systems, the pt denies recent fever or
chills.  no night sweats or recent weight loss or gain. denies
cough, shortness of breath.  denies chest pain or tightness,
palpitations.  denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  no recent change in bowel or bladder habits.
 no dysuria.  denies arthralgias or myalgias. denies rash.

past medical history:
- htn (average bp 160's)
- hl
- niddm
- ? silent mi (pt had a cardiac stress test ""many years ago"" for
chronic chest pain and palpitation, that was suggestive of a
prior mi)
- glaucoma
- cataracts s/p surgery bilaterally

social history:
lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies etoh or illicits. is
a part time hairdresser, was last full time 15 years ago.


family history:
mother died of chf at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or avms


physical exam:
**********
physical exam on admission
vitals: t: 97.7 p: 70 r: 18  bp: 166/90  sao2: 98% on ra
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: lungs cta bilaterally without r/r/w
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
bilaterally.
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 not dysarthric. able to
follow both midline and appendicular commands. pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  the pt. had
good
knowledge of current events.  there was no evidence of apraxia
or
neglect.

-cranial nerves:
i: olfaction not tested.
ii: pupils post-surgical bilaterally.  vff to confrontation.
funduscopic exam chronic changes c/w known glaucoma.
iii, iv, vi: eomi without nystagmus.  normal saccades.
v: facial sensation intact to light touch and pp on r side, but
decreased to lt and pp on the l forehead, cheek and chin in a
v1,
v2 and v3 distribution.
vii: no facial droop, facial musculature symmetric.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. no pronator drift
bilaterally.
no adventitious movements, such as tremor, noted. no asterixis
noted.
  delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb
l  5    5   5   5   5  5  5  5   5    5  5     5     5   5
r  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-sensory: decreased pp in the l face, l arm and l leg, but not l
torso.  decreased cold sensation to the knees bilaterally.
otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. no extinction to
dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   0
r  2  2    2    1   0
plantar response was flexor on the r and extensor on the l.

-coordination: no intention tremor, no dysdiadochokinesia noted.
no dysmetria on fnf or hks bilaterally.

-gait: good initiation. narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  unable
to
walk in tandem without significant difficulty. romberg positive
for sway.
.
*****
on discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

pertinent results:
labs on admission:
[**2147-4-8**] 09:00am blood wbc-8.3 rbc-5.13 hgb-15.7 hct-47.9 mcv-93
mch-30.5 mchc-32.7 rdw-13.6 plt ct-257
[**2147-4-8**] 09:00am blood pt-10.7 ptt-28.7 inr(pt)-1.0
[**2147-4-8**] 09:00am blood glucose-167* urean-10 creat-0.9 na-146*
k-3.9 cl-105 hco3-31 angap-14
[**2147-4-8**] 09:00am blood alt-21 ast-23 ld(ldh)-211 ck(cpk)-83
alkphos-84 totbili-0.6
[**2147-4-8**] 09:00am blood albumin-4.5 calcium-9.7 phos-4.0 mg-2.0
cholest-152
.
stroke risk factor assessment:
[**2147-4-8**] 09:00am blood triglyc-129 hdl-52 chol/hd-2.9 ldlcalc-74
[**2147-4-8**] 09:00am blood %hba1c-7.2* eag-160*
[**2147-4-8**] 09:00am blood tsh-2.3
.
cardiac enzymes:
[**2147-4-8**] 09:00am blood ck-mb-1 ctropnt-<0.01
.
[**2147-4-8**] eeg:
findings:
routine sampling: the background activity showed a symmetric 10
hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were 91 automated spike
detections
predominantly for electrode and movement artifact. there were no

epileptiform discharges.
seizure detection programs: there was one automated seizure
detection
for electrode artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activations. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] mri head:
findings:
there is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
there are several flair hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. there is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. this may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as nph. the bifrontal diameter
at the level of the foramen of [**last name (un) 2044**], measures 3.5 cm. bowing of
the corpus callosum upward is noted.
.
the cerebral aqueduct is better seen on the prior ct angiogram
sagittal
reformations with ? minimal narrowing inferiorly. foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. the right is diminutive in size. the
major intracranial arteries and the known av fistula/avm, in the
right parietal [**last name (un) 3630**] are better assessed on the prior ct
angiogram study.
.
the ocular lenses are not seen. there is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
impression:
1. no focus of slow diffusion to suggest an acute infarct.
2. mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. correlate clinically.
3. please see the prior ct angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**last name (un) 3630**] avm/av
fistula.
.
[**2147-4-9**] eeg:
routine sampling: the background activity showed a symmetric
9.5-10 hz
alpha rhythm which attenuated with eye opening.
spike detection programs: there were no automated spike
detections.
seizure detection programs: there was one automated seizure
detection
for movement artifact. there were no electrographic seizures.
pushbutton activations: there were no pushbutton activations.
sleep: the patient progressed from wakefulness to stage ii, then
slow
wave sleep at appropriate times with no additional findings.
cardiac monitor: showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
impression: this is a normal video eeg monitoring session with
no
pushbutton activation. background activity was normal. there
were no
epileptiform discharges or electrographic seizures. a note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] tte:
the left atrium is mildly dilated. no left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. the estimated
right atrial pressure is 5-10 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 aortic root is mildly dilated at the
sinus level. the descending thoracic aorta is mildly dilated.
the aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. the mitral valve leaflets are structurally
normal. there is no mitral valve prolapse. mild to moderate
([**12-19**]+) mitral regurgitation is seen. there is mild pulmonary
artery systolic hypertension. there is no pericardial effusion.
.
impression: normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
mild-moderate mitral regurgitation. mild pulmonary artery
hypertension. dilated aorta..
.
[**2147-4-11**] cerebral angiogram:
procedure performed: left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
anesthesia was moderate. sedation was provided by administering
divided doses of fentanyl and versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
indication: the patient had presented with a dural av fistula
and i had
performed this procedure in order to diagnose and possibly treat
this.
.
details of procedure: the patient was brought to the angiography
suite. iv sedation was given. following this, both groins were
prepped and draped in a sterile fashion. access was gained to
the right common femoral artery using a seldinger technique and
a 5 french vascular sheath was placed in the right common
femoral artery. we now catheterized the above-mentioned vessels
and ap, lateral filming was done. this revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
findings: left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. both anterior and middle cerebral arteries
are seen
well. there is no evidence of supply to the fistula.
.
left external carotid artery arteriogram shows supply to the
dural av fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
the right internal carotid artery arteriogram shows no evidence
of supply to the av fistula.
.
left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent pca on the left side. the pca
on the right is hypoplastic.
.
right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the pcas with no evidence of supply to the av
fistula.
.
[**first name8 (namepattern2) **] [**known lastname **] underwent cerebral angiography which revealed a
dural av
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. the
d raining vein is predominantly cortical draining into the
sensory motor area.
.
labs at time of discharge:


brief hospital course:
mr. [**known lastname **] 77 y.o. rh male with pmhx of htn, hl and niddm who
presented because of 2 episodes of l arm numbness with l facial
droop and 1 episode of slurred speech.

#right parietal arterio-venous malformation: patient initially
had a neurological exam which revealed fluctating l sided
numbness and mild dysarthria concerning for an ongoing process
in the r hemisphere.  seizure (secondary to an avm previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. these
episodes only lasted about 5 minutes in duration. the patient
was monitored with a continuous eeg for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). he initially
was started on keppra 1000mg [**hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**hospital1 **]. he tolerated this
well and did not have any other episodes while in the hospital.
.
other imaging obtained included an mri (see full report above)
which did not show any signs of acute infart. the patient had
his stroke risk factors evaluated and was noted that his hba1c
7.2% , ldl 74.  we continued him on his home dose statin, and
have recommended uptitration of his metformin with pcp on
[**name9 (pre) 85433**] basis for better control of blood sugars. the patient
had a tte performed without evidence of pfo/asd and normal ef
(see full report above).
.
of note the patient on a previous cta from osh had a r parietal
avm.  the neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal av fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. the
patient was taken by neurosurgery for an avm embolization on
[**2147-4-14**], and he tolerated the procedure well. the patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his avm and
significant associated venous congestion (rather than seizure).
we therefore decided to stop his keppra. the patient will have a
f/u mri/mra in 4 weeks and will have a follow-up appointment
with dr. [**first name (stitle) **] of nsurg and dr. [**first name (stitle) **] of neurology.
.
#atrial fibrillation: patient has new onset atrial fibrillation
(never had previous episodes documented before). his chads2
score is 3, so patient was deemed a good candidate for
anticoagulation. unfortunately as he has a known right parietal
avm that it is at increased risk of bleed, so his
anticoagulation was deferred initially. he was continued on a
baby aspirin prior to his neurosurgical intervention. the
patient was monitored on continuous telemetry without any
significant adverse events. patient also had his cardiac enzymes
evaluated which were negative. the patient went for embolization
of his dural avm on [**2147-4-14**]. afterwards he was started on asa
325 and coumadin (his last inr was 1.1 on day of discharge). he
will take the asa 325 until he is therapeutic on his coumadin
(goal inr [**1-20**]) for at least 24 hours. the antiocoagulation is to
be monitored by his pcp.
.
#hypertension: patient had his home bp meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. he was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#hyperlipidemia: patient had ldl of 74, he was continued on his
home dose of statin.
.
#diabetes mellitus type ii: hba1c 7.2%, patient on metformin
500bid at home. this was held during the hospital stay, and he
was placed on a riss with good control he will likely need
uptitration of his metformin on an outpatient basis.
.
transitional issues:
1) follow-up with pcp (scheudled day after discharge) re:
coumaadin and diabetes management
2) patient started on coumadin prior to discharge, inr was
subtherapeutic. will take asa 325 until he is thereapeutic (inr
[**1-20**]) on his coumadin.
3) follow-up with dr. [**first name (stitle) **] of neurology
4) follow-up with dr. [**first name (stitle) **] of neurosurgery in about 4 weeks
after having mri/mra perforemd at 4 weeks

medications on admission:
- amlodipine 10mg qd
- asa 81mg qd
- atenolol 25mg qd
- lovastatin 20mg qhs
- metformin 500mg [**hospital1 **]
- niacin 500mg [**hospital1 **]
- fish oil 1,000mg qd
- travatan eye drops 1gtt qhs both eyes

discharge medications:
1. amlodipine 10 mg tablet sig: one (1) tablet po once a day.
2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily).
[**hospital1 **]:*30 tablet(s)* refills:*0*
3. atenolol 25 mg tablet sig: one (1) tablet po daily (daily).
4. lovastatin 20 mg tablet sig: one (1) tablet po at bedtime.
5. metformin 500 mg tablet sig: one (1) tablet po twice a day.
6. travoprost 0.004 % drops sig: one (1) drop ophthalmic qhs
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg tablet sig: one (1) tablet po twice a day.
8. fish oil 1,000 mg capsule sig: one (1) capsule po once a day.

9. warfarin 1 mg tablet sig: five (5) tablet po once a day: to
be taken at 4pm daily. do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**name initial (nameis) **]:*70 tablet(s)* refills:*0*


discharge disposition:
home

discharge diagnosis:
primary diagnosis: dural arterio-venous malformation (right
parietal area), atrial fibrillation
secondary diagnosis: diabetes mellitus type ii, hypertension,
hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.
.
neuro exam at time of discharge:
mental status: alert, oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
cranial nerves; vfftc, face symmetric, no dysarthria
strength: full throughout
sensation:
- pinprick sensation 100% on rue and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face v2-v3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. we performed some imaging of your head and did not
see any signs of a stroke. in addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the eeg monitoring). importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an avm
(arterio-venous malformation). this is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  we think the secondary effects of this
""back pressure"" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. you subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. your irregular heart beat is known as
atrial fibrillation. due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as coumadin
(warfarin). this medication causes your blood to be thin which
can be measured by a simple blood test known as an inr. the inr
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal inr will be between [**1-20**]). before you reach that
range, it will be important for you to take aspirin 325mg one
tablet daily.  the aspirin can be discontinued after the inr has
been in the 2-3 range for at least 24 hours.
.
the blood thinning medication known as coumadin interacts with
several other mediations and can be affected by your diet. for
example, green vegetables such as spinach with a lot of vitamin
k can make the coumadin less effective. also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your inr. therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. in addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
we will work to contact your primary care provider [**name initial (pre) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your inr checked.
.
we assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. your hemoglobin a1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
also, neurosurgery would like for you to have a repeat scan of
your head and its vessels(mri/a). we have put in an order for
this, but you will need to call to setup your appointment
tomorrow. the number is: [**telephone/fax (1) 590**].  both the neurosurgeon,
dr. [**first name (stitle) **], and the neurologist, dr. [**first name (stitle) **], would like to meet
with you over the next few months.  we have been able to
schedule some follow-up appointments for you, please see below.
.
we made the following changes to your medications:
-change aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal inr [**1-20**])
-start coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as inr and your goal inr is [**1-20**])


followup instructions:
please call [**telephone/fax (1) 590**] tomorrow to schedule the mri/a of the
head with and without contrast for a time in four weeks from
now.
.
also, please call to setup an appointment with dr. [**first name8 (namepattern2) **] [**name (stitle) **]
(neurosurgery). you can schedule the appointment for a date that
is after your mri scan. the number for his office is: ([**telephone/fax (1) 85434**]
.
--please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
department: [**hospital1 18**] [**location (un) 2352**]
when: monday [**2147-4-17**] at 8:10 am
with: [**first name4 (namepattern1) 1575**] [**last name (namepattern1) 1576**], md [**telephone/fax (1) 1144**]
building: [**location (un) 2355**] ([**location (un) **], ma) [**location (un) 551**]
campus: off campus     best parking: free parking on site
.
please meet with dr. [**first name (stitle) **]:
department: neurology
when: tuesday [**2147-5-30**] at 10:30 am
with: [**first name8 (namepattern2) **] [**name8 (md) 162**], md [**telephone/fax (1) 2574**]
building: [**hospital6 29**] [**location (un) 858**]
campus: east     best parking: [**hospital ward name 23**] garage



"
286,"admission date:  [**2170-12-31**]              discharge date:   [**2171-1-2**]


service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 106**]
chief complaint:
fatigue, stemi

major surgical or invasive procedure:
cardiac catheterization with a bare metal stent to left anterior
descending coronary artery

history of present illness:
[**age over 90 **]f with unknown pmhx presented to [**hospital3 4107**] this
afternoon after being found in her home, unable to get up from
toilet, complaining of fatigue. at [**hospital1 **] she was noted to have
st elevations on ecg in inferior and lateral leads. she was
given a full dose aspirin, high dose statin, plavix load and a
heparin bolus. she was transferred directly to the [**hospital1 18**] cath
lab and underwent left heart catheterization. she was found to
have a tight lesion in the proximal lad, and a bms was deployed.
she tolerated the procedure well. she was brought to the ccu for
further monitoring. she was noted to have persistent stes on ecg
post-catheterization.
.
on arrival to the ccu, she was tachycardic but was otherwise
stable. she had no complaints. she did not recall exactly what
prompted her ed referral and did not know why she was here. she
knew that her friend had tried calling her and that she was
unable to come to the phone but is unable to tell me more than
that. she denies current chest pain or having ever had chest
pain. no sob, doe, pnd, orthopnea. no syncope or presyncope. no
palpitations. she notes that she has had slight bilateral lower
extremity swelling for the past three days. other ros is
negative.


past medical history:
1. cardiac risk factors:: diabetes-, dyslipidemia-, hypertension
?
2. cardiac history: none
-cabg: n/a
-percutaneous coronary interventions: n/a
-pacing/icd: n/a
3. other past medical history:
osteoporosis
scarlet fever as a child
? hypertension


social history:
-tobacco history: never
-etoh: 1 scotch per night
-illicit drugs: none
pt lives alone, is twice widowed, her second husband passed away
in [**2151**]. she has a house cleaner weekly and a close friend in
the area. she is responsible for her own bills and cooking. she
walks with a cane, admits that she has been having more
difficulty at home with stairs.


family history:
non-contributory

physical exam:
vs 96.9 113 119/66 19 98% 2l nc
general: elderly, frail appearing woman, very pleasant. nad
heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. small
xanthalesma near palpebral fissure
neck: supple with jvp to the angle of the jaw.
cardiac: tachycardic, regular. very distant. unable to
appreciate clear heart sounds.
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.
extremities: no femoral bruits. r groin site c/d/i, non-tender,
no hematoma. trace b/l le edema to mid tibia. extremities cool,
sensation intact.
skin: no stasis dermatitis, ulcers. b/l heels and sacrum pink,
blanching.
pulses:
right: femoral 2+ dp 1+ pt 1+
left: femoral 2+ dp 1+ pt 1+


pertinent results:
admission labs:
[**2170-12-31**] 10:23pm blood wbc-15.2* rbc-4.13* hgb-12.1 hct-36.2
mcv-88 mch-29.2 mchc-33.3 rdw-14.4 plt ct-475*
[**2170-12-31**] 10:23pm blood pt-14.2* ptt-29.1 inr(pt)-1.2*
[**2170-12-31**] 10:23pm blood glucose-172* urean-18 creat-0.6 na-132*
k-4.5 cl-96 hco3-25 angap-16
[**2170-12-31**] 10:23pm blood calcium-8.3* phos-2.9 mg-1.7
.
discharge labs:
[**2171-1-2**] 06:30am blood wbc-14.2* rbc-3.32* hgb-9.8* hct-29.2*
mcv-88 mch-29.5 mchc-33.5 rdw-14.3 plt ct-400
[**2171-1-2**] 06:30am blood pt-13.7* ptt-29.7 inr(pt)-1.2*
[**2171-1-2**] 06:30am blood glucose-103 urean-13 creat-0.5 na-134
k-4.0 cl-97 hco3-27 angap-14
[**2171-1-2**] 06:30am blood albumin-2.9* calcium-7.8* phos-2.8 mg-1.7
.
cardiac enzymes:
[**2170-12-31**] 10:23pm blood ck(cpk)-207* ck-mb-6 ctropnt-0.43*
[**2171-1-1**] 04:50am blood ck(cpk)-161* ck-mb-5 ctropnt-0.46*
[**2171-1-2**] 06:30am blood ck(cpk)-127  ck-mb-3 ctropnt-0.37*
.
metabolic profile:
[**2171-1-1**] 04:50am blood %hba1c-5.5
[**2171-1-1**] 04:50am blood triglyc-91 hdl-40 chol/hd-2.8 ldlcalc-53
.
anemia studies:
[**2171-1-1**] 04:50am blood caltibc-194* vitb12-191* folate-11.3
ferritn-313* trf-149*
.
c.cath study date of [**2170-12-31**] 1. selective coronary angiography
of this right dominant system demonstrated single vessel
coronary artery disease.  the lmca was without significant
disease.  the lad had 80-90% serial lesions in the proximal lad
just before d1.  the lcx and rca had no significant coronary
artery disease. 2. limited resting hemodynamics demonstrated
normal systemic arterial pressure of 107/63 mmhg. 3. successful
ptca and stenting of the proximal lad with a 2.5 x 28 mm
minivision bms which was deployed at 14 atm. the proximal stent
was post dilated with a 2.75 x 12 quantum maverick balloon at 14
atm. final angiography revealed no residual stenosis in the
stent, no dissection and timi iii flow.  (see ptca comments) 4.
right femoral arteriotomy site was closed with a 6 french mynx
device. final diagnosis: 1. one vessel coronary artery disease.
2. acute anterior myocardial infarction, managed by acute ptca.
ptca and stenting of the proximal lad.
.
portable tte (complete) done [**2171-1-1**] at 11:56:38 am the left
atrium is dilated. the left ventricular cavity size is normal.
there is moderate to severe regional left ventricular systolic
dysfunction with mid to distal anterior and septal akinesis with
apical akinesis/dyskinesis. right ventricular chamber size and
free wall motion are normal. the aortic arch is mildly dilated.
the aortic valve leaflets are moderately thickened. there is a
minimally increased gradient consistent with minimal aortic
valve stenosis. mild (1+) aortic regurgitation is seen. the
mitral valve leaflets are mildly thickened. trivial mitral
regurgitation is seen. the tricuspid valve leaflets are mildly
thickened. there is mild pulmonary artery systolic hypertension.
there is a small pericardial effusion. there is brief right
atrial diastolic collapse. left ventricle - ejection fraction:
30% to 35%.

brief hospital course:
[**age over 90 **]f with no prior cardiac history presented with stemi, now s/p
bms to lad. echo showed systolic chf with ef 30-35%. pt was
medically optimized and discharged to rehabilitation in stable
condition.
.
# coronaries: single vessel cad, s/p 2 bms to lad. hba1c for
risk stratification 5.5, so wnl. lipid panel: cholest 111,
triglyc 91, hdl 40, ldlcalc 53, so all within acceptable ranges.
started high dose statin with atorvastatin 80mg po hs for recent
mi and discharged on atorvastatin 40mg po hs for ongoing lipid
management over high dose for risk of adverse events in this
elderly patient. trended ces until falling. ck peaked at 207 on
the day of transfer. continued asa 325mg po daily and plavix
75mg po daily for thombotic ppx. initialy beta blocker therapy
with metoprolol tartrate 25 mg po bid. discharged on toprol xl
50mg po daily.
.
# pump: patient stated that she has a history of lower extremity
swelling over the past several weeks which is new. no echo in
our system. tte this admisison showed ef 30-355 with apical
hypokinesis. held off anticoagulation for apical hypokinesis
given age and risk factors. will continue on asa + plavix for
antiaggregation therapy and as thrombosis ppx. started
lisinopril 2.5 mg po daily for decreased ef and chf.
.
# rhythm: currently in sinus tachycardia with low-normal blood
pressures, given large territory of infarct tachycaridia is
likely compensatory mechanism to maintain co. initially held
bblockers to avoid precipitating cardiogenic shock. was able to
titrate up bblockade. telemetry showed frequent pacs. pt very
pre-renal with falling hct. unclear if this is due to dilution
or hemorrhage. ultimately believed to be due to hypovolemia.
encouraged pos and improved.
.
# leukocytosis: pt with ongoing leukocytosis. unclear if this is
due to recent mi, infection, or clonal process such as cll. cbc
with diff with 17% lymphcytes. this may be early cll but
ultimately was felt to be reactive leukocytosis from the mi.
cdiff, ua, ucx all negative.
.
# hyponatremia - na on admission was 132 and fell to 130.
improved with improvement of volume status and was ultimately
believed to be [**12-17**] hypovolemia.
.
# anemia - patient with drop in hct this admission. ultimately
the admisison hct was believed to be hemoconcentrated. amemia
studies were sent which showed mild iron and b12 def. added
supplementation. stools were guaiac negative.

medications on admission:
fosomax 70mg qweek
pred forte 1% 1gtt l eye qid
vigamox 0.5% 1gtt l eye qid
combigen 1gtt both eyes [**hospital1 **]
aspirin 81mg daily
tums daily
occuvite


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).
3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6
hours) as needed for pain, fever.
4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
5. prednisolone acetate 1 % drops, suspension sig: one (1) drop
ophthalmic qid (4 times a day).
6. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day)
as needed for constipation.
7. toprol xl 50 mg tablet sustained release 24 hr sig: one (1)
tablet sustained release 24 hr po once a day.
8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1)
tablet po daily (daily).
9. cyanocobalamin 250 mcg tablet sig: one (1) tablet po daily
(daily).
10. calcium with vitamin d 600-400 mg-unit tablet sig: one (1)
tablet po twice a day.
11. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily):
hold sbp< 100.
12. atorvastatin 40 mg tablet sig: one (1) tablet po daily
(daily).
13. alphagan p 0.1 % drops sig: one (1) drop ophthalmic three
times a day: 1 drop ou tid.
14. vigamox 0.5 % drops sig: one (1) drop os ophthalmic four
times a day: 1 drop os qid
until your ophthalmology appointment .
15. xalatan 0.005 % drops sig: one (1) drop ophthalmic at
bedtime: 1 drop qhs ou.


discharge disposition:
extended care

facility:
[**hospital3 7**] & rehab center - [**hospital1 8**]

discharge diagnosis:
st elevation myocardial infarction
iron defeciency anemia
chronic systolic congestive heart failure, ef 30%
.
secondary:
osteoporosis
scarlet fever as a child
? hypertension


discharge condition:
stable vital signs, afebrile, chest pain free

discharge instructions:
you had a heart attack and a bare metal stent was placed in your
left coronary artery to fix a blockage. your heart function is
weakened now and you will need to be followed closely for signs
of fluid retention that include swelling in your feet, trouble
breathing, or a dry cough. you were started on multiple new
medicines to help your heart work better:
new medicines:
- plavix (clopidogrel) 75mg daily to prevent blood clots and
keep the arteries of your heart open. do not stop taking this
medication unless told to by your cardiolgist. stopping this
medications prematurely could lead to a heart attack.
- aspirin 325mg daily to prevent blood clots
- iron tablets and vitamin b12 to treat your anemia and help
your body make more red blood cells
- colace and senna to prevent constipation
- metoprolol succinate (toprol xl)50mg daily to slow your heart
rate and help your heart pump better
- atorvastatin (lipitor) 40mg before bed to treat high
cholesterol
- lisinopril 2.5mg daily to keep your blood pressure low and
help your heart pump better
.
please call your doctor if you have any chest pain, trouble
breathing, nausea, fevers, cough or any unusual bleeding.
.
weigh yourself every morning. please call your doctor if you
gain more than 3lbs in a day or 10lbs in a week.
adhere to 2000mg sodium diet

followup instructions:
we have made you a follow up appointment to see your
cardiologist as below.
cardiology:
[**last name (lf) **],[**first name3 (lf) 251**] t. phone: [**telephone/fax (1) 4475**] date/time: [**1-15**] at 2:45
pm



completed by:[**2171-1-2**]"
287,"admission date:  [**2180-3-29**]              discharge date:   [**2180-4-2**]

date of birth:  [**2099-1-25**]             sex:   f

service: medicine

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 7333**]
chief complaint:
chest pain

major surgical or invasive procedure:
2units prbcs transfused


history of present illness:
this is an 81 yo female with history of cad, htn, ?gib in the
past was transferred from [**hospital3 4107**] for management of
melena, doe and chest tightness.  the episode begain this
morning.  she was walking to the bathroom and began to
experience sob, along with 8/10 'chest tightness', +nausea,
+diaphoresis.  she denies vomiting, palpitations or radiating
pain.  this episode lasted for 5 minutes and resolved on its
own.  she was taken to her pcps office by her daughter and was
then referred to the [**name (ni) **] [**1-31**] ecg changes and concern for acs.
she reports similar episodes for the past two days, 4-5 episodes
each day, but today's episode was worse, which was the reason
she sought medical attention.  she was sent to [**hospital1 **] er where
she had witnessed melena, documented as guaiac positive.

at [**hospital1 **], she was hemodynamically stable.  her trop i was found
to be 7.37.  hct 26.6.  ecg showed st depressions ii, iii, avf,
v3-v5, st elevation avr. patient was given lopressor, 1uprbc,
tylenol, lasix 40mg x 1.  cxr showed small right pleural
effusion with minimal basilar atelectasis.  she was transferred
to [**hospital1 18**] ccu for further management.

on arrival here, the patient was asymptomatic.  she denied any
chest pain, sob, n/v, diarrhea, abd pain.  last bm was this
morning.  no fevers, chills.  +dry cough for the past few days.


past medical history:
cad s/p mi and cabg in [**2162**] at [**hospital1 112**]
hypertension
hypothyroidism
anxiety

cardiac risk factors: htn, former smoker 30 pack year, quit 15
years ago
cardiac history:
-cabg:  [**2162**]
-percutaneous coronary interventions:  [**12-5**]


social history:
lives alone, has daughter, 50 year pack history tobacco, quit 15

years ago, no etoh, no drugs. from poland.

family history:
unknown, parents died when she was young.

physical exam:
vs:
general: nad, lying comfortably in bed
heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were
pink. op clear, mmm
neck: supple with jvp of 10 cm.
cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3
or s4.
lungs: no chest wall deformities, scoliosis or kyphosis. resp
were unlabored, no accessory muscle use. ctab, no crackles,
wheezes or rhonchi.
abdomen: soft, non-tender, non-distended
extremities: no c/c/e
rectal: normal tone, minimal black specks of stool, guaiac
positive



pertinent results:
osh lab data:
[**2180-3-29**]: wbc 5.8, hct 26.6, plt 153
na 135, k 4.6, cl 103, co2 25, bun 31, cr 1.0
pt 12.6, ptt 32.4, inr 1.14
troponin i  7.37, bnp 1340
.
labs on admission:
[**2180-3-29**] 08:45pm   glucose-103 urea n-30* creat-1.0 sodium-139
potassium-3.9 chloride-102 total co2-26 anion gap-15
[**2180-3-29**] 08:45pm   ck(cpk)-140
[**2180-3-29**] 08:45pm   ck-mb-16* mb indx-11.4* ctropnt-1.12*
[**2180-3-29**] 08:45pm   calcium-8.7 phosphate-5.1* magnesium-2.2
[**2180-3-29**] 08:45pm   wbc-4.9 rbc-3.22* hgb-9.7* hct-27.9* mcv-87
mch-30.1 mchc-34.8 rdw-16.4*
[**2180-3-29**] 08:45pm   neuts-61.9 lymphs-28.0 monos-7.5 eos-2.1
basos-0.5
[**2180-3-29**] 08:45pm   plt count-153
[**2180-3-29**] 08:45pm   pt-12.8 ptt-24.1 inr(pt)-1.1

ecg:  nsr, 1mm st depressions i, ii, v2-v5, <1mm std v6, 1mm st
elevation avr
.
cxr:
.
ct chest:
.

brief hospital course:
# nstemi:  ms. [**known lastname **] had diffuse ecg changes and troponin leak
in the setting of melena and ugib.  global ecg changes and
troponin leak were consistent with demand ischemia in the
setting of her ugib.  enzymes trended down and she remained
chest pain free during her hospitalization. initially we held
her asa, plavix, metoprolol, lasix in setting of bleed. she was
started on a statin given her history of severe cad and no
reported adverse events in her prior history with statins. as
her stent was placed >1 month ago and was bare metal the plavix
was stopped, not to be restarted. she was continued on 81mg
aspirin for stent restenosis. metoprolol was restarted prior to
discharge once her blood pressure was found to be stable and she
had no evidence of further bleeding.  she was taking lasix as an
outpatient for unclear reasons, thus this was not restarted.
the patient was instructed to follow up with her primary
cardiologist, dr. [**last name (stitle) 10543**], in [**hospital1 **] for evaluation of possible
diagnostic cardiac catheterization given her ischemic event in
the setting of a gi bleed.  at this follow up visit, she should
discuss the future need for lasix.

# ugib:  the patient has a history of gave syndrome per her
records from dr.[**name (ni) 49335**] office, her primary
gastroenterologist.  she presented to [**hospital3 **] with
melena.  at that time she has a hct of 26 which was down from 31
on her last admission in 12/[**2178**].  on transfer to [**hospital1 18**], 2 large
bore ivs were placed and she was started on her first unit of
prbcs.  at [**hospital1 18**], serial hcts were monitored and remained stable
after transfusion of 4 units of prbcs total. she was initially
on ppi iv bid and then switched to oral once daily (40mg). in
the meantime gi was consulted and said in the setting of no
acute bleeding, there was no need for emergent egd.  she should
follow up with her primary gastroenterologist for outpatient egd
in the next 2-4 weeks. prior to discharge she was restarted on
her iron and sucralfate.

# htn: initially held metoprolol, lasix in setting of bleed.
metoprolol was restarted prior to discharge, however lasix was
held given not clear reason for lasix use.  blood pressures were
well controlled on metoprolol only.

# hypothyroidism: continued levoxyl

# anxiety: held lorazepam at first but then restarted when
patient was started back on pos.

# decreased breath sounds on rll:  cxr was initially ordered to
evaluate this finding on physical exam.  a ct scan was
recommended for follow up.  ct scan showed pleural thickening on
the right, either indicative of fat or fluid however not
evidence of infection.  the patient never reported symptoms of
dyspnea or cough during her hospitalization.  a small 2mm
pulmonary nodule was noted on her ct scan.  as she has a long
history of tobacco abuse, it would be indicated to follow this
nodule as an outpatient.

# access: 2 large bore pivs
# prophylaxis: ppi as above, hold home colace
# code: full code, confirmed with patient
# comm: with patient, hct is daughter [**name (ni) **] [**name (ni) 110**] [**telephone/fax (1) 81673**]


medications on admission:
aspirin 81 mg daily (took this morning)
lorazepam 0.5 mg q8h prn
colace 100 mg po bid
levothyroxine 175 mcg daily
omeprazole 20 mg [**hospital1 **]
clopidogrel 75 mg daily (took this morning)
metoprolol tartrate 25 mg [**hospital1 **]
nitroglycerin 0.3 mg prn chest pain
lasix 40mg daily
kcl 20 meq p0 daily
hydromorphone 2mg (one) tab tid
sucralfate qid
ferrous sulfate daily

discharge medications:
1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable
po daily (daily).
disp:*30 tablet, chewable(s)* refills:*2*
2. lorazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a
day) as needed for foot cramps.
3. levothyroxine 175 mcg tablet sig: one (1) tablet po daily
(daily).
4. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2
times a day).
5. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one
(1) tablet po once a day.
6. sucralfate 1 gram tablet sig: one (1) tablet po four times a
day.
7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1)
capsule, delayed release(e.c.) po twice a day.
8. atorvastatin 80 mg tablet sig: one (1) tablet po once a day.
disp:*30 tablet(s)* refills:*2*


discharge disposition:
home with service

facility:
[**hospital3 **] vna

discharge diagnosis:
primary diagnoses:
gave
upper gib
anemia
nstemi in the setting of ugib

secondary diagnoses:
cad


discharge condition:
the patient was afebrile and hemodynamically stable without
chest pain prior to discharge.


discharge instructions:
you were admitted to the hospital with chest pain. you had low
blood counts because you were bleeding from your stomach. this
caused you to have strain on your heart which caused your chest
pain. you were given a blood transfusion and the pain went away.
the gi doctors here [**name5 (ptitle) **] not feel that you need to have another
procedure to look at your stomach because you have had several
that have all showed the same thing.

medication changes:
these medications were discontinued, do not restart these
medications on discharge:
-  plavix
-  lasix
.
these medications were started, please take them as prescribed
on discharge:

-  atorvastatin 80mg daily
.
these medications were continued, please take them as
prescribed:
-  aspirin 81mg daily
-  iron
-  sucralfate
-  levothyroxine
-  lorazepam
-  omeprazole to 20mg two times daily
.
please come back to the hospital or call your primary care
physician if you have fainting or near-fainting, dizziness,
light-headedness, shortness of breath, chest pain, jaw pain, arm
pain, abdominal pain, nausea, blood in your stools, black tarry
stools, leg swelling, or any other concerning symptoms.

followup instructions:
please follow up with dr. [**last name (stitle) 10543**] in the next 2-4 weeks.

please follow up with dr. [**first name (stitle) 15532**] in [**2-2**] weeks to schedule
outpatient upper endoscopy.

please follow up with dr. [**last name (stitle) 1005**] in about 4 weeks. he will
check your liver tests to make sure you can take the high doses
of the statin we gave you.



completed by:[**2180-4-2**]"
288,"admission date:  [**2199-9-22**]              discharge date:   [**2199-10-2**]

date of birth:  [**2143-12-23**]             sex:   f

service: surgery

allergies:
penicillins

attending:[**first name3 (lf) 598**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
[**2199-9-23**]: laparascopic repair of gastric ulcer


history of present illness:
55f w/ h/o carotid stenosis/le claudication and diverticulosis
(last c-scope ~ 1 yr ago @ osh) presents with an acute onset of
epigastric pain 4 hours prior to arrival in ed. she was seen at
[**hospital3 **] and was reportedly hypotensive
initially to sbp 80s.  upright cxr showed a question of bowel
gas vs free air below left diaphragm. there was no ct scanner
available at [**hospital1 **] due to power outage and so patient was
transferred here for further eval/management. the patient
reports recent h/o of nausea vomiting (from ""some stomach bug"")
and diarrhea x2 days (described as ""dark"" but no brbpr) but
wasn't sure about passing flatus recently.  she denies fevers or
chills, nausea/vomiting, hematemesis, history of gi
bleeds/diverticulitis, cp, sob.


past medical history:
past medical history: htn, hypercholesterolemia, diverticulosis
(last c-scope ~1yr ago), carotid stenosis, le claudication

past surgical history: tonsillectomy


social history:
lives in [**location 2624**] w/ husband, occupation is assistant to husband
in furniture business, +tobacco smoking h/o ~35yrs on/off,
social etoh, no ivdu


family history:
n/c

physical exam:
on admission:
physical exam:
vitals: 96.5  104  106/79  20  98% 4l nasal cannula
gen: a&o, nad
heent: no scleral icterus, mucus membranes moist
cv: tachycardic, regular rhythm, no m/g/r
pulm: clear to auscultation b/l, no w/r/r
abd: hypoactive bowel sounds, soft, mild distension, +ttp
midepigastrium/luq w/ focal rebound, no palpable masses
ext: no le edema, le warm and well perfused


pertinent results:
labs:
[**2199-10-2**] 07:05am blood wbc-7.4 rbc-3.30* hgb-11.0* hct-31.4*
mcv-95 mch-33.4* mchc-35.2* rdw-13.4 plt ct-567* glucose-94
urean-8 creat-0.4 na-143 k-3.9 cl-105 hco3-29 angap-13
calcium-8.8 phos-3.5 mg-2.3

[**2199-9-29**] 02:42pm blood gastrin-pnd

[**2199-9-26**] 10:01am blood vanco-6.9* 03:29am blood type-art
po2-111* pco2-33* ph-7.45 caltco2-24 base xs-0

[**2199-9-24**] 01:18am blood pt-13.7* ptt-34.2 inr(pt)-1.2* [**2199-9-24**]
01:18am blood probnp-988* [**2199-9-24**] 01:33am blood lactate-0.9

[**2199-9-22**] 04:15pm blood wbc-10.1 rbc-4.19* hgb-14.5 hct-40.0
mcv-95 mch-34.6* mchc-36.2* rdw-13.5 plt ct-433 neuts-85*
bands-1 lymphs-10* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0
hypochr-1+ anisocy-occasional poiklo-occasional macrocy-1+
microcy-normal polychr-occasional stipple-occasional
how-jol-occasional pappenh-1+ pt-11.9 ptt-20.8* inr(pt)-1.0
glucose-106* urean-15 creat-0.9 na-136 k-4.7 cl-101 hco3-23
angap-17 alt-18 ast-20 alkphos-67 amylase-159* totbili-0.7
lipase-58 calcium-9.7 phos-4.8* mg-1.6
glucose-98 lactate-1.6 na-135 k-4.2 cl-102 10:53pm blood
hgb-12.1 calchct-36 hgb-13.8 calchct-41 10:53pm blood
freeca-1.25

imaging:
[**2199-9-22**]:
cxr: impression: pneumoperitoneum. please correlate with ct
abdomen
ct abd & pelvis with contrast: impression: pneumoperitoneum with
active intraperitoneal spillage of oral (water soluble)
contrast, likely secondary to a perforated duodenal ulcer.
please note, given the mural edema and mucosal irregularity in
the gastric antrum, malignancy cannot be excluded.

[**2199-9-24**]:
impression: cta chest w&w/o c&recons, non-coronary: impression:
1. no evidence of pulmonary embolism.
2. multifocal consolidations concerning for pneumonia.
3. new bilateral pleural effusions and bilateral lower lobe
atelectasis.

[**2199-9-25**]:
ecg: impression: sinus rhythm. possible septal myocardial
infarction, age indeterminate. low voltage in the limb leads. no
previous tracing available for comparison

[**2199-9-27**]:
chest (portable ap): impression: since [**2199-9-26**], there
is mild interval worsening of the pulmonary edema. again, stable
left lung base atelectasis and bilateral mild pleural effusions.


[**2199-9-29**]:
impression: normal upper gi without evidence of leak.


brief hospital course:
ms. [**known lastname **] presented to an osh [**2199-9-22**] with acute onset
epigastric pain and hypotension.  an upright cxr was obtained at
the osh suggested a possible bowel gas pattern under the left
diaphragm versus free air.  the patient was subsequently
transferred to the [**hospital1 18**] emergency department for further
management.  an abdominal ct scan was obtained and revealed
pneumoperitoneum with active intraperitoneal spillage of oral
(water soluble) contrast attributed to a perforated duodenal
ulcer.  intravenous fluids, pain, and nausea medication were
administered.  intravenous ciprofloxacin was also administered.
the patient was then taken emergently to the operating room
where a perforated gastric ulcer was identified and a
laparascopic repair of the perforated gastric ulcer was
performed.  there were no adverse events in the operating room;
please see operative note for details.  pt was extubated, taken
to the pacu until stable, then transferred to the surgical
intensive care unit for further management. the patient remained
in the intensive care unit until pod 4.  she was then
transferred to the general surgical [**hospital1 **] for observation.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially managed with a dilaudid pca.
 pain medication was transitioned to oral oxycodone once
tolerating a diet.
cv: the patient required intraoperative pressors, which were
resumed on pod0, in addition to a fluid bolus, in the sicu due
to hypotension.  pressors were discontinued on pod2.
additionally, a lasix drip was initiated on pod1 due to. .; the
lasix drip was transitioned to [**hospital1 **] intravenous dosing on pod 4
and discontinued on pod 9; electrolytes were repleted prn.
pulmonary: the patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
gi/gu/fen: she was initially kept npo. patient's intake and
output were closely monitored.
id: the patient's fever curves were closely watched for signs of
infection, of which there were none.
heme: the patient's blood counts were closely watched for signs
of bleeding, of which there were none.
prophylaxis: the patient received subcutaneous heparin and [**last name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
toprol xl 200 mg daily
amlodipine 5 mg daily
lisinopril 20 mg daily
aspirin 81 mg daily
cilostazol 100 mg [**hospital1 **]
lovastatin 40 mg daily
ambien 5 mg q hs prn
aspirin 81 mg daily
caltrate + d 600 mg- 400 mg [**hospital1 **]
glucosamine 1000 mg daily

discharge medications:
1. oxycodone 5 mg tablet sig: one (1) tablet po every four (4)
hours as needed for pain.
disp:*50 tablet(s)* refills:*0*
2. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily).

3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every
6 hours): do not exceed 3000 mg per 24 hour period.
4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one
(1) tablet, delayed release (e.c.) po q24h (every 24 hours).
disp:*30 tablet, delayed release (e.c.)(s)* refills:*2*
5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid
(2 times a day).
disp:*60 tablet(s)* refills:*0*
6. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).

7. docusate sodium 100 mg capsule sig: one (1) capsule po twice
a day as needed for constipation.
disp:*30 capsule(s)* refills:*0*
8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable
po once a day.
9. cilostazol 100 mg tablet sig: one (1) tablet po twice a day.

10. lovastatin 40 mg tablet sig: one (1) tablet po once a day.


discharge disposition:
home

discharge diagnosis:
perforated gastric ulcer


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
you were admitted to the hospital with abdominal pain.  an
abdominal ct scan was obtained and was suspicious for an
intestinal perforation , therefore, you were taken to the
operating room and subsequently underwent a laparascopic repair
of a perforated gastric ulcer.  you recovered in the hospital
and are now preparing for discharge to home with the following
instructions:

please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications except for the
following changes:
1.  stop toprol xl(extended releas metoprol).  a new
prescription for twice daily metoprolol has been provided to
you.  please notify your primary care provider of this change.
please seek immediate medical attention if you experience a
severe headache, blurred vision, weakness, difficulty speaking
and/ dizziness.
2.  please take 20 mg lisinopril daily (current home dose 40 mg
daily).  please follow the above instructions regarding your
blood pressure.
also, please take any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-4**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.
incision care:
*please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*avoid swimming and baths until your follow-up appointment.
*you may shower, and wash surgical incisions with a mild soap
and warm water. gently pat the area dry.
*if you have staples, they will be removed at your follow-up
appointment.
*if you have steri-strips, they will fall off on their own.
please remove any remaining strips 7-10 days after surgery.


followup instructions:
please contact the acute care service to make a follow-up
appointment within 2 weeks.
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2200-2-26**] 12:30
provider: [**name10 (nameis) 14633**],equipment [**name10 (nameis) **] lmob (nhb) phone:[**telephone/fax (1) 1237**]
date/time:[**2200-2-26**] 12:30
provider: [**name10 (nameis) **] [**apartment address(1) 871**] ([**doctor first name **]) [**doctor first name **] lmob (nhb)
phone:[**telephone/fax (1) 1237**] date/time:[**2200-2-26**] 1:15


                             [**first name8 (namepattern2) **] [**name8 (md) **] md [**md number(2) 601**]

completed by:[**2199-10-2**]"
289,"admission date:  [**2118-6-4**]              discharge date:   [**2118-6-9**]

date of birth:  [**2050-3-31**]             sex:   m

service: neurology

allergies:
no known allergies / adverse drug reactions

attending:[**first name3 (lf) 2569**]
chief complaint:
code stroke for left sided weakness and dysarthria


major surgical or invasive procedure:
[**2118-6-4**] - cerebral angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery


history of present illness:
68rhm with no significant medical history (he reports having not
seen a physician in many years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 am after
taking
a shower. code stroke called given his significant acute
deficits.

the patient had been previously fit and well until 7:50 am. upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. he fell backward, hitting his
back and right elbow. during this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. he was initially reluctant
to call ems, but his son did. [**name2 (ni) **] was transferred to the [**hospital1 18**]
ed.

of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
""something was grabbing hold of me"". he attributed these to his
heart and they eased after he took a deep breath. these lessened
in frequency over the past 1 month but were still frequent. he
did however note that he had been very stressed over this period
as he has family and financial worries. he denies any prior
weakness or numbness or vision loss. no neck pain or trauma in
recent past. no stroke-like symptoms.

at [**hospital1 18**] ed, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on
cta. ctp shows right mca hypoperfusion. he was given iv tpa at
9:12 am. after this, his symptoms significantly improved by
assessment at 10:45 am, with nihss then 3. however, by 11:30
after his blood pressure dipped to sbp 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. due to his initial improvement, neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.


past medical history:
no known issues but has not seen a doctor in 10 years; possible
remote history of hypertension


social history:
lives with son.
retired systems worker for a publishing company. in process of
selling his house.
mobilises unaided.
never smoked, no etoh or illicit drug use.


family history:
mother - breast ca
father - blocked neck arteries per patient ahd had ? cea, no
strokes, prostate ca
sibs - sisters - breast ca
children - 5 well 1 with soem learning difficulties
.
there is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.


physical exam:
at admission:
vitals: t:afebrile p:70 sr  r:14  bp:156/77  sao2: 100%ra
general: awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
heent: nc/at, no scleral icterus noted, mmm, no lesions noted in
oropharynx
neck: supple, no carotid bruits appreciated. no nuchal rigidity
pulmonary: lungs cta bilaterally without r/r/w
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
bilaterally. calves snt.
skin: large hematoma right olecranon following fall and bruises
on back.

neurologic:

nih stroke scale score at 10:45 was 2 and 11:30 was 10

1a. level of consciousness: 0
1b. loc question: 0
1c. loc commands: 0
2. best gaze: 0  at 11:30 1
3. visual fields: 0
4. facial palsy: 1 at 11:30 1
5a. motor arm, left: 1 at 11:30 3
5b. motor arm, right: 0
6a. motor leg, left: 0 at 11:30 3
6b. motor leg, right: 0
7. limb ataxia: 0
8. sensory: 0 at 11:30 1
9. language: 0
10. dysarthria: 0 at 11:30 1
11. extinction and neglect: 0

-mental status:
orientation - alert, oriented x 3
the pt. had good knowledge of current events.
speech
able to relate history without difficulty.
language is fluent with intact repetition and comprehension.
normal prosody.  there were no paraphasic errors.
speech was not dysarthric initially then mild dysarthria.
naming pt. was able to name both high and low frequency objects.
[**location (un) **] - able to read without difficulty
attention - attentive, able to name [**doctor last name 1841**] backward without
difficulty.
registration and recall
pt. was able to register 3 objects and recall 3/ 3  at 5
minutes.
comprehension
able to follow both midline and appendicular commands
there was no evidence of apraxia or neglect


-cranial nerves:
i: olfaction not tested.
ii: perrl 3 to 2mm and brisk.  vff to confrontation. funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
iii, iv, vi: eomi without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
v: facial sensation intact to light touch.
vii: mild left facial weakness.
viii: hearing intact to finger-rub bilaterally.
ix, x: palate elevates symmetrically.
[**doctor first name 81**]: 5/5 strength in trapezii and scm bilaterally initially then
considerable weakness on left.
xii: tongue protrudes in midline.

-motor: normal bulk, tone throughout. initial assessment mild
left pronator drift then dens left hemiparesis.
no adventitious movements, such as tremor, noted. no asterixis
noted.
initial assessment post tpa.
  delt bic tri wre ffl fe  ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**]
l  5    5   4+  4+  5  4-  5   5    4  4+    5     5
r  5    5   5   5   5  5   5   5    5  5     5     5
following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.

-sensory: no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. on left
decreased temperature whole left side, decreased pinprick to
knee
in le and whole of left ue, decreased vibration to ankle on
leftle and sme decreased proprioception in left foot to ankle.
no
extinction to dss.

-dtrs:
  [**name2 (ni) **] tri [**last name (un) 1035**] pat ach
l  2  2    2    1   1
r  2  2    2    2   1
plantar response was flexor bilaterally with contraction of tfl
on left.

-coordination: no intention tremor. no dysmetria on fnf or hks
bilaterally but some difficulty with weakness on initail
assessment.

-gait: deferred
at transfer from neuroicu to stroke floor:
normal mental status, improved right gaze preference and no
longer has l neglect. mild dss extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in lue, joint position sense impairment in
lue, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
at discharge:

neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


pertinent results:
labs on admission:
[**2118-6-4**] 08:50am blood wbc-9.0 rbc-5.11 hgb-14.4 hct-42.6 mcv-83
mch-28.2 mchc-33.9 rdw-13.5 plt ct-249
[**2118-6-4**] 08:50am blood pt-12.7* ptt-33.6 inr(pt)-1.2*
[**2118-6-4**] 08:50am blood plt ct-249
[**2118-6-4**] 05:14pm blood fibrino-330
[**2118-6-4**] 08:50am blood urean-16
[**2118-6-4**] 08:51am blood creat-1.0
[**2118-6-4**] 05:14pm blood glucose-104* urean-12 creat-0.8 na-140
k-3.8 cl-108 hco3-25 angap-11
[**2118-6-4**] 05:14pm blood ck(cpk)-149
[**2118-6-5**] 01:17am blood alt-15 ast-25 ck(cpk)-273 alkphos-76
totbili-0.7
[**2118-6-4**] 05:14pm blood calcium-7.6* phos-2.9 mg-1.8
[**2118-6-5**] 01:17am blood albumin-4.0 calcium-8.0* phos-2.5* mg-1.8
cholest-175
[**2118-6-4**] 05:14pm blood asa-neg acetmnp-neg bnzodzp-neg
barbitr-neg tricycl-neg
[**2118-6-4**] 08:58am blood glucose-107* na-141 k-3.5 cl-101
calhco3-26
.
cardiac enzymes:
[**2118-6-4**] 05:14pm blood ck-mb-3 ctropnt-<0.01
[**2118-6-5**] 01:17am blood ck-mb-5 ctropnt-<0.01
.
stroke risk factors:
[**2118-6-5**] 01:17am blood %hba1c-5.4 eag-108
[**2118-6-5**] 01:17am blood triglyc-76 hdl-47 chol/hd-3.7 ldlcalc-113
[**2118-6-5**] 01:17am blood tsh-0.44
.
[**2118-6-6**] 10:34 am mrsa screen      source: nasal swab.

                            **final report [**2118-6-8**]**

   mrsa screen (final [**2118-6-8**]):    no mrsa isolated.

cta/ctp brain:
final report
indication: stroke, question fall.

comparison: retrieved on the omr.

technique: ct head without contrast; ct angiogram of the head
and neck with
iv contrast; ct cerebral perfusion study. with reformations of
the arteries
and _____ color maps.

findings:

non-contrast ct head: there is dense appearance of the right
middle cerebral
artery, representing thrombus within. there is a hypodense area
noted in the
right corona radiata, which is likely chronic.

there is no acute intracranial hemorrhage or mass effect at this
point. there
is mild prominence of the ventricles and extra-axial csf spaces
related to
volume loss.

no suspicious osseous lesions are noted. moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.

the cerebral perfusion study: there is a large area of increased
mtt with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right mca territory. associated small
acute infarct
is possible in addition with a large penumbra.

ct angiogram of the head and neck: the origins of the arch
vessels are
patent. on the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. in
the petrous
and the cavernous carotid segments, there is no flow noted. as
also in the
supraclinoid segment. there is no flow noted in the right middle
cerebral
artery. a few peripheral collaterals are noted.

the right a1 segment is partially occluded. there is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.

the left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
no flow
limitation is noted distally. there are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
there is no flow limitation. the left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.

the vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. scattered
calcifications are
noted in the distal vertebral arteries and the v4 segments,
predominantly on
the left side with moderate short segment stenosis. the major
branches of the
vertebral and basilar arteries are patent. the basilar artery is
diminutive
in size with fetal pca pattern, with prominent posterior
communicating
arteries and diminutive p1 segments.

the thyroid is unremarkable. a few small scattered nodes are
noted in both
sides of the neck, not enlarged by ct size criteria. mild
fullness is noted
in the left pyriform sinus.

a small subpleural based focus is noted in the right lung. in
the apex, which
can be correlated with dedicated ct chest imaging.

mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent ct c-spine study.

impression:

1. no acute intracranial hemorrhage or mass effect.

2. large area of perfusion abnormality in the right middle
cerebral artery
territory.

3. the large area of ischemia along with a possible small area
of acute
infarction. if there is continued concern, for the extent of
infarction, mri
can be considered.

4. new total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
possibilities include
dissections/thrombosis. partial occlusion of the right a1
segment.

please see the subsequent conventional angiogram study.

short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.

ct c-spine without contrast:
final report
indication: 68-year-old man with recent fall, with concern for
stroke, to
evaluate for c-spine fracture.

comparison: none available.

technique: mdct images were acquired through the cervical spine
without
intravenous contrast. sagittal and coronal reformats were
generated and
reviewed.

findings: no acute cervical spine fracture or malalignment is
detected. the
prevertebral soft tissues are normal. the vertebral body heights
are normal.
there is mild reduction of the intervertebral disc height at
c5-c6, c6-c7 and
c7-t1 levels. mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. no significant spinal
canal stenosis
is seen in the cervical level. there is some degree of rotation
at c1 and c2-
correlate clinically-? positional. the imaged portion of the
thyroid gland
is normal. a subpleural nodular focus is noted in the right lung
apex.
vascular calcifications and scattered nodes are noted. fullness
in the
piriform sinuses-correlate clinically.

impression: no acute cervical spine fracture or malalignment.
multilevel
degenerative changes with foraminal narrowing. correlate
clinically to decide
on the need for further workup.

cerebral angiogram:
final report
clinical history:

68-year-old male with history of sudden onset of left
hemiplegia. ct
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.


informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. risks and indications
were also
discussed with the patient's son.

the patient was brought to the neurointerventional suite and
prepared for
general anesthesia and was ready for puncture at 2:20 p.m.

access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. a 4 french berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:

right common carotid artery:

left common carotid artery:

right common carotid artery findings:

there is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. there is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and m2
segment of
the middle cerebral artery on the right.

later the catheter was withdrawn and the left common carotid
artery was
catheterized.

left common carotid artery findings:

there is moderate irregular plaque noted in the proximal left
internal carotid
artery. there is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. there is
cross flow noted
across the anterior communicating artery into the a2 branch of
the anterior
cerebral artery on the right.

the system was upgraded to a 9 french system and merci balloon
catheter was
introduced into the right common carotid artery. a rapid transit
catheter and
a gold tip glidewire was introduced to catheterize the right
internal carotid
artery. multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. at this
point, findings
were discussed with dr. [**first name (stitle) **], who suggested to abort the
procedure. 2
milligrams of tpa was introduced into the proximal right
internal carotid
artery.

impression:
1. unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of tpa was introduced into the proximal right internal
carotid
artery.

ecg:
sinus rhythm. normal tracing. no previous tracing available for
comparison.
  intervals axes
rate pr qrs qt/qtc p qrs t
71 188 86 [**telephone/fax (2) 110698**]5

mra brain without contrast:
final report
indication: right ica and mca occlusion with attempted
thrombolysis. mri to
evaluate for stroke.

comparison: cta head from [**2118-6-4**] and cerebral angiogram
from [**6-4**], [**2118**].

technique: mri and mra of the brain was performed without
contrast per
departmental protocol.

findings:

mri head: there is an area of slow diffusion with accompanying
flair signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. a small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. multiple tiny scattered
foci of slow
diffusion are also seen in the distal right mca territory. there
is no mass
effect, or edema seen. a chronic lacunar infarct is seen in the
right centrum
semiovale.

there is no hydrocephalus or midline shift. visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.

mra of the brain: as seen on the prior cta and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. there is
filling of the right aca and mca via collaterals from the circle
of [**location (un) 431**].
the right mca, however, appears attenuated. there is an overall
paucity of
the peripheral cortical branches of the right mca. the left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.

impression:
1. early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. multiple small scattered foci of slow diffusion in the right
mca
distribution, concerning for acute embolic infarcts.
3. chronic lacunar infarct in the right centrum semiovale.
4. persistent right ica occlusion with reconstitution of the
right aca and
mca. however, the right mca appears attenuated with an overall
paucity of
distal cortical branches.

r groin vascular u/s:
final report
indication: patient with recent diagnostic angiogram. assess for
aneurysm
formation in the right groin.
comparisons: none available.
findings:
grayscale and color doppler images of common femoral artery and
vein
demonstrate patent vessels. there is no evidence of
pseudoaneurysm or av
fistula. appropriate arterial and venous waveforms are
demonstrated. no focal hematoma in this region is seen.
impression:
no evidence of pseudoaneurysm, av fistula, or adjacent hematoma
involving
right common femoral vessels.

tte:
conclusions
the left atrium and right atrium are normal in cavity size. no
atrial septal defect or patent foramen ovale is seen by 2d,
color doppler or saline contrast with maneuvers. there is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (lvef>55%). there is an
apically displaced muscle band. right ventricular chamber size
and free wall motion are normal. the aortic arch is mildly
dilated. the aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. trace aortic regurgitation is
seen. the mitral valve appears structurally normal with trivial
mitral regurgitation. there is no mitral valve prolapse. the
pulmonary artery systolic pressure could not be determined.
there is no pericardial effusion.
impression: mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
dilated aortic arch. no definite cardiac source of embolism
identified.
clinical implications:
based on [**2113**] aha endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is not recommended. clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

ankle xray:
findings: the mortise is congruent. no fractures or dislocations
are
observed. no significant soft tissue swelling is observed. the
soft tissue
is unremarkable. there is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
impression: no fractures or dislocations. mild degenerative
changes seen in the ankle and tarsal joints.

cxr:
findings: there is no evidence of rib fractures. both lungs are
clear.
heart size is normal. mediastinal and hilar contours are
unremarkable. there is no pleural abnormality.
impression: no evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
labs at time of discharge:
[**2118-6-8**] 05:00am blood wbc-6.8 rbc-4.37* hgb-12.3* hct-36.4*
mcv-83 mch-28.0 mchc-33.7 rdw-13.2 plt ct-244
[**2118-6-9**] 05:35am blood pt-23.5* ptt-83.7* inr(pt)-2.2*
[**2118-6-9**] 05:35am blood calcium-8.9 phos-3.3 mg-1.9

brief hospital course:
mr. [**known lastname **] is a 68 rhm with no significant medical history (he
reports having not seen a physician in many years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 am ([**6-4**])
after taking a shower. he presented to the [**hospital1 18**] [**2118-6-4**] and was
admitted to the stroke service for further evaluation and care.
he was discharged on [**2118-6-4**] to rehabilitation.
.
#right basal ganglia infract from right internal carotid artery
occlusion (and right middle cerebral artery occlusion - since
recanalized): initially on admission a code stroke called given
his significant acute deficits. at [**hospital1 18**] ed, the patient was
hypertensive to 190s and initial nihss was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. there was evidence of a right mca and ica occlusion
on cta concerning for dissection. ctp showed a large area of
right mca hypoperfusion. he was administered iv tpa at 9:12 am.
after this, his symptoms initially significantly improved with
good antigravity on the left with nihss then 3. however, as his
blood pressure dipped to sbp 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. accordingly, the neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits.  unfortunately, the ica could not be opened. (the
difficulty passing the catheter through the ica was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
the patient was started on heparin gtt.  a subsequent mri showed
patent r mca later that night. his goal ptt was 50-70, and was
checked every 6 hours. dosing adjustments were made accordingly.
in the acute setting the patient required a nicardipine gtt with
goal sbp 140-190's, he eventually did not require this anymore.
after his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg qd with a goal sbp of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent r ica occlusion). he was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
his stroke risk factors were assessed: flp 175, tg 76, hdl 47,
ldl 113, a1c 5.4. as his ldl was not at goal <70 the patient was
started on high dose atorvastatin 80mg qd. a tte was obtained
(see full report above) which did not show an asd/pfo/thrombus,
and the patient had a preserved ef. a speech and swallow
evaluation was obtained, and the patient was cleared for a
regular diet. the patient was evaluated by physical therapy and
occupational therapy, and has been recommended for inpatient
rehab. also, the patient will have a follow-up cta in 3 months,
to be reviewed at his follow-up appointment with dr. [**first name (stitle) **] in
neurology (scheduled prior to discharge).
.
#hypertension: patient has had goal sbp 140's-180's, he
previously was not on any anti-htn medications. we started the
patient on lisinopril and uptitrated to 20mg qd. we have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. in about 2 days post discharge ([**2118-6-11**]) his
sbp range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#left rib pain, left ankle pain s/p fall: patient had a cxr and
a left ankle xray without evidence of fracture. he was treated
with acetaminophen for pain and tolerated this well.
.
#antiocoagulation: patient will need anticoagulation for his
occlusion for at least 3 months. his goal inr is [**3-18**]. his inr
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
.
transitional issues:
1) d/c to rehab
2) follow up cta at 3 months (scheduled prior to discharge)
3) anticoagulation with goal inr [**3-18**] on coumadin
4) follow up with dr. [**first name (stitle) **] (neurology)
5) follow up with primary care physian - who could potentially
follow the inr or help facilitate monitoring with the coumadin
clinic.

medications on admission:
aspirin 325mg qd
nil otc


discharge medications:
1. acetaminophen 650 mg/20.3 ml solution sig: one (1)  po q6h
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2
times a day).
3. atorvastatin 80 mg tablet sig: one (1) tablet po daily
(daily).
4. warfarin 5 mg tablet sig: one (1) tablet po daily (daily).
5. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily).



discharge disposition:
extended care

facility:
[**hospital6 85**] - [**location (un) 86**]

discharge diagnosis:
primary diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right mca  distribution
in the setting of  right internal carotid artery occlusion,
right middle cerebral artery occlusion (since recanalized)
secondaty diagnoses: hypertension, hyperlipidemia


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: out of bed with assistance to chair or
wheelchair.
.
neurological exam prior to discharge:
mental status: awake, alert, oriented to person, place, month,
day year, able to name months of year backwards
cranial nerves: notable for left facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal v1-v3 bilaterally, tongue midline,
unable to raise left shoulder (cn [**doctor first name 81**]), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
motor: 0/5 in left upper and left lower extremity
reflexes: unable to elicit reflexes on the l, right biceps and
right patella 2; upgoing toe on right
sensory: no extinguishing to double simultaneous tactile
stimulation (using face and arm)


discharge instructions:
dear mr. [**known lastname **],
.
it was a pleasure taking care of you at [**hospital1 18**]. you were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. we performed inital
imaging of your head and found out that you had a clot in
several of the arteries (right internal carotid and middle
cerebral arteries) that supply the right side of the brain.
there was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. you
were given an iv medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
to treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an inr.
your goal inr range is [**3-18**]. this will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. for this reason we recommended
starting a cholesterol medication (atorvastatin). plesae take
this as prescribed. please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this.  your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
you have appoinmtents scheduled for follow-up with a primary
care provider, [**name10 (nameis) 3**] well as dr. [**first name (stitle) **] of neurology. please see
below.

we made the following changes to your medications:
start atorvastatin 80mg take one tablet by mouth daily
start warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as inr with a goal inr of [**3-18**])
start lisinopril 20mg tablet take one tablet by mouth daily
start docusate 100mg take one tablet by mouth two times a day
stop aspirin 325
start acetaminophen 650mg take  one tablet by mouth every 6
hours as needed for pain

followup instructions:
we coordinated an appointment with [**first name11 (name pattern1) **] [**last name (namepattern4) 110520**], md and dr.
[**first name8 (namepattern2) **] [**last name (namepattern1) **] (the pcp for purposes of insurance)
phone:[**telephone/fax (1) 2010**] on [**2118-6-23**] at 1:45 pm.  please call your
insurance company in advance of the appointment to notify them
that dr. [**first name (stitle) **] is your primary care doctor.
.
neurologist [**first name8 (namepattern2) **] [**name8 (md) 162**], md (phone:[**telephone/fax (1) 2574**]) on [**2118-9-12**] at
1:30 pm.  the office is located on the [**location (un) **] of the [**hospital ward name 23**]
building on the [**hospital ward name 516**].
.
cta
wednesday [**2117-9-6**]:15 am
npo 3 hours prior
medications okay with water
performed on the [**hospital ward name 517**] in the clinical center building
[**location (un) **] radiology
[**hospital1 32464**] (off [**location (un) 71679**])
[**location (un) 86**], ma
.


                             [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]

"
290,"admission date:  [**2127-12-7**]              discharge date:   [**2127-12-17**]

date of birth:  [**2063-4-18**]             sex:   f

service: surgery

allergies:
patient recorded as having no known allergies to drugs

attending:[**first name3 (lf) 1556**]
chief complaint:
abdominal pain

major surgical or invasive procedure:
1. exploratory laparotomy.
2. lysis of adhesions.
3. oversew of colonic deserosalization.


history of present illness:
64 year old female who presents with sudden onset of
periumbilical pain that started early this morning at around
5am. abdominal pain is mid abdomen with no radiation; relieved
by pain meds and no definite aggravating factors. associated
nausea and vomiting ~6 times. bilious; no blood. denies any
fevers, chills. bowel movements this morning; flatus last night.


past medical history:
- ovarian cancer, diagnosed in [**2109**] and treated with tah bso and
6 runs of chemotherapy complicated by deep vein thrombosis in
left lower extremity and was on coumadin briefly
- bladder cancer, diagnosed in [**2114**] and treated with cystecomy
and ileal conduit and stoma
- documented to have chronic anemia of unknown etiology
- pt. reported last colonoscopy 5 years ago with no abnormal,
she did have polyp removed during colonoscopy 10 years ago but
was not sure if malignancy was found.
-osteoporosis

psychiatric history:
patient has a diagnosis of ""psychotic disorder"" and has been
treated by her primary care provider successfully with
thorazine. she does not see any therapists or psychiatrists at
this time. she saw dr. [**last name (stitle) 100898**] in therapy 1x/mo for 6yrs
until she changed her insurance in [**month (only) 547**]. she reports trying
zoloft for a short time in [**2111**] but did not mention results.

hospitalizations: [**2111**] - ""[**first name4 (namepattern1) **] [**last name (namepattern1) **] accomodations""
                  [**2110**] - [**hospital1 336**]
                  [**2092**] - [**hospital1 **] [**hospital1 **] 4

patient reports 1 prior suicide attempt in [**2084**] when she
""stopped eating and wearing warm clothes and stayed out all
night, everything to excess."" she was then hospitalized for
pneumonia, no history of hurting herself.

social history:
born in mission [**doctor last name **] and raised in [**location (un) 669**], one of 11 children
(10 per omr). she reports 7 living (omr notes say 6) and all
except two sisters are in the [**name (ni) 86**] area.  lives alone. remote
smoker, no drugs/etoh


family history:
she had ten siblings. malignancy in the family: deceased sister:
ovarian ca
sister: breast cancer brother : ca brain brother: liver cancer
father: prostate cancer; mother's sister had schizophrenia.

physical exam:
constitutional: comfortable
chest: clear to auscultation
cardiovascular: regular rate and rhythm, normal first and second
heart sounds
abdominal: diffuse tenderness to palpation. no guarding or
rebound tenderness to palpation. abdomen nondistended, soft.
extr/back: no cyanosis, clubbing or edema
skin: no rash, warm and dry
neuro: speech fluent
psych: normal mood, normal mentation


pertinent results:
[**2127-12-7**] 02:45pm urine  hours-random
[**2127-12-7**] 02:45pm urine  gr hold-hold
[**2127-12-7**] 02:45pm urine  color-yellow appear-clear sp [**last name (un) 155**]-1.016
[**2127-12-7**] 02:45pm urine  blood-tr nitrite-neg protein-25
glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-7.0 leuk-sm
[**2127-12-7**] 02:45pm urine  rbc-0-2 wbc-[**4-18**] bacteria-many yeast-none
epi-0-2
[**2127-12-7**] 02:11pm   k+-4.1
[**2127-12-7**] 02:02pm   glucose-129* urea n-28* creat-1.4* sodium-144
potassium-4.1 chloride-108 total co2-26 anion gap-14
[**2127-12-7**] 12:30pm   glucose-137* urea n-31* creat-1.4* sodium-143
potassium-5.1 chloride-104 total co2-28 anion gap-16
[**2127-12-7**] 12:30pm   alt(sgpt)-13 ast(sgot)-32 alk phos-75 tot
bili-0.3
[**2127-12-7**] 12:30pm   lipase-55
[**2127-12-7**] 12:30pm   calcium-9.6
[**2127-12-7**] 12:30pm   wbc-6.3# rbc-3.65* hgb-10.6* hct-32.6* mcv-89
mch-29.2 mchc-32.7 rdw-13.9
[**2127-12-7**] 12:30pm   neuts-87.4* lymphs-9.4* monos-2.4 eos-0.5
basos-0.3
[**2127-12-7**] 12:30pm   plt count-190

[**2127-12-8**] abdominal ct w/ contrast: 1. high-grade small-bowel
obstruction, with dilation of the mid small bowel up to 3.4 cm.
the proximal and distal small bowel are decompressed and two
closely approximated transition points are seen in the
mid-abdomen, concerning for a closed loop obtruction, possibly
secondary to either internal hernia or
adhesion. while there is associated wall edema, mesenteric
fluid, and
adjacent ascites, there is no pneumatosis or portal venous air
identified to definitively suggest ischemia.
2. status post right nephroureterectomy and radical cystectomy,
with
unremarkable appearance of urostomy in the right lower quadrant.
no definite evidence of metastatic disease. small nodular
density at the left lung base is stable, though attention on
followup is warranted.
3. stable 4 mm hypodensity within the body of the pancreas,
unchanged.
4. ivc filter in standard position.

[**2127-12-12**] ekg: sinus rhythm with sinus arrhythmia. borderline low
limb lead voltage. diffuse non-specific st-t wave abnormalities.
compared to the previous tracing of [**2127-12-8**] findings are
similar.



brief hospital course:
ms. [**known lastname 20400**] presented to the emergency department on [**2127-12-7**] with complaints of sudden onset abdominal pain at the
umbilical level associated with nausea and vomiting and not
relieved with over the counter pain medication.  an abdominal
x-ray was obtained, which indicated a small bowel obstruction.
therefore, [**initials (namepattern4) **] [**last name (namepattern4) **]-gastric tube was placed and the patient was
transferred to the general surgical [**hospital1 **] for management.

on hospital day #1 the patient developed worsening abdominal
pain.  additionally, an abdominal ct scan had beeb obtained,
which revealed a high grade small bowel obstruction.  given the
worsening abdominal exam and the results of the ct scan, the
patient was brought to the operating room, where an exploratory
laparotomy, lysis of adhesions and oversew of colonic
deserosaliazation was performed.  there were no adverse events
in the operating room; please see the operative note for
details. pt was extubated, taken to the pacu until stable, then
transferred to the surgical intensive care unit for close
observation.

on hosptial day #2 the patient remained stable, was weaned from
the ventilator and extubated.  she was subsequently transferred
to the general surgical [**hospital1 **] for further management.

neuro: the patient was alert and oriented throughout her
hospitalization; pain was initially controlled with intravenous
dilaudid.  the patient reported complete resolution of pain by
post-operative day #5 and did not require pain medication for
the remainder of her hospitalization.

cv: the patients vital signs were routinely monitored. she
became hypertensive in the intensive care unit with a systolic
blood pressure in the 160s.  additionally, she had 8 beats of
non-sustained ventricular tachycardia on post-operative day #4.
she was maintained on intravenous metoprolol which was initiated
in the intensive care unit and continued until post-operative
day #8; her blood pressure and heart rate remained within
acceptable limits without metoprolol administration.

pulmonary: the patient tolerated extubation postoperatively
without difficulty and maintained appropriate oxygen saturation
levels throughout her admission.

gi/gu/fen: she was initially npo with iv fluids and a
[**last name (un) **]-gastric tube, which was removed on post-operative day #4.
diet was advanced sequentially, which was well tolerated,
however, oral liquid and solid intake was initially suboptimal.
nutritional supplements were then provided with each meal with
improved overall oral intake; she will continue this regimen at
home to optimize her nutritional status  patient's intake and
output were closely monitored, and iv fluid was adjusted when
necessary; electrolytes were routinely monitored and repleted as
necessary.

id: the patient's white blood cell counts and fever curves were
monitored routinely throughout her admission and did not show
any signs of intrabdominal or wound infections.

hematology: the patient's complete blood count was examined
routinely; no transfusions were required.

prophylaxis: the patient received subcutaneous heparin and
venodyne boots were used during this stay; she was encouraged to
get up and ambulate as early as possible.

rehab: given her prolonged hospital course and operation, a
physical therapy consult was requested.  she was evaluted on
post-operative day #8 and deemed safe for discharge home without
additional physical therapy requirements.

at the time of discharge, the patient was doing well, afebrile
with stable vital signs.  the patient was tolerating a regular
diet, ambulating, voiding via her urostomy tube, and pain was
well controlled.  the patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


medications on admission:
risperidone 1 mg tab qpm
vitamin d 800 unit tab daily
calcium 1200 mg chewable tab daily

discharge medications:
1. risperidone 0.5 mg tablet sig: two (2) tablet po hs (at
bedtime).
2. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2)
tablet po daily (daily).
3. calcium 500 mg tablet sig: 2.5 tablets po once a day.


discharge disposition:
home

discharge diagnosis:
small bowel obstruction


discharge condition:
mental status: clear and coherent.
level of consciousness: alert and interactive.
activity status: ambulatory - independent.


discharge instructions:
please call your doctor or nurse practitioner or return to the
emergency department for any of the following:
*you experience new chest pain, pressure, squeezing or
tightness.
*new or worsening cough, shortness of breath, or wheeze.
*if you are vomiting and cannot keep down fluids or your
medications.
*you are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*you see blood or dark/black material when you vomit or have a
bowel movement.
*you experience burning when you urinate, have blood in your
urine, or experience a discharge.
*your pain in not improving within 8-12 hours or is not gone
within 24 hours. call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*you have shaking chills, or fever greater than 101.5 degrees
fahrenheit or 38 degrees celsius.
*any change in your symptoms, or any new symptoms that concern
you.
please resume all regular home medications , unless specifically
advised not to take a particular medication. also, please take
any new medications as prescribed.
please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. avoid lifting
weights greater than [**6-23**] lbs until you follow-up with your
surgeon.
avoid driving or operating heavy machinery while taking pain
medications.


followup instructions:
please call dr. [**last name (stitle) **] at [**telephone/fax (1) 3201**] to make a follow-up
appointment for friday, [**2127-12-26**].
provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 6198**], md phone:[**telephone/fax (1) 22**]
date/time:[**2127-12-12**] 3:30



completed by:[**2127-12-18**]"
291,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: intermittently opens eyes and possibly answers
   yes/no questions. waxing and [**doctor last name 533**]. no focal signs.
   - f/u 24 hour eeg (completed yesterday at noon)
   - avoid sedating meds
   - check abg this morning for acid/base abnormalities
   .
   # ileus: abdomen protruberant but not distended. good stool output.
   tolerating tube feeds
   - continue tube feeds
   - serial abdominal exam
   - kub prn if redistends
   # a fib/flutter: on digoxin and labetalol, nifedipine d/c
   historically difficult to control, s/p ablation. takes sotalol as
   outpatient
   - c/w daily digoxin
   - verify therapeutic dig levels
   - increase labetalol to 600 mg tid
   - ep consult today
   # fevers: daily low-grade fevers. infectious workup unrevealing, aside
   from past mrsa in sputum. dvt may represent source
   - will send c. diff given new stool output (low index of suspicion for
   infection)
   # dvt: on heparin gtt since yesterday. non occluding thrombi per u/s
   report. [**month (only) 51**] represent source of fevers.
   - c/w conservative heparin gtt for goal ptt 60-80, given recent ich
   - serial neuro exams to detect early re-bleed
   - d/w neurosurg long-term oral anti-coagulation
   # hypertension: on ace/[**last name (un) **] as outpatient, these have been held for [**last name (un) **]
   during hospitalization. given plateau in creatinine improvement, he may
   have new baseline and may warrant re-initiation of ace/[**last name (un) **] therapy
   - pending ep recs, start short acting captopril
   - continue labetalol as above
   # mrsa pneumonia: on day 12 of 14 day vanco course. respiratory status
   stable.
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   - follow periodic abgs
   # aocki: creatinine has plateaued at 1.5, with historical baseline of
   1.2. [**month (only) 51**] represent new baseline. good urine output
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # skull fracture/sah/sdh: course of cipro/dexamethasone ear drops now
   complete. ct unrevealing for worsening or new fractures.
   # etoh: holding benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: added standing glargine to sliding scale for elevated
   fingersticks; glipizide held
   # fen: tube feeds. dobhoff to be placed today
   # proph: pantoprazole, heparin gtt
   # access: triple lumen, right radial line, picc
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 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
   resident note, including the assessment and plan.  68m with etoh,
   s/p fall with ich, course c/b ams, difficult to control a-fib, resp
   failure now extubated, low grade fevers. leni with dvt, started on hep
   gtt. continue titrating labetolol for improved heart rate control.
   100.8--> 96.2  100  135/71  24  98% nc
   somnolent, awake intermittently, not following commands
   scant basilar rales
   [**last name (un) **], tachy
   distended, + bs, soft and nt
   2+ edema
   7.43/39/79  wbc 9.4  hct 11.2  cr 1.5 inr 1.2
   cxr with new picc in position, l basilar atelectasis/sm eff, no sig
   change
   in a-fib/flutter. hr control remains suboptimal.  will
   uptitrate labetolol, continuing dig, level pending, ep consulted for
   additional input.  bp control also remains suboptimal, consider
   resuming ace-i monitoriing renal function closely. his acute on cri is
   improving, cr possibly at new baseline, urine outpt remains
   adequate.  will adjust meds/ vanco dosing for improving gfr.  his ms
   remains altered--? delirium, neuro is following, eeg is pending, no
   evidence of new ic process on repeat imaging.   will check abg to r/o
   co2 retention/narcosis. he is on vanco day [**12-13**] for mrsa pna. he
   continues to have low grade fevers, no leukocytosis, ? [**2-1**] dvt.  now on
   heparin.  infection w/u has otherwise been unremarkable. will send c
   diff given stool output. he is tolerating tfs well.    follow abd
   exams, kubs for abd distention.  continue glargine and ssi for improved
   bs control.  icu: ppi, hep gtt, picc. pt following. continue case
   management screening/ for rehab.
   remainder of plan as outlined in resident note.
   patient is critically ill
   total time: 50 min
   ------ protected section addendum entered by:[**name (ni) 215**] [**last name (namepattern1) 216**], md
   on:[**2129-2-8**] 15:54 ------
"
292,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: seems more alert, eyes open, tracking, trying
   to speak
   - f/u 24 hour eeg (completed yesterday at noon)
   .
   # hypernatremia: serum [na+] 146
 144
   -  continue with free water po and flushes with tube feeds
   - check pm lytes.
   - note urine osmolality not c/w di
   # ileus: good stool output, ileus resolving. just written for tubefeeds
   but can start to take occasional gentle po
   - continue tube feeds
 when mental status improved, will order
   speech/swallow evaluation and advance diet as tolerated
   - serial abdominal exam
   # a fib/flutter: loaded with digoxin, also continues on esmolol gtt.
   known to be difficult to rate control in past.
   - c/w daily po digoxin
   - discontinue esmolol gtt today
   # hypertension:
   - continue labetalol po and will increase to tid today if becomes more
   hypertensive with esmolol off
   - continue nifedipine po
   # respiratory failure: respiratory status stable, with reasonable abgs
   now extubated
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   # [**last name (un) **]: creatinine improvement continuing
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # rash: cefepime has been d/c
d, rash resolved.
   # skull fracture: course of cipro/dexamethasone ear drops now complete
   # sah/sdh: ct unrevealing for worsening or new fractures.
   # etoh: now beyond duration during which withdrawal expected. holding
   benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: increased sliding scale for elevated fingersticks;
   glipizide held
   # fen: tube feeds now
   # proph: pantoprazole, pneumoboots
   # access: triple lumen, right radial line
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status: full code
   disposition:
"
293,"chief complaint:
   24 hour events:
 ultrasound - at [**2129-2-7**] 01:52 pm
 blood cultured - at [**2129-2-7**] 01:52 pm
 urine culture - at [**2129-2-7**] 01:52 pm
   - peripheral smear/haptoglobin sent for steady hct downward drift:
   haptoglobin high; smear pending
   - lft's normal
   - lenis revealed dvt. started on heparin gtt (no bolus), with neurosurg
   approval. should stop heparin gtt immediately if any new neuro findings
   on exam
   - dobhoff will be placed in am
   - vanco increased to 1 gram q24
   - increased standing labetalol to 400 mg po/ng tid
   - gave labetalol iv boluses for tachycardia/hypertension, with varying
   success
   - d/c'd nifedipine immediate release; can cause variety of cardiac
   adverse events
   - added glargine for long-acting coverage to start with breakfast
   tomorrow
   patient unable to provide history: answering with one word answers
   allergies:
   penicillins
   pain;
   last dose of antibiotics:
   vancomycin - [**2129-2-7**] 08:30 pm
   infusions:
   heparin sodium - 1,900 units/hour
   other icu medications:
   heparin sodium - [**2129-2-8**] 01:13 am
   labetalol - [**2129-2-8**] 03:16 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  [**2129-2-8**] 07:12 am
   vital signs
   hemodynamic monitoring
   fluid balance
                                                                  24 hours
                                                               since [**30**] am
   tmax: 38.2
c (100.8
   tcurrent: 35.7
c (96.2
   hr: 110 (84 - 118) bpm
   bp: 147/71(92) {122/61(78) - 168/81(105)} mmhg
   rr: 24 (13 - 28) insp/min
   spo2: 100%
   heart rhythm: af (atrial fibrillation)
   wgt (current): 107 kg (admission): 113 kg
   height: 72 inch
             total in:
                                                                  4,161 ml
                                                                    678 ml
   po:
             tf:
                                                                    901 ml
                                                                    357 ml
   ivf:
                                                                  1,545 ml
                                                                    271 ml
   blood products:
   total out:
                                                                  3,455 ml
                                                                    880 ml
   urine:
                                                                  2,555 ml
                                                                    580 ml
   ng:
   stool:
                                                                    900 ml
                                                                    300 ml
   drains:
   balance:
                                                                    706 ml
                                                                   -202 ml
   respiratory support
   spo2: 100%
   abg: 7.43/39/78.[**numeric identifier 181**]/26/1
   physical examination
   general appearance: well nourished, no acute distress, overweight /
   obese
   eyes / conjunctiva: perrl
   head, ears, nose, throat: normocephalic, ng tube
   lymphatic: cervical wnl
   cardiovascular: (s1: normal), (s2: normal)
   peripheral vascular: (right radial pulse: present), (left radial pulse:
   present), (right dp pulse: present), (left dp pulse: present)
   respiratory / chest: (expansion: symmetric), (percussion: resonant : ),
   (breath sounds: clear : )
   abdominal: soft, non-tender, bowel sounds present, distended, obese
   extremities: right lower extremity edema: trace, left lower extremity
   edema: trace
   skin:  not assessed
   neurologic: attentive, responds to: verbal stimuli, movement: not
   assessed, tone: not assessed
   labs / radiology
   330 k/ul
   6.8 g/dl
   177 mg/dl
   1.5 mg/dl
   26 meq/l
   3.9 meq/l
   25 mg/dl
   113 meq/l
   144 meq/l
   21.2 %
   9.4 k/ul
        [image002.jpg]
                             [**2129-2-6**]  04:27 pm
                             [**2129-2-6**]  09:16 pm
                             [**2129-2-7**]  01:01 am
                             [**2129-2-7**]  03:19 am
                             [**2129-2-7**]  03:28 am
                             [**2129-2-7**]  05:09 am
                             [**2129-2-7**]  11:43 am
                             [**2129-2-7**]  01:59 pm
                             [**2129-2-8**]  03:13 am
                             [**2129-2-8**]  05:32 am
   wbc
   11.3
   9.4
   hct
   22.4
   23.0
   21.2
   plt
   339
   330
   cr
   1.5
   1.5
   1.5
   tco2
   32
   29
   28
   28
   29
   28
   27
   glucose
   227
   187
   177
   other labs: pt / ptt / inr:13.7/55.6/1.2, alt / ast:[**11-14**], alk phos / t
   bili:76/0.6, amylase / lipase:/25, differential-neuts:83.5 %, band:0.0
   %, lymph:8.8 %, mono:6.3 %, eos:1.2 %, lactic acid:1.2 mmol/l,
   albumin:2.2 g/dl, ldh:233 iu/l, ca++:7.8 mg/dl, mg++:1.6 mg/dl, po4:2.5
   mg/dl
   imaging: [**2-7**] leni's: non-occlusive thrombus in the right common femoral
   vein extending
   into the proximal superficial femoral vein. the proximal extent of clot
   is
   not visualized on this study
   microbiology: [**2-8**] c diff pending
   other recent outstanding cultures: negative or pending
   assessment and plan
   68m s/p fall with etoh onboard leading to skull fracture, sah, sdh.
   admission c/b intermittent ileus, acute on chronic renal failure,
   respiratory distress, atrial flutter and atrial fib, and altered mental
   status.
   # altered mental status: intermittently opens eyes and possibly answers
   yes/no questions. waxing and [**doctor last name 533**]. no focal signs.
   - f/u 24 hour eeg (completed yesterday at noon)
   - avoid sedating meds
   - check abg this morning for acid/base abnormalities
   .
   # ileus: abdomen protruberant but not distended. good stool output.
   tolerating tube feeds
   - continue tube feeds
   - serial abdominal exam
   - kub prn if redistends
   # a fib/flutter: on digoxin and labetalol, nifedipine d/c
   historically difficult to control, s/p ablation. takes sotalol as
   outpatient
   - c/w daily digoxin
   - verify therapeutic dig levels
   - increase labetalol to 600 mg tid
   - ep consult today
   # fevers: daily low-grade fevers. infectious workup unrevealing, aside
   from past mrsa in sputum. dvt may represent source
   - will send c. diff given new stool output (low index of suspicion for
   infection)
   # dvt: on heparin gtt since yesterday. non occluding thrombi per u/s
   report. [**month (only) 51**] represent source of fevers.
   - c/w conservative heparin gtt for goal ptt 60-80, given recent ich
   - serial neuro exams to detect early re-bleed
   - d/w neurosurg long-term oral anti-coagulation
   # hypertension: on ace/[**last name (un) **] as outpatient, these have been held for [**last name (un) **]
   during hospitalization. given plateau in creatinine improvement, he may
   have new baseline and may warrant re-initiation of ace/[**last name (un) **] therapy
   - pending ep recs, start short acting captopril
   - continue labetalol as above
   # mrsa pneumonia: on day 12 of 14 day vanco course. respiratory status
   stable.
   - will organize family meeting for monday to discuss chronic care
   issues
   - continue albuterol and ipratropium
   - continue with  vanco, day [**11-13**]
   - follow periodic abgs
   # aocki: creatinine has plateaued at 1.5, with historical baseline of
   1.2. [**month (only) 51**] represent new baseline. good urine output
   - continue to monitor bun/creatinine, uop
   - dose vancomycin by trough
   # skull fracture/sah/sdh: course of cipro/dexamethasone ear drops now
   complete. ct unrevealing for worsening or new fractures.
   # etoh: holding benzos or other sedatives. getting thiamine/folate.
    - sw / advice about rehabilitation when acute issues resolved
   # diabetes: added standing glargine to sliding scale for elevated
   fingersticks; glipizide held
   # fen: tube feeds. dobhoff to be placed today
   # proph: pantoprazole, heparin gtt
   # access: triple lumen, right radial line, picc
   # communication: [**doctor first name 753**] and [**first name8 (namepattern2) 129**] [**known lastname 12875**]
   # code: full
 will discuss with case management re: screening for
   rehab
   icu care
   nutrition:
   peptamen 1.5 (full) - [**2129-2-8**] 05:37 am 50 ml/hour
   glycemic control:
   lines:
   multi lumen - [**2129-1-28**] 12:59 pm
   arterial line - [**2129-1-28**] 09:00 pm
   prophylaxis:
   dvt:
   stress ulcer:
   vap:
   comments:
   communication:  comments:
   code status: full code
   disposition:
"
294,"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
"
295,"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
"