diff --git "a/demo_shpi_w_rouge21Nov.csv" "b/demo_shpi_w_rouge21Nov.csv" new file mode 100644--- /dev/null +++ "b/demo_shpi_w_rouge21Nov.csv" @@ -0,0 +1,10890 @@ +SUBJECT_ID,HADM_ID,ROW_ID,adm_notes_text,discharge_summary_text,hpi_input_text,hpi_reference_summary,BertSummarizer,BertGPT2,t5seq2eq,t5,gensim,pysummarizer,rougeBertSummarizer,rougeBertGPT2,rouget5seq2eq,rouget5,rougegensim,rougepysummarizer,r1_recall_BertSummarizer,r1_precision_BertSummarizer,r1_f_BertSummarizer,r2_recall_BertSummarizer,r2_precision_BertSummarizer,r2_f_BertSummarizer,rl_recall_BertSummarizer,rl_precision_BertSummarizer,rl_f_BertSummarizer,r1_recall_BertGPT2,r1_precision_BertGPT2,r1_f_BertGPT2,r2_recall_BertGPT2,r2_precision_BertGPT2,r2_f_BertGPT2,rl_recall_BertGPT2,rl_precision_BertGPT2,rl_f_BertGPT2,r1_recall_t5seq2eq,r1_precision_t5seq2eq,r1_f_t5seq2eq,r2_recall_t5seq2eq,r2_precision_t5seq2eq,r2_f_t5seq2eq,rl_recall_t5seq2eq,rl_precision_t5seq2eq,rl_f_t5seq2eq,r1_recall_t5,r1_precision_t5,r1_f_t5,r2_recall_t5,r2_precision_t5,r2_f_t5,rl_recall_t5,rl_precision_t5,rl_f_t5,r1_recall_gensim,r1_precision_gensim,r1_f_gensim,r2_recall_gensim,r2_precision_gensim,r2_f_gensim,rl_recall_gensim,rl_precision_gensim,rl_f_gensim,r1_recall_pysummarizer,r1_precision_pysummarizer,r1_f_pysummarizer,r2_recall_pysummarizer,r2_precision_pysummarizer,r2_f_pysummarizer,rl_recall_pysummarizer,rl_precision_pysummarizer,rl_f_pysummarizer +44146,163043,9133,"TITLE: + Chief Complaint: Fevers, hypotension + HPI: + 37 yo M with a PMH of sinus headaches s/p septal surgery and GERD who + presented to the ED from clinic with fevers. He reports that he thought + he had a URI for the last 3-4 days. Then last night he developed high + fevers and fatigue. Sunday he began feeling as if he had a cold then + monday began feeling achy this progressed on teusday and then teusday + night he began having shaking chills and back pain. He went to see his + PCP's office today. They noted a temperature of 102 and pleuritic chest + pain and sent him to the ED for further work up because he was so ill + appearing. He also notes a sore throat and productive cough with clear + sputum, chills and rigors last night and pleuritic right chest pain. He + had some nausea and dizziness as well. + . + In the ED, his initial vital signs were T 98.9, HR 94, BP 96/54, RR 17, + O2sat 100. He had a CXR which suggested RLL pneumonia. He was ordered + for levofloxacin, ceftriaxone and vancomycin as the ED was concerned + over community acquired MRSA pneumonia given question of preceeding + viral syndrome. Lactate was elevated to 2.6; therefore, he was given 3L + NS. However, his BPs continued to drift to the low 90s when IVF were + stopped. Thus he is admitted to the [**Hospital Unit Name 1**] for further managment. + . + He denies N/V/D, numbness, tingling, and shortness of breath. He does + complain of decreased urine output. Review of systems is otherwise + negative. + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Pantoprazole 40mg QD + Past medical history: + Family history: + Social History: + -Chronic headaches-resolved with saline rinse s/p nasal septum surgery + -hx tension headaches,neuro-[**First Name8 (NamePattern2) 31**] [**Last Name (NamePattern1) 6697**] + -hay fever- seasonal spring through fall - triggers + migraines + -moles-atypical nevi + -genetic testing [**Doctor Last Name **] [**Doctor Last Name 5344**] disease-negative + -Deviated septum - DX by Dr. [**Last Name (STitle) **], ENT '[**61**]-nasal surgery in [**10-2**] + Mother with hypoglycemia. Father with coronary + artery disease and prostate cancer, CVA, PD. + Occupation: Lawyer + Drugs: None + Tobacco: none + Alcohol: occasional + Other: No Hx of MSM, IVDU or recent international travel. Recently + traveled to [**Location (un) 1161**] about 1 month ago. Lives with wife and two children w/ + 2 cats in JP. + Review of systems: + +lightheadedness, decreased urine output, nausea, headache. Denies V/D, + paresthesias, shortness of breath. + Flowsheet Data as of [**2163-2-23**] 09:31 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 39.4 +C (103 + Tcurrent: 39.4 +C (103 + HR: 97 (87 - 97) bpm + BP: 109/50(65) {103/50(65) - 113/64(73)} mmHg + RR: 36 (20 - 36) insp/min + SpO2: 94% + Heart rhythm: SR (Sinus Rhythm) + Total In: + 5,199 mL + PO: + 120 mL + TF: + IVF: + 779 mL + Blood products: + Total out: + 0 mL + 1,450 mL + Urine: + 250 mL + NG: + Stool: + Drains: + Balance: + 0 mL + 3,749 mL + Respiratory + O2 Delivery Device: Nasal cannula + SpO2: 94% + ABG: 7.42/32/67//-2 + Physical Examination + GENERAL: Pleasant, well appearing male in NAD + HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral + icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No + thyromegaly. + CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs + or [**Last Name (un) 1011**]. JVP= flat + LUNGS: Bronchial breath sounds throughout R lung, left lung CTA. + ABDOMEN: NABS. Soft, NT, ND. No HSM + EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial + pulses. + SKIN: No rashes/lesions, ecchymoses. + NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Normal + coordination. Gait assessment deferred + PSYCH: Listens and responds to questions appropriately, pleasant + Labs / Radiology + [image002.jpg] + [**2159-11-26**] + 2:33 A4/1/[**2162**] 07:19 PM + [**2159-11-30**] + 10:20 P + [**2159-12-1**] + 1:20 P + [**2159-12-2**] + 11:50 P + [**2159-12-3**] + 1:20 A + [**2159-12-4**] + 7:20 P + 1//11/006 + 1:23 P + [**2159-12-27**] + 1:20 P + [**2159-12-27**] + 11:20 P + [**2159-12-27**] + 4:20 P + TC02 + 21 + Other labs: Lactic Acid:1.9 mmol/L + Assessment and Plan + 37 yo otherwise healthy M p/w RLL PNA and SIRS + . + #. Relative Hypotension: [**Name2 (NI) 1490**] fever, leukocytosis, PNA on CXR the most + likely etiology is sepsis. His previous BP at his GI appt. was 114/70. + Has received aggressive IVF so far and remained relatively stable. No + cardiac disease and no renal impairment currently. + -Continue aggressive IVF repletion but low threshold for central line + and pressors if needed. Lactate trending down + -Treat pneumonia as below + -Trend lactate + - Has 2 PIVs for now + . + #. PNA. Posterior segment RLL PNA seen on CXR. No significant medical + exposures recently so less likely to be HAP. However, given his + impressive SIRS physiology in a young, healthy male, there is a concern + for CA-MRSA pneumonia. Has already received vanc, CTX, and + levofloxacin. Must also consider viral etiologies/flu. + -Con't CTX and add Azithromycin for CAP coverage as well as vancomycin + for CA-MRSA + -Obtain and F/U sputum and blood cultures and alter ABX as needed + -Nasopharyngeal aspirate for Flu. + - urine legionella antigen + . + #. Anemia: Per PCP, [**Name10 (NameIs) 6698**] HCT in [**5-2**] was 40. MCV is low and has a + significant history of GERD. ? chronic GIB as appears iron deficient. + Hemolysis labs negative. + -GAS + -Trend HCT + -F/u B12, Folate + #. GERD: Con't pantoprazole. + . + FEN: Regular diet + . + PPX: + -DVT ppx with HSC + -Bowel regimen + . + ACCESS: PIV's + . + CODE STATUS: full + . + EMERGENCY CONTACT: Wife [**Name (NI) 2774**] cell [**Telephone/Fax (1) 6699**], home [**Telephone/Fax (1) 6700**] + . + DISPOSITION: ICU pending improvement in blood pressures. + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2163-2-23**] 06:54 PM + 20 Gauge - [**2163-2-23**] 06:54 PM + Prophylaxis: + DVT: + Stress ulcer: + VAP: + Comments: + Communication: Comments: + Code status: + Disposition: +","Admission Date: [**2163-2-23**] Discharge Date: [**2163-2-26**] + +Date of Birth: [**2125-6-9**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 4365**] +Chief Complaint: +Fever + +Major Surgical or Invasive Procedure: +None + +History of Present Illness: +Patient is a 37 year old man without significant past medical +history who presents with fever, hypotension, right lower lobe +pneumonia on chest x-ray, now called out of ICU to regular +medical floor. +Patient initially presented with worsening URI symptoms, +fatigue, malaise, cough, fevers/chills, orthostasis, pleuritic +chest pain. In ED, was febrile, borderline tachycardic, low +blood pressures (SBP low 90's from baseline of low 100's), +lactate 2.6, WBC 25.9. Chest x-ray demonstrated RLL pneumonia. +Patient was administered 4 liters of NS and admitted to the +intensive care unit. +In the intensive care unit, patient was continued on IV fluid +repletion with resolution of his elevated lactate and +hypotension to baseline BPs. He was initially started on +Vancomycin, CTX, levofloxacin and transitioned to Vanc, CTX, +azithromycin. His oxygenation has remained stable in the high +90's on 3L NC. His WBC has come down to 18.6. Urine legionella +was sent and is negative. Blood cultures are no growth to date, +sputum culture contaminated, respiratory viral screen (including +influenza) is preliminarily negative, MRSA screen pending. LFTs +(including LDH) are within normal limits. +Of note, patient is also noted to have new anemia with Hct 30 -> +26 on admission, decreased from last level of 40 1 year ago (per +discussion wit PCP), with MCV of 70. Iron studies demonstrate +iron deficiency anemia. Patient has been started on iron +supplements. When questioned about this, patient denies any +melena, BRBPR. Does state that in [**Month (only) 404**] underwent surgery for +deviated septum, and after this surgery had ""horrible"" bloody +noses for 1 week, with a lot of associated blood loss. +Also of note, patient is noted to have elevated INR of 2.1. +Liver enzymes WNL, DIC labs pending. +Currently pt states he feels better than on admission, but +remains slightly achy, getting a fever again currently, +continued cough which is spastic. Pleuritic chest pain +improved. + + +Past Medical History: +-Chronic headaches-resolved with saline rinse s/p nasal septum +surgery +-hx tension headaches,neuro-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31464**] +-hay fever- seasonal spring through fall - triggers migraines +-moles-atypical nevi +-genetic testing [**Doctor Last Name **] [**Doctor Last Name 3450**] disease-negative +-Deviated septum - DX by Dr. [**Last Name (STitle) 699**], ENT '[**61**]-nasal surgery in +[**10-2**] + +Social History: +He is married. He does not smoke. He is an attorney. Lives w/ +wife and children, 2 cats, no recent travel outside of U.S. but +decades ago traveled to eastern Europe, [**Country 149**] and [**Country 28334**]. No +Hx of MSM, No Hx of IVDU, one current sexual partner (wife). +Does not smoke, occasionally drinks etoh + +Family History: +:Mother with hypoglycemia. Father with coronary +artery disease and prostate cancer, CVA, PD. + + +Physical Exam: +VITAL SIGNS: +T= 101.5 BP= 105/60 HR= 88 RR=32 O2= 92%2L NC +. +. +PHYSICAL EXAM +GENERAL: Pleasant, well appearing male in NAD +HEENT: Normocephalic, atraumatic. No conjunctival pallor. No +scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No +LAD, No thyromegaly. +CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, +rubs or [**Last Name (un) 549**]. JVP= flat +LUNGS: Bronchial breath sounds throughout R lung, left lung CTA. + +ABDOMEN: NABS. Soft, NT, ND. No HSM +EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior +tibial pulses. +SKIN: No rashes/lesions, ecchymoses. +NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Normal +coordination. Gait assessment deferred +PSYCH: Listens and responds to questions appropriately, pleasant + + + +Pertinent Results: +Labs on admission: +[**2163-2-23**] 11:00AM BLOOD WBC-25.9* RBC-4.32* Hgb-9.5* Hct-30.4* +MCV-70* MCH-21.9* MCHC-31.1 RDW-14.9 Plt Ct-244 +[**2163-2-23**] 11:00AM BLOOD Neuts-86* Bands-0 Lymphs-7* Monos-7 Eos-0 +Baso-0 Atyps-0 Metas-0 Myelos-0 +[**2163-2-24**] 04:46AM BLOOD PT-22.2* PTT-35.4* INR(PT)-2.1* +[**2163-2-24**] 04:46AM BLOOD Fibrino-403* +[**2163-2-23**] 11:00AM BLOOD Glucose-114* UreaN-19 Creat-1.2 Na-138 +K-4.1 Cl-103 HCO3-20* AnGap-19 +[**2163-2-23**] 11:00AM BLOOD ALT-14 AST-18 LD(LDH)-210 AlkPhos-70 +TotBili-1.4 DirBili-0.3 IndBili-1.1 +[**2163-2-23**] 11:00AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.5* Iron-6* +[**2163-2-23**] 11:00AM BLOOD calTIBC-394 VitB12-304 Folate-11.9 +Hapto-243* Ferritn-33 TRF-303 +[**2163-2-24**] 10:24AM BLOOD D-Dimer-1385* +[**2163-2-23**] 07:19PM BLOOD Type-ART pO2-67* pCO2-32* pH-7.42 +calTCO2-21 Base XS--2 +[**2163-2-23**] 11:37AM BLOOD Lactate-2.6* +. +MICROBIOLOGY: +[**2-23**], 4/2 blood culture - no growth to date +[**2-23**] urine legionella - negative +[**2-23**] urinalysis negative, culture negative +[**2-23**] sputum culture - cancelled (oropharyngeal flora) +[**2-24**] MRSA screen - pending +[**2-24**] Respiratory viral screen - influenza negative. +. +IMAGING: +[**2-23**] Chest x-ray AP/lateral: +IMPRESSION: Posterior segment right lower lobe pneumonia. +. +[**2-23**] repeat Chest x-ray (portable) - prelim read: +Hazy airspace consolidation in lower right lung, without +obscuration of right hemidiaphragm or right heart border, more +conspicuous than 7 hours prior, likely due to interval +hydration, and again consistent with posterior RLL pneumonia. No +other newly apparent consolidation. +. +[**2-24**] Chest x-ray: +There is mild cardiomegaly. There is new mild pulmonary edema. +Known right lower lobe pneumonia is obscured by the new +pulmonary abnormality. +. +Labs on discharge: +********* + + +Brief Hospital Course: +37 year old man without significant past medical history who +presents with fever, hypotension, leukocytosis, elevated lactate +and right lower lobe pneumonia on chest x-ray, consistent with +sepsis. +. +# Pneumonia/sepsis: Patient presented with fever, hypoxia, +leukocytosis, elevated lactate, evidence of right lower lobe +pneumonia on chest x-ray. +Was initially admitted to the intensive care unit where he +underwent aggressive volume hydration, was placed on vancomycin, +ceftriaxone and azithromycine. Urine legionella was negative, +Influenza screen was negative, sputum culture was attempted but +was cancelled as was contaminated with oropharyngeal flora. The +patient had no HIV risk factors and LDH was normal, making PCP +pneumonia less likely. +With above measures, patient stabilized with resolution of his +hypotension and elevated lactate, WBC trended down, oxygenation +improved and he was transferred to the regular medical floor. +After transfer, the patient was transitioned from vancomycin, +ceftriaxone, azithromycin to levofloxacin. He was weaned off of +oxygen completely, but remained with dyspnea on exertion and an +ambulatory O2 saturdation was in the high 80's. His exam and +chest x-ray were consistent with continued right lower lobe +pneumonia as well as small amount of volume overload, felt to be +due to his aggressive IV fluid hydration on presentation. We +therefore administerd 1 dose of lasix to assist with diuresis. +With above measures, patient improved and was discharged home to +complete a 14 day course of antibiotics, with outpatient follow +up with his primary care physician. +[**Name10 (NameIs) **] note, patient was still having fevers at time of discharge, +but remainder of clinical indicators were improved (including +oxygenation, blood pressure, heart rate, decreased WBC), so felt +he was safe for discharge with close follow up with his primary +care physician. +. +# Leukocytosis: Presumably due to presenting pneumonia as +above. Trending down on discharge. +. +# Iron deficiency anemia: Last Hct = 40 in [**5-2**], on +presentation Hct was 30, low MCV of 68-70, iron studies were +consistent with iron deficiency anemia. Hemolysis labs were +negative, B12 and folate were normal. Guiac negative on exam. +In discussion with patient regarding this new anemia, he +described 1 week of profuse epistaxis in [**Month (only) **] following +repair of his septal deviation, which was felt to be the +possible etiology of his iron deficiency (also, patient is a +vegetarian, and therefore possibly unable to increase stores of +iron following the bleeding). His hematocrit remained stable in +the mid to high 20's during his hospitalization. +Given his history of GERD, he should likely have GI follow up +with possible endoscopy as an outpatient. +He otherwise was started on iron supplementation and should +follow up regarding this issue. +. +# Elevated INR: Elevated at 2.1 on admission. DIC labs and +Hemolysis labs were negative. Patient received 1 dose of +vitamin K, with INR decreasing at time of discharge (at 1.4 at +time of discharge). +. +# GERD: Continued outpatient pantoprazole. +. +EMERGENCY CONTACT: Wife [**Name (NI) **] cell [**Telephone/Fax (1) 31465**] Home +[**Telephone/Fax (1) 31466**] + +Medications on Admission: +Protonix 40mg QD + +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. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 +hours) as needed. +3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every +6 hours) as needed. +4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY +(Daily) for 10 days. +[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*0* +5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) +Tablet PO BID (2 times a day). +[**Telephone/Fax (1) **]:*60 Tablet(s)* Refills:*2* +6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H +(every 6 hours) as needed. +[**Telephone/Fax (1) **]:*1 bottle* Refills:*0* +7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: +Two (2) puffs Inhalation every 2 hours as needed for shortness +of breath or wheezing: If need to use more frequently than every +4-6 hours, please notify your physician. +[**Name Initial (NameIs) **]:*1 cartridge* Refills:*0* + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Sepsis +Pneumonia, bacterial + + +Discharge Condition: +Stable. Some continued shortness of breath although oxygenation +is stable. Continued fevers. + + +Discharge Instructions: +You were admitted to the hospital with pneumonia and sepsis. +You were treated with antibiotics with improvement in your +symptoms. + +Please take medications as directed. New medications include: +- Levofloxacin to complete full coures of antibiotics +- Iron (ferrous sulfate) to continue indefinitely (will follow +up with your primary care physician regarding this issue) +- Albuterol inhaler to take as needed +- Robitussin with codeine to take as needed + +Please follow up with appointments as directed. + +Please contact physician if develop worsening shortness of +breath/cough, chest pain/pressure, increased fevers/chills, any +other questions or concerns + +Followup Instructions: +Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6923**] +[**Name (STitle) 6924**] ([**Telephone/Fax (1) 8417**] on Tuesday [**3-1**] at 1:30pm (you will be +seeing a nurse practitioner in the office). + + + +","37 yo m with a pmh of sinus headaches s/p septal surgery and gerd who presented to the ed from clinic with fevers. he reports that he thought he had a uri for the last 3-4 days. then last night he developed high fevers and fatigue. sunday he began feeling as if he had a cold then monday began feeling achy this progressed on teusday and then teusday night he began having shaking chills and back pain. he went to see his pcp's office today. they noted a temperature of 102 and pleuritic chest pain and sent him to the ed for further work up because he was so ill appearing. he also notes a sore throat and productive cough with clear sputum, chills and rigors last night and pleuritic right chest pain. he had some nausea and dizziness as well. in the ed, his initial vital signs were t 98.9, hr 94, bp 96/54, rr 17, o2sat 100. he had a cxr which suggested rll pneumonia. he was ordered for levofloxacin, ceftriaxone and vancomycin as the ed was concerned over community acquired mrsa pneumonia given question of preceeding viral syndrome. lactate was elevated to 2.6; therefore, he was given 3l ns. however, his bps continued to drift to the low 90s when ivf were stopped. thus he is admitted to the [**hospital unit name 1**] for further managment. he denies n/v/d, numbness, tingling, and shortness of breath. he does complain of decreased urine output. review of systems is otherwise negative.","37 year old man without significant past medical history who presents with fever, hypotension, leukocytosis, elevated lactate and right lower lobe pneumonia on chest x-ray, consistent with sepsis.","37 yo m with a pmh of sinus headaches s/p septal surgery and gerd who presented to the ed from clinic with fevers. they noted a temperature of 102 and pleuritic chest pain and sent him to the ed for further work up because he was so ill appearing. he had some nausea and dizziness as well. in the ed, his initial vital signs were t 98.9, hr 94, bp 96/54, rr 17, o2sat 100. he had a cxr which suggested rll pneumonia. lactate was elevated to 2.6; therefore, he was given 3l ns.","['The doctor said he thought he had a uri for the last 3-4 days.\nHe also noticed a sore throat and strained sphincter.\nThe ed was also noted to have a sore chest and productive cough.\nBut he was given a dose of levconazole and a coltoxaban.\nIt was found to be high in 102 and pleurisy, bronchiolitis and constipation.\nAnd he was also given a coltrigam and vancomycin.\nThis was the same dose as the one he was ordered for.\nand he was told to']",37 yo m with a pmh of sinus headaches s/p septal surgery and gerd who presented to the ed with fevers. sunday he began feeling as if he had a cold then monday began feeling as if he had a cold. he went to see his pcp's office today. they noted a temperature of 102 and pleuritic chest pain.,"[""37 yo man with sinus headaches presents to the hospital for further treatment. his initial vital signs were positive, but later went downhill after surgery and was ordered by an antibiotic company as part of community acquired pneumonia case in which there is no evidence that this patient had viral syndrome or not at all; however lactate levels continued up until low 90' when they stopped him from taking 3l-naloxacinous drugs (ivf).""]","they noted a temperature of 102 and pleuritic chest pain and sent him to the ed for further work up because he was so ill appearing. +he also notes a sore throat and productive cough with clear sputum, chills and rigors last night and pleuritic right chest pain. +he was ordered for levofloxacin, ceftriaxone and vancomycin as the ed was concerned over community acquired mrsa pneumonia given question of preceeding viral syndrome.","37 yo m with a pmh of sinus headaches s/p septal surgery and gerd who presented to the ed from clinic with fevers.he reports that he thought he had a uri for the last 3-4 days.then last night he developed high fevers and fatigue.sunday he began feeling as if he had a cold then monday began feeling achy this progressed on teusday and then teusday night he began having shaking chills and back pain.he went to see his pcp's office today.they noted a temperature of 102 and pleuritic chest pain and sent him to the ed for further work up because he was so ill appearing.he also notes a sore throat and productive cough with clear sputum, chills and rigors last night and pleuritic right chest pain.he had some nausea and dizziness as well.in the ed, his initial vital signs were t 98.he was ordered for levofloxacin, ceftriaxone and vancomycin as the ed was concerned over community acquired mrsa pneumonia given question of preceeding viral syndrome.","[{'rouge-1': {'r': 0.2962962962962963, 'p': 0.10256410256410256, 'f': 0.15238094856054432}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.2222222222222222, 'p': 0.07692307692307693, 'f': 0.11428571046530626}}]","[{'rouge-1': {'r': 0.07407407407407407, 'p': 0.03571428571428571, 'f': 0.04819276669473113}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.07407407407407407, 'p': 0.03571428571428571, 'f': 0.04819276669473113}}]","[{'rouge-1': {'r': 0.18518518518518517, 'p': 0.11627906976744186, 'f': 0.1428571381183675}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.14814814814814814, 'p': 0.09302325581395349, 'f': 0.11428570954693897}}]","[{'rouge-1': {'r': 0.2222222222222222, 'p': 0.0821917808219178, 'f': 0.11999999605800013}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.14814814814814814, 'p': 0.0547945205479452, 'f': 0.07999999605800019}}]","[{'rouge-1': {'r': 0.18518518518518517, 'p': 0.09090909090909091, 'f': 0.12195121509518161}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.18518518518518517, 'p': 0.09090909090909091, 'f': 0.12195121509518161}}]","[{'rouge-1': {'r': 0.2962962962962963, 'p': 0.07079646017699115, 'f': 0.11428571117244907}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.25925925925925924, 'p': 0.061946902654867256, 'f': 0.09999999688673479}}]",0.296296296,0.102564103,0.152380949,0,0,0,0.222222222,0.076923077,0.11428571,0.074074074,0.035714286,0.048192767,0,0,0,0.074074074,0.035714286,0.048192767,0.185185185,0.11627907,0.142857138,0,0,0,0.148148148,0.093023256,0.11428571,0.222222222,0.082191781,0.119999996,0,0,0,0.148148148,0.054794521,0.079999996,0.185185185,0.090909091,0.121951215,0,0,0,0.185185185,0.090909091,0.121951215,0.296296296,0.07079646,0.114285711,0,0,0,0.259259259,0.061946903,0.099999997 +81775,177734,9136,"Chief Complaint: hematemesis + HPI: + 59 y/o M with hx of hepatitis C cirrohsis who presents to the emergency + room today with hematemesis. He had been feeling well except for mild + fluid overload and back pain until yesterday when he spit up about a + cupful of blood. He denies abdominal pain, nausea, vomiting, cough, + fevers, chills. Has mild abominal pain and increased bloating. Has + chronic back pain as well. He denies bloody or melanotic stools. His + last BM was this morning. He has diarrhea when he takes lactulose, but + otherwise has pretty normal BMs. + . + Of note, he had recently been hospitalized at [**Hospital 1233**] hospital and + discharged a little over a week ago. He had problems with + encephalopathy, increased fluid overload. He had a 3L paracentesis, + but per him, no SBP. He was having fevers and chills at that time. + Also, while hospitalized, he was having difficulty breathing, but that + improved with the paracentesis. + . + In the ED, initial vs were T 97.2, p 79, bp 105/66, r 20, 97% on RA. + Patient was started on an octreotide gtt and given protonix 40 mg IV + and zofran in the ED. He did not receive any blood products in the ED. + . + On the floor, patient is in bed, comfortable except for his chronic + back pain. Does not complain of dizziness, light-headedness, stomach + ache, nausea, vomiting. + Patient admitted from: [**Hospital1 19**] ER + History obtained from [**Hospital 15**] Medical records + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Octreotide - 8 mcg/hour + Other ICU medications: + Other medications: + Past medical history: + Family history: + Social History: + Past Medical History: + # Hepatitis C Cirrhosis + -completed four years in the COPILOT trial in [**2117-9-8**]. He was + treated with interferon and ribavirin prior to that but did not have a + sustained virologic response + # Esophageal Varices + -s/p banding multiple times, most recently [**2122-3-8**] + # Ascites + . + Medications: + # Fluticasone 50 mcg nasally 2 sprays daily + # Adviar 100-50 mcg [**Hospital1 7**] + # Lasix 40 mg daily + # Ketoconazole cream [**Hospital1 7**] + # Lactulose 30 mg TID PRN + # Nadolol 10 mg daily + # Oxycodone 5 mg q6hrs PRN + # Protonix 40 mg daily + # Potassium Chloride 20 mg daily + # Spironolactone 100 mg daily + # Sonata 10 mg qHS PRN + # Tylenol 1000 mg [**Hospital1 7**] PRN + # Tums PRN + . + Allergies: + [**Name (NI) 6725**] + dad with DM, mom with COPD; otherwise non-contributory + Occupation: + Drugs: none + Tobacco: few cigarettes daily + Alcohol: heavy drinking in past; none for 9+ years + Other: + Review of systems: + Constitutional: Fatigue, weight gain, bloating + Cardiovascular: No(t) Chest pain, Edema + Respiratory: Dyspnea, prior to previous admission + Gastrointestinal: Abdominal pain, Nausea, Emesis, hematemesis + Musculoskeletal: Joint pain, back pain + Heme / Lymph: Anemia + Flowsheet Data as of [**2123-4-2**] 06:45 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since [**25**] AM + Tmax: 36.4 +C (97.6 + Tcurrent: 36.4 +C (97.6 + HR: 87 (87 - 97) bpm + BP: 123/62(76) {123/62(76) - 134/67(78)} mmHg + RR: 12 (12 - 18) insp/min + SpO2: 95% + Height: 69 Inch + Total In: + 2,006 mL + PO: + TF: + IVF: + 6 mL + Blood products: + Total out: + 0 mL + 200 mL + Urine: + NG: + Stool: + Drains: + Balance: + 0 mL + 1,806 mL + Respiratory + SpO2: 95% + Physical Examination + General Appearance: Well nourished, Overweight / Obese + Eyes / Conjunctiva: PERRL, Conjunctiva pale + Head, Ears, Nose, Throat: Normocephalic + Cardiovascular: (PMI Normal), (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 : ) + Abdominal: Bowel sounds present, Distended, epigastric tenderness, + distended, no rebound or guarding + Extremities: Right lower extremity edema: 1+, Left lower extremity + edema: 1+ + Skin: Not assessed + Neurologic: Attentive, Responds to: Not assessed, Movement: Not + assessed, Tone: Not assessed + Labs / Radiology + [image002.jpg] + Fluid analysis / Other labs: see OMR + wbc 7.3, hct 34.4 (baseline 41 [**Month (only) **]), plt 112 + electrolytes were within normal limits, ammonia 43 + pt 19.6, ptt 43.8, inr 1.8 + AFP 4.3 (from yesterday) + alt 22, ast 53, alk phos 88, t bili 4.1, albumin 2.2 + Imaging: none, CXR pending + Microbiology: none + ECG: none + Assessment and Plan + .H/O ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING) + .H/O BACK PAIN + .H/O CIRRHOSIS OF LIVER, OTHER + Assessment and Plan: + 59 y/o M with ESLD secondary to hepatitis C cirrhosis who presents to + the emergency room today with hematemesis. + . + # Hematemesis: has been ""spitting up"" blood the last few days without + nausea or vomiting. Likely is from an upper GI source, either + gastritis vs. varices vs. peptic ulcer disease. Liver team is + following. + - EGD will be post poned as it may be hemoptysis vs. oropharygeal bleed + - 2 large bore IVs + - will transfuse more for hct <25 or active bleeding; maintain active + type and cross + - protonix IV BID + - octreotide gtt will be stopped + - ceftriaxone 1 gm daily for now + - FFP for INR >2.0 or active bleeding + - vitamin K now + - CXR to evaluate for lung abnormality incase the blood is from the + pulmonary system rather than GI + . + # Anemia: has hct of 35 down from baseline of around 40 (although last + hct was in [**2122-7-8**]). Could be anemia of chronic disease, from + upper GI bleed or slow lower GI bleed. + - add on Fe studies, vit B12, folate + - EGD as above per liver in future + - transfuse for Hct <25 + - plan for colonoscopy, likely this admission + . + # Abdominal Pain: again unclear etiology, could be secondary to either + gastritis, peptic ulcer disease or potentially SBP. + - EGD as above + - ceftriaxone 1 gm daily + - diagnostic paracentesis per liver team + - ultrasound liver with dopplers in AM + . + # Ascites: is slowly reaccumulating ascites since last admission one + week ago per patient and his brother. Is on lasix and aldactone at + home and has been compliant. + - hold lasix/aldactone in setting of possible bleeding; restart in AM + - diagnostic para to r/o SBP + . + # Hepatitis C Cirrhosis: having worsening liver disease with rising + INR, increasing ascites and decreasing albumin. + - supportive care with treatments as above + - AFP normal yesterday, continue to trend as outpatient + - liver US with dopplers tomorrow + . + # Back Pain: chronic in nature, stable excpet has not been receiving + his PO medications today. Continue to hold PO meds. + - morphine IV PRN + - consider advancing to clears + . + # FEN: No IVF, replete electrolytes, NPO + # Prophylaxis: pneumoboots, hold SQ heparin in setting of bleed + # Access: peripherals + # Communication: Patient + # Code: Full (discussed with patient) + # Disposition: ICU for now, will call out to floor this evening + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2123-4-2**] 06:13 PM + 20 Gauge - [**2123-4-2**] 06:13 PM + Prophylaxis: + DVT: Boots + Stress ulcer: PPI + VAP: + Comments: + Communication: Patient discussed on interdisciplinary rounds Comments: + Code status: Full code + Disposition: ICU +","Admission Date: [**2123-4-2**] Discharge Date: [**2123-4-6**] + +Date of Birth: [**2063-10-17**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 1377**] +Chief Complaint: +Hemoptysis + +Major Surgical or Invasive Procedure: +Diagnostic Paracentesis +Endoscopy + + +History of Present Illness: +59 y/o M with hx of hepatitis C cirrohsis who presents to the +emergency room today with hematemesis. He had been feeling well +except for mild fluid overload and back pain until yesterday +when he spit up about a cupful of blood. He denies abdominal +pain, nausea, vomiting, cough, fevers, chills. Has mild abominal +pain and increased bloating. Has chronic back pain as well. + +Of note, he had recently been hospitalized at [**Hospital **] hospital +and discharged a little over a week ago. He had problems with +encephalopathy, increased fluid overload. He had a 3L +paracentesis, but per him, no SBP. He was having fevers and +chills at that time. Also, while hospitalized, he was having +difficulty breathing, but that improved with the paracentesis. + +In the ED, initial vs were T 97.2, p 79, bp 105/66, r 20, 97% on +RA. Patient was started on an octreotide gtt and given protonix +40 mg IV and zofran in the ED. He did not receive any blood +products in the ED. + +On the floor, patient is in bed, comfortable except for his +chronic back pain. Does not complain of dizziness, +light-headedness, stomach ache, nausea, vomiting. + +Review of systems: +(+) 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: +# Hepatitis C Cirrhosis +-completed four years in the COPILOT trial in [**2117-9-8**]. He +was treated with interferon and ribavirin prior to that but did +not have a sustained virologic response +# Esophageal Varices +-s/p banding multiple times, most recently [**2122-3-8**] +# Ascites + + +Social History: +- Tobacco: yes, few cigarettes daily +- Alcohol: used to drink when younger; no drinking in 9+ years +- Illicits: none + + +Family History: +dad with DM, mom with COPD; otherwise non-contributory + +Physical Exam: +Vitals: T 97.6, P 88, BP 123/62, R 15, 97% on RA +General: Alert, oriented, no acute distress +HEENT: Sclera anicteric, MMM, oropharynx clear +Neck: supple, JVP not elevated, no LAD +Lungs: Clear to auscultation bilaterally, no wheezes, rales, +ronchi +CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, +gallops +Abdomen: mildly distended, firm, tympanic, epigastric point +tenderness, no rebound or guarding, positive BS +GU: no foley +Ext: warm, well perfused, 2+ pulses, 1+ B edema + + +Pertinent Results: +LABS ON ADMISSION: + +[**2123-4-2**] 02:20PM PT-19.6* PTT-43.8* INR(PT)-1.8* +[**2123-4-2**] 02:16PM AMMONIA-43 +[**2123-4-2**] 02:00PM GLUCOSE-104* UREA N-8 CREAT-0.8 SODIUM-133 +POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11 +[**2123-4-2**] 02:00PM ALT(SGPT)-22 AST(SGOT)-53* ALK PHOS-88 TOT +BILI-4.1* +[**2123-4-2**] 02:00PM LIPASE-32 +[**2123-4-2**] 02:00PM ALBUMIN-2.2* +[**2123-4-2**] 02:00PM WBC-7.3 RBC-3.21* HGB-11.6* HCT-34.4* +MCV-107* MCH-36.0* MCHC-33.6 RDW-15.2 +[**2123-4-2**] 02:00PM NEUTS-67.4 LYMPHS-18.0 MONOS-11.3* EOS-2.2 +BASOS-1.1 +[**2123-4-2**] 02:00PM PLT COUNT-112* +[**2123-4-1**] 10:40AM UREA N-9 CREAT-0.9 SODIUM-132* POTASSIUM-4.2 +CHLORIDE-95* TOTAL CO2-29 ANION GAP-12 +[**2123-4-1**] 10:40AM estGFR-Using this +[**2123-4-1**] 10:40AM ALT(SGPT)-23 AST(SGOT)-57* ALK PHOS-90 TOT +BILI-4.8* DIR BILI-1.6* INDIR BIL-3.2 +[**2123-4-1**] 10:40AM ALBUMIN-2.4* +[**2123-4-1**] 10:40AM AFP-4.3 +[**2123-4-1**] 10:40AM WBC-8.0 RBC-3.30* HGB-11.7* HCT-36.5* +MCV-111* MCH-35.6* MCHC-32.2 RDW-14.4 +[**2123-4-1**] 10:40AM NEUTS-68 BANDS-0 LYMPHS-16* MONOS-13* EOS-1 +BASOS-1 ATYPS-1* METAS-0 MYELOS-0 +[**2123-4-1**] 10:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL +POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL +POLYCHROM-OCCASIONAL TARGET-OCCASIONAL +[**2123-4-1**] 10:40AM PLT SMR-LOW PLT COUNT-102* +[**2123-4-1**] 10:40AM PT-20.0* INR(PT)-1.8* +[**2123-4-1**] 10:40AM PT-20.0* INR(PT)-1.8* +. +Micro: +[**2123-4-2**] 7:28 pm PERITONEAL FLUID PERITONEAL. + + GRAM STAIN (Final [**2123-4-3**]): + 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR +LEUKOCYTES. + NO MICROORGANISMS SEEN. + + FLUID CULTURE (Final [**2123-4-6**]): NO GROWTH. + + ANAEROBIC CULTURE (Preliminary): NO GROWTH. +. +Images: CXR [**2123-4-3**] +IMPRESSION: Blunting of the posterior costophrenic sulci likely +due to small pleural effusions. +. +[**2123-4-3**] Abdominal Ultrasound +IMPRESSIONS: +1. Cirrhotic liver, without focal liver lesion seen. +2. Splenomegaly as before. New moderate ascites since [**2122-8-5**]. +3. Patent hepatic vasculature, with normal hepatopetal flow +within portal veins. +. +Discharge labs: +[**2123-4-6**] 06:00AM BLOOD WBC-4.6 RBC-2.89* Hgb-10.5* Hct-31.4* +MCV-109* MCH-36.3* MCHC-33.5 RDW-16.4* Plt Ct-95* +[**2123-4-6**] 06:00AM BLOOD PT-20.1* PTT-43.4* INR(PT)-1.9* +[**2123-4-6**] 06:00AM BLOOD Glucose-79 UreaN-12 Creat-0.7 Na-134 +K-3.9 Cl-103 HCO3-26 AnGap-9 +[**2123-4-6**] 06:00AM BLOOD ALT-17 AST-44* LD(LDH)-277* AlkPhos-70 +TotBili-2.9* +[**2123-4-6**] 06:00AM BLOOD Albumin-1.8* Calcium-7.6* Phos-3.6 Mg-2.1 +. +Iron studies: +[**2123-4-5**] 06:36AM BLOOD calTIBC-127* VitB12-1301* Folate-10.2 +Ferritn-522* TRF-98*\ +. +EGD [**4-5**]: +Unable to intubate the esophagus secondary to patient agitation +and discomfort. Unable to increase sedatives secondary to +hypotension to 70's. Responded to 1.5 L fluid bolus. Patient +currently stable. NPO after midnight. EGD tomorrow under MAC +anesthesia. +. +EGD [**4-6**]: +Small AVM at GE junction +Varices at the lower third of the esophagus and gastroesophageal +junction +Erythema, congestion, abnormal vascularity and mosaic appearance +in the whole stomach compatible with portal hypertensive +gastropathy +Otherwise normal EGD to third part of the duodenum +Recommendations: grade I esophageal varices. Not large enough to +band. Portal hypertensive gastropathy. Please continue current +management. + +Brief Hospital Course: +Mr. [**Known lastname 31469**] is a 59 year old man with ESLD secondary to hepatitis +C cirrhosis who presented with an episode of +hemoptysis/hematemesis. He was initially admitted to the ICU out +of concern for ongoing bleeding. His hematocrit remained stable. + +. +# Hematemesis/Hemoptysis: Unclear initially if episodes of +hemoptysis or hematemesis. Then, patient clarified episode as +hemoptysis (no vomiting, just coughed up blood gob). He has a +history of varices requiring banding. Hct drifted down slightly +but then stable throughout hospitalization. [**Hospital1 **] PPI. Attempted +EGD on [**4-5**], but patient hypotensive with increased sedation +needed to prevent gagging. As such, procedure did not occur. On +[**4-6**] patient sedated with general anesthesia and underwent EGD. +No evidence of active bleed, and no varices requiring banding. +Patient tolerated EGD well, was feeling well after procedure +ended. Discharged later that day. +Given GI was not believed to be source of hemoptysis, set-up +patient with pulmonologist appointment and CT scan of the chest; +this was explained to patient. There is obviously concern for +malignancy in smoker, 59 y/o male, and we feel this needs a +pulmonary work-up with imaging and specialist investigation. +Patient and pulmonologist aware of need for imaging and +appointment. +. +# Abdominal Pain: Resolved. No evidence of SBP. +. +# Fatigue: Likely due to anemia, hypotension, cirrhosis. +Monitored, keen to go home. + +# Ascites: Restarted furosemide and spironolactone. +. +# Hepatitis C Cirrhosis: Continue current treatment of +furosemide, nadolol, and spironolactone. +. +# Back Pain: Chronic and stable. Oxycodone - home regimen. +. +# ?COPD: Patient without reported history of COPD but on +inhalers at home. Continue home medications +. +Code: Mr. [**Known lastname 31469**] was a full code during this admission. + +Medications on Admission: +# Fluticasone 50 mcg nasally 2 sprays daily +# Adviar 100-50 mcg [**Hospital1 **] +# Lasix 40 mg daily +# Ketoconazole cream [**Hospital1 **] +# Lactulose 30 mg TID PRN +# Nadolol 10 mg daily +# Oxycodone 5 mg q6hrs PRN +# Protonix 40 mg daily +# Potassium Chloride 20 mg daily +# Spironolactone 100 mg daily +# Sonata 10 mg qHS PRN +# Tylenol 1000 mg [**Hospital1 **] PRN +# Tums PRN + + +Discharge Medications: +1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) +Spray Nasal DAILY (Daily). +2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: +One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). +3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +4. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). +5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +6. Zaleplon 10 mg Capsule Sig: One (1) Capsule PO QHS (once a +day (at bedtime)) as needed for insomnia. +7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) +Tablet, Chewable PO QID (4 times a day) as needed for dyspepsia. + +8. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times +a day). +9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 +hours) as needed for severe pain. +10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) +Tablet, Delayed Release (E.C.) PO once a day. +11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal +Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. +12. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO +three times a day as needed for confusion or constipation. +13. CT scan at [**Hospital1 18**] [**Hospital Ward Name 516**] Radiology, before [**2123-5-7**]. + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Primary Diagnosis: +Hepatitis C Cirrhosis +Hemoptysis +Esophageal varices + + +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 with bleeding. There was a concern that +you may have been bleeding from varices in your esophagus. You +underwent an EGD or endoscopy with anesthesia which used a +camera to look at your esophagus and stomach. This did not show +bleeding; it only showed very small varices that need to be +monitored every 6 months. Your blood counts remained stable +while you were in the hospital. + +You will need to follow up with a pulmonary (lung) doctor to +make sure that the blood you coughed up was not coming from your +lungs. Before going to the appointment with the pulmonologist on +[**5-7**], please have a CT scan done at [**Hospital1 18**], at your convenience. +It is important that they have the results of the CT scan when +you go to the appointment with the lung doctor, so that they can +take care of you. + +We made no changes to your medications. Please continue your +home medications as prescribed. + +Followup Instructions: +Because you coughed up blood, we would like you to have your +lungs examined. Please go to [**Hospital1 18**] [**Hospital Ward Name 516**] Radiology to have +a CT scan (please call the attached phone # first, to schedule +an appointment for the scan). Also, please go to the following +important appointment at the Pulmonary (Lung) clinic: +[**Last Name (LF) 2974**], [**5-7**] at 8:30AM; [**Hospital Ward Name 23**] Building, [**Location (un) 436**], +Medical specialties. Dr. [**First Name (STitle) 437**]. [**Telephone/Fax (1) 612**]. +Please have the CT scan done before the appointment so that its +results can be used to guide your care. +. +Previously-scheduled appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] +Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2123-4-14**] at 11:10 + + + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] + +Completed by:[**2123-4-7**]","59 y/o m with hx of hepatitis c cirrohsis who presents to the emergency room today with hematemesis. he had been feeling well except for mild fluid overload and back pain until yesterday when he spit up about a cupful of blood. he denies abdominal pain, nausea, vomiting, cough, fevers, chills. has mild abominal pain and increased bloating. has chronic back pain as well. he denies bloody or melanotic stools. his last bm was this morning. he has diarrhea when he takes lactulose, but otherwise has pretty normal bms. of note, he had recently been hospitalized at [**hospital 1233**] hospital and discharged a little over a week ago. he had problems with encephalopathy, increased fluid overload. he had a 3l paracentesis, but per him, no sbp. he was having fevers and chills at that time. also, while hospitalized, he was having difficulty breathing, but that improved with the paracentesis. in the ed, initial vs were t 97.2, p 79, bp 105/66, r 20, 97% on ra. patient was started on an octreotide gtt and given protonix 40 mg iv and zofran in the ed. he did not receive any blood products in the ed. on the floor, patient is in bed, comfortable except for his chronic back pain. does not complain of dizziness, light-headedness, stomach ache, nausea, vomiting. patient admitted from: [**hospital1 19**] er history obtained from [**hospital 15**] medical records",mr. [**known lastname 31469**] is a 59 year old man with esld secondary to hepatitis c cirrhosis who presented with an episode of hemoptysis/hematemesis.,"59 y/o m with hx of hepatitis c cirrohsis who presents to the emergency room today with hematemesis. he had been feeling well except for mild fluid overload and back pain until yesterday when he spit up about a cupful of blood. has mild abominal pain and increased bloating. of note, he had recently been hospitalized at [**hospital 1233**] hospital and discharged a little over a week ago. he had problems with encephalopathy, increased fluid overload. he did not receive any blood products in the ed. patient admitted from: [**hospital1 19**] er history obtained from [**hospital 15**] medical records","['He has been suffering from acute fluid overload and nausea.\nHe has had several bouts of vomiting and colds.\nHas mild abdominal pain and is in bed comfortably.\nWas hospitalized at (XXX) 123rd (XXX), 123rd, 123rd and 123rd.\nHad a 3lb paracectomy and zofranosum.\nNo sphincteritis.']","59 y/o m with cirrohsis presents to the emergency room with hematemesis. he had been feeling well except for mild fluid overload and back pain. he denies abdominal pain, nausea, vomiting, cough, fevers, chills.","['59-year old presents to the emergency room with severe back pain and fluid overload. patient has mild abdominal discomfort, nausea vomiting; denies bloody or melanotic stool but otherwise is normal in his condition as well!']","he had been feeling well except for mild fluid overload and back pain until yesterday when he spit up about a cupful of blood. +he denies abdominal pain, nausea, vomiting, cough, fevers, chills. +on the floor, patient is in bed, comfortable except for his chronic back pain.","59 y/o m with hx of hepatitis c cirrohsis who presents to the emergency room today with hematemesis.he had been feeling well except for mild fluid overload and back pain until yesterday when he spit up about a cupful of blood.he denies abdominal pain, nausea, vomiting, cough, fevers, chills.has mild abominal pain and increased bloating.he has diarrhea when he takes lactulose, but otherwise has pretty normal bms.of note, he had recently been hospitalized at [**hospital 1233**] hospital and discharged a little over a week ago.he had problems with encephalopathy, increased fluid overload.he had a 3l paracentesis, but per him, no sbp.he was having fevers and chills at that time.also, while hospitalized, he was having difficulty breathing, but that improved with the paracentesis.","[{'rouge-1': {'r': 0.34782608695652173, 'p': 0.10526315789473684, 'f': 0.16161615804917875}, 'rouge-2': {'r': 0.043478260869565216, 'p': 0.010526315789473684, 'f': 0.016949149403907505}, 'rouge-l': {'r': 0.30434782608695654, 'p': 0.09210526315789473, 'f': 0.14141413784715853}}]","[{'rouge-1': {'r': 0.13043478260869565, 'p': 0.075, 'f': 0.09523809060216702}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13043478260869565, 'p': 0.075, 'f': 0.09523809060216702}}]","[{'rouge-1': {'r': 0.13043478260869565, 'p': 0.09375, 'f': 0.1090909042247936}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13043478260869565, 'p': 0.09375, 'f': 0.1090909042247936}}]","[{'rouge-1': {'r': 0.17391304347826086, 'p': 0.11428571428571428, 'f': 0.1379310296967897}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.17391304347826086, 'p': 0.11428571428571428, 'f': 0.1379310296967897}}]","[{'rouge-1': {'r': 0.13043478260869565, 'p': 0.07317073170731707, 'f': 0.09374999539550805}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13043478260869565, 'p': 0.07317073170731707, 'f': 0.09374999539550805}}]","[{'rouge-1': {'r': 0.34782608695652173, 'p': 0.08791208791208792, 'f': 0.14035087397199147}, 'rouge-2': {'r': 0.043478260869565216, 'p': 0.008130081300813009, 'f': 0.013698627482642662}, 'rouge-l': {'r': 0.30434782608695654, 'p': 0.07692307692307693, 'f': 0.12280701432286867}}]",0.347826087,0.105263158,0.161616158,0.043478261,0.010526316,0.016949149,0.304347826,0.092105263,0.141414138,0.130434783,0.075,0.095238091,0,0,0,0.130434783,0.075,0.095238091,0.130434783,0.09375,0.109090904,0,0,0,0.130434783,0.09375,0.109090904,0.173913043,0.114285714,0.13793103,0,0,0,0.173913043,0.114285714,0.13793103,0.130434783,0.073170732,0.093749995,0,0,0,0.130434783,0.073170732,0.093749995,0.347826087,0.087912088,0.140350874,0.043478261,0.008130081,0.013698627,0.304347826,0.076923077,0.122807014 +66264,173568,9141,"Chief Complaint: weakness/ hypotension + HPI: + This is a 41 year-old female with a history of gastric + bypass in [**2092**], seizure d/o, chonic back pain, h/o dilated + cardiomyopathy now resolved (EF >55% 9/09) who presents with diarrhea + and hypotension. + . + Patient was recently admitted from [**Date range (1) 11145**] and treated with c. diff + colitis. She was initially treated with IV flagyl and po vanco, but + was discharged on a 14 day course of po vanco (last day [**12-7**]). The + patient was also on TPN via a PICC line that was d/c during that + admission over concern for infection, although the culture remained + negative. She also underwent a paracentesis that showed >250 polys, + but GI felt it was reactive in the setting of pancolitis and not SBP. + She was not treated with additional antibiotics and cultures returned + no growth. + In the ED, the patient arrived with SBP in the 60s and emergent right + femoral line was placed and she was started on levophed. She was + mentating and reported diarrhea, weakness and increased thrist. Her + stools were initially guaiac positive and she was given 1U pRBC, Hct + returned 33 and no additional blood procducts were given. She was given + 4L NS and intubated for agitation and mild respiratory distress (CMV, + Vt:450, PEEP 5, RateL 18, FiO2 100%). Her blood pressures improved to + 105/64 on 0.09mcg/kg/min of levophed, but with HR 134. She underwent + CT-scan of abd/pelvis that showed bibasilar opacities, small [**Last Name (un) 11146**], + and unchaged wall thickening consistent with pancolitis. Her lactate + was 3.7 and she was ordered for flagyl, IV vanco, and zosyn. + Patient admitted from: [**Hospital1 5**] ER + History obtained from Medical records + Patient unable to provide history: Sedated + Allergies: + Ultram (Oral) (Tramadol Hcl) + question sezuir + Last dose of Antibiotics: + Infusions: + Norepinephrine - 0.2 mcg/Kg/min + Midazolam (Versed) - 5 mg/hour + Fentanyl - 100 mcg/hour + Other ICU medications: + Other medications: + Past medical history: + Family history: + Social History: + . Seizure disorder, has not had seizure in 4 years. Described + as grand mal seizure possibly in the setting of ultram. + 2. Status post gastric bypass in [**2092**]. + 3. DJD L5-S1, facet DJD and L4-L5 annular tear. + 4. Systolic/diastolic congestive heart failure due to + cardiomyopathy of unclear etiology, likely viral diagnosed in + 9/[**2101**]. EBV IGM neg, CMV IGM equivocal, Lyme neg + 5. Depression. + 6. Chronic back pain, narcotics dependence for the past several + 7. Nausea, weight loss, nutritional deficiencies of unclear + etiology, possibly related to depression, malabsorption or + related to her gastric bypass. She was recommended to followup + with outpatient gastroenterology for colonoscopy + 8. Normocytic anemia per notes attributed to iron deficiency in + the past although no evidence in lab values here. + unable to obtain + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: unable to obtain + Review of systems: + Flowsheet Data as of [**2102-12-25**] 08:29 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since [**04**] AM + Tmax: 38.3 +C (101 + Tcurrent: 38.3 +C (101 + HR: 113 (113 - 125) bpm + BP: 81/46(54) {81/46(54) - 136/65(84)} mmHg + RR: 19 (19 - 21) insp/min + SpO2: 97% + Heart rhythm: ST (Sinus Tachycardia) + Wgt (current): 83.1 kg (admission): 83.1 kg + Total In: + 7,061 mL + PO: + TF: + IVF: + 3,061 mL + Blood products: + Total out: + 0 mL + 25 mL + Urine: + 25 mL + NG: + Stool: + Drains: + Balance: + 0 mL + 7,036 mL + Respiratory + O2 Delivery Device: Endotracheal tube + Ventilator mode: CMV/ASSIST/AutoFlow + Vt (Set): 450 (450 - 450) mL + RR (Set): 18 + RR (Spontaneous): 3 + PEEP: 5 cmH2O + FiO2: 50% + PIP: 11 cmH2O + SpO2: 97% + Ve: 10.5 L/min + Physical Examination + General Appearance: Well nourished, No acute distress, Overweight / + Obese, No(t) Thin, No(t) Anxious, Diaphoretic, intubated and sedated + Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale + Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube + Cardiovascular: (S1: Normal), (S2: Normal) + 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: No(t) + Clear : , Crackles : mild at b/l bases) + Abdominal: Bowel sounds present, Tender: unable to assess, mildly + distended + Extremities: Right lower extremity edema: Trace, Left lower extremity + edema: Trace + Skin: Not assessed, mottled + Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: + Not assessed + Labs / Radiology + 83 mg/dL + 105 mEq/L + 4.0 mEq/L + 129 mEq/L + 33 + [image002.jpg] + [**2098-12-1**] + 2:33 A1/25/[**2102**] 05:53 PM + [**2098-12-5**] + 10:20 P + [**2098-12-6**] + 1:20 P + [**2098-12-7**] + 11:50 P + [**2098-12-8**] + 1:20 A + [**2098-12-9**] + 7:20 P + 1//11/006 + 1:23 P + [**2099-1-1**] + 1:20 P + [**2099-1-1**] + 11:20 P + [**2099-1-1**] + 4:20 P + Hct + 33 + Glucose + 83 + Other labs: Lactic Acid:2.1 mmol/L + Assessment and Plan + C. DIFFICILE INFECTION (C DIFF, CDIFF COLITIS, CLOSTRIDIUM DIFFICILE) + Assesment: + This is a 41 year-old female with a history of gastric bypass in [**2092**], + seizure d/o, chonic back pain, h/o dilated cardiomyopathy now resolved + (EF >55% 9/09) who presents with diarrhea and hypotension. + . + Plan: + # Septic Shock - Patient with leukocytosis, diarrhea, hypotension, + lactate 3.7, and tachycardia. Given history of c. diff colitis and + CT-findings of unchanged pancolitis despite treatment likely shock + secondary to c. diff colitis. Other sources although unlikely are: pna + given bibasilar consolidations on CT, although no history of cough or + other symptoms. Additionally, ascites likely due to reactive + pancolitis and not SBP. CE enzymes negative for cardiogenic shock. Pt + with history of CM, but normalized. +guaiac in ED given 1U pRBC, but + stable Hct no evidence of massive bleeding. + - place a-line + - CVL in OR, will need to remove fem CVL + - IV fluids to goal CVP 8-12 + - Transfuse for Hct > 30 + - IV fluid boluses and Levophed to maintain MAP > 65 and UOP > 30cc/hr + - Vanco po 500mg q6, IV flagyl for C. diff coverage + - IV Vanco aand cefepime for ? pneumonia + - Surgery consult + will take to OR overnight (maintain NPO) + - Gi consult + - Follow-up blood, urine and sputum cultures + - Trend WBC count fever curve. + - f/u CT-scan results + - check central venous O2 and monitor CI with vigileo + . + #. Resp Distress: Pt was intubated in the ED for airway protection [**1-2**] + agitation. + - cont current vent settings and monitor with ABG + - sedation with fent & versed given hypotension. + . + #. Coagulapathy: Pt with elevated INR. Possible DIC in the setting of + septic shock vs malabsorbtion + - 4U FFP + - IV Vit K + - cont to monitor coags + - DIC labs + #. Hyponatermia: Likely [**1-2**] to hypovolemia. Will volume replete as + above and monitor. + . + # FEN: NPO + . + # Access R fem CVL, a-line, PIV + . + ICU Care + Nutrition: + Glycemic Control: + Lines: + Multi Lumen - [**2102-12-25**] 06:49 PM + Prophylaxis: + DVT: Boots + Stress ulcer: + VAP: HOB elevation, Mouth care, Daily wake up, RSBI + Need for restraints reviewed + Comments: + Communication: Patient discussed on interdisciplinary rounds , Family + meeting held , ICU consent signed Comments: + Code status: Full code + Disposition: ICU for now, will go to SICU after surgery + ------ Protected Section ------ + I have seen and examined the patient with the fellow and agree with the + assessment and plan as above with the following modifications/emphasis: + 41 year old female with history and presentation as above. In sum, she + has pancolitis from C. dif which has already been treated with IV + flagyl and PO vanc but now returns in shock with elevated lactate. + Surgery has evaluated and planning to bring to the operating room. + T 101 P 110 BP 128/64 RR 16 Sat: 100% + Intubated, sedated + CTA bilaterally + S1 S2 reg + Soft distended + Ext: no edema + Labs: as above + CT: pancolitis + Assessment: + 1) Septic Shock likely secondary to C. diff colitis + may also have + translocation of bacteria from colitis + 2) C. diff Colitis + refractory to antibiotic therapy + 3) Nutritional Deficiency, s/p gastric bypass + Plan: + 1) Intravenous fluid resuscitation + 2) Broad-spectrum antibiotics covering for C. dif as well as other + pathogens + 3) Surgery Consultation -> operating [**Apartment Address(1) 11147**]) Intravenous thiamine + Time Spent: 45 minutes + Patient is critically ill + ------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD + on:[**2102-12-25**] 21:16 ------ +","Admission Date: [**2102-12-25**] Discharge Date: [**2103-1-15**] + +Date of Birth: [**2061-5-10**] Sex: F + +Service: SURGERY + +Allergies: +Ultram + +Attending:[**First Name3 (LF) 301**] +Chief Complaint: +diarrhea, lightheadedness + +Major Surgical or Invasive Procedure: +1. Total colectomy, abdominal with ileostomy. +2. Gastrostomy tube placement. + + +History of Present Illness: +41F s/p lap gastric bypass in [**2092**] followed by a revision of the +jejunojejunostomy 1 month later for a ? obstruction. She was +lost to follow up since [**2093**] and her surgical weight loss and +medications are unknown. Over the past year she was being seen +by gastroenterology for persistent dry heaves, inability to +tolerate POs and a 60lb weight loss. During her last admission +she has a documented C.diff infection on [**2102-11-23**] and she was +discharged on [**2102-11-30**] on a 14 day course of PO Vanc. She +presented to the ED today with fatigue, lightheadedness and +diarrhea. While in the ED she had a precipitous decline in her +clinical status, she became septic, had to be intubated, and +levophed had to be started to maintain an adequate blood +pressure. + +Past Medical History: +1. Seizure disorder, has not had seizure in 4+ years. Described +as grand mal seizure possibly in the setting of ultram. +2. Status post gastric bypass in [**2092**]. +3. DJD L5-S1, facet DJD and L4-L5 annular tear. +4. Systolic/diastolic congestive heart failure due to +cardiomyopathy of unclear etiology, likely viral diagnosed in +9/[**2101**]. EBV IGM neg, CMV IGM equivocal, Lyme neg +5. Depression. +6. Chronic back pain with narcotic dependence +7. Nausea, weight loss, nutritional deficiencies of unclear +etiology, possibly related to depression, malabsorption or +related to her gastric bypass. +8. Normocytic anemia per notes attributed to iron deficiency in +the past although no evidence in lab values here. + + +Social History: +She works as an administrative assistant. Denies any previous or +current tobacco use, no current alcohol use. No illegal drugs or +IV drug use. + + +Family History: +Father with cirrhosis of the liver. + +Physical Exam: +Physical exam on admission: +VS 97.9, 104, 100/46, 24 on vent +Gen: intubated and sedated +Chest: tachycardic, lungs clear +Abd: soft, markedly distended +Rectal: guaiac positive +Ext: no edema + +Physical exam on discharge: +VS +Gen: weak but alert and oriented x3, NAD +CV: RRR +Chest: CTAB +Abd: soft, appropriately tender near incision, erythematous and +abd with flaky skin and excoriations +Wound: 1.5x1.5 opened area of midline incision inferiorly, +packed with iodoform gauze, also small 1.0x1.0 area of midline +incision superior to umbilicus with is opened and pack with +iodoform gauze rest of incision clean/dry/intact with steris; G +tube in place and functioning +Ext: erythematous inferiorly, 1+ edema bilaterally + +Pertinent Results: +[**2102-12-25**] 03:05PM WBC-37.0*# RBC-3.82* HGB-10.4* HCT-33.4* +MCV-88 MCH-27.4 MCHC-31.3 RDW-16.1* +[**2102-12-25**] 03:05PM NEUTS-88* BANDS-3 LYMPHS-6* MONOS-3 EOS-0 +BASOS-0 ATYPS-0 METAS-0 MYELOS-0 +[**2102-12-25**] 03:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL +MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL + +CT abd/pelvis [**2102-12-25**]: +1. Bibasilar opacities concerning for infection and/or +aspiration. +2. Diffuse colonic wall thickening, consistent with pancolitis, +unchanged +from [**2102-10-31**]. +3. Cholelithiasis. +4. NG tube in gastric pouch with sideport at GE junction. +5. Ascites, similar to [**2102-10-31**]. +6. Fatty liver. +7. Status-post gastric bypass. + +CT abd/pelvis [**2103-1-9**]: +1. No evidence of loculated fluid collection or abscess +formation within the +abdomen or pelvis. +2. Persistent ascites with simple fluid tracking along bilateral +paracolic +gutters into the pelvis. +3. Unchanged diffuse hepatic steatosis without focal lesion. +4. Cholelithiasis without cholecystitis. +5. Unchanged pancreatic cystic lesions. +6. Unchanged anasarca. + + +Brief Hospital Course: +Mrs. [**Known lastname 18036**] had been admitted to [**Hospital1 18**] with C. difficile +pancolitis from [**Date range (1) 31488**] and discharged home at that time +on PO vancomycin. She represented to the ED on [**12-25**] with +headache and weakness and decompensated, requiring intubation +and pressors. She was initially admitted to the MICU but then, +after consultation with ID, GI, Medicine, Surgery, and the MICU, +it was decided to take her to the operating room for total +abdominal colectomy with end ileostomy. She was kept intubated +for 4 days and extubated on [**12-29**], and transferred to the floor a +day later. She recovered on the floor slowly but surely and was +finally discharged home on [**2103-1-15**] to complete another 7 days of +flagyl. The rest of her stay is summarized below by system. + +Neuro: In addition to her chronic back pain, Mrs. [**Known lastname 18036**] had +the addition of the new pain from the operation. She was started +on methadone standing and dilaudid prn and her pain control is +being given over to her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. By the time of discharge, +her pain was well controlled on this regimen. + +CV: Upon admission she required pressor support and significant +resuscitation for her sepsis, which continued after she went to +the OR. She was monitored in the ICU with a Swan-Ganz catheter +and was given fluids, blood products, derivatives, and pressors +as needed. She underwent echocardiography on [**12-28**] which showed a +LVEF of 70% and otherwise normal function except for new +moderate PA hypertension. Pressors were weaned appropriately and +she was able to be transferred to the floor where she remained +hemodynamically stable. Vital signs were monitored regularly. + +Pulm: She was intubated in the ED and remained so until [**12-29**] +when she was finally weaned from the ventilator and extubated. +After extubation, she was weaned off oxygen appropriately and +left the hospital on room air. + +GI/GU: She was quite surprised on awakening that she had a new +ostomy and this will require a long time for her to adjust. An +ostomy/wound care nursing consult was obtained and the ostomy +was changed regularly and monitored for signs of breakdown. By +the end of her hospital stay, Mrs. [**Known lastname 18036**] was becoming slowly +more comfortable managing her ostomy, but still required nursing +help. Due to the antibiotic received throughout her stay, she +began to develop a vaginal yeast infection which was treated +with fluconazole. + +F/E/N: Electrolytes and fluids were monitore during her stay. +She received appropriate repletion when necessary. Tube feeds +were started on [**12-27**], but not continued for long. She was +started on TPN on [**12-28**] and continued on that until [**1-2**]. Her diet +was advanced appropriately to a bariatric stage V diet. She was +not taking in enough orally however to meet her needs, thus tube +feeds were started through her gastric remnant. The patient +complained of being stuck to the IV pole while getting tube +feeds and ultimately refused further feedings until it was +suggested that she take the tube feeds as boluses. The patient +learned how to do this herself and was ultimately much happier +with this arrangement, giving herself four cans of replete with +fiber daily. She was discharged home with qid tube feeds and a +regular diet. + +Heme: The patient was coagulopathic upon presentation due to her +sepsis and required in total 6 units of packed RBCs, 6 units of +FFP, 2 cryoprecipitates, and 11 vials of albumin for repletion +of cofactors, treatment of her coagulopathy, anemia, and sepsis. +As she normalized following her operation, she no longer +required further products. + +ID: The patient was put on PO vanc and IV flagyl on admission as +well as variably cefepime, zosyn, and tigecycline. After +discharge from the unit, the patient was maintained on +vancomycin and flagyl and eventually the vancomycin was dc'd. +Her flagyl was transitioned to po and she was discharged on a 7 +day course of flagyl. Her wound started to show some breakdown +inferiorly and [**4-5**] staples were removed on [**1-6**] and a wound +culture sent. For this she was started on unasyn, which was +continued for a short course. On the day before discharge, +another few staples were removed above the umbilicus with some +serous drainage. The patient refused removal of further staples +at that time and it was decided that the wound could be +monitored for a little longer. + +Psych: The patient has baseline depression and anxiety and this +was exacerbated by the long and difficult hospital course as +well as by the surprise finding, upon wakening, that she no +longer had a colon and would have to pass stool through an +ostomy for at least a number of months. These stressors were +difficult for her and she had a tough time with acclimating +herself to the idea. She initially refused to work with the +ostomy nurse but later showed some willingness to start taking +over some of the ostomy care herself. She was seen by psych +consult in house who thought that the anxiety component was much +more prevalent and recommended treatment with benzodiazepines. +She was discharged with a short prescription for ativan and will +follow up with her PCP for further management of her pain and +anxiety. + +Medications on Admission: +Cyanocobalamin 1,000 mcg/mL once a month. +Calcium Carbonate 500 mg PO QAM +Cholecalciferol 1000 units PO DAILY +Venlafaxine 200 mg PO DAILY +Topiramate 100 mg PO HS +Omeprazole 40 mg PO once a day. +Levetiracetam 500 mg PO BID +Acetaminophen 500 mg PO TID +Morphine 30 mg Tablet Sustained Release PO Q12H +Morphine 15 mg PO Q6H prn +Ondansetron 8 mg Tablet, Rapid Dissolve PO three times a day as +needed for nausea. +Vitamin D-3 1,000 unit Tablet PO once a day. +Ferrous Sulfate 325 mg PO once a day. +Compazine 5 mg PO three times a day as needed for nausea. +Tizanidine 4 mg PO at bedtime for muscle spasm. + +Discharge Medications: +1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) +Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*2* +2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*2* +3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a +day): For lower extremity swelling. Please follow up with your +primary care doctor for further diuretic (water pill) needs. . +Disp:*60 Tablet(s)* Refills:*2* +4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) +Capsule, Delayed Release(E.C.) PO DAILY (Daily). +Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* +5. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every +24 hours) for 2 days. +Disp:*2 Tablet(s)* Refills:*0* +6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 +times a day). +7. Multivitamin Tablet Sig: One (1) Tablet PO BID (2 times a +day). +8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) +Tablet PO DAILY (Daily). +9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) +Tablet, Chewable PO BID (2 times a day). +10. Methadone 5 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every 8 +Hours). +Disp:*250 Tablet(s)* Refills:*0* +11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 +times a day) for 7 days. +Disp:*21 Tablet(s)* Refills:*0* +12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 +hours) as needed for breakthrough pain. +Disp:*54 Tablet(s)* Refills:*0* + + +Discharge Disposition: +Home With Service + +Facility: +[**Hospital6 486**] + +Discharge Diagnosis: +C. difficile pancolitis and sepsis + + +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: +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 [**4-9**] lbs until you follow-up with your +surgeon, who will instruct you further regarding activity +restrictions. + +Avoid driving or operating heavy machinery while taking pain +medications. + +Please follow-up with your surgeon and Primary Care Provider +(PCP) as advised. + +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. + +Please call your doctor or come to the emergency room if you +experience 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 or have +ileostomy output. +*You experience burning when you urinate, have blood in your +urine, or experience a discharge. +*Your pain is not improving within 8-12 hours or is not gone +within 24 hours. Call or return immediately if your pain is +getting worse or changes location or moving to your chest or +back. +*You have shaking chills, or fever greater than 101.5 degrees +Fahrenheit or 38 degrees Celsius. +*Any change in your symptoms, or any new symptoms that concern +you. + +*Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more +than 3 lbs. + +Continue giving yourself the tube feeds as directed at least +until your follow up with Dr. [**Last Name (STitle) **]. It will be helpful to your +doctors [**First Name (Titles) **] [**Last Name (Titles) 31489**] for you to document your oral intake +by keeping a log of what you eat and how many cans of tube feeds +you give yourself so that the sufficiency of your oral intake +can be assessed. + +Followup Instructions: +Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. You can call his +office at ([**Telephone/Fax (1) 9000**] to set up an appointment. + +Please follow up with your primary care provider as soon as you +can. You should discuss not only your recent hospitalization but +also any need for diuretics (water-pills) for your lower +extremity swelling as well as for your future pain and anxiety +medication needs. + + + +","this is a 41 year-old female with a history of gastric bypass in [**2092**], seizure d/o, chonic back pain, h/o dilated cardiomyopathy now resolved (ef >55% 9/09) who presents with diarrhea and hypotension. patient was recently admitted from [**date range (1) 11145**] and treated with c. diff colitis. she was initially treated with iv flagyl and po vanco, but was discharged on a 14 day course of po vanco (last day [**12-7**]). the patient was also on tpn via a picc line that was d/c during that admission over concern for infection, although the culture remained negative. she also underwent a paracentesis that showed >250 polys, but gi felt it was reactive in the setting of pancolitis and not sbp. she was not treated with additional antibiotics and cultures returned no growth. in the ed, the patient arrived with sbp in the 60s and emergent right femoral line was placed and she was started on levophed. she was mentating and reported diarrhea, weakness and increased thrist. her stools were initially guaiac positive and she was given 1u prbc, hct returned 33 and no additional blood procducts were given. she was given 4l ns and intubated for agitation and mild respiratory distress (cmv, vt:450, peep 5, ratel 18, fio2 100%). her blood pressures improved to 105/64 on 0.09mcg/kg/min of levophed, but with hr 134. she underwent ct-scan of abd/pelvis that showed bibasilar opacities, small [**last name (un) 11146**], and unchaged wall thickening consistent with pancolitis. her lactate was 3.7 and she was ordered for flagyl, iv vanco, and zosyn. patient admitted from: [**hospital1 5**] er history obtained from medical records patient unable to provide history: sedated",mrs. [**known lastname 18036**] had been admitted to [**hospital1 18**] with c. difficile pancolitis from [**date range (1) 31488**] and discharged home at that time on po vancomycin.,"this is a 41 year-old female with a history of gastric bypass in [**2092**], seizure d/o, chonic back pain, h/o dilated cardiomyopathy now resolved (ef >55% 9/09) who presents with diarrhea and hypotension. she also underwent a paracentesis that showed >250 polys, but gi felt it was reactive in the setting of pancolitis and not sbp. she was not treated with additional antibiotics and cultures returned no growth. she was given 4l ns and intubated for agitation and mild respiratory distress (cmv, vt:450, peep 5, ratel 18, fio2 100%). her lactate was 3.7 and she was ordered for flagyl, iv vanco, and zosyn. patient admitted from: [**hospital1 5**] er history obtained from medical records patient unable to provide history: sedated",['The 41-year-old woman was recently admitted from ‘#1114545’\nShe was initially treated with \xa0c. difficile and po voc.\nShe also underwent a paracelsis procedure.\nThe patient was discharged on a 14 day course of panto vanco.\nHer bowel was then\xa0determined\xa0to be\xa0deteriorated\xa0by\xa0papillary\xa0line.\nThis was done to remove excess mucus and\xa0increase\xa0herbal\xa0strength.\nIt was then removed and she was given a sac.\nof colonic'],"a 41 year-old female with a history of gastric bypass in [**2092**] presents with diarrhea and hypotension. she was treated with iv flagyl and po vanco, but was discharged on a 14 day course of po vanco. she was not treated with additional antibiotics and cultures returned no growth.","['41 year-old female with a history of gastric bypass in [**2092] presents as diarrhea and hypotension. she was treated on 14 day course for colitis, but no antibiotics were given to her at that time; the patient had not been diagnosed yet because it seemed reactive against pancolite or other infections (gi).']","patient was recently admitted from [**date range (1) 11145**] and treated with c. +she was not treated with additional antibiotics and cultures returned no growth. +in the ed, the patient arrived with sbp in the 60s and emergent right femoral line was placed and she was started on levophed.","this is a 41 year-old female with a history of gastric bypass in [**2092**], seizure d/o, chonic back pain, h/o dilated cardiomyopathy now resolved (ef >55% 9/09) who presents with diarrhea and hypotension.patient was recently admitted from [**date range (1) 11145**] and treated with c.she was initially treated with iv flagyl and po vanco, but was discharged on a 14 day course of po vanco (last day [**12-7**]).the patient was also on tpn via a picc line that was d/c during that admission over concern for infection, although the culture remained negative.she also underwent a paracentesis that showed >250 polys, but gi felt it was reactive in the setting of pancolitis and not sbp.she was not treated with additional antibiotics and cultures returned no growth.in the ed, the patient arrived with sbp in the 60s and emergent right femoral line was placed and she was started on levophed.her stools were initially guaiac positive and she was given 1u prbc, hct returned 33 and no additional blood procducts were given.she underwent ct-scan of abd/pelvis that showed bibasilar opacities, small [**last name (un) 11146**], and unchaged wall thickening consistent with pancolitis.7 and she was ordered for flagyl, iv vanco, and zosyn.","[{'rouge-1': {'r': 0.2857142857142857, 'p': 0.08163265306122448, 'f': 0.12698412352733696}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.21428571428571427, 'p': 0.061224489795918366, 'f': 0.09523809178130524}}]","[{'rouge-1': {'r': 0.32142857142857145, 'p': 0.17647058823529413, 'f': 0.22784809668963318}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.32142857142857145, 'p': 0.17647058823529413, 'f': 0.22784809668963318}}]","[{'rouge-1': {'r': 0.17857142857142858, 'p': 0.1388888888888889, 'f': 0.15624999507812518}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.17857142857142858, 'p': 0.1388888888888889, 'f': 0.15624999507812518}}]","[{'rouge-1': {'r': 0.2857142857142857, 'p': 0.1509433962264151, 'f': 0.19753085967383033}, 'rouge-2': {'r': 0.037037037037037035, 'p': 0.019230769230769232, 'f': 0.02531645119692437}, 'rouge-l': {'r': 0.21428571428571427, 'p': 0.11320754716981132, 'f': 0.14814814362444764}}]","[{'rouge-1': {'r': 0.32142857142857145, 'p': 0.2571428571428571, 'f': 0.2857142807760142}, 'rouge-2': {'r': 0.14814814814814814, 'p': 0.08888888888888889, 'f': 0.1111111064236113}, 'rouge-l': {'r': 0.32142857142857145, 'p': 0.2571428571428571, 'f': 0.2857142807760142}}]","[{'rouge-1': {'r': 0.4642857142857143, 'p': 0.09848484848484848, 'f': 0.16249999711250002}, 'rouge-2': {'r': 0.14814814814814814, 'p': 0.020618556701030927, 'f': 0.036199092877705334}, 'rouge-l': {'r': 0.4642857142857143, 'p': 0.09848484848484848, 'f': 0.16249999711250002}}]",0.285714286,0.081632653,0.126984124,0,0,0,0.214285714,0.06122449,0.095238092,0.321428571,0.176470588,0.227848097,0,0,0,0.321428571,0.176470588,0.227848097,0.178571429,0.138888889,0.156249995,0,0,0,0.178571429,0.138888889,0.156249995,0.285714286,0.150943396,0.19753086,0.037037037,0.019230769,0.025316451,0.214285714,0.113207547,0.148148144,0.321428571,0.257142857,0.285714281,0.148148148,0.088888889,0.111111106,0.321428571,0.257142857,0.285714281,0.464285714,0.098484848,0.162499997,0.148148148,0.020618557,0.036199093,0.464285714,0.098484848,0.162499997 +42055,171088,9144,"Chief Complaint: shortness of breath, coughs, wheezing + HPI: + 64-year-old with COPD (no PFT in OMR), CAD, AAA, HTN presented with + several days of worsening shortness of breath with some intermittent + nonproductive coughs. No fevers, chills, chest pain, abdominal pain, + changes in bowel habits. No lower extremity edema. No sick contact, no + flu shot, no myalgias. + . + In the ED, initial VS: T 100, HR 93, BP 164/108, RR 22, 81%RA. He was + started on BiPAP. He received albuterol and ipratropium nebs, + methylpred 125 mg IV x 1, ceftriaxone 1 gm x 1, azithromycin 500 mg x + 1, Mg sulfate 2 gm x 1. Trop 0.05, CK normal, ECG unchanged from prior. + . + Prior to transfer to MICU, HR 80, BP 105/48, RR 22, 99% on BIPAP. On + arrival here, ABG was 7.35/59/63/34. He was breathing comfortably on + 5LNC. + Patient admitted from: [**Hospital1 1**] ER + History obtained from [**Hospital 31**] Medical records + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + albuterol prn + fluoxetine 60 mg qday + fluticasone-salmeterol 1 puff inh [**Hospital1 **] + hydrochlorothiazide 25 mg qday + montelukast 10 mg qday prn + omeprazole 20 mg qday + trazodone 50 mg qday + penicillamine 500 mg 6 times/day + Past medical history: + Family history: + Social History: + COPD + hypertension + CAD + AAA: 5 cm in [**2105-9-5**], being followed conservatively by Dr. [**Last Name (STitle) **] + nephrolithiasis + chronic back pain + alcohol abuse + n/c + Occupation: unemployed; used to work as a painter + Drugs: no illicit drug + Tobacco: currently smokes 0.5 pk/day; used to smoke 2 pks/day for + decades + Alcohol: history of alcohol abuse, states that he quit months ago + Other: lives by self; separated from wife + Review of systems: + Constitutional: Fatigue + Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema, + No(t) Orthopnea + Respiratory: Cough, Dyspnea, Wheeze + Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, + No(t) Diarrhea, No(t) Constipation + Genitourinary: No(t) Dysuria + Musculoskeletal: No(t) Joint pain, No(t) Myalgias + Neurologic: No(t) Numbness / tingling, No(t) Headache + Flowsheet Data as of [**2106-3-28**] 07:39 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since [**08**] AM + Tmax: 36.4 +C (97.6 + Tcurrent: 36.4 +C (97.6 + HR: 94 (81 - 102) bpm + BP: 114/84(91) {114/68(79) - 122/84(91)} mmHg + RR: 19 (17 - 22) insp/min + SpO2: 95% + Heart rhythm: SR (Sinus Rhythm) + Height: 70 Inch + 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: Nasal cannula + SpO2: 95% + ABG: 7.35/59/63//4 + PaO2 / FiO2: 1,260 + Physical Examination + General Appearance: Well nourished, No acute distress, Anxious + Eyes / Conjunctiva: PERRL + Head, Ears, Nose, Throat: Normocephalic + Lymphatic: Cervical WNL + 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: (Expansion: Symmetric), (Breath Sounds: Wheezes : + expiratory, Diminished: bilaterally) + Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended + Extremities: Right lower extremity edema: Absent, Left lower extremity + edema: Absent, No(t) Cyanosis, No(t) Clubbing + Skin: Not assessed + Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3, + Movement: Not assessed, Tone: Not assessed + Labs / Radiology + 177 + 1.0 + 17 + 32 + 97 + 4.0 + 138 + 44.5 + 6.3 + [image002.jpg] + [**2102-2-6**] + 2:33 A2/21/[**2106**] 06:45 PM + [**2102-2-10**] + 10:20 P + [**2102-2-11**] + 1:20 P + [**2102-2-12**] + 11:50 P + [**2102-2-13**] + 1:20 A + [**2102-2-14**] + 7:20 P + 1//11/006 + 1:23 P + [**2102-3-9**] + 1:20 P + [**2102-3-9**] + 11:20 P + [**2102-3-9**] + 4:20 P + TC02 + 34 + Other labs: PT / PTT / INR:// 1.0, CK / CKMB / Troponin-T:247 / 15 / + 0.05 + Imaging: CXR: A single bedside radiograph of the chest excludes the + lateral most + portions of the left lung from the field of view. Cardiac, mediastinal + and hilar contours are unremarkable. Minimal pulmonary vascular + congestion is seen without focal consolidation. + Microbiology: Viral panel: pending + Flu swab: pending + Blood cx: pending + ECG: sinus with 1:1 AV conduction, rate 84 bpm, normal axis, normal + intervals, no pathologic Q, no ST/T changes; unchanged from prior study + Assessment and Plan + CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA) + WITH ACUTE EXACERBATION + 64-year-old man with COPD, CAD, HTN here with several days of shortness + of breath, productive coughs, fever, most likely COPD exacerbation in + the setting of an infection. + # COPD exacerbation: on BiPAP initially but now down 5L NC, breathing + comfortably. ABG 7.35/59/64 suggests chronic respiratory acidosis. + - standing albuterol nebs q2h + - standing ipratropium nebs q6h + - nebs prn + - prednisone 40 mg qday given good PO intake + - back on BiPAP tonight + - treat infection as below + - supplemental oxygen as needed + # Possible pulmonary infection: ?bacterial pneumonia versus a viral + infection. No + - empiric levoflox and ceftriaxone for now (MICU admission); no recent + hospitalization + - sputum cx + - nasopharyngeal aspirate for flu and rapid viral panel; droplet + precautions for now + # HTN: + - continue HCTZ + # Anxiety: + - continue diazepam + # Cystinuria: dx'ed at age 19 + - continue penicillamine + # Questionable substance abuse: history of cutting and substance abuse + - tox screen + # FEN: IVFs / replete lytes prn / regular diet + # PPX: PPI, heparin SQ + # ACCESS: PIV + # CODE: full, discussed with patient + # CONTACT: + # DISPO: ICU + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2106-3-28**] 03:55 PM + Prophylaxis: + DVT: SQ UF Heparin + Stress ulcer: PPI + VAP: + Comments: + Communication: Comments: + Code status: Full code + Disposition: ICU +","Admission Date: [**2106-3-28**] Discharge Date: [**2106-4-1**] + +Date of Birth: [**2041-4-4**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**Doctor First Name 2080**] +Chief Complaint: +shortness of breath + +Major Surgical or Invasive Procedure: +none + +History of Present Illness: +64-year-old with COPD (no PFT in OMR), CAD, AAA, HTN presented +with several days of worsening shortness of breath with some +intermittent nonproductive coughs. No fevers, chills, chest +pain, abdominal pain, changes in bowel habits. No lower +extremity edema. No sick contact, no flu shot, no myalgias. +. +In the ED, initial VS: T 100, HR 93, BP 164/108, RR 22, 81%RA. +He was started on BiPAP. He received albuterol and ipratropium +nebs, methylpred 125 mg IV x 1, ceftriaxone 1 gm x 1, +azithromycin 500 mg x 1, Mg sulfate 2 gm x 1. Trop 0.05, CK +normal, ECG unchanged from prior. +. +Prior to transfer to MICU, HR 80, BP 105/48, RR 22, 99% on +BIPAP. On arrival here, ABG was 7.35/59/63/34. He was breathing +comfortably on 5LNC. + + +Past Medical History: +COPD +hypertension +CAD +AAA: 5 cm in [**2105-9-5**], being followed conservatively by Dr. +[**Last Name (STitle) **] +nephrolithiasis +chronic back pain +alcohol abuse + + +Social History: +divorced, unemployed (used to work as a painter and handyman). +Smokes 0.5 pk/day. History of alcohol abuse. + +Family History: +n/c + +Physical Exam: +Vitals - 98.5 87 122/88 91% on 3L +GENERAL: resting in bed, somewhat short of breath with long +sentences, but no acute distress at rest +HEENT: EOMI, PERRL, sclerae anicteric +CARDIAC: regular rhythm, normal rate, normal S1/S2, no m/r/g +LUNG: coarse breath sounds bilaterally, poor aeration +bilaterally, expiratory wheezing +ABDOMEN: soft, nontender, nondistended +EXT: no edema +NEURO: alert, oriented x 3, non-focal + + +Pertinent Results: +ADMISSION LABS: +[**2106-3-28**] 01:32PM BLOOD WBC-6.3 RBC-5.03 Hgb-14.9 Hct-44.5 +MCV-88# MCH-29.6# MCHC-33.5 RDW-14.9 Plt Ct-177 +[**2106-3-28**] 01:32PM BLOOD Neuts-65.1 Lymphs-24.4 Monos-7.4 Eos-2.6 +Baso-0.5 +[**2106-3-28**] 01:32PM BLOOD PT-12.2 PTT-27.7 INR(PT)-1.0 +[**2106-3-28**] 01:32PM BLOOD Glucose-136* UreaN-17 Creat-1.0 Na-138 +K-4.0 Cl-97 HCO3-32 AnGap-13 +[**2106-3-28**] 01:32PM BLOOD Calcium-8.7 Phos-4.3 Mg-1.8 +[**2106-3-28**] 01:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG +Bnzodzp-POS Barbitr-NEG Tricycl-NEG +[**2106-3-28**] 01:32PM BLOOD CK-MB-15* MB Indx-6.1* +[**2106-3-28**] 01:32PM BLOOD cTropnT-0.05* +[**2106-3-29**] 01:50AM BLOOD CK-MB-13* MB Indx-7.1* cTropnT-0.02* +[**2106-3-29**] 05:39AM BLOOD CK-MB-12* MB Indx-7.8* cTropnT-0.02* +[**2106-3-28**] 01:32PM BLOOD CK(CPK)-247 +[**2106-3-29**] 01:50AM BLOOD CK(CPK)-184 +[**2106-3-29**] 05:39AM BLOOD CK(CPK)-153 +[**2106-3-28**] 06:45PM BLOOD Type-ART pO2-63* pCO2-59* pH-7.35 +calTCO2-34* Base XS-4 +[**2106-3-28**] 01:39PM BLOOD Lactate-1.3 +[**2106-4-1**] 03:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 +[**2106-4-1**] 03:54PM URINE Blood-NEG Nitrite-NEG Protein-TR +Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG +[**2106-4-1**] 03:54PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE +Epi-<1 +. +MICROBIOLOGY: +. +Nasal Swab [**2106-3-28**]: Respiratory Viral Antigen Screen (Final +[**2106-3-29**]): + REPORTED BY PHONE TO DR [**First Name (STitle) 31494**], [**Name (NI) **] [**2106-3-29**] 10:40AM. + Positive for Respiratory viral antigens. + Specimen screened for: Adeno, Parainfluenza 1, 2, 3, +Influenza A, B, + and RSV by immunofluorescence. + Refer to Respiratory Virus Identification for further +information. +. + Respiratory Virus Identification (Final [**2106-3-29**]): + POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV). + Viral antigen identified by immunofluorescence. +Blood Cx [**2106-3-28**]: Negative +. +IMAGING: +CXR [**2106-3-28**]: FINDINGS: A single bedside radiograph of the chest +excludes the lateral most portions of the left lung from the +field of view. Cardiac, mediastinal and hilar contours are +unremarkable. Minimal pulmonary vascular congestion is seen +without focal consolidation. +IMPRESSION: Mild pulmonary vascular congestion. No focal +consolidation. + +Brief Hospital Course: +64-year-old man with COPD, CAD, HTN here with several days of +shortness of breath, productive coughs, fever, most likely COPD +exacerbation in the setting of an infection. +. +# COPD exacerbation: Patient was on BiPAP initially but quickly +weaned to 5L NC, breathing comfortably. ABG 7.35/59/64 suggested +chronic respiratory acidosis. He was given standing albuterol +nebs q2h, standing ipratropium nebs q6h, prednisone 40 mg qday. +He was initially treated with empiric levofloxacin and +ceftriaxone given requirement for ICU admission. However, +nasopharyngeal aspirate demonstrated RSV, which was more likely +the trigger. Thus, antibiotics were stopped. His breathing and +cough improved significantly over the next several days, and he +was discharged home with supplemental oxygen. He was also given +a prednisone taper and instructed to start spiriva as well as +advair. Smoking cessation counseling was provided and the +patient started on a nicotine patch. He was instructed to +follow-up in pulmonary clinic after discharge. +. +# RSV infection: Initially treated with empiric antibiotics for +CAP, which were stopped when respiratory viral antigen returned +positive for RSV. He was treated symptomatically with +supplemental oxygen and anti-tussive agents, as well as +prednisone and nebulizers for COPD as above. +. +# CAD s/p PCI in [**2098**]: The patient was started on ASA 81 mg +daily. +. +# HTN: HCTZ was continued. +. +# Anxiety: Diazepam and trazodone qhs were continued. +. +# GERD: Continued on home regimen of omeprazole. +. +# Cystinuria: Diagnosed at age 19, with history of multiple +kidney stones. During this admission, the patient reported +intermittent right groin pain consistent with his pain from +prior kidney stones. He was treated with gentle IV fluids, and +continued on home dose of penicillamine. +. +Code status was addressed, and he was full code throughout this +hospital stay. + +Medications on Admission: +albuterol prn +fluoxetine 60 mg qday +fluticasone-salmeterol 1 puff inh [**Hospital1 **] +hydrochlorothiazide 25 mg qday +montelukast 10 mg qday prn +omeprazole 20 mg qday +trazodone 50 mg qday +penicillamine 500 mg 6 times/day + +Discharge Medications: +1. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for +4 days: Take two tabs daily for two days, then one tab daily for +two days, then stop. +Disp:*8 Tablet(s)* Refills:*0* +2. Oxygen O2 1-2 L continuous pulse dose for portability. Dx: +COPD +3. 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. +4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY +(Daily). +5. Fluticasone-Salmeterol 230-21 mcg/Actuation Aerosol Sig: Two +(2) Inhalation twice a day. +Disp:*1 case* Refills:*2* +6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO +DAILY (Daily). +7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. +8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) +Capsule, Delayed Release(E.C.) PO once a day. +9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) +as needed for insomnia. +10. Penicillamine 250 mg Tablet Sig: Two (2) Tablet PO 6 TIMES A +DAY (). +11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr +Transdermal DAILY (Daily). +12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable +PO DAILY (Daily). +Disp:*30 Tablet, Chewable(s)* Refills:*2* +13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device +Sig: One (1) Inhalation once a day. +Disp:*1 inhaler* Refills:*2* + + +Discharge Disposition: +Home With Service + +Facility: +[**Hospital 119**] Homecare + +Discharge Diagnosis: +Primary Diagnosis: +COPD Exacerbation +RSV Infection +. +Secondary Diagnoses: +Hypertension +Aoric Aneurysm + + +Discharge Condition: +Mental Status: Clear and coherent +Level of Consciousness: Alert and interactive +Activity Status: Ambulatory - Independent +Ambulatory SaO2 86% + + +Discharge Instructions: +You were admitted to the hospital for shortness of breath and +cough, and were found to have a viral infection of the lungs. +While in the hospital you were treated with nebulizers and cough +suppressants, and your symptoms improved. +. +We made the following changes to your home medications: +- Start Spiriva - use daily to treat your COPD +- Start Prednisone - take 20 mg daily for the next 2 days, then +10 mg daily for the following two days and stop. +- Start Aspirin 81 mg daily; this will help protect you from +damage to the arteries in your heart. Please discuss this +medication with your PCP at your next visit. +- Start a Nicotine patch to help you to quit smoking. This can +be purchased over the counter. +- You may also use over the counter cough suppressants to help +with your symptoms +- Start using Oxygen at home; this will help with your shorness +of breath. +. +We did not make any further changes to your home medications. +Please take all other medications as prescribed. + +Followup Instructions: +Appointment #1 +MD: Dr [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 19751**] +Specialty: Primary Care +Date/ Time: [**4-13**] at 2pm +Location: [**Apartment Address(1) **], [**Location (un) 86**] +Phone number: [**Telephone/Fax (3) **] +. +Appointment #2 +MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] +Specialty: Pulmonology +Date/ Time: [**4-28**] at 8am +Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) 436**] +Phone number: :([**Telephone/Fax (1) 513**] +. +Appointment #3 - Please present to the [**Hospital Ward Name 517**] clinical +center at 10:30 AM on [**4-12**] for a CT of your Abdomen. After +this study, you should proceed to your appointment with Dr. +[**Last Name (STitle) **]. +MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] +Specialty: Vascular Surgery +Date/ Time: [**2108-4-12**]:30 PM. +Location: [**Hospital **] Medical Office Building, [**Location (un) 442**] +Phone Number ([**Telephone/Fax (1) 8343**] + + + +","64-year-old with copd (no pft in omr), cad, aaa, htn presented with several days of worsening shortness of breath with some intermittent nonproductive coughs. no fevers, chills, chest pain, abdominal pain, changes in bowel habits. no lower extremity edema. no sick contact, no flu shot, no myalgias. in the ed, initial vs: t 100, hr 93, bp 164/108, rr 22, 81%ra. he was started on bipap. he received albuterol and ipratropium nebs, methylpred 125 mg iv x 1, ceftriaxone 1 gm x 1, azithromycin 500 mg x 1, mg sulfate 2 gm x 1. trop 0.05, ck normal, ecg unchanged from prior. prior to transfer to micu, hr 80, bp 105/48, rr 22, 99% on bipap. on arrival here, abg was 7.35/59/63/34. he was breathing comfortably on 5lnc. patient admitted from: [**hospital1 1**] er history obtained from [**hospital 31**] medical records","64-year-old man with copd, cad, htn here with several days of shortness of breath, productive coughs, fever, most likely copd exacerbation in the setting of an infection.","64-year-old with copd (no pft in omr), cad, aaa, htn presented with several days of worsening shortness of breath with some intermittent nonproductive coughs. no sick contact, no flu shot, no myalgias. in the ed, initial vs: t 100, hr 93, bp 164/108, rr 22, 81%ra.","['The 64-year-old had a number of days of worsening shortness of breath.\nHe was starting on bp, a ca, aa, a c, a and a d.\nThe patient was given albino and isotopic abscessions.\nNo ill contact was recorded.']","64-year-old with copd (no pft in omr) presented with several days of worsening shortness of breath with intermittent nonproductive coughs. he was started on bipap. he received albuterol and ipratropium nebs, ceftriaxone 1 gm x 1, azithromycin 500 mg x 1, mg sulfate 2 gm x 1.","['64-year old with copd (no pft in the hospital) presented as having shortness of breath and intermittent nonproductive coughs. patient was started on bipap; abg 7.35/59/63/34, but his condition worseened after 5lc treatment for several days prior to transfer from micu into canada at age 65 years ago [**hospital1 1]']","64-year-old with copd (no pft in omr), cad, aaa, htn presented with several days of worsening shortness of breath with some intermittent nonproductive coughs. +prior to transfer to micu, hr 80, bp 105/48, rr 22, 99% on bipap.","64-year-old with copd (no pft in omr), cad, aaa, htn presented with several days of worsening shortness of breath with some intermittent nonproductive coughs.no fevers, chills, chest pain, abdominal pain, changes in bowel habits.no sick contact, no flu shot, no myalgias.in the ed, initial vs: t 100, hr 93, bp 164/108, rr 22, 81%ra.he was started on bipap.he received albuterol and ipratropium nebs, methylpred 125 mg iv x 1, ceftriaxone 1 gm x 1, azithromycin 500 mg x 1, mg sulfate 2 gm x 1.05, ck normal, ecg unchanged from prior.prior to transfer to micu, hr 80, bp 105/48, rr 22, 99% on bipap.on arrival here, abg was 7.he was breathing comfortably on 5lnc.","[{'rouge-1': {'r': 0.4583333333333333, 'p': 0.275, 'f': 0.3437499953125}, 'rouge-2': {'r': 0.19230769230769232, 'p': 0.1111111111111111, 'f': 0.14084506578059924}, 'rouge-l': {'r': 0.4166666666666667, 'p': 0.25, 'f': 0.3124999953125}}]","[{'rouge-1': {'r': 0.16666666666666666, 'p': 0.12903225806451613, 'f': 0.14545454053553736}, 'rouge-2': {'r': 0.07692307692307693, 'p': 0.05128205128205128, 'f': 0.06153845673846192}, 'rouge-l': {'r': 0.16666666666666666, 'p': 0.12903225806451613, 'f': 0.14545454053553736}}]","[{'rouge-1': {'r': 0.3333333333333333, 'p': 0.21621621621621623, 'f': 0.2622950771943027}, 'rouge-2': {'r': 0.15384615384615385, 'p': 0.09090909090909091, 'f': 0.11428570961632674}, 'rouge-l': {'r': 0.25, 'p': 0.16216216216216217, 'f': 0.19672130670249946}}]","[{'rouge-1': {'r': 0.3333333333333333, 'p': 0.1568627450980392, 'f': 0.21333332898133342}, 'rouge-2': {'r': 0.11538461538461539, 'p': 0.06, 'f': 0.07894736391966785}, 'rouge-l': {'r': 0.2916666666666667, 'p': 0.13725490196078433, 'f': 0.18666666231466678}}]","[{'rouge-1': {'r': 0.4166666666666667, 'p': 0.29411764705882354, 'f': 0.3448275813555292}, 'rouge-2': {'r': 0.15384615384615385, 'p': 0.10810810810810811, 'f': 0.12698412213655852}, 'rouge-l': {'r': 0.3333333333333333, 'p': 0.23529411764705882, 'f': 0.2758620641141499}}]","[{'rouge-1': {'r': 0.4583333333333333, 'p': 0.12087912087912088, 'f': 0.19130434452325146}, 'rouge-2': {'r': 0.19230769230769232, 'p': 0.04310344827586207, 'f': 0.07042253221979779}, 'rouge-l': {'r': 0.4166666666666667, 'p': 0.10989010989010989, 'f': 0.1739130401754254}}]",0.458333333,0.275,0.343749995,0.192307692,0.111111111,0.140845066,0.416666667,0.25,0.312499995,0.166666667,0.129032258,0.145454541,0.076923077,0.051282051,0.061538457,0.166666667,0.129032258,0.145454541,0.333333333,0.216216216,0.262295077,0.153846154,0.090909091,0.11428571,0.25,0.162162162,0.196721307,0.333333333,0.156862745,0.213333329,0.115384615,0.06,0.078947364,0.291666667,0.137254902,0.186666662,0.416666667,0.294117647,0.344827581,0.153846154,0.108108108,0.126984122,0.333333333,0.235294118,0.275862064,0.458333333,0.120879121,0.191304345,0.192307692,0.043103448,0.070422532,0.416666667,0.10989011,0.17391304 +48340,144841,9184,"Chief Complaint: coagulopathy (INR>20) and hyperglycemia. + HPI: + [**Known firstname 67**] [**Known lastname 68**] 64 yo male hx of PVD, DM s/p renal transplant [**2130**]. and + ulcers. Patient states that he has been nauseated with vomiting and + diarrhea for the past 2 weeks. He reports having decreased food + intaked and that he has not been able to take or keep his medications + down consistently. He states that in the past when he has been + hyperglycemic, he has not had nausea and vomiting like this. He also + reports SOB and DOE for the past 4-5 days. He denies orthopnea and + PND. He reports some edema in his legs bilat which is a chronic + problem. [**Name (NI) **] came to the ER today because his wife finally made him + after his temperature spiked to 102. Patient also has chronic ulcers. + His wife helps care for them and has not noticed any increasing + erythema 2 days ago when last she changed the dressing. However, in + ED, found to have swollen RLE with right ulcers some and surrounding + erythema concerning for celluliti. In ED found to be hyperglycemic + with BS of 420 and AG 24. They treated him with SQ insulin rather than + an insulin drip because they were concerned about hypoglycemia. ED + with q 1-2 hr fingersticks brought AG down to 16 currently. + ED concerned about possible cellulitis started on Vanco and unsyn for + cellulitis. xray of leg did not show osteomyelitis. CXR clear. + Vascular was consulted and they took a foot cx. Podiatry also saw + patient. Patient was going go to floor when INR came back at 20.0. + Patient then given FFP x1 unit and Vit K. + Patient admitted from: [**Hospital1 5**] ER + History obtained from Patient + Allergies: + Tegaderm (Topical) (Transparent Dressing) + Unknown; + Prinivil (Oral) (Lisinopril) + Unknown; + Reglan (Oral) (Metoclopramide Hcl) + Unknown; + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Past medical history: + Family history: + Social History: + 1. Coronary artery disease s/p CABG X 4 in [**2121**]. Echo [**9-2**] nml + LV function + 2. Type 1 Diabetes with complications including retinopathy, + neuropathy, end-stage renal disease, and Charcot foot + 3. End-stage renal disease status post cadaveric renal + transplant [**10-1**] + 4. Right lower extremity DVT since [**7-4**] requiring life-long + anticoagulation on coumadin and IVC filter placement + 5. Hypertension + 6. GERD + 7. Osteopenia of hip [**10-31**] + 8. Neuropathy Rfoot > Lfoot + 9. Bilateral cataract surgery + [**37**]. Right foot surgery and Charcot foot [**12/2125**] + 11. Diverticulosis + 12. Status post flexible bronchoscopy with biopsy of RUL, + lingula [**4-3**] + 13. Cryptococcus pneumonia, treated with Fluconazole + 14. ORIF left ulna [**4-3**] + 15. IVC filter placement [**4-3**] + 16. PVD - [**2135-6-9**]: Abdominal aortogram with RLE extremity + runoff, angioplasty of popliteal stenosis. [**9-4**] bilat LE arteriograms + without intervention + DM type II in father and paternal grandfater. Mother had ""heart + disease."" + Occupation: + Drugs: + Tobacco: 30 pack year hx. quit after CABG in [**2121**] + Alcohol: History of up to [**7-8**] drinks daily, 5x/wk for many + years, only 1-2 beers/ week recently. + Other: He retired from his job as an electrician in the Marine Corps, + which required travel to HI, CA, NC, [**Country 69**]. He lives at home with + his supportive wife. They have 3 children + Review of systems: + Constitutional: Fatigue, Fever + Ear, Nose, Throat: Dry mouth, Epistaxis, No(t) OG / NG tube + Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t) + Tachycardia, No(t) Orthopnea, no PND + Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, DOE + on walking up stairs past 4-5 days + Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t) + Constipation, no hematemsis, no BRBPR + Genitourinary: No(t) Dysuria + Musculoskeletal: Joint pain, No(t) Myalgias, +Right knee pain past 2 + weeks + Integumentary (skin): No(t) Jaundice, Rash + Endocrine: Hyperglycemia + Heme / Lymph: Coagulopathy + Allergy / Immunology: Immunocompromised + Pain: [**1-31**] Mild + Pain location: right knee + Flowsheet Data as of [**2136-5-29**] 03:19 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 38.4 +C (101.2 + Tcurrent: 38.4 +C (101.2 + HR: 82 (82 - 93) bpm + BP: 127/52(69) {123/51(68) - 127/52(69)} mmHg + RR: 20 (20 - 22) insp/min + SpO2: 99% + Heart rhythm: SR (Sinus Rhythm) + Height: 65 Inch + Total In: + 4,475 mL + PO: + TF: + IVF: + 175 mL + Blood products: + Total out: + 0 mL + 800 mL + Urine: + NG: + Stool: + Drains: + Balance: + 0 mL + 3,675 mL + Respiratory + O2 Delivery Device: None + SpO2: 99% + Physical Examination + General Appearance: Well nourished, No acute distress, Overweight / + Obese + Eyes / Conjunctiva: PERRL + Head, Ears, Nose, Throat: Normocephalic + Lymphatic: Cervical WNL, Supraclavicular WNL + 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: Not assessed), (Left DP pulse: Not + assessed), capillary refill WNL + Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) + Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, + Obese + Extremities: Right: 1+, Left: Trace, No(t) Cyanosis, No(t) Clubbing + Skin: Not assessed, Rash: area of erythema on right lower leg + surrounding wound. purpura present on back of hands. + Neurologic: Attentive, Responds to: Not assessed, Oriented (to): + person, place & time, Movement: Purposeful, Tone: Not assessed + Labs / Radiology + 12.3 + 243 + 12.1 + 420 + 2.1 + 34 + 20 + 90 + 3.8 + 134 + 37.8 + [image002.jpg] AG 24 + PT 145 PTT 89 INR 21 repeat 22 + Microbiology: wound cx sent. + blood cx sent x2 + Assessment and Plan + Mr. [**Known lastname 68**] is a 64 yo male with a history of T1DM s/p cadoveric renal + transplant, chronic RLE ulcers, and IVC filter on Coumadin, who was + admitted with mild DKA in the setting of one week of N/V, diarrhea and + fevers. + . + #. DKA: likely [**12-31**] infection; sugars max ~400, but improved to mid + 200's with IV insulin in ED; patient was not on drip. Potassium + dropping with improvement in gap, which is now ~16. + -- will give SQ insulin SS Q2 hours --> will space out to Q4 hours once + FSG consistently < 200 + -- will treat infection and evaluate for other causes as below + -- no need for bicarb currently + . + #. NAUSEA/VOMITING, DIARRHEA: IC host from IS for renal transplant. No + h/o CP, but at risk for silent MI give DM status. ? slight Q waves on + inferior leads. Also had recent linezolid use for RLE ulcers. + -- will send urinary Legionella antigen, C. diff, stool cultures + -- will check cardiac enzymes with am labs, though likely to be + negative given time course of symptoms. + . + #. SOB: CXR clear and unlikely infectious, though with chronic + cryptococcal PNA; symptoms have been worsening over last couple days. + ? whether related to a silent MI or possibly Legionella or some other + pulm infection. Patient anemic but at baseline. Does not have an O2 + requirement currently. CXR clear. + -- will evaluate for MI, per below + -- t/c echo if symptoms do not improve with treatment of leg infection, + t/c adding levofloxacin for Legionella + -- cont home fluconazole 200 mg QD + . + #. RLE ULCER/CELLULITIS: was previously treated with linezolid; + followed by podiatry as out-patient; seen by vascular and podiatry in + ED, who had no acute recs + -- cont. vanco + -- wound care consult + -- will follow right knee symptoms and consider tap if not improving, + although he had no obvious effusion on exam on admission to the [**Hospital Unit Name 4**] + . + #. VOLUME BALANCE: dehydrated per history, BUN/Cr + -- will hold home lasix + -- cont IV fluids w/ K+ + . + #. ANTICOAGULATION: INR 20 on presentation likely [**12-31**] diarrhea and poor + PO intake over last week; received 1 unit FFP in the ED as well as + vitamin K. + -- will check INR in am + -- cont vit K 10 mg PO x 2 more doses + -- no evidence of bleeding currently, though will maintain active T&S + . + #. ARF: Cr 2.1 on admission; with IVF in ED, repeat Cr 1.7 with BUN + 28. Baseline ~0.9 - 1.0. Likely mostly prerenal, but patient also + with poor PO intake and poor absorption in recent week while on + prednisone/prograf for renal allograft and, thus, at risk for + rejection. + -- will cont to monitor response to IVF; cont to follow UOP + -- f/u renal recs + . + #. PPX: + -- INR supratherapeutic; no need for SQH currently + -- cont home protonix and bowel regimen + . + #. FEN: + -- diabetic diet as tolerated + -- will cont IVF overnight and reassess volume status in the morning + . + #. ACCESS: 2x PIV + . + #. CODE: full + . + #. DISPO: to [**Last Name (un) 70**] in ICU overnight for further observation and + treatment; likely d/c to floor in am if stable + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2136-5-29**] 01:32 AM + Prophylaxis: + DVT: + Stress ulcer: + VAP: + Comments: + Communication: Comments: + Code status: Full code + Disposition: +","Admission Date: [**2136-5-28**] Discharge Date: [**2136-6-7**] + +Date of Birth: [**2071-10-10**] Sex: M + +Service: MEDICINE + +Allergies: +Tegaderm / Prinivil / Reglan + +Attending:[**First Name3 (LF) 9853**] +Chief Complaint: +hyperglycemia + +Major Surgical or Invasive Procedure: +debridement of right foot ulcer +PICC line placement + + +History of Present Illness: +[**Known firstname **] [**Known lastname **] 64 yo male hx of PVD, DM s/p renal transplant +[**2130**]. and ulcers. Patient states that he has been nauseated +with vomiting and diarrhea for the past 2 weeks. He reports +having decreased food intake and that he has not been able to +take or keep his medications down consistently. He states that +in the past when he has been hyperglycemic, he has not had +nausea and vomiting like this. He also reports SOB and DOE for +the past 4-5 days. He denies orthopnea and PND. He reports some +edema in his legs bilat which is a chronic problem. [**Name (NI) **] came to +the ER today because his wife finally made him after his +temperature spiked to 102. Patient also has chronic ulcers. His +wife helps care for them and has not noticed any increasing +erythema 2 days ago when last she changed the dressing. +However, in ED, found to have swollen RLE with right ulcers some +and surrounding erythema concerning for celluliti. In ED found +to be hyperglycemic with BS of 420 and AG 24. They treated him +with SQ insulin rather than an insulin drip because they were +concerned about hypoglycemia. ED with q 1-2 hr fingersticks +brought AG down to 16 currently. + +ED concerned about possible cellulitis started on Vanco and +unsyn for cellulitis. xray of leg did not show osteomyelitis. +CXR clear. [**Name (NI) **] was consulted and they took a foot cx. +Podiatry also saw patient. Patient was going go to floor when +INR came back at 20.0. Patient then given FFP x1 unit and Vit K. + + + +Past Medical History: +1. Coronary artery disease s/p CABG X 4 in [**2128**]. Echo [**9-2**] nml +LV function +2. Type 1 Diabetes with complications including retinopathy, +neuropathy, end-stage renal disease, and Charcot foot +3. End-stage renal disease status post cadaveric renal +transplant [**10-1**] +4. Right lower extremity DVT since [**7-4**] requiring life-long +anticoagulation on coumadin and IVC filter placement +5. Hypertension +6. GERD +7. Osteopenia of hip [**10-31**] +8. Neuropathy Rfoot > Lfoot +9. Bilateral cataract surgery +[**37**]. Right foot surgery and Charcot foot [**12/2125**] +11. Diverticulosis +12. Status post flexible bronchoscopy with biopsy of RUL, +lingula [**4-3**] +13. Cryptococcus pneumonia, treated with Fluconazole +14. ORIF left ulna [**4-3**] +15. IVC filter placement [**4-3**] +16. [**2135-6-9**]: Abdominal aortogram with RLE extremity +runoff, angioplasty of popliteal stenosis. + + +Social History: +He retired from his job as an electrician in the Marine Corps, +which required travel to HI, CA, NC, [**Country 5976**]. He lives at home with +his supportive wife. They have 3 children (M36, F34, M26). + +Alcohol: History of up to [**7-8**] drinks daily, 5x/wk for many +years, only 1-2 beers/ week recently. +Tobacco: 30 pack years, quit [**2121**] after MI. + +Family History: +DM type II in father and paternal grandfater. Mother had ""heart +disease."" + +Physical Exam: +Tmax: 38.4 ??????C (101.2 ??????F) +Tcurrent: 38.4 ??????C (101.2 ??????F) +HR: 82 (82 - 93) bpm +BP: 127/52(69) {123/51(68) - 127/52(69)} mmHg +RR: 20 (20 - 22) insp/min +SpO2: 99% +Heart rhythm: SR (Sinus Rhythm) +Height: 65 Inch + +General Appearance: Well nourished, No acute distress, +Overweight / Obese +Eyes / Conjunctiva: PERRL +Head, Ears, Nose, Throat: Normocephalic +Lymphatic: Cervical WNL, Supraclavicular WNL +Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, +No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) +Peripheral [**Year (4 digits) **]: (Right radial pulse: Present), (Left radial +pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse: +Not assessed), capillary refill WNL +Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: +Clear : ) +Abdominal: Soft, Non-tender, Bowel sounds present, No(t) +Distended, Obese +Extremities: Right: 1+, Left: Trace, No(t) Cyanosis, No(t) +Clubbing +Skin: Not assessed, Rash: area of erythema on right lower leg +surrounding wound. purpura present on back of hands. +Neurologic: Attentive, Responds to: Not assessed, Oriented (to): +person, place & time, Movement: Purposeful, Tone: Not assessed + + +Pertinent Results: +Admit labs: +134 90 34 +---------------< 420 +3.8 20 2.1 D +LDH: 296 +. +WBC: 12.3 +HCT: 37.8 +PLT: 243 +N:88.9 L:7.5 M:3.5 E:0.1 Bas:0.1 +. +HCT: 37 -> 32 -> 29 +AG: closed prior to d/c out of ICU +. +CXR: neg +Ankle: Cortical irregularity and soft tissue swelling at the +base of the +fifth metatarsal are unchanged. Stable neuropathic changes in +the mid foot. No new areas identified to indicate osteomyelitis. + +. +EKG: NSR, Q III, no acute ST-T changes +. + + +Brief Hospital Course: +Mr. [**Known lastname **] is a 64 yo male with a history of T1DM s/p cadoveric +renal transplant, chronic RLE ulcers, and IVC filter on +coumadin, who was admitted with DKA in the setting of one week +of N/V, diarrhea and fevers. + +#. DKA: Thought [**12-31**] infection (MRSA bacteremia and C diff +colitis found in workup) He received aggressive IVF and IV +insulin bolus but no gtt. His gap closed overnight in the ICU. +EKG without signs of active ischemia. He was restarted on his +home insulin regimen once gap closed, with no further incidents. + +#. R FOOT ULCER/CELLULITIS: was previously treated with +linezolid and followed by podiatry as out-patient; seen by +[**Month/Day (2) 1106**] and podiatry on admission. He was started on vanco and +unasyn on admission, and this was narrowed to just vanco after +his culture data returned. Initial wound swab grew MRSA and was +the likely source of MRSA bacteremia. He underwent debridement +in OR by podiatry on [**2136-5-31**], cultures sent from OR and also grew +MRSA. ID consulted and suggested 6 weeks vancomycin: his wound +probes to bone so there was certainly concern for osteomyelitis. +Pathology eventually confirmed acute osteomyelitis. He will +follow up with Dr. [**Last Name (STitle) 31564**] of podiatry. + +# MRSA BACTEREMIA: [**12-31**] sets on admission. Source likely foot +ulcer. TTE negative. Surveillance blood cultures neg to date. +Treating with 6 weeks vancomycin as above. + +#. NAUSEA/VOMITING, DIARRHEA, C DIFF COLITIS: sx improved with +appropriate tx with flagyl. Will be treated with 2 weeks Flagyl +and if diarrhea recurs while on vancomycin, will consider +retreating with Flagyl. + +#. SOB: sx resolved without further intervention. No signs ACS +or pneumonia. Low suspicion PE. No hypoxia + +#. Right knee pain: There was initially significant concern for +possible septic knee in the setting of MRSA bacteremia; however +on further evaluation by rheum, they reported that he had no +effusion, no fluid for arthrocentesis. Their differential +included CPPD/crystalline disease, other musculoskeletal such as +meniscal tear, avascular necrosis (chronic steroids), occult +fracture. MRI showed no evidence of meniscal or ligamentous +injury, non-specific circumferential subcutaneous edema, and +only trace joint fluid. His pain improved with conservative +management. + +#. Coagulopathy: INR 20 on presentation likely [**12-31**] diarrhea and +poor PO intake over last week; received 1 unit FFP in the ED as +well as vitamin K. INR improved to 6. We held coumadin but +also gave no further vitamin K in the ICU. His INR was allowed +to drift down and was 3.7 on discharge. He will follow up with +[**Hospital3 **] who will determine when he will restart +coumadin. + +#. ARF: Cr 2.1 on admission; with IVF in ED. Likely prerenal as +it improved with appropriate hydration. Continued +prednisone/prograf for renal allograft. On resumption of his +outpatient diuretics, his creatinine started rising again. +Diuretics were held as urine lytes suggested this was again +prerenal. Given his worsening lower extremity edema and after +his creatinine had stabilized around 1.7-1.8, Lasix was +restarted at 40mg qd and florinef was stopped. + +#. Hx heavy EtOH use: ciwa scale and mvi/folate/thiamine; no +signs withdrawal so CIWA discontinued. + +# T1 DM, uncontrolled with complications: as above, DKA +resolved with appropriate insulin IV in ICU and tx of multiple +infections. + +# CAD s/p CABG: continued ASA, Plavix + +# Anemia: he was guaiac negative and iron studies were +consistent with ACD. Procrit was started in-house, to be +continued as an outpatient. + +Medications on Admission: +Medications confirmed with pt's wife who has a handwritten list + +OXYCODONE - (Prescribed by Other Provider) - 5 mg Capsule - +as +needed for pain ---> wife says most recently he has been using +percocet +ACETIC ACID (BULK) - (Prescribed by Other Provider) - 3 % +Liquid +- to wash foot wound daily apply dressing after wash +AMLODIPINE [NORVASC] - 5 mg Tablet - 1 Tablet(s) by mouth once a +day +ASCENSIA ELITE TEST STRIPS - - USE AS DIRECTED +ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg +Tablet - 1 Tablet(s) by mouth hs +BECAPLERMIN [REGRANEX] - (Prescribed by Other Provider) - 0.01 +% +Gel - as needed +CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once +a +day +COUMADIN - 1MG Tablet - one to three Tablet(s) by mouth once a +day +FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth once a day +FLUDROCORTISONE [FLORINEF] - 0.1 mg Tablet - 1 Tablet(s) by +mouth +once a day - No Substitution +FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 +Tablet(s) by mouth twice a day +FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth every other day +GLUCAGON EMERGENCY KIT - 1MG Kit - USE AS DIRECTED +IMDUR - 60MG Tablet Sustained Release 24 hr - ONE TABLET EVERY +DAY +INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - +100 +unit/mL Solution - 36 units every noon +METOPROLOL TARTRATE - 50MG Tablet - ONE TABLET TWICE A DAY +NITROQUICK - 0.4MG Tablet, Sublingual - USE 0.4 MG UNDER THE +TONGUE AS NEEDED FOR CHEST PAIN +NOVOLOG - 100 U/ML Solution - SLIDING SCALE - [**First Name8 (NamePattern2) **] [**Last Name (un) **] +OS-CAL 500+D - 500-200 Tablet - ONE TABLET THREE TIMES A DAY + +PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - +1 Tablet(s) by mouth once a day +PAPAIN-UREA [ETHEZYME] - (Prescribed by Other Provider) - 1.1 +million unit/gram Ointment - as needed +PAPAIN-UREA-CHLOROPHYLLIN [PANAFIL] - (Prescribed by Other +Provider) - 521,700 unit/gram-10 %-0.5 % Ointment - as needed +POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq +Tab +Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth once a day +PREDNISONE - 5MG Tablet - ONE Tablet(s) by mouth q day +RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 Tablet(s) by mouth once +a week take on empty stomach with lots of water, stay upright +for +30 min afterwards +SILVER SULFADIAZINE - (Prescribed by Other Provider) - 1 % +Cream +- as needed +TACROLIMUS [PROGRAF] - 1 mg Capsule - 1 Capsule(s) by mouth +twice +a day +TRAVOPROST (BENZALKONIUM) [TRAVATAN] - (Prescribed by Other +Provider) - 0.004 % Drops - 1 drop in the left eye once a day +TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] - (Prescribed by Other +Provider) - 400 mg-80 mg Tablet - one Tablet(s) by mouth mon, +wed,fri + +Medications - OTC +ALCOHOL SWABS - Pads, Medicated - USE AS DIRECTED +ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) - +500 +mg Tablet - 1 Tablet(s) by mouth once a day +ASPIRIN [ASPIRIN EC] - (OTC) - 81 mg Tablet, Delayed Release +(E.C.) - 1 Tablet(s) by mouth once a day +CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider) - 500 +mg Tablet, Chewable - Tablet(s) by mouth as needed +COLACE - 100MG Capsule - ONE TABLET TWICE A DAY +HYDROCOLLOID DRESSING [AQUACEL HYDROFIBER DRESSING] - +(Prescribed by Other Provider) - Dosage uncertain +HYDROCOLLOID DRESSING [AQUACEL HYDROFIBER DRESSING] - +(Prescribed by Other Provider) - 4"" X 4"" Bandage - as needed +LANCETS - Misc - AS DIRECTED 5 TIMES PER DAY +MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a +day +NON-ADHERENT BANDAGE [ADAPTIC] - (Prescribed by Other Provider) +- Dosage uncertain +POVIDONE-IODINE [BETADINE] - (Prescribed by Other Provider) - +10 +% Solution - as needed + + +Discharge Medications: +1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g +Intravenous Q48H (every 48 hours) for 5 weeks. +Disp:*18 g* Refills:*0* +2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML +Intravenous PRN (as needed) as needed for line flush. +Disp:*100 ML(s)* Refills:*1* +3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL +Injection once a week. +Disp:*4 mL* Refills:*2* +4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) +Tablet, Chewable PO Q 8H (Every 8 Hours). +7. Cholecalciferol (Vitamin D3) 400 unit 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 Q24H (every 24 hours). +9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) +Tablet PO MWF (Monday-Wednesday-Friday). +10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable +PO DAILY (Daily). +11. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). +12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every +24 hours). +14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID +(2 times a day). +15. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a +day: in left eye. +16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H +(every 6 hours) as needed for pain. +17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +19. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every +12 hours). +20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID +(2 times a day). +21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 +times a day) for 1 weeks. +Disp:*21 Tablet(s)* Refills:*0* +22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 +hours) as needed for pain. +23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a +day) as needed for constipation. +24. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr +Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). +25. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +26. Insulin Glargine 100 unit/mL Solution Sig: Thirty Six (36) +Units Subcutaneous once a day. +27. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). + + +Discharge Disposition: +Home With Service + +Facility: +[**Hospital1 1474**] VNA + +Discharge Diagnosis: +Methicillin Resistant Staph Aureus bacteremia +Right foot ulcer infection +Diabetic ketoacidosis, resolved +Acute renal failure +Clostridium difficile colitis + +Secondary: +Type 1 diabetes mellitus with complications +hx of renal transplant +Coronary artery disease, s/p coronary artery bypass graft +peripheral [**Hospital1 1106**] disease +bilateral deep vein thrombosis + + +Discharge Condition: +stable, afebrile, ambulating with cane + + +Discharge Instructions: +You were admitted with cellulitis and found to have MRSA +bacteremia, likely from a foot ulcer. The ulcer was debrided by +podiatry and also grew MRSA. You will need IV antibiotics +(vancomycin) for 6 weeks from the date of [**2136-5-31**]. Visting nurses +will draw blood once a week and fax results to the [**Hospital **] clinic. +You should take Flagyl for one more week. + +You should continue to hold coumadin. VNA will draw blood for +INR and fax the results to the [**Hospital3 **]. They will +tell you when to resume coumadin. + +Resume your Lasix at 40mg daily. Depending on your creatinine +level, this may be adjusted by Dr. [**First Name (STitle) 805**] or Dr. [**Last Name (STitle) **]. + +If you have recurrent fevers, chills, worsening pain, or any +other concerning symptoms, call your doctor immediately. + +If you have recurrent diarrhea, call the [**Hospital **] clinic, as you may +need to restart Flagyl. + +Followup Instructions: +Podiatry: follow up with Dr. [**Last Name (STitle) **] in his [**Location (un) 701**] office +on [**6-15**] at 3:10. + +PCP: [**Name10 (NameIs) **] up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**] +[**Last Name (NamePattern1) **], on [**6-13**] at 11:10am. You may call his office at +[**Telephone/Fax (1) 250**] with any questions. + +[**Telephone/Fax (1) **]: Follow up with Dr. [**Last Name (STitle) **] on [**7-24**] at 1pm. + +Renal: Follow up with Dr. [**First Name (STitle) 805**] on [**7-9**] at 11am. + +ID: Follow up with Dr. [**Last Name (STitle) 12838**] on [**2136-6-21**] at 1:30pm. +Phone:[**Telephone/Fax (1) 457**] + + + +","[**known firstname 67**] [**known lastname 68**] 64 yo male hx of pvd, dm s/p renal transplant [**2130**]. and ulcers. patient states that he has been nauseated with vomiting and diarrhea for the past 2 weeks. he reports having decreased food intaked and that he has not been able to take or keep his medications down consistently. he states that in the past when he has been hyperglycemic, he has not had nausea and vomiting like this. he also reports sob and doe for the past 4-5 days. he denies orthopnea and pnd. he reports some edema in his legs bilat which is a chronic problem. [**name (ni) **] came to the er today because his wife finally made him after his temperature spiked to 102. patient also has chronic ulcers. his wife helps care for them and has not noticed any increasing erythema 2 days ago when last she changed the dressing. however, in ed, found to have swollen rle with right ulcers some and surrounding erythema concerning for celluliti. in ed found to be hyperglycemic with bs of 420 and ag 24. they treated him with sq insulin rather than an insulin drip because they were concerned about hypoglycemia. ed with q 1-2 hr fingersticks brought ag down to 16 currently. ed concerned about possible cellulitis started on vanco and unsyn for cellulitis. xray of leg did not show osteomyelitis. cxr clear. vascular was consulted and they took a foot cx. podiatry also saw patient. patient was going go to floor when inr came back at 20.0. patient then given ffp x1 unit and vit k. patient admitted from: [**hospital1 5**] er history obtained from patient","mr. [**known lastname **] is a 64 yo male with a history of t1dm s/p cadoveric renal transplant, chronic rle ulcers, and ivc filter on coumadin, who was admitted with dka in the setting of one week of n/v, diarrhea and fevers.","[**known firstname 67**] [**known lastname 68**] 64 yo male hx of pvd, dm s/p renal transplant [**2130**]. he states that in the past when he has been hyperglycemic, he has not had nausea and vomiting like this. name (ni) **] came to the er today because his wife finally made him after his temperature spiked to 102. ed with q 1-2 hr fingersticks brought ag down to 16 currently. vascular was consulted and they took a foot cx. patient was going go to floor when inr came back at 20.0. patient then given ffp x1 unit and vit k. patient admitted from: [**hospital1 5**] er history obtained from patient",['The 64-year-old man has been vomiting and diarrhea for the past 2 weeks.\nHe has been hospitalized with a urinary tract infection and a chronic condition.\nHis wife has not noticed any increase in the number of edema.\nShe has not been able to take or keep his medications down consistently.'],patient has been nauseated with vomiting and diarrhea for the past 2 weeks. he reports some edema in his legs bilat which is a chronic problem. his wife finally made him after his temperature spiked to 102.,"['patient has been nauseated with vomiting and diarrhea for the past 2 weeks . his wife finally made him after temperature spiked to 101 degrees yesterday morning, but she did not notice any increasing swelling when last changed dressings on her husband\' ""i have no idea what this is,"" says one of our patients who was admitted today from hospital in los angeleses where they were treated by podistry doctors at 3:00 pm (pt)']","patient states that he has been nauseated with vomiting and diarrhea for the past 2 weeks. +he states that in the past when he has been hyperglycemic, he has not had nausea and vomiting like this. +patient also has chronic ulcers. +however, in ed, found to have swollen rle with right ulcers some and surrounding erythema concerning for celluliti.","[**known firstname 67**] [**known lastname 68**] 64 yo male hx of pvd, dm s/p renal transplant [**2130**].patient states that he has been nauseated with vomiting and diarrhea for the past 2 weeks.he reports having decreased food intaked and that he has not been able to take or keep his medications down consistently.he states that in the past when he has been hyperglycemic, he has not had nausea and vomiting like this.he also reports sob and doe for the past 4-5 days.he denies orthopnea and pnd.he reports some edema in his legs bilat which is a chronic problem.[**name (ni) **] came to the er today because his wife finally made him after his temperature spiked to 102.patient also has chronic ulcers.his wife helps care for them and has not noticed any increasing erythema 2 days ago when last she changed the dressing.","[{'rouge-1': {'r': 0.4594594594594595, 'p': 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0.24999999603914363}}]",0.459459459,0.184782609,0.263565887,0.097560976,0.037037037,0.053691271,0.405405405,0.163043478,0.232558135,0.216216216,0.186046512,0.199999995,0.048780488,0.040816327,0.044444439,0.189189189,0.162790698,0.174999995,0.216216216,0.228571429,0.222222217,0.024390244,0.027777778,0.025974021,0.162162162,0.171428571,0.166666662,0.297297297,0.150684932,0.199999996,0.048780488,0.027777778,0.035398225,0.216216216,0.109589041,0.145454541,0.189189189,0.175,0.181818177,0.024390244,0.018867925,0.021276591,0.189189189,0.175,0.181818177,0.459459459,0.171717172,0.249999996,0.12195122,0.036764706,0.056497172,0.459459459,0.171717172,0.249999996 +73037,192662,9200,"Chief Complaint: Shortness of breath + HPI: + Mr. [**Known lastname 1873**] is a 75 year old male with a history of hemorrhagic stroke 2 + months ago admitted for shortness of breath. He was noted by VNA to + have labored breathing and was found to be hypoxic at home to 70s on + RA. + . + He was initially taken to [**Location (un) 78**], where CTA showed massive bilateral + PEs. He was also found to be in A. fib with RVR which resolved with + oxygen, but no nodal agents. He was started on a nitropaste and + transferred to [**Hospital1 1**] for further management. + . + Patient reports that that he has had 2-3 weeks of RLE edema, but was + without SOB, CP, nausea, vomiting, diarrhea, melena, hematemasis. + Reports he is up to date on colonoscopy and PSA and carries no cancer + diagnosis. Patient reports he was highly mobile over the summer, but + over the past 2-3 months has been primarily bedbound due to sciatica + symptoms and deconditioning after recent stroke. Was prescribed lasix + for LE edema by PCP [**Name Initial (PRE) **] few weeks ago. Also of note, patient underwent + dental extraction of 7 teeth last week. + . + In the ED, his vitals were 82, 108/92, 24, 96% on [**Name Initial (PRE) 1351**]. He got a CXR + which showed no acute process. He got LENIs with showed LLE DVT. + . + Patient admitted from: [**Hospital1 1**] ER + History obtained from Patient, Family / Friend + Allergies: + Percocet (Oral) (Oxycodone Hcl/Acetaminophen) + Unknown; + Vicodin (Oral) (Hydrocodone Bit/Acetaminophen) + Unknown; + Ambien (Oral) (Zolpidem Tartrate) + Unknown; + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Finasteride 5 mg daily + Ezetemibe 10 mg daily + Simvastatin 20 mg daily + Felodipine 5 mg daily + Lisinopril 20 mg daily + Lasix 40 daily + K-dur + . + Past medical history: + Family history: + Social History: + Left internal capsule lacunar infarct [**2180**] + Hemmoragic stroke [**2185**] + Hypertension + Lumbar disc disease + Hypercholesterolemia + BPH s/p TURP + Mother with stroke at age 77. Father with CAD. Sister with dementia. + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: Patient previously work for Schering Plough in sales. Currently + bedbound, but was very active until 4 months ago due to sciatica. Rare + tobacco use in his youth but currently non-smoker. Rare wine use. + Review of systems: + Flowsheet Data as of [**2186-10-18**] 01:25 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 36.1 +C (97 + Tcurrent: 36.1 +C (97 + HR: 102 (93 - 102) bpm + BP: 115/64(72) {115/59(72) - 149/97(108)} mmHg + RR: 27 (17 - 28) insp/min + SpO2: 96% + Heart rhythm: AF (Atrial Fibrillation) + Total In: + 17 mL + 13 mL + PO: + TF: + IVF: + 17 mL + 13 mL + Blood products: + Total out: + 0 mL + 0 mL + Urine: + NG: + Stool: + Drains: + Balance: + 17 mL + 13 mL + Respiratory + O2 Delivery Device: Face tent + SpO2: 96% + ABG: 7.46/37/171//3 + PaO2 / FiO2: 171 + Physical Examination + General Appearance: Well nourished + Eyes / Conjunctiva: PERRL + Head, Ears, Nose, Throat: Normocephalic + Cardiovascular: (S1: Normal), (S2: Normal), irregular + 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 : ) + Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended + Extremities: Right: Absent, Left: 2+ + Skin: Not assessed + Neurologic: Attentive, Follows simple commands, Responds to: Not + assessed, Oriented (to): x 3, Movement: Purposeful, Tone: Not assessed + Labs / Radiology + [image002.jpg] + [**2183-12-15**] + 2:33 A11/4/[**2185**] 10:51 PM + [**2183-12-19**] + 10:20 P + [**2183-12-20**] + 1:20 P + [**2183-12-21**] + 11:50 P + [**2183-12-22**] + 1:20 A + [**2183-12-23**] + 7:20 P + 1//11/006 + 1:23 P + [**2184-1-15**] + 1:20 P + [**2184-1-15**] + 11:20 P + [**2184-1-15**] + 4:20 P + TC02 + 27 + Other labs: Lactic Acid:0.8 mmol/L + Fluid analysis / Other labs: + Labs: + 142 | 106 | 16 / + ---------------- 107 + 3.9 | 28 | 1.1 \ + . + .. \ 13.7 / + 10.0 ----- 213 + .. / 39.5 \ + . + PT 14.6 + PTT 25.9 + INR 1.3 + . + EKG: + NSR at 95 bpm, Normal PACs. Normal PR interval, qrs, qtc intervals. + . + Imaging: Imaging: + [**2186-10-17**]. CTA. Preliminary read: bilateraly central PEs. + . + CT Head. [**2186-8-21**]. + FINDINGS: 27 x 10 mm parenchymal hemorrhage within the left basal + ganglia/internal capsule. Exerts mild mass effect upon anterior [**Doctor Last Name **] of + left lateral ventricle. No other foci of bleeding, and no midline + shift. Chronic small vessel ischemia. + Microbiology: none + ECG: NSR at 95 bpm, bigemeny. Normal PR interval, qrs, qtc intervals. + normal axis. q wave in v3. + Assessment and Plan + Mr. [**Known lastname 1873**] is a 75 year old male with recent hemorrhagic stroke, HTN, + BPH, HL, admitted for bilateral PE. + . + 1. PE. Recent hemorrhagic stroke on [**2186-8-22**] makes anticoagulation a + concerning choice. Spoke with [**Date Range 1874**] who feel that anticoagulation + is only a relative contraindication to anticoagulation given that the + hemorrhagic stroke occured two months ago, however, the risks of + anticoagulation are high in this patient. Will likely need family + meeting with PCP involvement to reach an agreement re: + anticoagulation. Will pursue IVC filter tonight. Currently + hemodyamically stable. Pa02 of 173 on 100%[**Last Name (LF) 1351**], [**First Name3 (LF) **] will titrate down + oxygen. Etiology of PE likely secondary to prolonged immobility; no + history of malignancy or prior clots. + - titrate supplemental oxygen + - IVC filter placement + - discuss with PCP, [**Name10 (NameIs) 1874**], family, re: risks & benefits of systemic + anticoagulation in this patient + - echo to evaluate biventricular function + - [**Name10 (NameIs) 1874**] consult re: whether anticoagulation is possible in this + patient + - r/o MI + . + 2. H/o CVA. History of hemorrhagic and ischemic CVA with minimal + residual deficits. Will pursue head imaging tonight given that + systemic anticoagulation remains a possibility in this patient. Will + consult [**Name10 (NameIs) 1874**] re: anticoagulation in this patient. + - neuro consult + - head ct w/o contrast + . + 2. HTN. History of hemorrhagic stroke, so will aim to maintain SBP < + 140. + - continue lisinopril, felodipine + . + 3. BPH. s/p turp. + - finasteride + . + 4. Hyperlipidemia. + - ezetemibe, simvastatin + . + 5. PPx. PPI, bowel regimen, HSQ. + . + Access: PIVs + Communication: Wife [**Name (NI) 117**] [**Name (NI) 651**] [**Telephone/Fax (1) 1875**]. Daughter [**Name (NI) 63**]. + [**Telephone/Fax (1) 1876**] + DNR/DNI, confirmed with patient, wife [**Name (NI) 117**], daughter + . + ICU Care + Nutrition: + Glycemic Control: Regular insulin sliding scale + Lines: + 18 Gauge - [**2186-10-17**] 10:20 PM + 20 Gauge - [**2186-10-17**] 10:20 PM + Prophylaxis: + DVT: SQ UF Heparin(Systemic anticoagulation: None) + Stress ulcer: + VAP: + Comments: + Communication: Family meeting held Comments: + Code status: DNR / DNI + Disposition: ICU +","Admission Date: [**2186-10-17**] Discharge Date: [**2186-10-23**] + +Date of Birth: [**2111-5-16**] Sex: M + +Service: MEDICINE + +Allergies: +Percocet / Vicodin / Ambien + +Attending:[**First Name3 (LF) 905**] +Chief Complaint: +Shortness of breath + +Major Surgical or Invasive Procedure: +IVC filter + +History of Present Illness: +Mr. [**Known lastname 31611**] is a 75 year old male with a history of hemorrhagic +stroke 2 months ago admitted for shortness of breath. He was +noted by VNA to have labored breathing and was found to be +hypoxic at home to 70s on RA. +. +He was initially taken to [**Location (un) 620**], where CTA showed massive +bilateral PEs. He was also found to be in A. fib with RVR which +resolved with oxygen, but no nodal agents. He was started on a +nitropaste and transferred to [**Hospital1 18**] for further management. +. +Patient reports that that he has had 2-3 weeks of RLE edema, but +was without SOB, CP, nausea, vomiting, diarrhea, melena, +hematemasis. Reports he is up to date on colonoscopy and PSA +and carries no cancer diagnosis. Patient reports he was highly +mobile over the summer, but over the past 2-3 months has been +primarily bedbound due to sciatica symptoms and deconditioning +after recent stroke. Was prescribed lasix for LE edema by PCP [**Name Initial (PRE) **] +few weeks ago. Also of note, patient underwent dental +extraction of 7 teeth last week. +. +In the ED, his vitals were 82, 108/92, 24, 96% on NRB. He got a +CXR which showed no acute process. He got LENIs with showed LLE +DVT. + + +Past Medical History: +Left internal capsule lacunar infarct [**2180**] +Hemmoragic stroke [**2185**] +Hypertension +Lumbar disc disease +Hypercholesterolemia +BPH- s/p TURP +. + +Social History: +Patient previously work for Schering Plough in sales. Currently +with limited activity, bedbound secondary to sciatica and recent +stroke, but was very active until 4 months ago. Rare tobacco +use in his youth but currently non-smoker. Rare wine use. + +Family History: +Mother with stroke at age 77. Father with CAD. Sister with +dementia. + +Physical Exam: +VS:T 97.5 BP 120/60 HR 91 RR24 95%4L NC O2 +Gen: Pleasant, conversive, interactive elderly gentleman in NAD +HEENT: nc/at PERRL. EOMI. +Neck: Supple. FROM. No carotid bruits. JVP approx. 7-8cm +CV: Regularly irreg. Distant. No murmurs heard. +Pulm: Diminished BS. CTAB +Abd: Soft. NT/Nd. +BS. No HSM +Ext: No c/c. Left foot edematous with trace pitting edema. CP/PT +2+ BL +Neuro: AAO x 3. CN 2-12 intact. [**4-17**] strenth UE, prox LE BL. [**1-17**] +strength left plantar and dorsiflexor. Gross sensation intact. + +Pertinent Results: +[**2186-10-17**] 07:27PM BLOOD WBC-10.0 RBC-4.68 Hgb-13.7* Hct-39.5* +MCV-85 MCH-29.2 MCHC-34.6 RDW-13.9 Plt Ct-213 +[**2186-10-20**] 06:10AM BLOOD WBC-9.3 RBC-4.56* Hgb-13.3* Hct-39.4* +MCV-86 MCH-29.2 MCHC-33.9 RDW-13.8 Plt Ct-245 +[**2186-10-23**] 07:10AM BLOOD WBC-7.4 RBC-4.27* Hgb-12.3* Hct-35.9* +MCV-84 MCH-28.8 MCHC-34.4 RDW-14.3 Plt Ct-299 +[**2186-10-21**] 06:18AM BLOOD PT-16.8* PTT-91.6* INR(PT)-1.5* +[**2186-10-22**] 07:15AM BLOOD PT-21.6* PTT-104.6* INR(PT)-2.0* +[**2186-10-23**] 07:10AM BLOOD PT-25.6* PTT-96.7* INR(PT)-2.5* +[**2186-10-17**] 07:27PM BLOOD Glucose-107* UreaN-16 Creat-1.1 Na-142 +K-3.9 Cl-106 HCO3-28 AnGap-12 +[**2186-10-23**] 07:10AM BLOOD Glucose-101 UreaN-6 Creat-0.8 Na-143 +K-3.8 Cl-110* HCO3-26 AnGap-11 +[**2186-10-18**] 03:22AM BLOOD ALT-9 AST-15 LD(LDH)-299* AlkPhos-56 +TotBili-0.8 +[**2186-10-17**] 07:27PM BLOOD CK-MB-4 cTropnT-0.02* proBNP-6974* +[**2186-10-18**] 11:24AM BLOOD CK-MB-NotDone cTropnT-0.01 + +[**10-17**] CXR: IMPRESSION: No acute cardiopulmonary abnormality. + +[**10-17**] LENIS: IMPRESSION: Acute deep venous thrombosis within the +left distal superficial +femoral vein and extending into the popliteal and posterior +tibial veins as +described. No deep venous thrombosis of the right lower +extremity. + +[**10-18**] ECHO: The left atrium is normal in size. 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 10-20mmHg. There is mild symmetric left ventricular +hypertrophy with normal cavity size and regional/global systolic +function (LVEF>55%). The right ventricular cavity is markedly +dilated with moderate global free wall hypokinesis. There is +abnormal septal motion/position consistent with right +ventricular pressure/volume overload. The ascending aorta is +mildly dilated. The aortic valve leaflets (3) are mildly +thickened but aortic stenosis is not present. The mitral valve +leaflets are mildly thickened. There is moderate pulmonary +artery systolic hypertension. There is a trivial/physiologic +pericardial effusion. +IMPRESSION: Right ventricular dilation and hypokinesis. Moderate +pulmonary artery systolic hypertension. Mild left ventricular +hypertrophy with normal systolic function. Findings consistent +with pulmonary emboli. No ASD or PFO identified. + +[**10-17**] ECG: Sinus rhythm with frequent premature beats, probably +atrial premature beats +with aberrant conduction. Non-specific ST-T wave abnormalities. +Compared to +the previous tracing of [**2186-8-21**] rhythm is similar, T wave +inversions in +leads V1-V3 are now present. Cannot exclude ischemia. + +[**10-18**] Head CT: IMPRESSION: No evidence of recent hemorrhage. +Subtle hyperattenuation in +region of prior left basal ganglia/internal capsule parenchymal +hemorrhage. + +Foot XRay: IMPRESSION: Soft tissue swelling. No fracture +identified. + + +Brief Hospital Course: +In summary, Mr. [**Known lastname 31611**] is a 75 year old male with recent +hemorrhagic stroke, HTN, BPH, HL, admitted for bilateral PE and +LLE DVT. +. +Pulmonary Embolism. Patient found to have bilateral central PEs +and LLE DVT. IVC filter placed and anticoagulation with heparin +initiated in spite of recent hemorrhagic stroke (2 months ago) +after discussion with neurology who recommended anticoagulation. + Patient remained hemodyamically stable and was weaned off +supplemental oxygen during hospital stay. Echo showed evidence +of RV strain and he was found to have elevated BNP on admission. + Etiology of PE likely secondary to prolonged immobility; no +history of malignancy or prior clots. He was bridged to Coumadin +prior to discharge and had therapeutic INR for 2 days prior to +discontinuation of heparin drip. +. +H/o CVA. History of hemorrhagic and ischemic CVA with minimal +residual deficits. He was followed by neurology during hospital +stay. Head CT on admission showed no acute event. +. +HTN. Patient continue on lisinopril and felodipine. +. +BPH. S/p turp. He was continued on finasteride. +. +Hyperlipidemia. He was continued on ezetemibe and simvastatin. +. +Left foot/toe pain: Pt c/o pain over dorsum of left foot/toes. +He did not have any focal tenderness or erythema. XR only showed +soft tissue swelling and no fracture. He had edema in left foot, +likely [**1-14**] DVT. He was given 0.5 tab Vicodin with good effect as +needed for toe pain in hospital which was improved at time of +discharge. + +Communication: Wife [**Name (NI) 382**] [**Name (NI) 4115**] [**Telephone/Fax (1) 31612**]. Daughter [**Name (NI) 5036**]. + [**Telephone/Fax (1) 31613**] +DNR/DNI, confirmed with patient, wife [**Name (NI) 382**] + +Medications on Admission: +Finasteride 5 mg daily +Ezetemibe 10 mg daily +Simvastatin 20 mg daily +Felodipine 5 mg daily +Lisinopril 20 mg daily +Lasix 40 daily +K-dur + +Discharge Medications: +1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +3. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) +Tablet Sustained Release 24 hr PO DAILY (Daily). +4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY +(Daily). +5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) +as needed. +6. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: +Your blood levels will be checked on Wednesday and your dose of +this medication may be adjusted by your primary care physician. +[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0* +7. Outpatient Lab Work +Please check INR and Chem 7 on Wednesday [**2186-10-25**] and fax +results to Dr.[**Name (NI) 31614**] office at ([**Telephone/Fax (1) 31615**]. +8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. +9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. +10. K-Dur 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab +Sust.Rel. Particle/Crystal PO once a day. +11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 +hours) as needed. + + +Discharge Disposition: +Home With Service + +Facility: +[**Hospital 119**] Homecare + +Discharge Diagnosis: +Primary Diagnosis +1. Pulmonary Embolism +2. Left lower extremity DVT +Secondary Diagnosis +1. Left internal capsule lacunar infarct [**2180**] +2. Hemorrhagic basal ganglia stroke [**8-/2186**] +3. HTN +4. Lumbar disc disease +5. Hypercholesterolemia +6. BPH s/p TURP + + +Discharge Condition: +Hemodynamically stable, afebrile, oxygenating mid 90s on room +air + + +Discharge Instructions: +You were admitted to the hospital with shortness of breath and +low oxygen saturations. You were found to have blood clots in +your lungs and one in your left leg which were causing these +symptoms. You had a filter placed in your blood vessels to +prevent clots from going from your legs to your lungs. We also +started you on a blood thinning medication called Coumadin. Your +blood levels of this medication need to be followed very +closely. + +We made the following changes to your medications +1. We added Coumadin 7.5 mg by mouth daily. The dose of this +medications may be adjusted based on blood work. + +Please return to the ER or call your primary care physician if +you develop any chest pain, shortness of breath, leg swelling, +changes in your vision or speech, numbness, weakness, if you +notice any blood in your stools or if you have any falls or any +other concerning symptoms. + +Followup Instructions: +Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**]. He +is aware of your recent hospital course. You should call ([**Telephone/Fax (1) 31616**] to make an appointment within the next two weeks. + + + + [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] + +","mr. [**known lastname 1873**] is a 75 year old male with a history of hemorrhagic stroke 2 months ago admitted for shortness of breath. he was noted by vna to have labored breathing and was found to be hypoxic at home to 70s on ra. he was initially taken to [**location (un) 78**], where cta showed massive bilateral pes. he was also found to be in a. fib with rvr which resolved with oxygen, but no nodal agents. he was started on a nitropaste and transferred to [**hospital1 1**] for further management. patient reports that that he has had 2-3 weeks of rle edema, but was without sob, cp, nausea, vomiting, diarrhea, melena, hematemasis. reports he is up to date on colonoscopy and psa and carries no cancer diagnosis. patient reports he was highly mobile over the summer, but over the past 2-3 months has been primarily bedbound due to sciatica symptoms and deconditioning after recent stroke. was prescribed lasix for le edema by pcp [**name initial (pre) **] few weeks ago. also of note, patient underwent dental extraction of 7 teeth last week. in the ed, his vitals were 82, 108/92, 24, 96% on [**name initial (pre) 1351**]. he got a cxr which showed no acute process. he got lenis with showed lle dvt. patient admitted from: [**hospital1 1**] er history obtained from patient, family / friend","in summary, mr. [**known lastname 31611**] is a 75 year old male with recent hemorrhagic stroke, htn, bph, hl, admitted for bilateral pe and lle dvt.","known lastname 1873**] is a 75 year old male with a history of hemorrhagic stroke 2 months ago admitted for shortness of breath. he was noted by vna to have labored breathing and was found to be hypoxic at home to 70s on ra. he was started on a nitropaste and transferred to [**hospital1 1**] for further management. patient reports that that he has had 2-3 weeks of rle edema, but was without sob, cp, nausea, vomiting, diarrhea, melena, hematemasis. was prescribed lasix for le edema by pcp [**name initial (pre) **] few weeks ago.",['The 75-year-old man was found to be hypoxic at home to 70 on ra.\nHe was also found to have a history of hemorrhagic stroke.\nThe condition was treated with lupus and was not fatal.\nIt is thought he has had 2-3 weeks of rle edema.'],a 75 year old male with a history of hemorrhagic stroke 2 months ago was admitted for shortness of breath. he was found to be hypoxic at home to 70s on ra. he was started on a nitropaste and transferred to [**hospital1 1**] for further management.,"[""a 75 year old male with history of hemorhagic stroke 2 months ago was admitted for shortness-of breath and hypoxic at home to 70s on the drug, lazix. patient reports that has had 2-3 weeks' worth (without sob) but is upto date in colonoscope/psie; no cancer diagnosis found yet!""]","[**known lastname 1873**] is a 75 year old male with a history of hemorrhagic stroke 2 months ago admitted for shortness of breath. +was prescribed lasix for le edema by pcp [**name initial (pre) **] few weeks ago.","[**known lastname 1873**] is a 75 year old male with a history of hemorrhagic stroke 2 months ago admitted for shortness of breath.he was noted by vna to have labored breathing and was found to be hypoxic at home to 70s on ra.he was initially taken to [**location (un) 78**], where cta showed massive bilateral pes.he was also found to be in a.fib with rvr which resolved with oxygen, but no nodal agents.he was started on a nitropaste and transferred to [**hospital1 1**] for further management.patient reports that that he has had 2-3 weeks of rle edema, but was without sob, cp, nausea, vomiting, diarrhea, melena, hematemasis.reports he is up to date on colonoscopy and psa and carries no cancer diagnosis.patient reports he was highly mobile over the summer, but over the past 2-3 months has been primarily bedbound due to sciatica symptoms and deconditioning after recent stroke.patient admitted from: [**hospital1 1**] er history obtained from patient, family / friend.","[{'rouge-1': {'r': 0.46153846153846156, 'p': 0.16216216216216217, 'f': 0.23999999615200004}, 'rouge-2': {'r': 0.28, 'p': 0.07526881720430108, 'f': 0.11864406445705268}, 'rouge-l': {'r': 0.46153846153846156, 'p': 0.16216216216216217, 'f': 0.23999999615200004}}]","[{'rouge-1': {'r': 0.19230769230769232, 'p': 0.125, 'f': 0.15151514674012873}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.19230769230769232, 'p': 0.125, 'f': 0.15151514674012873}}]","[{'rouge-1': {'r': 0.38461538461538464, 'p': 0.2777777777777778, 'f': 0.3225806402913632}, 'rouge-2': {'r': 0.24, 'p': 0.13636363636363635, 'f': 0.17391303885738302}, 'rouge-l': {'r': 0.38461538461538464, 'p': 0.2777777777777778, 'f': 0.3225806402913632}}]","[{'rouge-1': {'r': 0.38461538461538464, 'p': 0.20408163265306123, 'f': 0.26666666213688894}, 'rouge-2': {'r': 0.2, 'p': 0.10416666666666667, 'f': 0.13698629686620395}, 'rouge-l': {'r': 0.38461538461538464, 'p': 0.20408163265306123, 'f': 0.26666666213688894}}]","[{'rouge-1': {'r': 0.46153846153846156, 'p': 0.35294117647058826, 'f': 0.399999995088889}, 'rouge-2': {'r': 0.32, 'p': 0.21621621621621623, 'f': 0.2580645113163372}, 'rouge-l': {'r': 0.46153846153846156, 'p': 0.35294117647058826, 'f': 0.399999995088889}}]","[{'rouge-1': {'r': 0.6153846153846154, 'p': 0.1391304347826087, 'f': 0.22695035160203214}, 'rouge-2': {'r': 0.32, 'p': 0.05063291139240506, 'f': 0.08743169163008756}, 'rouge-l': {'r': 0.5769230769230769, 'p': 0.13043478260869565, 'f': 0.21276595443891153}}]",0.461538462,0.162162162,0.239999996,0.28,0.075268817,0.118644064,0.461538462,0.162162162,0.239999996,0.192307692,0.125,0.151515147,0,0,0,0.192307692,0.125,0.151515147,0.384615385,0.277777778,0.32258064,0.24,0.136363636,0.173913039,0.384615385,0.277777778,0.32258064,0.384615385,0.204081633,0.266666662,0.2,0.104166667,0.136986297,0.384615385,0.204081633,0.266666662,0.461538462,0.352941176,0.399999995,0.32,0.216216216,0.258064511,0.461538462,0.352941176,0.399999995,0.615384615,0.139130435,0.226950352,0.32,0.050632911,0.087431692,0.576923077,0.130434783,0.212765954 +54514,125949,9706,"Chief Complaint: [**Hospital Unit Name 10**] Resident Admission Note + . + Reason for MICU Admission: Respiratory distress + . + Primary Care Physician: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2139**], MD + . + CC: SOB + . + HISTORY: PT poor historian, per ED records/OMR + HPI: + : This is a 53 y.o with MS, asthma with 2 days of cough, SOB, fever to + 102 per husband with increased agitation, AMS and s/p unwitnessed fall + per husband. + . + In the ED, inital vitals were Tm101.6, BP 129/60, HR 88, RR 16, sat 96% + on 6L. ABG 7.31/44/65. CXR found opacification of the L.lung with + ?layering pleural effusion vs. lobar collapse. R.lung with patchy + airspace opacity with concern for PNA. PT given dose of levofloxacin + and ceftriaxone. Pt also given nebs and lorazepam. EKG unchanged, + head/neck CT negative. + . + Per neurology, pt with limited o2 sats, advanced MS, sleep + disturbances. + . + Upon speaking with pt's family, pt normal waxes and wanes in terms of + alertness. Has chronic pain. + . + Of note, pt admitted and tx for L.sided pna with flagyl/levo. However, + abx switched to vanco/azithro/flagyl/cefepime. PT symptoms gradually + improved. + . + ROS: Unable to assess for complete ROS as pt with altered MS. + . + Patient admitted from: [**Hospital1 1**] ER + History obtained from Patient, Family / [**Hospital 380**] Medical records + Patient unable to provide history: Encephalopathy + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + amantadine 100mg [**Hospital1 **] + baclofen 20mg, 1 tab qam, 2 tabs midday, 1, 3.5 QHS + betaseron 0.3mg qod + buproprion 150mg SR daily + carisoprodol 350mg , 2 tabs QHS, 1 daily + celexa 20mg daily + diamox 250mg, 2 tabs daily + fluticasone 50mcg spray, 2sprays daily + lamotrigine 200mg, 2 tabs TID + meclizine 25mg QID + oxycontin SR [**Hospital1 **] + kCL 10meq SR TID + colace + ibuprofen 200mg, 2-3 tabs q6h prn pain + Past medical history: + Family history: + Social History: + Venous Stasis Dermatitis + Constipation + Disruption of sleep wake cycle + Depression + Chronic pain + Mother with breast cancer at 76. Alzheimer's disease + Son with asthma + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: Lives with husband in [**Name2 (NI) **]. Quit smoking for seven years and + just restarted this past summer. Currently smoking a pack a + week. + Review of systems: + Flowsheet Data as of [**2134-10-1**] 12:35 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 37.6 +C (99.7 + Tcurrent: 37.6 +C (99.7 + HR: 94 (94 - 97) bpm + BP: 105/82(88) {105/61(78) - 127/82(88)} mmHg + RR: 23 (23 - 23) insp/min + SpO2: 92% + Heart rhythm: SR (Sinus Rhythm) + Height: 60 Inch + Total In: + 2,010 mL + PO: + TF: + IVF: + 10 mL + Blood products: + Total out: + 0 mL + 600 mL + Urine: + 180 mL + NG: + Stool: + Drains: + Balance: + 0 mL + 1,410 mL + Respiratory + O2 Delivery Device: Non-rebreather + SpO2: 92% + ABG: 7.30/43/46//-4 + Ph Vitals: T. 99.7 BP 127/61, HR 97, RR 23 sat 99% on 15% NRB + GEN: obese,ill appearing, mild respiratory distress, 2 word sentences, + confused, lethargic + HEENT: +L.eye abrasion, ~3cm, dried blood. +ecchymoses L.eye. EOMI, + anicteric, PERRLA, MMM + neck: supple, unable to assess for JVP 2/2 body habitus, no LAD + chest: b/l AE, anterior exam, +diffuse rhonchi L.lung, exp wheezing + L.lung + heart: s1s2 rrr no m/r/g + abd:+bs, TTP LLQ, soft, distended, obese, no guarding/rebound + ext: no c/c/ trace edema, 2+pulses, chronic venous status changes. + neuro: AAOx2 (name/place) perseveration over place, +full body + intermittent twitching, FROMx4, no tremor. ysical Examination + Labs / Radiology + [image002.jpg] + [**2131-11-19**] + 2:33 A11/14/[**2133**] 12:14 PM + [**2131-11-23**] + 10:20 P + [**2131-11-24**] + 1:20 P + [**2131-11-25**] + 11:50 P + [**2131-11-26**] + 1:20 A + [**2131-11-27**] + 7:20 P + 1//11/006 + 1:23 P + [**2131-12-20**] + 1:20 P + [**2131-12-20**] + 11:20 P + [**2131-12-20**] + 4:20 P + TC02 + 22 + Other labs: Lactic Acid:1.4 mmol/L + Imaging: Laboratories: Notable for neg serum/urine tox. LDH 656, AST + 52, BNP 1300, no wbc count. + . + ECG: NSR @91, no acute st/t changes. No change compared to prior + [**2133-8-25**]. + . + ECHO [**2133-8-19**]: + The left atrium is normal in size. Left ventricular wall thickness, + cavity size, and systolic function are normal (LVEF>55%). Due to + suboptimal technical quality, a focal wall motion abnormality cannot be + fully excluded. Right ventricular chamber size and free wall motion are + normal. The aortic valve leaflets appear structurally normal with good + leaflet excursion. No aortic regurgitation is seen. The mitral valve + appears structurally normal with trivial mitral regurgitation. There is + mild pulmonary artery systolic hypertension. There is no pericardial + effusion. + IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes + with preserved global and regional biventricular systolic function. + Pulmonary artery systolic hypertension. Mild-moderate tricuspid + regurgitation. + . + Imaging: + CXR: low lung volumes, interval opacification of left lung layering + pleural effusion vs lobar collapse; right lung demonstrates patchy + airspace opacity concerning for PNA. Streaky opacity in right mid lung + may be consistent w/atelactasis. + CTA chest(wet read): Confluent ground-glass opacity in both lungs in + similar pattern to [**2133-8-17**]. Most likely atypical pneumonia given + fever, but drug reaction, pulmonary hemorrhage are additional + considerations. + CT C-spine(wet read): No fracture. C1 right-rotated (clockwise) upon + C2, likely positional given patient was moving on scanner. If concern + for rotary subluxation could repeat. + CT head: No hemorrhage, edema, or change since [**2133-4-17**]. + . + MRI [**2134-2-5**]:IMPRESSION: Multiple nonenhancing T2 hyperintense lesion in + the subcortical, deep, and periventricular white matter as well as + lesions in the corpus callosum and the left cerebellar hemisphere. The + findings are likely the result of a demyelinating process such as + multiple sclerosis. + Assessment and Plan + A/P: PT is a 53 y.o woman with h.o MS, asthma, chronic pain who + presents with SOB/cough/ fever s/p fall. + . + #SOB/respiratory distress: Likely a result of infection given CT and + CXR findings, opacification of the L.lung(effusion vs.collapse), + R.lung with patchy airspace opacity. CT findings of ground glass + opacities in both lungs suggesting atypical pneumonia. Per CT read, + other possibilites include drug rxn, pulm hemorrhage. However, given + fever infection more likely. In terms of sources of infection, + considerations include bacterial, viral such as influenza, or less + likely fungal PCP (however LDH elevated)-given immunosuppression MS tx. + Other less likely possibilies include fluid overload from cardiac + causes (however last echo with perserved function, BNP 1300). + Malignancy also a possibility. Given history of asthma and MS will have + to be mindful of pt's respiratory status. PE also in differential, + however imaging findings and clinical exam not suggestive at this time. + . + -broad spectrum abx at this time. + - Follow-up blood, urine and sputum cultures, including for influenza, + legionella. + - Trend WBC count fever curve. + -sating ok now on NRB, however given asthma and MS will have low + threshold to intubate. + -nebs prn + -consider further imaging or thoracentesis for further dx + -serial CXR. + . + #s/p fall: unknown if fall with any pre/post symptoms to suggest + syncope from vasovagal, orthostatic, or cardiac cause. Other + possibilies include neurologic such as seizure or TIA. Other + possibilities include mechanical from underlying MS/sleep disturbance. + -tele + -EKG + -orthostatics when more stable + -IVF. + . + #altered mental status: pt appears delerious. Unclear of pt's baseline + status. Pt has reasons including infection, narcotic intake (although + tox negative), toxic metabolic. Pt is s/p fall but CT head/neck + negative for acute process. + -neuro consult + -monitor neuro exam. + -w/u and tx for infection. + . + #MS-pt with h.o MS,per last neuro note, has unsteady gait, dizziness, + eye pain, and sleep disturbances including sleep walking. PER ED note, + Pt with advanced MS. Unclear of pt's baseline mental status will have + to confirm with neuro. + -notify neuro of pt's admission, recs: + -continue amantidine, baclofen, carisoprodolo for now. Will d/w neuro + re: betaseron. + -head/neck CT negative for acute process. + . + #chronic pain-will hold on baclofen, oxycontin, but may continue + celexa, lamictal. + . + #eye abrasion-wound care. Consider optho consult if visual changes. + . + #depression-continue celexa. + . + # FEN: NPO until MS clears. lytes prn. + . + # Access: 2 peripherals 18,20 gauge. + . + # PPx: PPI, pneumoboots, bowel reg + . + # Code: full discussed with husband/son. + . + # Dispo: ICU pending improvement in resp status. + . + # Comm: with pt, husband, son + ICU [**Name (NI) 232**] + Nutrition: npo + Glycemic Control: n/a + Lines: + 18 Gauge - [**2134-10-1**] 11:26 AM + 20 Gauge - [**2134-10-1**] 11:26 AM + Prophylaxis: + DVT: pneumoboots, hep sc + Stress ulcer: h2 blocker + VAP: n/a + Comments: + Communication: Comments: with patient, family + Code status: Full code + Disposition: icu +","Admission Date: [**2134-10-1**] Discharge Date: [**2134-10-11**] + +Date of Birth: [**2081-7-25**] Sex: F + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 1257**] +Chief Complaint: +CC: SOB +Reason for MICU Admission: Respiratory distress + +Major Surgical or Invasive Procedure: +Endotracheal Intubation from [**Date range (1) 32787**] + +History of Present Illness: +This is a 53 y.o with Multiple Sclerosis and Asthma with 2 days +of cough, SOB, and fever upto 102 per husband. She had increased +agitation, AMS, and unwitnessed fall per husband. +. +In the ED, inital vitals were Tm 101.6, BP 129/60, HR 88, RR 16, +sat 96% on 6L. ABG 7.31/44/65. CXR found opacification of the +left lung with question of layering pleural effusion vs. lobar +collapse. The right lung with patchy airspace opacity with +concern for PNA. She received dose of levofloxacin and +ceftriaxone. Pt also given nebs and lorazepam. EKG unchanged, +head and neck CT was negative. +. +Per neurology, she has limited o2 sats, advanced MS, and sleep +disturbances. +. +Upon speaking with pt's family, pt normal waxes and wanes in +terms of alertness. +. +Of note, she was admitted and treated for left sided pneumonia +with flagyl/levo. However, abx switched to +vanco/azithro/flagyl/cefepime. Her symptoms gradually improved. +. +ROS: Unable to assess for complete ROS as pt with altered MS. +. + + +Past Medical History: +Multiple Sclerosis +Venous Stasis Dermatitis +Constipation +Disruption of sleep wake cycle +Depression +Chronic pain +. + + +Social History: +Lives with husband in [**Name2 (NI) **]. Quit smoking for seven years and +just restarted this past summer. Currently smoking a pack a +week. + + +Family History: +Mother with breast cancer at 76. Alzheimer's disease +Son with asthma + + +Physical Exam: +On Presentation: +Vitals: T. 99.7 BP 127/61, HR 97, RR 23 sat 99% on 15% NRB +GEN: obese,ill appearing, mild respiratory distress, 2 word +sentences, confused, lethargic +HEENT: +L.eye abrasion, ~3cm, dried blood. +ecchymoses L.eye. +EOMI, anicteric, PERRLA, MMM +neck: supple, unable to assess for JVP 2/2 body habitus, no LAD +chest: b/l AE, anterior exam, +diffuse rhonchi L.lung, exp +wheezing L.lung +heart: s1s2 rrr no m/r/g +abd:+bs, TTP LLQ, soft, distended, obese, no guarding/rebound +ext: no c/c/ trace edema, 2+pulses, chronic venous status +changes. +neuro: AAOx2 (name/place) perseveration over place, +full body +intermittent twitching, FROMx4, no tremor. +. + + +Pertinent Results: +Admission Labs: +[**2134-10-1**] 05:05AM WBC-7.4 RBC-3.68* HGB-11.7*# HCT-35.3* MCV-96 +MCH-31.7 MCHC-33.1 RDW-14.0 +[**2134-10-1**] 05:05AM NEUTS-90.6* LYMPHS-6.2* MONOS-2.8 EOS-0.1 +BASOS-0.2 +[**2134-10-1**] 05:05AM PLT COUNT-163 +[**2134-10-1**] 04:55AM TYPE-ART PO2-65* PCO2-44 PH-7.31* TOTAL +CO2-23 BASE XS--4 INTUBATED-NOT INTUBA +[**2134-10-1**] 05:05AM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-2.9# +MAGNESIUM-2.0 +[**2134-10-1**] 05:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG +bnzodzpn-NEG barbitrt-NEG tricyclic-NEG +[**2134-10-1**] 05:05AM CK-MB-8 cTropnT-<0.01 proBNP-1300* +[**2134-10-1**] 05:05AM LIPASE-16 +[**2134-10-1**] 05:05AM ALT(SGPT)-22 AST(SGOT)-52* LD(LDH)-656* +CK(CPK)-184* ALK PHOS-117 TOT BILI-0.5 +[**2134-10-1**] 05:05AM GLUCOSE-126* UREA N-22* CREAT-1.0 SODIUM-141 +POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13 +[**2134-10-1**] 05:10AM URINE HYALINE-0-2 +[**2134-10-1**] 05:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 +GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 +LEUK-NEG +[**2134-10-1**] 05:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG +cocaine-NEG amphetmn-NEG mthdone-NEG +[**2134-10-1**] 05:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023 +[**2134-10-1**] 05:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG +cocaine-NEG amphetmn-NEG mthdone-NEG +. +CTA [**10-1**]: +1. No evidence of pulmonary embolus or dissection. +2. Multifocal confluent airspace opacities, left lung greater +than right. The pattern is similar to [**2133-8-17**], and the +differential diagnosis includes atypical pneumonia, aspiration. +Less likely etiologies of pulmonary hemorrhage and drug reaction +are also possibilities. + + +Brief Hospital Course: +53 y.o woman with h.o MS, asthma, chronic pain who presents with +SOB/cough/ fever s/p fall. +. +# Atypical vs CAP: She presented with dyspnea on [**10-1**]. CT and +CXR of lung showed opacification of the left lung (effusion +vs.collapse), and right lung with patchy airspace opacity. CT +findings of ground glass opacities in both lungs suggested +atypical pneumonia. On [**10-3**], she was started on +Methylprednisolone 60 Q 8 and given lasix 20 IV x 1. Pt +continued to have worsening dyspnea and was intubated on [**10-3**] +until [**10-6**]. Pt's abx was broadened to Zosyn for 5 days and +after extubation, she was placed on Levaquin again by ICU to +finish a 7 day course of abx. ON floor, pt continued to have +productive cough but oxygen requirement is stable at 0 liters +and has remained afebrile. Pt finished levaquin on [**2134-10-10**]. For +ongoing cough, pt is on frequent nebs, guaifenisen, prn +suctioning and also ordered for chest PT. +. +# S/P Fall: She had a fall with no available history for +pre/post symptoms to suggest syncope from vasovagal, +orthostatic, or cardiac cause. Pt remembers the fall and she +denies pre-syncopal/syncopal sx. She thinks she tripped. She has +an L eyelid superficial lac which was steri-stripped in ICU. CT +head and C spine are negative. + +# Altered Mental Status: Pt appeared delerious upon admission. +It was believe that the pt was AOx3 at baseline, however had +been noted to be suffering from hallicinations/paranoia prior to +admission. DDx included infection, narcotic intake (although tox +negative), toxic metabolic. Pt is s/p fall but CT head/neck +negative for acute process. Following extubation on [**10-6**], the +patient's mental status cleared and she was subsequently AOx3 on +the morning of [**10-8**] and has continued to remain oriented and +calm on floor. +. +# advanced MS (multiple sclerosis). Neurology was consulted for +help on medical management, they recommended continuing all her +MS meds but they were inaccurately dosed in ICU. Home meds +reconciled with husband on [**10-9**] and except for soma, pt is on +all of her MS meds again as of [**10-9**]. + +# Chronic Pain: Per husband, pt is on oxycontin 40mg [**Hospital1 **]. Pt +continued on Oxycontin 20mg [**Hospital1 **] here with prn oxycodone and +appeared to be doing well. + +# Diarrhea - in ICU. Stool studies sent when came to floor. +Cdiff X 1 neg. Cdiff X 2 pending. Stool cx ordered. She was +started on flagyl for 14 days for high clinical suspecion. +. +. +. +total discharge time 36 minutes. + + +Medications on Admission: +The following list verified with husband on [**2134-10-9**]: +1. [**Name2 (NI) 32788**]on 0.3mg SQ QOD +2. KCL 10meq TID +3. Lamictal 400mg TID +4. Azetazolamide 250mg [**Hospital1 **] +5. Amantadine 100mg [**Hospital1 **] +6. Baclofen 20mg at 8AM, 40mg at noon, 20mg at 6pm and 70mg QHS +7. Celexa 20mg QD +8. Wellbutrin XL 150mg QD +9. Oxycontin 40mg [**Hospital1 **] (and prn - advised husband and pt to not +do prns w long acting agents) +10. Meclizine 25mg QID +11. Soma 350mg QAM, 700mg QHS +12. Flonase NS prn +13. Colace QOD +14. FeSO4 325mg twice a week + +Discharge Medications: +1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every +6 hours) as needed for pain/fever. +2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) +Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. +3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a +day) as needed. +4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 +times a day). +5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 +hours). +6. Lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO TID (3 +times a day). +7. Betaseron 0.3 mg Recon Soln Sig: One (1) Subcutaneous QOD +(). +8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 +times a day). +10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-18**] +Drops Ophthalmic PRN (as needed). +12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation +Q6H (every 6 hours) as needed. +13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for +Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as +needed. +14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 +hours) as needed for Pain. +15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff +Inhalation [**Hospital1 **] (2 times a day). +16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 +hours) as needed. +17. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) +Tablet Sustained Release 12 hr PO Q12H (every 12 hours). +18. Bupropion 150 mg Tablet Sustained Release Sig: One (1) +Tablet Sustained Release PO QAM (once a day (in the morning)). +19. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2 +times a day). +20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID +(3 times a day) as needed. +21. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr +Transdermal DAILY (Daily). +Disp:*15 Patch 24 hr(s)* Refills:*2* +22. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a +day). +23. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO NOON (At +Noon). +24. Baclofen 10 mg Tablet Sig: Seven (7) Tablet PO HS (at +bedtime). +25. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times +a day). +26. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H +(every 12 hours). +27. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO QAM (once +a day (in the morning)). +28. Carisoprodol 350 mg Tablet Sig: Two (2) Tablet PO HS (at +bedtime). +29. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H +(every 8 hours) for 10 days. +Disp:*30 Tablet(s)* Refills:*0* + + +Discharge Disposition: +Home + +Discharge Diagnosis: +pneumonia + + +Discharge Condition: +excellent + + +Discharge Instructions: +you had pneumonia and you were in the ICU. you finished +treatment. you developed diarrhea while on antibiotics. this +could be related to infection called C-Diff. you were started on +Flagyl. please follow with your PCP the stool studies testing +for that bacteria. + +Followup Instructions: +[**Last Name (LF) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 1579**] + + + +",": this is a 53 y.o with ms, asthma with 2 days of cough, sob, fever to 102 per husband with increased agitation, ams and s/p unwitnessed fall per husband. in the ed, inital vitals were tm101.6, bp 129/60, hr 88, rr 16, sat 96% on 6l. abg 7.31/44/65. cxr found opacification of the l.lung with ?layering pleural effusion vs. lobar collapse. r.lung with patchy airspace opacity with concern for pna. pt given dose of levofloxacin and ceftriaxone. pt also given nebs and lorazepam. ekg unchanged, head/neck ct negative. per neurology, pt with limited o2 sats, advanced ms, sleep disturbances. upon speaking with pt's family, pt normal waxes and wanes in terms of alertness. has chronic pain. of note, pt admitted and tx for l.sided pna with flagyl/levo. however, abx switched to vanco/azithro/flagyl/cefepime. pt symptoms gradually improved. ros: unable to assess for complete ros as pt with altered ms. patient admitted from: [**hospital1 1**] er history obtained from patient, family / [**hospital 380**] medical records patient unable to provide history: encephalopathy","53 y.o woman with h.o ms, asthma, chronic pain who presents with sob/cough/ fever s/p fall.",": this is a 53 y.o with ms, asthma with 2 days of cough, sob, fever to 102 per husband with increased agitation, ams and s/p unwitnessed fall per husband. cxr found opacification of the l.lung with ? r.lung with patchy airspace opacity with concern for pna. per neurology, pt with limited o2 sats, advanced ms, sleep disturbances. of note, pt admitted and tx for l.sided pna with flagyl/levo.","['In general, in the lumbosacral compartment, the lumen is the most prominent.\nIn the oedema, the most obvious sign is a lack of sleep.\nThe most common cause of lumbomastia is a misdiagnosis.\nA misdiagnoses can lead to a range of symptoms including headaches, fatigue, sleep disturbances and sleep disturbances.']","this is a 53 y.o with ms, asthma with 2 days of cough, sob, fever to 102 per husband. pt with limited o2 sats, advanced ms, sleep disturbances. pt normal waxes and wanes in terms of alertness.","['pt with limited oxygen saturations, advanced asthma and sleep disturbance. normal waxed alertness; had chronic pain after treatment for the condition in 2003-2004 but was not diagnosed until 2004 or 2005 due to poor blood pressure levels at birth of child under 5 years old (acute respiratory syndrome).']","r.lung with patchy airspace opacity with concern for pna. +of note, pt admitted and tx for l.sided pna with flagyl/levo. +patient admitted from: [**hospital1 1**] er history obtained from patient, family / [**hospital 380**] medical records patient unable to provide history: encephalopathy","o with ms, asthma with 2 days of cough, sob, fever to 102 per husband with increased agitation, ams and s/p unwitnessed fall per husband.in the ed, inital vitals were tm101.6, bp 129/60, hr 88, rr 16, sat 96% on 6l.cxr found opacification of the l.lung with patchy airspace opacity with concern for pna.pt given dose of levofloxacin and ceftriaxone.pt also given nebs and lorazepam.per neurology, pt with limited o2 sats, advanced ms, sleep disturbances.upon speaking with pt's family, pt normal waxes and wanes in terms of alertness.of note, pt admitted and tx for l.","[{'rouge-1': {'r': 0.5, 'p': 0.14814814814814814, 'f': 0.228571425044898}, 'rouge-2': {'r': 0.11764705882352941, 'p': 0.02857142857142857, 'f': 0.045977008349848275}, 'rouge-l': {'r': 0.5, 'p': 0.14814814814814814, 'f': 0.228571425044898}}]","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]","[{'rouge-1': {'r': 0.375, 'p': 0.18181818181818182, 'f': 0.24489795478550605}, 'rouge-2': {'r': 0.11764705882352941, 'p': 0.05405405405405406, 'f': 0.07407406975994539}, 'rouge-l': {'r': 0.375, 'p': 0.18181818181818182, 'f': 0.24489795478550605}}]","[{'rouge-1': {'r': 0.1875, 'p': 0.061224489795918366, 'f': 0.09230768859644985}, 'rouge-2': {'r': 0.058823529411764705, 'p': 0.020833333333333332, 'f': 0.030769226906509364}, 'rouge-l': {'r': 0.1875, 'p': 0.061224489795918366, 'f': 0.09230768859644985}}]","[{'rouge-1': {'r': 0.0625, 'p': 0.02631578947368421, 'f': 0.03703703286694149}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0625, 'p': 0.02631578947368421, 'f': 0.03703703286694149}}]","[{'rouge-1': {'r': 0.375, 'p': 0.07792207792207792, 'f': 0.1290322552156319}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.375, 'p': 0.07792207792207792, 'f': 0.1290322552156319}}]",0.5,0.148148148,0.228571425,0.117647059,0.028571429,0.045977008,0.5,0.148148148,0.228571425,0,0,0,0,0,0,0,0,0,0.375,0.181818182,0.244897955,0.117647059,0.054054054,0.07407407,0.375,0.181818182,0.244897955,0.1875,0.06122449,0.092307689,0.058823529,0.020833333,0.030769227,0.1875,0.06122449,0.092307689,0.0625,0.026315789,0.037037033,0,0,0,0.0625,0.026315789,0.037037033,0.375,0.077922078,0.129032255,0,0,0,0.375,0.077922078,0.129032255 +92281,164460,9712,"Chief Complaint: Fever, abdominal pain, worsening ascites, jaundice + and diarrhea. + HPI: + Mr. [**Known lastname 919**] is a 42 y.o. M with AIDS (CD4 65 on [**2119-10-31**]), hepatitis C + cirrhosis, recently discharged on [**10-14**] after a five day admission for + abdominal pain, worsening ascites, jaundice and diarrhea, now presents + with fever, and abdominal pain. + . + . + During his prior admission from [**Date range (1) 9722**], he presented with abdominal + pain, worsening ascites, jaundice, and diarrhea. CT scan on admission + showed ?colitis. Stool cultures and CMV were negative. He underwent EGD + and colonoscopy which were unrevealing. Biopsies were negative. He + underwent therapeutic paracentesis, removing 3.2 liters of ascites. He + was started on immodium for diarrhea, lasix, and aldactone. + . + The patient mentions that 1 week ago he started having diarrhea with + dark stools. About 3 days ago, he had worsening abdominal pain and + chills. He has been having [**3-8**] bowel movements per day, which is more + than usual even with taking lactulose and [**Month/Day (3) 9723**]. He has had poor po + intake over the past 3 days secondary to nausea and vomiting. Emesis + has been non bloody, non bilious. Patient denies any cough, shortness + of breath, or chest pain. No BRBPR. No dysuria. He does not believe his + abdomen is larger than baseline. + . + . + In the ED, initial VS: 98.2, 63, 81/41, 20, 100%. He was found to have + diffuse abdominal tenderness, and brown, guaiac positive stool. + Abdominal paracentesis was attempted twice, however was stopped due to + superficial bleeding. Given INR of 3.3, further attempts were not + pursued. Hepatology was consulted. + Initial labs revealed hyponatremia to 126, BUN/Creat 58/4.4. LFT's + were elevated including AST 517, ALT 174, Alk phos 170, and TBil 26.8. + Lipase was elevated at 70. Lactate 2.1. He had a leukocytosis of 11.2 + with 71% PMN's. He received levofloxacin 750 mg, vancomycin 1 g + empirically for community acquired pneumonia, with flagyl for abdominal + coverage, and bactrim. He also received Pantoprazole 40mg x1. CT + abdomen/pelvis revealed colitis. He received 2L IV fluids. On + transfer, vital signs were HR 56 BP 97/43 RR 23 100% on RA. + . + . + . + . + Currently, the patient has some mild abdominal pain and weakness, but + no other complaints. + . + . + ROS: Denies night sweats, headache, vision changes, rhinorrhea, + congestion, sore throat, cough, shortness of breath, chest pain, + constipation, BRBPR, hematochezia, dysuria, hematuria. + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Ciprofloxacin - [**2119-11-6**] 06:30 PM + Metronidazole - [**2119-11-6**] 08:00 PM + Infusions: + Other ICU medications: + Pantoprazole (Protonix) - [**2119-11-6**] 08:00 PM + Other medications: + HOME MEDICATIONS: + ATAZANAVIR [REYATAZ] 300 mg po daily + RITONAVIR [NORVIR] - 100 mg po daily + TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg po daily + AZITHROMYCIN - 1200 mg po q Tuesday + FUROSEMIDE - 40 mg po daily + LACTULOSE - 10 gram/15 mL Solution - 30 ml(s) by mouth (One table + spoon) ONCE per day as needed for for [**3-8**] BMs per day. + NADOLOL - 40 mg po daily + OMEPRAZOLE - 20 mg po daily + [**Month/Day (3) **] [XIFAXAN] - 400 mg po tid + SPIRONOLACTONE - 50 mg po daily + TRIMETHOPRIM-SULFAMETHOXAZOLE - 400 mg-80 mg po daily + FERROUS SULFATE - 325 mg po tid + MULTIVITAMIN - po daily + Past medical history: + Family history: + Social History: + 1) HIV/AIDS, diagnosed in [**2104**]. (last CD4 65, VL undetect on [**2119-10-1**]). + 2) h/o heart murmur since childhood + 3) Bronchospastic lung disease + 4) Bipolar disorder + 5) OSA + 6) Hepatitis C, diagnosed in [**2113**] (Genotype 4). He has never been on + therapy for this due to his psychiatric problems. [**Name (NI) **] is Hepatitis B cAb + positive and sAg negative and Hep B DNA negative when last checked in + 1/[**2116**]. + 7) h/o E. coli bacteremia in [**2114**], with no identified source + 8) Appendicitis in [**2116**], managed medically with antibiotics + 9) Clostridium difficile colitis [**11/2117**] + 10) GERD + 11) h/o polysubstance abuse - heroin & EtOH + 12) Cirrhosis - pt reports diagnosed 1 year ago thought [**2-6**] Hep C. + Denies being followed by GI/liver specialist. Child [**Doctor Last Name 4682**] class C based + on most recent lab values. + 13) h/o candidal esophagitis [**2107**] + 14) s/p treatment for TB. per patient completed 8 month course. + His mother, 63, had hypertension and type II diabetes mellitus, died of + unknown malignancy. His father had hypertension, died of head trauma. + He reports having 2 brother, one with unknown malignancy and another + one with AIDS (due to drug abuse). + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: He is of [**Country **] Rican descent, born in [**Hospital1 2228**], previous + records says [**State 966**] City. He completed 11th grade. He has never been + married, and has no children. He has a (HIV-negative) girlfriend. [**Name (NI) **] is + on disability for his problems with drug and alcohol abuse and + psychiatric problems. [**Name (NI) **] has a history of polysubstance abuse. He + reports that he last used heroin 9 months ago and last drank alcohol 1 + year ago. He has been imprisoned multiple times for possession. He was + incarcertated for the past 9months. He has smoked for 20+ years but + reports quitting 1 year ago. He lives with his girlfriend. + Review of systems: + Flowsheet Data as of [**2119-11-6**] 09:47 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 35.4 +C (95.7 + Tcurrent: 35.1 +C (95.1 + HR: 67 (59 - 67) bpm + BP: 94/42(55) {85/24(52) - 126/49(60)} mmHg + RR: 16 (10 - 26) insp/min + SpO2: 100% + Heart rhythm: SR (Sinus Rhythm) + Total In: + 4,330 mL + PO: + TF: + IVF: + 3,130 mL + Blood products: + Total out: + 0 mL + 180 mL + Urine: + 180 mL + NG: + Stool: + Drains: + Balance: + 0 mL + 4,150 mL + Respiratory + O2 Delivery Device: None + SpO2: 100% + 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 + [image002.jpg] + Imaging: [**11-6**] CT Abdomen (wet read): + Colonic wall thickening. In the setting of cirrhosis and ascited some + component of mural edema is not excluded, though, given the provided + symptoms, + this more likely reflects colitis. Infiltration of the omentum is also + noted. + Would recommend a repeat evaluation with contrast on a non-emergent + basis + when the patient is better able to tolerate contrast. + [**2119-11-6**] PORTABLE CXR (wet read): Low lung volumes. Limited evaluation. + Lungs appear clear bilaterally. No large pleural effusion or + pneumothorax. No acute findings on chest radiograph. + [**2119-10-13**] EGD: Abnormal mucosa in the stomach + Normal mucosa in the duodenum (biopsy) + Varices at the lower third of the esophagus + Otherwise normal EGD to third part of the duodenum + . + [**2119-10-13**] Colonoscopy: Preparation was adequate to the splenic flexure. + From the splenic flexure to the hepatic flexure the preparation was + fair. The scope was not traversed passed the hepatic flexure because + the preparation was poor. No abnormalities noted. There was some + bleeding after the biopsies were obtained but hemostasis was + successfully achieved. (biopsy) + Grade 1 internal hemorrhoids + Otherwise normal colonoscopy to hepatic flexure + Microbiology: [**2119-11-6**] Blood cultures x 2: pending + Assessment and Plan + 42 y/o male with AIDS & hepatitis C cirrhosis, who presents with fever, + loose stools, and abdominal pain. + . + . + # Diarrhea/Abdominal pain: Patient has had worsening abdominal pain for + 3 days, though diarrhea for one week, and similar symptoms on admission + 1 month prior. At that time, work up including EGD, colonoscopy + (including biopsies), and stool studies were negative. CT abdomen + concerning for colitis. Most likely source of abdominal pain with + fevers and ascites is SBP. Differential for diarrhea includes CMV + colitis, cryptosprodium, microspora, cyclospora, C diff colitis, + giardia, and bacterial etiologies. Patient had negative CMV viral load + on last hospitalization on [**2119-10-10**]. Non infectious causes may be + diarrhea secondary to lactulose. + -consider paracentesis in the morning after correcting coagulopathy + -send stool O+P, C diff studies + -send CMV viral load + -Cipro and Flagyl for coverage for colitis and SBP + -f/u final read of CT abdomen + -liver consulted -follow up recs regarding need for EGD and colonoscopy + -trend lipase, clinically does not appear to have pancreatitis. + -NPO until final read of CT abdomen obtained + . + # Subjective Fevers: most likely source is abdomen. CT concerning for + colitis on wet read. CXR clear. Patient denies SOB or cough. No + dysuria. No evidence of altered mental status or meningeal signs. + -see above + -UA, UCx + -f/u blood cultures from ED + -panculture if spikes + . + # Hypotension: BPs 80s/40s on admission to ED. Currently 89/47. Likely + hypovolemic secondary to poor po intake. Given subjective fevers, + septic physiology is a possibility. Currently responding well to IV + fluids. See above for work up for fevers. + -IV fluid boluses overnight to maintain MAP>55 + . + # Decompensated Cirrhosis: Likely progression of liver disease [**2-6**] + underlying Hep C (viral load 405K) with concurrent AIDS. Patient + reports that he has been compliant with his medications. Now has + coagulopathy, secondary to severe liver disease. + -continue lactulose and [**Last Name (LF) 9723**], [**First Name3 (LF) 77**] outpatient regimen + -continue nadolol for known varices + -hold lasix and spironolactone given acute renal failure + -f/u hepatology recs + -plan for paracentesis in the AM + -po vitamin K tonight + . + # HIV/AIDS: CD4 65, VL<48K in [**2119-10-31**]. Patient reports compliance with + medications with the exception of 1 day PTA. + - continue outpatient HAART regimen + - azithro and bactrim PPX restarted + . + # Acute renal failure: Creatinine 4.4, was 0.6 one week ago. Appears + hypovolemic. Likely secondary to poor po intake. Differential includes + HIV nephropathy and hepatorenal syndrome. + -trial of IV fluids tonight + . + # HCT drop: HCT 27.6, 32.6 one week prior. Had guaiac positive brown + stool in ED, and subjective melena at home. Patient has known + esophageal varices and hemorrhoids. + -monitor HCT q 8h + -transfuse for HCT<24 + -active T&S + # Hyponatremia: Na 126. Likely hypovelmic hyponatremia. + -trial of IV fluids tonight. If does not correct, would send urine + lytes. + . + # FEN: IVFs / replete lytes prn / NPO for now + # PPX: PPI, pneumoboots, bowel regimen + # ACCESS: PIV x2 + # CODE: FULL confirmed + # CONTACT: patient does not want any family or friends [**Name (NI) 161**] + currently + # DISPO: ICU + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2119-11-6**] 05:22 PM + Prophylaxis: + DVT: pneumoboots + Stress ulcer: PPI + VAP: + Comments: + Communication: Comments: + Code status: FULL confirmed + Disposition: ICU for now +","Admission Date: [**2119-11-6**] Discharge Date: [**2119-11-12**] + +Date of Birth: [**2077-4-27**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 949**] +Chief Complaint: +fever, abdominal pain + +Major Surgical or Invasive Procedure: +diagnostic paracentesis + + +History of Present Illness: +Mr. [**Known lastname 3234**] is a 42 y.o. M with AIDS (CD4 65 on [**2119-10-31**]), +hepatitis C cirrhosis, recently discharged on [**10-14**] after a five +day admission for abdominal pain, worsening ascites, jaundice +and diarrhea, now presents with fever, and abdominal pain. +. +During his prior admission from [**Date range (1) 32802**], he presented with +abdominal pain, worsening ascites, jaundice, and diarrhea. CT +scan on admission showed ?colitis. Stool cultures and CMV were +negative. He underwent EGD and colonoscopy which were +unrevealing. Biopsies were negative. He underwent therapeutic +paracentesis, removing 3.2 liters of ascites. He was started on +immodium for diarrhea, lasix, and aldactone. +. +The patient mentions that 1 week ago he started having diarrhea +with dark stools. About 3 days ago, he had worsening abdominal +pain and chills. He has been having [**3-8**] bowel movements per day, +which is more than usual even with taking lactulose and +rifaximin. He has had poor po intake over the past 3 days +secondary to nausea and vomiting. Emesis has been non bloody, +non bilious. Patient denies any cough, shortness of breath, or +chest pain. No BRBPR. No dysuria. He does not believe his +abdomen is larger than baseline. +. +. +In the ED, initial VS: 98.2, 63, 81/41, 20, 100%. He was found +to have diffuse abdominal tenderness, and brown, guaiac positive +stool. Abdominal paracentesis was attempted twice, however was +stopped due to bleeding. Given INR of 3.3, further attempts were +not pursued. He received levofloxacin 750 mg, vancomycin 1 g +empirically for community acquired pneumonia, with flagyl for +abdominal coverage, and bactrim. He also received Pantoprazole +40mg x1. CT abdomen/pelvis revealed colitis. He received 2L IV +fluids. On transfer, vital signs were HR 56 BP 97/43 RR 23 100% +on RA. +. +On evaluation in the ICU, the patient has some mild abdominal +pain and weakness, but no other complaints. +. +ROS: Denies night sweats, headache, vision changes, rhinorrhea, +congestion, sore throat, cough, shortness of breath, chest pain, +abdominal pain, nausea, constipation, BRBPR, hematochezia, +dysuria, hematuria. +. + +Past Medical History: +1) HIV/AIDS, diagnosed in [**2104**]. (CD4 65, VL<48 [**2119-10-31**]) +2) h/o heart murmur since childhood +3) Bronchospastic lung disease +4) Bipolar disorder +5) OSA +6) Hepatitis C, diagnosed in [**2113**] (Genotype 4). He has never +been on therapy for this due to his psychiatric problems. [**Name (NI) **] is +Hepatitis B cAb positive and sAg negative and Hep B DNA negative +when last checked in 1/[**2116**]. +7) h/o E. coli bacteremia in [**2114**], with no identified source +8) Appendicitis in [**2116**], managed medically with antibiotics +9) Clostridium difficile colitis [**11/2117**] +10) GERD +11) h/o polysubstance abuse - heroin & EtOH +12) Cirrhosis - pt reports diagnosed 1 year ago thought [**2-6**] Hep +C. Denies being followed by GI/liver specialist. Child [**Doctor Last Name 14477**] +class C based on most recent lab values. +13) h/o candidal esophagitis [**2107**] +14) s/p treatment for TB. per patient completed 8 month course. + + +Social History: +family from [**Male First Name (un) 1056**] but pt. born in [**State 531**] +Live with fiance who is HIV negative- sexually active- condoms +100% of time ++ETOH abuse - sober ++IVDA- heroin- sober ++Tobacco +Hx of incarceration in [**2100**]'s and [**2113**] +No travel +Multiple cats +on disability +Stayed at Pine street in x 1 month + + +Family History: +noncontributory + +Physical Exam: +Vitals - T: 96.8 BP: 112/58 HR: 89 RR: 16 02 sat: 96RA +GENERAL: Alert, NAD +HEENT: Sclera icteric. MM slightly dry. +CARDIAC: RRR. No murmurs, rubs, gallops. +LUNG: CTAB except bibasilar crackles. +ABDOMEN: + BS. Somewhat tense and distended, non TTP. No rebound +or guarding. +EXT: Warm, well perfused. 1+ LE edema. +NEURO: A+O to self, location, not date. Interacts appropriately. + +DERM: Tattoo over L chest. No rashes. + +Pertinent Results: +[**2119-11-6**] 12:45PM WBC-11.2* RBC-3.18* HGB-8.8* HCT-27.6* MCV-87 +MCH-27.7 MCHC-32.0 RDW-21.2* +[**2119-11-6**] 12:45PM PLT COUNT-133* +[**2119-11-6**] 12:45PM NEUTS-71.4* LYMPHS-17.6* MONOS-7.8 EOS-2.9 +BASOS-0.3 +[**2119-11-6**] 12:45PM PT-32.7* PTT-60.2* INR(PT)-3.3* +[**2119-11-6**] 12:45PM ALT(SGPT)-174* AST(SGOT)-517* CK(CPK)-67 ALK +PHOS-130* TOT BILI-26.8* +[**2119-11-6**] 12:45PM LIPASE-70* +[**2119-11-6**] 12:45PM GLUCOSE-80 UREA N-58* CREAT-4.4*# SODIUM-126* +POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-16* ANION GAP-14 +[**2119-11-6**] 12:55PM LACTATE-2.1* +[**2119-11-6**] 06:23PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 +[**2119-11-6**] 06:23PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 +GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-5.5 +LEUK-NEG +[**2119-11-6**] 06:23PM URINE RBC-1 WBC-2 BACTERIA-MOD YEAST-NONE +EPI-0 +. +ASCITES +[**11-7**] wbc 1313 (78% polys, 5 lymph, 17 monos), hct 8.0 +T protein 1.8, Alb<1.0 +. +MICO +11/2 blood cultures PENDING +[**11-6**] urine culture negative +[**11-7**] CMV viral load - detectable but <600 copies/mL +[**11-7**] ascites PENDING +[**11-8**] stool negative for C diff, O+P negative +. +[**11-6**] CT abd/pelvis +1. Diffuse bowel wall thickening of the ascending and transverse +colon, +appearing similar to CT from [**10-10**]. While liver failure +may contribute +to this appearance, infectious/inflammatory colitis cannot be +excluded. +2. Cirrhosis with large volume ascites. +2. Hematocrit level in the pelvic ascites suggests a component +of blood in the fluid - possibly secondary to traumatic +paracentesis? +. +[**11-10**] CXR +FINDINGS: There has been interval clearing of the airspace +opacity in the +right lower lung with stable airspace opacities in the right +upper lung and unchanged left retrocardiac atelectasis. +Cardiomediastinal silhouette is unchanged and normal. Position +of the left internal jugular central venous line tip is at the +cavoatrial junction. No pneumothorax or pleural effusion. +IMPRESSION: +Interval improvement with clearing of the right lower lung; +stable airspace opacities in the right upper lobe most likely +pneumonia. + +Brief Hospital Course: +Mr. [**Known lastname 3234**] is a 42 year old man with AIDS and HCV with +decompensated cirrhosis who presented on [**11-6**] with fevers and +abdominal pain with hypotension requiring ICU admission. +. +* Goal of care +Given the patient's end stage liver disease and advanced AIDS, +the palliative care service was consulted. In discussion with +the patient and his family the decision was reached to make him +DNR/DNI and comfort measures only. He will be treated with +anxiolytics and pain medications as needed. +. +* Hypotension +Likely due to volume depletion and possible sepsis. Improved +with IVF resuscitation and antibiotics. +. +* Fever, possible SBP +Patient underwent a therapeutic paracentesis complicated by +bleeding (Hct 8%). A component of SBP could not be absolutely +excluded therefore he was treated empirically with ceftriaxone. +CMV assay showed detectable virus, but at a very low level (<600 +copies, below limits of assay to quantify) and was felt to most +likely be a false positive. +. +* AIDS +Patient had supressed viral load, with poor immunologic +recovery. After being made CMO, his antiretrovirals and +prophylactic antimicrobials were discontinued. +. +* HCV cirrhosis +He was continued on lactulose and rifaximin for management of +encephalopathy. Once made CMO, his nadolol was discontinued. He +may undergo therapeutic paracentesis if required for symptomatic +relief with his large ascites. +. +* Acute renal failure +Likely pre-renal on presentation, with ATN in setting of +hypotension. With his tense ascites abdominal compartment +syndrome was a consideration, as was hepatorenal syndrome given +possible SBP. Further workup was deferred once he was made CMO. +--- +TO DO: +[ ] comfort measures only, please titrate dilaudid as needed + +Medications on Admission: +ATAZANAVIR [REYATAZ] 300 mg po daily +RITONAVIR [NORVIR] - 100 mg po daily +TRUVADA 1 tab daily +AZITHROMYCIN - 1200 mg po q Tuesday +FUROSEMIDE - 40 mg po daily +LACTULOSE - 10 gram/15 mL Solution - 30 ml(s) by mouth (One +table +spoon) ONCE per day as needed for for [**3-8**] BMs per day. +NADOLOL - 40 mg po daily +OMEPRAZOLE - 20 mg po daily +RIFAXIMIN [XIFAXAN] - 400 mg po tid +SPIRONOLACTONE - 50 mg po daily +TRIMETHOPRIM-SULFAMETHOXAZOLE - 400 mg-80 mg po daily +FERROUS SULFATE - 325 mg po tid +MULTIVITAMIN - po daily + + +Discharge Medications: +1. Lorazepam 2 mg/mL Concentrate Sig: 0.5-2 mg PO Q2H (every 2 +hours) as needed for anxiety: give SL. +Disp:*30 day supply* Refills:*0* +2. Haloperidol Lactate 2 mg/mL Concentrate Sig: 0.5-2 mg PO q2h +as needed for agitation: give SL. +Disp:*30 day supply* Refills:*0* +3. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 +hours) as needed for pain. +Disp:*250 Tablet(s)* Refills:*0* + + +Discharge Disposition: +Extended Care + +Facility: +[**Location (un) **] + +Discharge Diagnosis: +Possible spontaneous bacterial peritonitis +Cirrhosis +AIDS + + +Discharge Condition: +fair, hemodynamically stable, comfort measures only, DNR/DNI + + +Discharge Instructions: +You came into the hospital because of fever and abdominal pains. +Because your blood pressure was low, you were treated in the +intensive care unit. You had a procedure called a paracentesis +to examine the fluid in your abdomen. You were treated for a +possible infection of this fluid. Upon further discussion with +you and your family, a decision was reached to avoid further +aggressive medical care and focus on your comfort, with +discharge to hospice. +. +Please let your doctors know if [**Name5 (PTitle) **] are in pain, and we will +make every effort to improve your comfort. + +Followup Instructions: +No appointments as pt is comfort measures only. + + + +Completed by:[**2119-11-12**]","mr. [**known lastname 919**] is a 42 y.o. m with aids (cd4 65 on [**2119-10-31**]), hepatitis c cirrhosis, recently discharged on [**10-14**] after a five day admission for abdominal pain, worsening ascites, jaundice and diarrhea, now presents with fever, and abdominal pain. . during his prior admission from [**date range (1) 9722**], he presented with abdominal pain, worsening ascites, jaundice, and diarrhea. ct scan on admission showed ?colitis. stool cultures and cmv were negative. he underwent egd and colonoscopy which were unrevealing. biopsies were negative. he underwent therapeutic paracentesis, removing 3.2 liters of ascites. he was started on immodium for diarrhea, lasix, and aldactone. the patient mentions that 1 week ago he started having diarrhea with dark stools. about 3 days ago, he had worsening abdominal pain and chills. he has been having [**3-8**] bowel movements per day, which is more than usual even with taking lactulose and [**month/day (3) 9723**]. he has had poor po intake over the past 3 days secondary to nausea and vomiting. emesis has been non bloody, non bilious. patient denies any cough, shortness of breath, or chest pain. no brbpr. no dysuria. he does not believe his abdomen is larger than baseline. . in the ed, initial vs: 98.2, 63, 81/41, 20, 100%. he was found to have diffuse abdominal tenderness, and brown, guaiac positive stool. abdominal paracentesis was attempted twice, however was stopped due to superficial bleeding. given inr of 3.3, further attempts were not pursued. hepatology was consulted. initial labs revealed hyponatremia to 126, bun/creat 58/4.4. lft's were elevated including ast 517, alt 174, alk phos 170, and tbil 26.8. lipase was elevated at 70. lactate 2.1. he had a leukocytosis of 11.2 with 71% pmn's. he received levofloxacin 750 mg, vancomycin 1 g empirically for community acquired pneumonia, with flagyl for abdominal coverage, and bactrim. he also received pantoprazole 40mg x1. ct abdomen/pelvis revealed colitis. he received 2l iv fluids. on transfer, vital signs were hr 56 bp 97/43 rr 23 100% on ra. . . currently, the patient has some mild abdominal pain and weakness, but no other complaints. . ros: denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, constipation, brbpr, hematochezia, dysuria, hematuria.",mr. [**known lastname 3234**] is a 42 year old man with aids and hcv with decompensated cirrhosis who presented on [**11-6**] with fevers and abdominal pain with hypotension requiring icu admission.,"m with aids (cd4 65 on [**2119-10-31**]), hepatitis c cirrhosis, recently discharged on [**10-14**] after a five day admission for abdominal pain, worsening ascites, jaundice and diarrhea, now presents with fever, and abdominal pain. . during his prior admission from [**date range (1) 9722**], he presented with abdominal pain, worsening ascites, jaundice, and diarrhea. the patient mentions that 1 week ago he started having diarrhea with dark stools. he does not believe his abdomen is larger than baseline. . in the ed, initial vs: 98.2, 63, 81/41, 20, 100%. he was found to have diffuse abdominal tenderness, and brown, guaiac positive stool. given inr of 3.3, further attempts were not pursued. lft's were elevated including ast 517, alt 174, alk phos 170, and tbil 26.8. currently, the patient has some mild abdominal pain and weakness, but no other complaints. .","['The patient has been having anaphylactic paroxysms for three days.\nHe has been suffering from abdominal pain, diarrhoea and vomiting.\nThe patient is now having a bowel movement.\nThis is the first time he has been treated for abdominal pain.\nIt is not known if the patient is suffering from any underlying health conditions.']","a 42 y.o. m with aids, hepatitis c cirrhosis, recently discharged after a five day admission for abdominal pain, worsening ascites, jaundice and diarrhea. he underwent therapeutic paracentesis, removing 3.2 liters of ascites. emesis has been non bloody, non bilious.","[""mr. [**known lastname 919*] is 42 years old with aids, and has been admitted to hospital for abdominal pain after five days of treatment in february 2012; symptoms include fever (acid reflux), ascite'd jaundice/ diarrhea(iv) the patient had no complaints at all but denies night sweating or headache from his condition which was diagnosed on monday morning by an internal medicine physician who performed paracenteses twice before being discharge-bound again this week due back surgery later that day""]","[**known lastname 919**] is a 42 y.o. m with aids (cd4 65 on [**2119-10-31**]), hepatitis c cirrhosis, recently discharged on [**10-14**] after a five day admission for abdominal pain, worsening ascites, jaundice and diarrhea, now presents with fever, and abdominal pain. +. during his prior admission from [**date range (1) 9722**], he presented with abdominal pain, worsening ascites, jaundice, and diarrhea. +the patient mentions that 1 week ago he started having diarrhea with dark stools. +about 3 days ago, he had worsening abdominal pain and chills. +patient denies any cough, shortness of breath, or chest pain. +currently, the patient has some mild abdominal pain and weakness, but no other complaints.","[**known lastname 919**] is a 42 y.m with aids (cd4 65 on [**2119-10-31**]), hepatitis c cirrhosis, recently discharged on [**10-14**] after a five day admission for abdominal pain, worsening ascites, jaundice and diarrhea, now presents with fever, and abdominal pain.during his prior admission from [**date range (1) 9722**], he presented with abdominal pain, worsening ascites, jaundice, and diarrhea.stool cultures and cmv were negative.he underwent egd and colonoscopy which were unrevealing.he underwent therapeutic paracentesis, removing 3.he was started on immodium for diarrhea, lasix, and aldactone.the patient mentions that 1 week ago he started having diarrhea with dark stools.about 3 days ago, he had worsening abdominal pain and chills.he has been having [**3-8**] bowel movements per day, which is more than usual even with taking lactulose and [**month/day (3) 9723**].","[{'rouge-1': {'r': 0.37037037037037035, 'p': 0.08849557522123894, 'f': 0.1428571397438776}, 'rouge-2': {'r': 0.1, 'p': 0.021897810218978103, 'f': 0.03592814076517648}, 'rouge-l': {'r': 0.2962962962962963, 'p': 0.07079646017699115, 'f': 0.11428571117244907}}]","[{'rouge-1': {'r': 0.18518518518518517, 'p': 0.125, 'f': 0.14925372653152166}, 'rouge-2': {'r': 0.03333333333333333, 'p': 0.02, 'f': 0.02499999531250088}, 'rouge-l': {'r': 0.14814814814814814, 'p': 0.1, 'f': 0.11940298026286499}}]","[{'rouge-1': {'r': 0.2222222222222222, 'p': 0.15, 'f': 0.17910447280017833}, 'rouge-2': {'r': 0.03333333333333333, 'p': 0.024390243902439025, 'f': 0.028169009204523757}, 'rouge-l': {'r': 0.14814814814814814, 'p': 0.1, 'f': 0.11940298026286499}}]","[{'rouge-1': {'r': 0.4074074074074074, 'p': 0.14102564102564102, 'f': 0.2095238057034014}, 'rouge-2': {'r': 0.06666666666666667, 'p': 0.025974025974025976, 'f': 0.037383173534806975}, 'rouge-l': {'r': 0.3333333333333333, 'p': 0.11538461538461539, 'f': 0.17142856760816338}}]","[{'rouge-1': {'r': 0.48148148148148145, 'p': 0.15476190476190477, 'f': 0.2342342305527149}, 'rouge-2': {'r': 0.2, 'p': 0.05825242718446602, 'f': 0.09022556041607792}, 'rouge-l': {'r': 0.4444444444444444, 'p': 0.14285714285714285, 'f': 0.21621621253469692}}]","[{'rouge-1': {'r': 0.48148148148148145, 'p': 0.1326530612244898, 'f': 0.20799999661312005}, 'rouge-2': {'r': 0.2, 'p': 0.04580152671755725, 'f': 0.07453415845839294}, 'rouge-l': {'r': 0.4444444444444444, 'p': 0.12244897959183673, 'f': 0.19199999661312003}}]",0.37037037,0.088495575,0.14285714,0.1,0.02189781,0.035928141,0.296296296,0.07079646,0.114285711,0.185185185,0.125,0.149253727,0.033333333,0.02,0.024999995,0.148148148,0.1,0.11940298,0.222222222,0.15,0.179104473,0.033333333,0.024390244,0.028169009,0.148148148,0.1,0.11940298,0.407407407,0.141025641,0.209523806,0.066666667,0.025974026,0.037383174,0.333333333,0.115384615,0.171428568,0.481481481,0.154761905,0.234234231,0.2,0.058252427,0.09022556,0.444444444,0.142857143,0.216216213,0.481481481,0.132653061,0.207999997,0.2,0.045801527,0.074534158,0.444444444,0.12244898,0.191999997 +12233,147721,6142,"Chief Complaint: shortness of breath, chest pain, subjective fevers + HPI: + HISTORY OF PRESENTING ILLNESS: [**Age over 90 52**] yo M w/ CHF, CAD s/p CABG in [**2137**], + with LIMA->LAD, SVG->PDA, SVG->PLB, SVG->RI, with CABG RI revision in + [**2147**], s/p pacemaker for sick sinus and s/p St. Jude's valve for AVR who + presented to the ED with worsening SOB, chest pain x 2 days. Of note, + pt intubated/sedated and history primarily obtained by patient's + sister-in-law who is the de facto HCP (not official). The patient's + wife was currently unable to provide a history at the time. The + patient's sister-in-law describes the patient feeling increasingly + short of breath and feverish (no temperature recorded at home). She + notes that when the patient becomes fluid overloaded, he typically + develops a cough with respiratory distress, however, this time no cough + or sputum either. The patient was also complaining of chest pain x 1 + day, which unfortunately cannot be further delineated based on this + limited history. The patient's sister-in-law also notes the patient has + been consuming a high sodium diet. She denies sick contacts, recent + travel, sweats, chills, nausea, vomitting, diarrhea, constipation, + black/red stools, headaches, back pain, abdominal pain. Because of + worsening respiratory distress, the patient asked his wife to call EMS. + . + In the ED, initial vitals were 97.1 150/94 87 32 and 80s on RA. + He occasionally dipped to 70s. The patient was later found to be + hypertensive to 222/94. The patient was then placed on a nitro gtt. The + patient's CXR revealed pulmonary edema and was given Lasix 40mg IV ONCE + and made 400cc of urine. The patient remained hypoxic. Bipap was + attempted without success. ABG revealed 7.39/54/326. The patient was + successfully intubated after one pass and CXR confirmed proper + placement. The patient subsequently dropped his pressures to 93/38 and + was given a 500cc bolus. Unfortunately, a medication reconciliation + sheet was not available. Per report and OMR, he was also given + ceftriaxone 1gm IV ONCE, levofloxacin 750mg IV ONCE, ASA 600mg PR ONCE. + The patient was also given albuterol/ipratropium nebs x 2, midazolam + 2mg/2ml/fentanyl 100mcg/2mL ONCE for sedation. + . + The patient arrived to the floor seeming to be breathing synchronously + with the ventilator. He did not appear in acute distress. He nodded + afirmative to pain, but could not specify where. + No overnight events. + . + PAST MEDICAL HISTORY: + CAD s/p CABG in [**2137**], with current anatomy: LIMA->LAD, SVG->PDA, + SVG->PLB, SVG->RI. + 1. Status post two coronary bypass procedures with the most recent one + in [**4-/2147**], at which time a revision of ramus graft was performed. + Currently, angina free with a negative Persantine myocardial perfusion + study having been performed in the spring of [**2153**]. + 2. Aortic stenosis, status post aortic valve replacement in + [**4-/2147**] with a #19 St. [**Male First Name (un) 6198**] prosthesis having been placed at + that time. Most recent echocardiogram in [**1-/2154**] revealed a + normally functioning prosthesis. + 3. Mild to moderate mitral and moderate tricuspid regurgitation. + 4. Sick sinus syndrome, status post permanent pacemaker + insertion. + 5. Chronic atrial fibrillation treated with AV nodal blocking + agents and chronic Coumadin therapy. + 6. History of congestive heart failure for which he is on beta + blocker, diuretic, and [**Last Name (un) 239**] therapy. + 7. Hyperlipidemia, on statin therapy. + 8. History of embolic CVA, on chronic Coumadin therapy. + AFib on coumadin + Sick sinus syndrome s/p PPM, ? h/o complete heart block per OMR + Aortic stenosis s/p [**First Name8 (NamePattern2) **] [**Male First Name (un) 6198**] aortic valve [**2147**] + CHF with preserved EF on TTE from [**10/2154**] + HTN + Hyperlipidemia + Chronic LLQ pain + Insomnia + Vertobrobasilar artery stenosis + Fecal incontinence + h/o severe epistaxis + C7 Radicular pain + . + CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension + CARDIAC HISTORY: + -CABG: + -PERCUTANEOUS CORONARY INTERVENTIONS: + -PACING/ICD: +PPM for sick sinus + . + . + MEDICATIONS per OMR (phone # for pharmacy: [**Telephone/Fax (1) 12015**]). Per patient's + sister-in-law he does not miss [**First Name (Titles) **] [**Last Name (Titles) 3138**]. + Lovenox 60mg [**Hospital1 **] as directed + Warfarin 5-7.5mg as directed + ASA 81mg daily + Metoprolol succinate 25mg daily + Valsartan 320mg daily + Furosemide 80mg daily + Potassium chloride 10mEq daily + Imdur 30mg daily + NTG 0.3mg SL prn + Simvastatin 40mg daily + Pantoprazole 40mg daily prn + Gabapentin 300mg [**Hospital1 **] + MVI with iron daily + Lactulose 15ml daily prn constipation + Bisacodyl 10mg PR every other day + Colace 100mg daily + Senna 1 tablet QAM and 2 tablets QPM + Tylenol 1000mg [**Hospital1 **] prn pain + Fluticasone 50mcg nasal daily + Trimacinolone acetonide 0.1% cream [**Hospital1 **] prn + Sarna lotion [**Hospital1 **] prn itch + . + . + ALLERGIES: NKDA per OMR and sister-in-law + . + . + SOCIAL HISTORY + -Tobacco history: Never smoked + -ETOH: No alcohol + -Illicit drugs: None + . + . + FAMILY HISTORY: + Noncontributory + History obtained from [**Hospital 85**] Medical records + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Ceftriaxone - [**2155-5-8**] 02:30 AM + Azithromycin - [**2155-5-8**] 04:00 AM + Infusions: + Propofol - 5 mcg/Kg/min + Other ICU medications: + Heparin Sodium (Prophylaxis) - [**2155-5-8**] 06:00 AM + Other medications: + Past medical history: + Family history: + Social History: + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: + Review of systems: + Flowsheet Data as of [**2155-5-8**] 07:28 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since [**57**] AM + Tmax: 36.6 +C (97.8 + Tcurrent: 36.6 +C (97.8 + HR: 60 (60 - 64) bpm + BP: 113/46(61) {92/38(52) - 135/56(75)} mmHg + RR: 16 (16 - 18) insp/min + SpO2: 100% + Heart rhythm: V Paced + Height: 67 Inch + Total In: + 134 mL + PO: + TF: + IVF: + 134 mL + Blood products: + Total out: + 0 mL + 720 mL + Urine: + 720 mL + NG: + Stool: + Drains: + Balance: + 0 mL + -586 mL + Respiratory + O2 Delivery Device: Endotracheal tube + Ventilator mode: CMV/ASSIST/AutoFlow + Vt (Set): 450 (450 - 450) mL + RR (Set): 16 + RR (Spontaneous): 0 + PEEP: 5 cmH2O + FiO2: 40% + RSBI Deferred: No Spon Resp + PIP: 27 cmH2O + Plateau: 21 cmH2O + Compliance: 31.3 cmH2O/mL + SpO2: 100% + ABG: ///30/ + Ve: 7.3 L/min + Physical Examination + VS: 97.1 135/56 64 17 100% on AC 100% 450/16 PEEP 5. + GENERAL: Elderly gentleman intubated and mildly sedated in NAD. + HEENT: NCAT. Sclera anicteric. + NECK: Supple with EJs bilaterally engorged up to jaw at 30 degrees. + CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, + normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. + LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were + unlabored, no accessory muscle use. CTAB, no crackles, wheezes or + rhonchi. + ABDOMEN: Soft, distended, nontender, tympanic to percussion with flank + dullness. No HSM or tenderness. + EXTREMITIES: No c/c/e. + SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. + Labs / Radiology + 126 K/uL + 10.3 g/dL + 167 mg/dL + 1.5 mg/dL + 38 mg/dL + 30 mEq/L + 101 mEq/L + 3.7 mEq/L + 140 mEq/L + 31.3 % + 12.9 K/uL + [image002.jpg] + [**2151-2-8**] + 2:33 A4/1/[**2155**] 03:27 AM + [**2151-2-12**] + 10:20 P + [**2151-2-13**] + 1:20 P + [**2151-2-14**] + 11:50 P + [**2151-2-15**] + 1:20 A + [**2151-2-16**] + 7:20 P + 1//11/006 + 1:23 P + [**2151-3-11**] + 1:20 P + [**2151-3-11**] + 11:20 P + [**2151-3-11**] + 4:20 P + WBC + 12.9 + Hct + 31.3 + Plt + 126 + Cr + 1.5 + TropT + 0.06 + Glucose + 167 + Other labs: PT / PTT / INR:29.6/36.3/2.9, CK / CKMB / + Troponin-T:94//0.06, ALT / AST:17/30, Alk Phos / T Bili:83/0.5, + Differential-Neuts:86.0 %, Band:4.0 %, Lymph:5.0 %, Mono:5.0 %, Eos:0.0 + %, Albumin:3.5 g/dL, LDH:264 IU/L, Ca++:8.7 mg/dL, Mg++:1.6 mg/dL, + PO4:2.6 mg/dL + Imaging: 2D-ECHOCARDIOGRAM [**2154-10-23**]: + The left atrium is mildly dilated. There is mild symmetric left + ventricular hypertrophy with normal cavity size and regional/global + systolic function (LVEF>55%). Overall left ventricular systolic + function is normal (LVEF>55%). Right ventricular chamber size and free + wall motion are normal. The right ventricular cavity is mildly dilated + A bioprosthetic aortic valve prosthesis is present. The aortic valve + prosthesis appears well seated, with normal leaflet/disc motion and + transvalvular gradients. The mitral valve leaflets are moderately + thickened. There is no mitral valve prolapse. Mild to moderate ([**2-8**]+) + mitral regurgitation is seen. [Due to acoustic shadowing, the severity + of mitral regurgitation may be significantly UNDERestimated.] There is + mild pulmonary artery systolic hypertension. The pulmonary artery + systolic pressure could not be determined. There is no pericardial + effusion. + IMPRESSION: Normally functioning aortic prosthesis. Mild symmetric LVH + with preserved regional and global biventricular systolic function. + Mild to moderate mitral regurgitation. Mild pulmonary hypertension. + Compared with the prior study (images reviewed) of [**2154-1-15**], the + estimated pulmonary artery systolic pressure is slightly lower. The + other findings are similar. + . + CARDIAC CATH [**2149-8-4**]: + 1. Selective coronary arteriography of this right dominant system + revealed angiographic evidence of three vessel native coronary artery + disease. The LMCA was diffusely disease up to 50%. The LAD was totally + occluded in the proximal segment. The CFX had diffuse disease up to 60% + and gave origen to a 70% lesion in the first obtuse marginal branch. + The RCA had diffuse disease up to 80% with serial lesions throghout its + course. The distal PDA and PLB fill [**Last Name (un) 12016**] patent SVG. + 2. Graph angiography showed patent LIMA->LAD, SVG->PDA, SVG->PLB, + SVG->RI. + 3. Left ventriculography was not performed due to the presence of a + prosthetic aortic valve. + 4. Hemodynamic evaluation showed normal right and left heart filling + pressures with a preserved cardiac index calculated by Fick using an + assumed O2 consumption. + . + FINAL DIAGNOSIS: + 1. Three vessel coronary artery disease. + 2. Patent LIMA->LAD, SVG->PDA, SVG->PLB, SVG->RI. + 3. Normal right and left heart filling pressures. + ECG: EKG: Atrial fibrillation with moderate ventricular response with + RBBB and LAD c/w LAFB. Also TW inversions and ST depressions in + anterolateral precordial leads, most c/w expected ST changes in setting + of RBBB but cannot exclude ischemia. + Assessment and Plan + HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, CHRONIC + ASSESSMENT AND PLAN + [**Age over 90 52**] yo M w/ CHF, CAD s/p CABG in [**2137**], with LIMA->LAD, SVG->PDA, + SVG->PLB, SVG->RI, with CABG RI revision in [**2147**], s/p pacemaker for + sick sinus and s/p St. Jude's valve for AVR who presented to the ED + with worsening SOB, chest pain x 2 days. + . + # Hypoxic respiratory failure: Radiographic and clinical pneumonia of + RLL. Cause most likely community acquired pneumonia, possibly secondary + to aspiration given RML location. This is supported by fever, white + count, and tachypnea. Probable mild concominant acute on chronic dCHF + probaly as a result of flash pulmonary edema in setting of BPs in 200s + systolic. + - Get gas and RSBI/PSV as below + - Goal to extubate this a.m. + - Send sputum culture from endotracheal sputum + - Continue ceftriaxone 1gm IV Q24H (start date [**2155-5-7**]) + - Start Azithromycin 500mg IV Q24H (start date [**2155-5-7**]) + - Obtain endotracheal sputum culture + - F/u blood and urine culture + - Go back to home dose Lasix (aiming for slightly negative, but not of + clinical significance) + . + # Sepsis: Pt with at least [**3-13**] SIRS with fever and white count with + probable pulmonary source. SBP possible given distended belly with + possible ascites, however, unlikely given h/o distended/tympanic belly + in past due to chronic constipation. Of note, ceftriaxone covers SBP + organisms. + - Monitor cx + - Plan per above + - Bowel reg + - Consider KUB today + - If develops abdominal pain/tenderness, consider U/S to look for + ascites for possible diagnostic tap + . + # Acute on chronic dCHF: Most likely flash in the setting of malignant + hypertension in the 200s. acute CHF before this episode less likely + given stable weight (near baseline of 137), BNP below baseline, no + rhales on lung exam. + - Consider diuresis later today esp if still hypoxic + - Low Na diet + - Strict Is/Os, daily weights + - Hold on antihypertensives in setting of question of sepsis + - Extubate so that he can take Pos and meds (rather than converting do + Isordil) + - Holding beta blocker, diuretic, and [**Last Name (un) 239**] therapy for now. + . + # CAD: Status post two coronary bypass procedures with the most recent + one in [**4-/2147**], at which time a revision of ramus graft was performed. + - Continue ASA, statin, + - holding BB and [**Last Name (un) 239**] + - Continue imdur 15mg PO BID for angina given ST depressions may be + secondary to demand + this is awaiting extubation and if can take PO If + cannot take Po then consider isordil instead of imdur + - Afterload reduction and rate control with v-pacer at 60 + . + # Aortic stenosis, status post aortic valve replacement in [**4-/2147**] with + a #19 St. [**Male First Name (un) 6198**] prosthesis having been placed at + that time. Most recent echocardiogram in [**1-/2154**] revealed a normally + functioning prosthesis. No active issues. + # Mild to moderate mitral and moderate tricuspid regurgitation. + # Sick sinus syndrome, status post permanent pacemaker insertion. + - Monitor tele + # Chronic atrial fibrillation treated with AV nodal blocking agents and + chronic Coumadin therapy. INR therapeutic at 2.9 (goal 1.8 to 2.5). + - Monitor INR + - Restart home Coumadin dosing today + # Hyperlipidemia, continue statin therapy. + # History of embolic CVA, on chronic Coumadin therapy. + . + FEN: NPO except meds, replete lytes PRN + . + ACCESS: 2 PIV's + . + PROPHYLAXIS: + -DVT ppx with heparin SC + -Pain management with tylenol + -Bowel regimen with docusate, senna, lactulose + . + CODE: Confirmed full w/ [**Year (4 digits) 12017**] (she will discuss further with his wife) + . + COMM: with sister-in-law [**Name (NI) 12017**] home: [**Telephone/Fax (1) 12018**], cell: [**Telephone/Fax (1) 12019**], + or at her daughter's: [**Telephone/Fax (1) 12020**]. Wife [**Name (NI) 12021**] is his HCP: + [**Telephone/Fax (1) 12022**] + . + DISPO: CCU for now , likely call out tomorrow AM + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2155-5-8**] 12:26 AM + 20 Gauge - [**2155-5-8**] 12:27 AM + 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. [**Last Name (STitle) **]. + I would add the following remarks: Addendum to the ROS: A 10 system + review of systems was otherwise negative + History + [**Age over 90 52**] year old man with likely community acquired pneumonia with blood + culture growing [**Age over 90 **]. Clinically, he has done better with antibiotic + therapy and supportive cardiac care. + Medical Decision Making + Given the [**Last Name (LF) **], [**First Name3 (LF) 178**] broaden antimicrobial regimen + Reinstitute CHF and anginal medication. + 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:[**2155-5-8**] 21:14 ------ +","Admission Date: [**2155-5-7**] Discharge Date: [**2155-5-19**] + + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 2186**] +Chief Complaint: +SOB, CP, fevers + +Major Surgical or Invasive Procedure: +Transesophageal echocardiogram + +History of Present Illness: +[**Age over 90 **] year old Russian-speaking male with h/o CHF, CAD s/p CABG in +[**2137**] and revision in [**2147**], PPM for sick sinus s/p replacement 6 +weeks ago and AS s/p [**Year (4 digits) 1291**] who presented to the ED with worsening +SOB, chest pain x 2 days. + +He was increasingly short of breath with fevers. He denied +cough but complained of chest pain x 1 day. He also had +reportedly been consuming a high sodium diet. + +In the ED, he had O2 sats in the 80's and was placed on BiPap, +nitro gtt and given Lasix. He remained hypoxic and was +intubated. He was also reportedly given ceftriaxone, +levofloxacin and ASA. He was then admitted to the CCU and +continued diuresis. There was some question of whether he had a +pneumonia on CXR and he was started on ceftriaxone and +azithromycin. Blood cultures grew pan-sensitive pseudomonas and +his Abx were changed to cefepime and azithro. He also complains +of pain at the pacer site. He has had negative Cks and +troponins. ECG showed paced rhythm with ""memory T waves"" per +CCU team. He was extubated yesterday without complication. + +Today he states he remembers feeling SOB at home and had pain at +his pacer site. Cannot give the timeframe of his symptoms. +Also endorses chest pain. States he does not remember coming to +the hospital and ""must have lost consciousness."" Now he denies +SOB, cough, urinary symptoms. Endorses abdominal pain due to +constipation and complains his home regimen is not being given +to him. He also endorses left-sided chest pain, worse with +inspiration. + +Past Medical History: +CAD s/p CABG in [**2137**], with current anatomy: LIMA->LAD, SVG->PDA, +SVG->PLB, SVG->RI. Has second CABG [**2147**] with revision of ramus +graft. Had negative Persantine myocardial perfusion study +having been performed in the spring of [**2153**]. +Aortic stenosis, status post aortic valve replacement in [**4-/2147**] +with a #19 St. [**Male First Name (un) 1525**] prosthesis having been placed at that +time. +Mild to moderate mitral and moderate tricuspid regurgitation. +Sick sinus syndrome, status post permanent pacemaker insertion +with replacement about 6 weeks ago +Chronic atrial fibrillation treated with AV nodal blocking +agents and chronic Coumadin therapy +History of chronic diastolic congestive heart failure +Hyperlipidemia, on statin therapy. +History of embolic CVA, on chronic Coumadin therapy. +HTN +Hyperlipidemia +Chronic LLQ pain +Insomnia +Vertobrobasilar artery stenosis +Fecal incontinence +H/o severe epistaxis +C7 Radicular pain + +Social History: +Patient is primarily Russian speaking but does speak minimal +English. He lives at home with his wife and denies tobacco, +alcohol, and drug use. + +Family History: +No known history of CAD, HTN, DM, or stroke + +Physical Exam: +VS: 97.7 133/46 62 17 100%2L +GENERAL: Elderly gentleman, with nasal cannula, alert and in NAD + +HEENT: NCAT. Sclera anicteric. +CARDIAC: Marked tenderness to palpation over pacemaker site and +up to 8cm inferior to pacer site. Regular rate with mechanical +S2, no murmurs heard. +LUNGS: Coarse crackles at right mid-lung and at left base. Mild +inspiratory wheezing at the bases. +ABDOMEN: Soft but distended and very slightly tender to +palpation. Tympanic to percussion. No hepatosplenomegaly +palpable. +EXTREMITIES: Left foot edema around ankle without pain, +otherwise no peripheral edema, cyanosis, or clubbing. Chronic +skin changes on BLE. +NEURO: Alert and oriented x 3, able to say days of the week +backwards. + +Pertinent Results: +Admission Labs: +[**2155-5-7**] 07:30PM WBC-13.1* RBC-3.61* HGB-11.4* HCT-36.2* +MCV-100* MCH-31.6 MCHC-31.5 RDW-14.4 +[**2155-5-7**] 07:30PM NEUTS-69 BANDS-3 LYMPHS-16* MONOS-12* EOS-0 +BASOS-0 ATYPS-0 METAS-0 MYELOS-0 +[**2155-5-7**] 07:30PM PLT COUNT-155 +[**2155-5-7**] 07:30PM PT-23.8* PTT-29.4 INR(PT)-2.3* +[**2155-5-7**] 07:30PM GLUCOSE-157* UREA N-36* CREAT-1.6* SODIUM-142 +POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-33* ANION GAP-15 +[**2155-5-7**] 07:30PM CALCIUM-9.7 PHOSPHATE-3.8 MAGNESIUM-1.8 +[**2155-5-7**] 08:09PM LACTATE-2.4* +[**2155-5-7**] 09:17PM TYPE-ART PO2-326* PCO2-54* PH-7.39 TOTAL +CO2-34* BASE XS-6 + +Studies: + +[**2155-5-7**] ECG: Atrial fibrillation with a single ventricularly +paced beat. Right bundle-branch block and left anterior +fascicular block. Non-specific precordial T wave inversions may +be related to the right bundle-branch block. Compared to the +previous tracing of [**2155-3-28**] native rhythm is now seen + +[**2155-5-7**] Chest Xray: 1. Suboptimal study due to patient motion +and a repeat is suggested. 2. Relative mild haziness of the +right lung fields may relate to patient motion, although +interstitial edema or infectious process cannot be excluded. +Possible minimal right pleural effusion. + +[**2155-5-9**] KUB: No evidence of bowel obstruction. + +[**2155-5-12**] Ankle Xray: In comparison with the study of [**2154-12-27**], +there is no interval change. Extensive vascular calcification is +again consistent with diabetes. No evidence of bony or joint +space abnormality or appreciable soft tissue swelling. Multiple +surgical clips are seen in the soft tissues medially. Although +there is no definite radiographic evidence for osteomyelitis, if +this is a serious clinical concern, MRI could be considered. + +[**2155-5-12**] CT Abdomen/Pelvis: +1. Moderate right and small left-sided pleural effusion. Right +lower lung base opacity likely represents associated compressive +atelectasis, however, superimposed pneumonia cannot be +completely excluded and should be considered in the correct +clinical setting. +2. Prominence of left intrahepatic duct and common bile duct is +unchanged +since [**2154-12-22**]. +3. Multiple stable bilateral renal cysts. +4. Air in the bladder likely secondary to recent +instrumentation. + +[**2155-5-13**]: Chest Xray: In comparison with the study of [**5-9**], there +is little change. Continued enlargement of the cardiac +silhouette in a patient with a dual-channel pacemaker device in +place. Blunting of both costophrenic angles persist, though +there is no evidence of acute pneumonia or vascular +congestion. Residual contrast material is seen within the colon. + + +[**2155-5-13**]: CT Head: No evidence of acute intracranial +abnormalities. However, a small acute infarction could be +difficult to detect in the setting of multiple previous chronic +infarctions. If clinically indicated, MRI with and without +contrast would be helpful to detect a new infarction and to +assess for septic emboli. + +[**2155-5-13**]: CTA Head/Neck: 1. Hemodynamically significant +atherosclerotic stenosis at the origin of the left vertebral +artery and of the intracranial right vertebral artery. +2. No acute vascular abnormalities of the cervical and +intracranial arteries including no evidence of occlusion, +dissection or aneurysm. +3. For further evaluation of the intracranial structures, please +see +non-enhanced CT of the head from the same date. + +[**2155-5-14**]: TEE: The left atrium and right atrium are normal in +cavity size. Mild spontaneous echo contrast is seen in the body +of the left atrium and left atrial appendage but no +mass/thrombus. No mass or thrombus is seen in the right atrium +or right atrial appendage. Catheter/pacemaker leads are seen in +the right atrium and right ventricle wthout associated +vegetation/thrombus. No atrial septal defect is seen by 2D or +color Doppler. Overall left ventricular systolic function is +normal (LVEF>55%). There are simple atheroma in the aortic arch +and descending thoracic aorta. A mechanical aortic valve +prosthesis is present. The aortic valve prosthesis appears well +seated, with normal disc motion. No masses or vegetations are +seen on the aortic valve. Trace aortic regurgitation is seen +(may be normal for this prosthesis). The mitral valve leaflets +are mildly thickened. No mass or vegetation is seen on the +mitral valve. Moderate (2+) mitral regurgitation is seen. No +vegetation/mass is seen on the pulmonic valve. There is no +pericardial effusion. IMPRESSION: Moderate mitral regurgitation. +Well seated mechanical aortic valve with trace aortic +regurgitation. No discrete vegetation identified. Simple plaque +in aortic arch and descending aorta. + +[**2155-5-15**] EEG: This is an abnormal routine EEG due to slowing and +disorganization of the background rhythm suggestive of a +moderate encephalopathy. Medications, toxic/metabolic +disturbances, and infections are common causes. No epileptiform +discharges or electrographic seizures were seen during this +recording. Note is made of two narrow QRS complex morphologies +as above. + +Brief Hospital Course: +[**Age over 90 **] year old Russian-speaking male with history of diastolic CHF, +CAD s/p CABG in [**2137**] and revision in [**2147**], PPM for sick sinus +s/p replacement 6 weeks ago and AS s/p [**Year (4 digits) 1291**] who presented to the +ED with worsening SOB and chest pain x 2 days, found to have +pseudomonas bacteremia. + +#. Acute on chronic diastolic CHF with Hypoxic Respiratory +Failure: Patient had hypoxic respiratory in the emergency room. +He was intubated in the ED and transferred to the MICU. He was +quickly extubated after diuresis. It was felt that he likely +had an an acute exacerbation of his chronic diastolic CHF in the +setting of bacteremia and severe sepsis. He was put back on his +home CHF medications and his respiratory status remained stable +post-extubation. He was placed back on his home CHF regimen +after extubation and had no further respiratory distress. + +#. Pseudomonas Bacteremia: His admission blood cultures grew +pan-sensitive pseudomonas. A source was not identified despite +a thorough workup. Urinalysis was negative for infection. +Chest xray did not show evidence of pneumonia. He did have a +moderate right-sided pleural effusion on CT and thoracentesis +was considered but there was not enough effusion to sample. He +underwent TTE and TEE which showed no evidence of endocarditis. +He did complain of abdominal distension but KUB and abdominal +and pelvic CT did not show any acute intraabdominal pathology. +He did have tenderness at the site of his pacemaker pocket, +tracking down along the anterior chest wall. Since he had +recently had manipulation of his pacer for replacement, it was +felt this was the most likely source of his infection. He will +be treated with 4 weeks of IV cefepime and the ID team +recommended subsequent lifelong suppression with oral +ciprofloxacin. All surveillance cultures were negative and he +remained afebrile after admission. + +#. Altered mental status due to possible seizure: One morning, +the patient experienced an episode of altered mental status with +word-finding difficulty, urinary incontinence, and weakness. He +underwent ECG, ABG, and CXR which were unremarkable and CT head +which showed old CVAs but no acute event. The neurology team +felt that he may have had a seizure and started the patient on a +zonisamide load. He should continue this medication as an +outpatient. We have considered that his lifelong suppression +with ciprofloxacin may lower his seizure threshold, but it was +recommended that he take cipro indefinitely anyway. He +continued to have word-finding difficulties during the duration +of admission which seemed to wax and wane. + +#. Pleural Effusion: He had a moderate right and small +left-sided pleural effusion seen on CT scan. It was decided to +pursue thoracentesis to rule out this fluid as a source of his +infection. His Coumadin was held in preparation, and when his +INR was <1.6, the fluid was no longer prominent enough to tap. +His Coumadin was therefore restarted and he will transition on a +heparin drip until therapeutic. + +#. CAD: He is status post two coronary bypass procedures with +the most recent one in [**4-/2147**], at which time a revision of +ramus graft was performed. He was continued on his aspirin, +statin. His beta blocker and [**Last Name (un) **] were initially held but +restarted prior to discharge. His Imdur was switched in the +cardiac care unit to twice daily due to possible ST changes on +ECG on admission that may have been demand ischemia. + +#. Aortic stenosis, status post aortic valve replacement in +[**4-/2147**] with a #19 St. [**Male First Name (un) 1525**] prosthesis: He underwent TTE and +TEE that showed a normally functioning prosthesis. He was +maintained either on a heparin gtt or Coumadin for +anticoagulation with a goal INR of 2.0-2.5 (due to history of GI +bleed). Upon discharge INR was 1.5 and he was on a heparin drip +at 500 units/hour with a PTT of 72.5 at 12:00 PM on [**2155-5-19**]. + +#. Sick sinus syndrome, status post permanent pacemaker +insertion: It was felt that his pacemaker pocket may have been +infected given the tenderness on palpation. His pain also +decreased with antibiotics, although chest ultrasound did not +reveal a fluid collection. He was evaluated by the EP service +who felt conservative management of a possible infection was +reasonable. + +#. Chronic atrial fibrillation: He was monitored on telemetry +and given Coumadin for anticoagulation. Coumadin was held +temporarily due to possible thoracentesis and he was bridged +with a heparin drip. + +#. Hyperlipidemia: He was continued on a statin + +#. Constipation: He had a persistently distended abdomen and +complained of constipation regularly. He was kept on an +aggressive bowel regimen and had daily bowel movements. KUB and +CT abdomen/pelvis showed no obstruction. + +#. Code Status: He was DNR/DNI during this hospitalization, as +confirmed by his primary care provider who had had discussions +with the patient prior to hospitalization. He was intubated +initially in the MICU, but was subsequently made DNR/DNI. + + +Medications on Admission: +Lovenox 60mg [**Hospital1 **] as directed +Warfarin 5-7.5mg as directed +ASA 81mg daily +Metoprolol succinate 25mg daily +Valsartan 320mg daily +Furosemide 80mg daily +Potassium chloride 10mEq daily +Imdur 30mg daily +NTG 0.3mg SL prn +Simvastatin 40mg daily +Pantoprazole 40mg daily prn +Gabapentin 300mg [**Hospital1 **] +MVI with iron daily +Lactulose 15ml daily prn constipation +Bisacodyl 10mg PR every other day +Colace 100mg daily +Senna 1 tablet QAM and 2 tablets QPM +Tylenol 1000mg [**Hospital1 **] prn pain +Fluticasone 50mcg nasal daily +Trimacinolone acetonide 0.1% cream [**Hospital1 **] prn +Sarna lotion [**Hospital1 **] prn itch + +Discharge Medications: +1. Outpatient Lab Work +Please check weekly CBC with Diff, BMP, ESR, CRP and LFTs. +Please fax all laboratory results to Infectious disease R.Ns. at +([**Telephone/Fax (1) 1353**]. +2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK (Sun, +Mon, Wed, Fri). +3. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO 3X/week (Tues, +Thurs, Sat). +4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable +PO DAILY (Daily). +5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr +Sig: One (1) Tablet Sustained Release 24 hr PO once a day. +6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). + +7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). + +8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr +Sig: 0.5 Tablet Sustained Release 24 hr PO BID (2 times a day). + +9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet +Sublingual every 5 minutes as needed for chest pain: Take every +5 minutes for 3 times. +10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every +24 hours). +12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at +bedtime). +13. Multivitamins with Iron Tablet Sig: One (1) Tablet PO +once a day. +14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY +(Daily). +15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) +Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for +Constipation. +16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once +a day. +17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a +day). +18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H +(every 6 hours) as needed for Pain/fever. +19. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) +Spray Nasal DAILY (Daily). +20. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) application +Topical twice a day. +21. Multivitamin Tablet Sig: One (1) Tablet PO DAILY +(Daily). +22. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One +(1) Tablet Sustained Release PO once a day. +23. Cefepime 2 gram Recon Soln Sig: Two (2) gram Intravenous +twice a day: Give until [**2155-6-7**]. +24. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen +(17) gram PO DAILY (Daily) as needed for constipation. +25. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +26. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every +6 hours) as needed for cough. +27. Heparin (Porcine) in NS 10 unit/mL Kit Sig: Heparin IV +Sliding Scale Intravenous IV drip: Please start at 500 +Unit/hour and check PTT in AM [**2155-5-20**]. +28. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO HS (at +bedtime). + + +Discharge Disposition: +Extended Care + +Facility: +[**Hospital6 459**] for the Aged - MACU + +Discharge Diagnosis: +Primary Diagnosis: +Pseudomonas Bacteremia +Altered mental status + +Secondary Diagnosis: +Chronic diastolic congestive heart failure +Coronary Artery Disease + + +Discharge Condition: +Mental Status: Confused - sometimes, at times difficulty with +word-finding +Level of Consciousness: Alert and interactive. +Activity Status: Ambulatory - requires assistance or aid (walker +or cane). + + +Discharge Instructions: +You were admitted to the hospital due to difficulty breathing. +You were initially admitted to the intensive care unit. + +You were found to have a bacterial infection in your blood. It +was not clear where your infection was coming from but you are +being treated with intravenous antibiotics. You had an +ultrasound of your heart in two different ways which did not +show any infection on your heart valves. There was some concern +that your pacemaker site is infected. Therefore, you will need +to be on antibiotics indefinitely (intravenous antibiotics until +[**2155-6-7**], then oral antibiotics). If you develop increasing pain +at the site of your pacemaker, please call your cardiologist. + +You also had episodes of altered mental status and were +evaluated by the neurology team. There is a possibility that +you had a seizure so you were started on a medication to prevent +seizures. + +Changes to your medications: +Added cefepime 2g IV every 12 hours until [**2155-6-7**] +Changed Imdur to 15mg by mouth twice daily +Changed pantoprazole to famotidine 20mg by mouth daily +Changed gabapentin to 300mg by mouth at bedtime +Added colchicine 0.6 mg daily +Added zonisamide 300mg by mouth at bedtime +STOP taking lovenox + +You should weigh yourself every morning and call your primary +care doctor if your weight goes up more than 3 lbs. + +Followup Instructions: +You have the following appointments scheduled: + +Department: INFECTIOUS DISEASE +When: WEDNESDAY [**2155-6-4**] at 9:30 AM [**Telephone/Fax (1) 457**] +Building: LM [**Hospital Unit Name **] [**Hospital 1422**] +Campus: WEST Best Parking: [**Hospital Ward Name **] Garage + +Department: [**Hospital3 249**] +When: MONDAY [**2155-6-9**] at 10:50 AM +With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**] +Building: [**Hospital6 29**] [**Location (un) **] +Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage + +Department: CARDIAC SERVICES +When: THURSDAY [**2155-7-10**] at 10:00 AM +With: DEVICE CLINIC [**Telephone/Fax (1) 62**] +Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] +Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage + + + +","history of presenting illness: [**age over 90 52**] yo m w/ chf, cad s/p cabg in [**2137**], with lima->lad, svg->pda, svg->plb, svg->ri, with cabg ri revision in [**2147**], s/p pacemaker for sick sinus and s/p st. jude's valve for avr who presented to the ed with worsening sob, chest pain x 2 days. of note, pt intubated/sedated and history primarily obtained by patient's sister-in-law who is the de facto hcp (not official). the patient's wife was currently unable to provide a history at the time. the patient's sister-in-law describes the patient feeling increasingly short of breath and feverish (no temperature recorded at home). she notes that when the patient becomes fluid overloaded, he typically develops a cough with respiratory distress, however, this time no cough or sputum either. the patient was also complaining of chest pain x 1 day, which unfortunately cannot be further delineated based on this limited history. the patient's sister-in-law also notes the patient has been consuming a high sodium diet. she denies sick contacts, recent travel, sweats, chills, nausea, vomitting, diarrhea, constipation, black/red stools, headaches, back pain, abdominal pain. because of worsening respiratory distress, the patient asked his wife to call ems. in the ed, initial vitals were 97.1 150/94 87 32 and 80s on ra. he occasionally dipped to 70s. the patient was later found to be hypertensive to 222/94. the patient was then placed on a nitro gtt. the patient's cxr revealed pulmonary edema and was given lasix 40mg iv once and made 400cc of urine. the patient remained hypoxic. bipap was attempted without success. abg revealed 7.39/54/326. the patient was successfully intubated after one pass and cxr confirmed proper placement. the patient subsequently dropped his pressures to 93/38 and was given a 500cc bolus. unfortunately, a medication reconciliation sheet was not available. per report and omr, he was also given ceftriaxone 1gm iv once, levofloxacin 750mg iv once, asa 600mg pr once. the patient was also given albuterol/ipratropium nebs x 2, midazolam 2mg/2ml/fentanyl 100mcg/2ml once for sedation. the patient arrived to the floor seeming to be breathing synchronously with the ventilator. he did not appear in acute distress. he nodded afirmative to pain, but could not specify where. no overnight events. past medical","[**age over 90 **] year old russian-speaking male with history of diastolic chf, cad s/p cabg in [**2137**] and revision in [**2147**], ppm for sick sinus s/p replacement 6 weeks ago and as s/p [**year (4 digits) 1291**] who presented to the ed with worsening sob and chest pain x 2 days, found to have pseudomonas bacteremia.","history of presenting illness: [**age over 90 52**] yo m w/ chf, cad s/p cabg in [**2137**], with lima->lad, svg->pda, svg->plb, svg->ri, with cabg ri revision in [**2147**], s/p pacemaker for sick sinus and s/p st. the patient's wife was currently unable to provide a history at the time. the patient's sister-in-law describes the patient feeling increasingly short of breath and feverish (no temperature recorded at home). because of worsening respiratory distress, the patient asked his wife to call ems. in the ed, initial vitals were 97.1 150/94 87 32 and 80s on ra. the patient was later found to be hypertensive to 222/94. the patient was then placed on a nitro gtt. the patient was successfully intubated after one pass and cxr confirmed proper placement. he nodded afirmative to pain, but could not specify where.","[""The patient's sister-in-law was unable to provide a history of illness.\nThe patient was also complaining of chest pain and respiratory distress.\nShe was also suffering from a cough and chest pain.\nA new medication reconciliation sheet was not available.\nIt was not possible to determine the patient's exact history.\nPatient's sister was also unable to give a history.""]","the patient's sister-in-law is the de facto hcp (not official) the patient's sister-in-law denies sick contacts, recent travel, sweats, chills, nausea, vomiting, diarrhea, black/red stools, headaches, back pain, abdominal pain. because of worsening respiratory distress, the patient asked his wife to call ems.","['avr patient was intubated/sedated with worsening sob and chest pain for 2 days, sister-in law says. she denies sick contacts; claims the doctor has been on high sodium diet since diagnosis of acute respiratory distress (pt).']","of note, pt intubated/sedated and history primarily obtained by patient's sister-in-law who is the de facto hcp (not official). +she notes that when the patient becomes fluid overloaded, he typically develops a cough with respiratory distress, however, this time no cough or sputum either. +the patient was also complaining of chest pain x 1 day, which unfortunately cannot be further delineated based on this limited history. +because of worsening respiratory distress, the patient asked his wife to call ems. +the patient's cxr revealed pulmonary edema and was given lasix 40mg iv once and made 400cc of urine.","history of presenting illness: [**age over 90 52**] yo m w/ chf, cad s/p cabg in [**2137**], with lima->lad, svg->pda, svg->plb, svg->ri, with cabg ri revision in [**2147**], s/p pacemaker for sick sinus and s/p st.jude's valve for avr who presented to the ed with worsening sob, chest pain x 2 days.of note, pt intubated/sedated and history primarily obtained by patient's sister-in-law who is the de facto hcp (not official).the patient's wife was currently unable to provide a history at the time.the patient's sister-in-law describes the patient feeling increasingly short of breath and feverish (no temperature recorded at home).she notes that when the patient becomes fluid overloaded, he typically develops a cough with respiratory distress, however, this time no cough or sputum either.the patient was also complaining of chest pain x 1 day, which unfortunately cannot be further delineated based on this limited history.the patient's sister-in-law also notes the patient has been consuming a high sodium diet.because of worsening respiratory distress, the patient asked his wife to call ems.per report and omr, he was also given ceftriaxone 1gm iv once, levofloxacin 750mg iv once, asa 600mg pr once.","[{'rouge-1': {'r': 0.42, 'p': 0.2079207920792079, 'f': 0.27814569093460817}, 'rouge-2': {'r': 0.21428571428571427, 'p': 0.09302325581395349, 'f': 0.12972972550825435}, 'rouge-l': {'r': 0.38, 'p': 0.18811881188118812, 'f': 0.25165562470944264}}]","[{'rouge-1': {'r': 0.14, 'p': 0.175, 'f': 0.15555555061728413}, 'rouge-2': {'r': 0.05357142857142857, 'p': 0.05660377358490566, 'f': 0.055045866563421045}, 'rouge-l': {'r': 0.14, 'p': 0.175, 'f': 0.15555555061728413}}]","[{'rouge-1': {'r': 0.12, 'p': 0.15789473684210525, 'f': 0.13636363145661173}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.1, 'p': 0.13157894736842105, 'f': 0.11363635872933905}}]","[{'rouge-1': {'r': 0.24, 'p': 0.32432432432432434, 'f': 0.27586206407715685}, 'rouge-2': {'r': 0.10714285714285714, 'p': 0.16666666666666666, 'f': 0.13043477784499072}, 'rouge-l': {'r': 0.2, 'p': 0.2702702702702703, 'f': 0.22988505258290406}}]","[{'rouge-1': {'r': 0.22, 'p': 0.13924050632911392, 'f': 0.170542630911604}, 'rouge-2': {'r': 0.03571428571428571, 'p': 0.021505376344086023, 'f': 0.02684563289221288}, 'rouge-l': {'r': 0.2, 'p': 0.12658227848101267, 'f': 0.15503875494261177}}]","[{'rouge-1': {'r': 0.54, 'p': 0.19852941176470587, 'f': 0.290322576714071}, 'rouge-2': {'r': 0.35714285714285715, 'p': 0.1092896174863388, 'f': 0.16736401314822927}, 'rouge-l': {'r': 0.52, 'p': 0.19117647058823528, 'f': 0.279569888542028}}]",0.42,0.207920792,0.278145691,0.214285714,0.093023256,0.129729726,0.38,0.188118812,0.251655625,0.14,0.175,0.155555551,0.053571429,0.056603774,0.055045867,0.14,0.175,0.155555551,0.12,0.157894737,0.136363631,0,0,0,0.1,0.131578947,0.113636359,0.24,0.324324324,0.275862064,0.107142857,0.166666667,0.130434778,0.2,0.27027027,0.229885053,0.22,0.139240506,0.170542631,0.035714286,0.021505376,0.026845633,0.2,0.126582278,0.155038755,0.54,0.198529412,0.290322577,0.357142857,0.109289617,0.167364013,0.52,0.191176471,0.279569889 +59687,179109,6143,"Chief Complaint: fatigue, ARF + HPI: + This patient is a 65 y/o M with history of DMIx35 years (A1c 6.7), + kidney tx in [**2165**], transferred from [**Hospital3 2089**] ED where he + presented with fatigue x5 days, worsening edema and mild dyspnea on + exertion. He was was in the ER to have acute on chronic renal failure + with a creatinine of 5.6, hyponatremia to 113 and ? PNA on chest Xray. + Patient reports feeling extremely week for the past 5 days. He c/o + extreme fatigue preventing him from getting up on his own. he denies + fevers, chills. he complains of some difficulty breathing and orthopnea + for the past week. He has been nauseated with dry heave for the past 5 + days. He has also noticed increased scrotal edema x1 month and + periorbital edema occassionally for the past month. He has had + worsening LE edema since [**Month (only) 807**] and was started on lasix in the beginning + of [**Month (only) **]. He reports no change in his urination, denies frequency + or burning. No changed in the color. His stool has changed, as he goes + about 3 times a day now, and previously he was constipated. He also + reports decreased PO intake + His issues started around last [**Month (only) **] when he had an epsidode of + vomitting in the setting of 4 days of constipation. This resolved, but + he remained weak since then. He went to [**State 2090**] for a week at the end + of [**Month (only) 51**] and that is when he first noticed swelling in his feet. He + recalls that the swelling has been getting worse slowly since then. He + finally called his nephrologist Dr. [**First Name (STitle) 2091**] in the middle of [**Month (only) **] who + scheduled an ECHO and requested him to have his labs drawn. He also + adjusted the dosages of his Tacro. + The patient went to [**Hospital3 2089**] [**7-22**] or low blood sugar and again + [**2177-7-28**] because he was feeling very weak. At that time he was found to + have low sodium and chloride and low blood count and was given 2 units + of blood and 2 bags of NS (according to wife). He felt much better + after this admission, was able to take long walks with his wife, and + his appetite returned. This last until 5 days ago when he started with + the above symptoms. + In the ED his blood pressure ranged from 151-208/77-106, T 97, HR + 65-79, RR 16 sat 100% RA. He was fiven LEvaquin 750mg IV, Lasix 80mg + IV, labetolol 10mg IV, Compazine 10mg IV. He put out 1300 cc lasix + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Home meds: + Fosamax 70mg qweek + Azathioprine 50mg once a day + Calcium 600mg daily + Cyclosporine 50mg twice a day + Fludrocortisone Acetate 0.1mg once a day + Glyburide 5mg once a day + Lipitor 10mg + Lantus 5-6 units before breakfast. Novolog [**11-27**] units before each meal + Midodrine 5mg three times a day + Protonix 40mg da;ly + Prednisone 1mg 3 3 tablets once a day + lasix 20mg twice daily + Past medical history: + Family history: + Social History: + - Diabetes type 1 x34 years a1c 6.7 [**8-4**] + - s/p living related kidney transplant [**1-/2166**] + - gastroparesis + - neuropathy + - retinopathy with microaneurysms, s/p surgery [**2155**] + - GERD + - Hypercholesterolemia + - Gastroparesis + - osteopenia + Moms sister with [**Name (NI) 2092**], dads [**Name (NI) 2093**] with [**Name (NI) 2092**]. No heart disease. + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: denies smoking, drinking drug use. retired teacher. lives in + [**Location 2094**] with his wife. has 2 grown children, one in michagin one in + [**Location (un) 2095**]. + Review of systems: + Constitutional: Fatigue, No(t) Fever + Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, Orthopnea + Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze + Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea, + No(t) Constipation + Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis + Heme / Lymph: No(t) Lymphadenopathy, Anemia + Neurologic: No(t) Headache + Psychiatric / Sleep: No(t) Agitated + Flowsheet Data as of [**2177-8-21**] 10:55 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 35.6 +C (96 + Tcurrent: 35.6 +C (96 + HR: 79 (69 - 79) bpm + BP: 149/86(101) {148/74(92) - 149/86(101)} mmHg + RR: 14 (13 - 15) insp/min + SpO2: 96% + Heart rhythm: SR (Sinus Rhythm) + Total In: + PO: + TF: + IVF: + Blood products: + Total out: + 0 mL + 1,300 mL + Urine: + 1,300 mL + NG: + Stool: + Drains: + Balance: + 0 mL + -1,300 mL + Respiratory + O2 Delivery Device: None + SpO2: 96% + Physical Examination + Gen: no acute distress + HEENT: Clear OP, MMM, periorbital edema + NECK: Supple, No LAD, JVD about 7 cm + CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops + LUNGS: CTA, BS BL, No W/R/C + ABD: Soft, NT, ND. NL BS. No HSM + EXT: 3+ pitting edema. Upper extremity edema. Anasarcic + Scrotum: edematous + NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation + throughout. 5/5 strength throughout. [**11-27**]+ reflexes, equal BL. Normal + coordination. Gait assessment deferred + PSYCH: Listens and responds to questions appropriately, pleasant + Labs / Radiology + CXR + 351 + 10.3 + 273 + 5.6 + 45 + 18 + 79 + 3.8 + 113 + 28.7 + 8.6 + [image002.jpg] + Assessment and Plan + Acute Renal Failure: Patient with kidney transplant from living related + donor in [**2165**]. creatinine 4.0 on [**7-30**], now 5.6. Pt appears volume + overloaded and is possible that he is prerenal secondary to 3rd spacing + in the settig of kidney failure. FeUrea 63% which is consistent with + intrinsic renal disease or ATN, both possible in this case. Patient + fluid overload is likely secondary to renal failure, but may also be + cardiac, although he denies cardiac history. Got 80mg Lasix IV, put out + 1300. Also considering prerenal in setting of 3rd spacing, but FeUrea + >50%. Post obstructive also possible with scrotal edema, but has foley + right now. + - F/u ECHO from OSH + - ECHO here + - Renal transplant team is following + - will likely require kidney biopsy + - [**Month (only) 51**] need dialysis, althoug is puttig out well to lasix currently. + - check urine for casts + - follow lytes closely in setting of ARF, K normal currently + - will give 80iv Lasix PRN for goal neg 1-2 L. + s/p Kidney transplant: renal doctor recent decrease cyclosporine [**Last Name (un) **] + because of increase in creatinine + - continue cyclosporine, azathioprine, prednisone + - will check cyclosporine [**Last Name (un) **] in the AM given recent dose change. + Hypertensive Emergency: Blood pressure 200/100 in the ED, likely + because of fluid overload ARF. Responded well to 10mg IV labetolol and + 80mg IV lasix. now BP 140s + - continue to monitor for now + - will give either lasix or PRN labetolol if increases again. + Diabetes Mellitus Type 1: recent A1C [**5-3**]. + - Lantus 5units qAM per home regimen + - regular ISS + - hold glyburide + Hyponatremia: likely in setting of fluid overload. Per note, baseline + sodium is 120-125. currently 113. + - diurese as above + - fluid restriction 750cc + Pneumonia: CXR suscpicious for PNA, but no wbc count and no fever. + strange place for loculated effusion + - will treat for now with levaquin 250mg daily + FEN: diabetic, renal, low salt + ICU Care + Nutrition: + Glycemic Control: Regular insulin sliding scale + Lines: + 20 Gauge - [**2177-8-21**] 08:38 PM + Prophylaxis: + DVT: SQ UF Heparin + Stress ulcer: Not indicated + VAP: + Comments: + Communication: Comments: + Code status: + Disposition: +","Admission Date: [**2177-8-21**] Discharge Date: [**2177-8-22**] + +Date of Birth: [**2112-7-30**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 5893**] +Chief Complaint: +Fatigue, shortness of breath, edema + +Major Surgical or Invasive Procedure: +None. + +History of Present Illness: +This patient is a 65 year old male with history of type 1 +diabetes melltius for 35 years (A1c 6.7), kidney transplant in +[**2165**], who was transferred from [**Hospital3 24012**] ED where he +presented with fatigue x5 days, worsening edema and mild dyspnea +on exertion. He was was in the ER to have acute on chronic renal +failure with a creatinine of 5.6, hyponatremia to 113 and +question of PNA on chest Xray. + +Patient reports feeling extremely week for the past 5 days. He +complaints of extreme fatigue preventing him from getting up on +his own. he denies fevers, chills. he complains of some +difficulty breathing and orthopnea for the past week. He has +been nauseated with dry heave for the past 5 days. He has also +noticed increased scrotal edema x1 month and periorbital edema +occassionally for the past month. He has had worsening LE edema +since [**Month (only) **] and was started on lasix in the beginning of +[**Month (only) 462**]. He reports no change in his urination, denies +frequency or burning. No changed in the color. His stool has +changed, as he goes about 3 times a day now, and previously he +was constipated. He also reports decreased PO intake + +His issues started around last [**Month (only) 547**] when he had an epsidode of +vomitting in the setting of 4 days of constipation. This +resolved, but he remained weak since then. He went to [**State **] +for a week at the end of [**Month (only) 116**] and that is when he first noticed +swelling in his feet. He recalls that the swelling has been +getting worse slowly since then. He finally called his +nephrologist Dr. [**First Name (STitle) **] in the middle of [**Month (only) **] who scheduled an +ECHO and requested him to have his labs drawn. He also adjusted +the dosages of his Tacro. + +The patient went to [**Hospital3 24012**] [**7-22**] or low blood sugar and +again [**2177-7-28**] because he was feeling very weak. At that time he +was found to have low sodium and chloride and low blood count +and was given 2 units of blood and 2 bags of NS (according to +wife). He felt much better after this admission, was able to +take long walks with his wife, and his appetite returned. This +last until 5 days ago when he started with the above symptoms. + +In the ED his blood pressure ranged from 151-208/77-106, T 97, +HR 65-79, RR 16 sat 100% RA. He was fiven LEvaquin 750mg IV, +Lasix 80mg IV, labetolol 10mg IV, Compazine 10mg IV. He put out +1300 cc lasix after a foley was placed. + + +Past Medical History: +- Diabetes type 1 x34 years Last Hb A1c 6.7 [**8-4**] +- s/p living related kidney transplant [**1-/2166**] +- gastroparesis +- neuropathy +- retinopathy with microaneurysms, s/p surgery [**2155**] +- GERD +- Hypercholesterolemia +- Gastroparesis +- Osteopenia + + +Social History: +Patient denies smoking, drinking, or ilicit drug use. He is a +retired teacher. lives in [**Location 24013**] with his wife. [**Name (NI) **] has 2 +grown children, one in [**State **] one in [**Location (un) **]. + + +Family History: +His mother's sister has type two diabetes, and a paternal aunt +also has type two diabetes mellitus. There is no family history +of heart disease. + + +Physical Exam: +On admission: + +Vitals: T: 97.5 BP: 142/79 P: 80 RR: 16 O2Sat 92% RA +Gen: no acute distress +HEENT: Clear OP, MMM, periorbital edema +NECK: Supple, No LAD, JVD about 7 cm +CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops +LUNGS: CTA, BS BL, No W/R/C +ABD: Soft, NT, ND. NL BS. No HSM +EXT: 3+ pitting edema. Upper extremity edema. Anasarcic +Scrotum: edematous +NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved +sensation throughout. 5/5 strength throughout. [**11-27**]+ reflexes, +equal BL. Normal coordination. Gait assessment deferred +PSYCH: Listens and responds to questions appropriately, pleasant + + +Pertinent Results: +[**2177-8-21**] 11:13PM GLUCOSE-313* UREA N-50* CREAT-5.6* +SODIUM-112* POTASSIUM-3.9 CHLORIDE-82* TOTAL CO2-16* ANION +GAP-18 +[**2177-8-21**] 06:30PM URINE HOURS-RANDOM UREA N-169 CREAT-33 +SODIUM-30 +[**2177-8-21**] 06:30PM URINE OSMOLAL-196 +[**2177-8-21**] 06:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 +[**2177-8-21**] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 +GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 +LEUK-NEG +[**2177-8-21**] 06:30PM URINE RBC-0-2 WBC-[**1-29**] BACTERIA-FEW YEAST-NONE +EPI-[**1-29**] +[**2177-8-21**] 06:30PM URINE AMORPH-FEW +[**2177-8-21**] 04:54PM CYCLSPRN-43* tacroFK-LESS THAN +[**2177-8-21**] 03:50PM GLUCOSE-273* UREA N-45* CREAT-5.6*# +SODIUM-113* POTASSIUM-3.8 CHLORIDE-79* TOTAL CO2-18* ANION +GAP-20 +[**2177-8-21**] 03:50PM estGFR-Using this +[**2177-8-21**] 03:50PM proBNP-[**Numeric Identifier 24014**]* +[**2177-8-21**] 03:50PM CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.3 +[**2177-8-21**] 03:50PM WBC-8.6 RBC-3.27* HGB-10.3* HCT-28.7* MCV-88# +MCH-31.5 MCHC-35.8* RDW-14.6 +[**2177-8-21**] 03:50PM PLT COUNT-351# +[**2177-8-21**] 03:50PM PT-12.8 PTT-30.2 INR(PT)-1.1 + +Chest x-ray [**2177-8-21**]: +CONCLUSION: + +Pulmonary edema, likely cardiogenic. Bibasal effusions. +Increased density at right lung base, confluent edema versus +pneumonia. Followup post diuresis is recomended. + +The study and the report were reviewed by the staff radiologist. + + +Renal Ultrasound [**2177-8-21**]: +IMPRESSION: +1. Interval development of mild-to-moderate hydronephrosis +within the +transplanted kidney. +2. Slight broadening of the waveform of the mid pole renal +artery, +hoever resistive indices within normal range + +Transthoracic Echo [**2177-8-22**]: +Conclusions +The left atrium is mildly dilated. There is mild symmetric left +ventricular hypertrophy. The left ventricular cavity size is +normal. Overall left ventricular systolic function is normal +(LVEF 70%). Tissue Doppler imaging suggests an increased left +ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler +and tissue velocity imaging are consistent with Grade II +(moderate) LV diastolic dysfunction. There is no left +ventricular outflow obstruction at rest or with Valsalva. There +is no ventricular septal defect. Right ventricular chamber size +and free wall motion are normal. The ascending aorta is mildly +dilated. There are focal calcifications in the aortic arch. The +aortic valve leaflets (3) are mildly thickened but aortic +stenosis is not present. No aortic regurgitation is seen. The +mitral valve leaflets are mildly thickened. There is no mitral +valve prolapse. Mild (1+) mitral regurgitation is seen. There is +mild pulmonary artery systolic hypertension. There is a small +pericardial effusion. There are no echocardiographic signs of +tamponade. + +Compared with the findings of the prior report (images +unavailable for review) of [**2170-10-1**], concentric left +ventricular hypertrophy and moderate diastolic dysfunction now +evident. + +IMPRESSION: moderate diastolic dysfunction of the left ventricle +with normal ejection fraction + + +Brief Hospital Course: +Patient is a 65 year old male with type one diabetes mellitus, +renal transplant in [**2165**], gastroparesis, who presented with +fatigue, hyponatremia, worsening edema, dyspnea on exertion, and +worsening renal insufficiency who was transferred from an +outside hospital for further management. + +Patient was admitted to the medical intensive care unit. The +nephrology team was consulted and discussed dialysis with the +patient. He refused dialysis, and was able to state the risks +associated with doing so. He understood what dialysis entailed, +and was also not interested in temporary dialysis. It was +recommended that he be treated with trial hypertonic saline to +see if there was improvement in his hyponatremia and energy +level. He refused to stay as an inpatient and declined a PICC +line for administration of hypertonic saline. He was evaluated +by the psychiatry team to help assess whether there was a +component of depression, and to ensure that his mental status +was not clouded by his low sodium. The psychiatry team felt that +the patient was competent and had the capacity to make medical +decisions and fully understood the implications of refusing +dialysis and other treatments. His primary nephrologist +confirmed that this was in accordance with prior discussions +regarding the goals of his care. + +The patient stated that his goals were to return home and spend +time with his wife. Social work, palliative care, and case +management were then involved to assist with arranging home +Hospice services to meet the patient's wishes. A Hospice bed was +available for the next day and would be arranged for him in his +home. Per his and his wife's wishes, he was discharged home. A +regimen of salt tabs and lasix was initiated for his +hyponatremia after discussion with the renal team. + +His code status is DNR/DNI, and paperwork was completed for his +ambulance ride home for this order. + +Medications on Admission: + Fosamax 70mg qweek + Azathioprine 50mg once a day + Calcium 600mg daily + Cyclosporine 50mg twice a day + Fludrocortisone Acetate 0.1mg once a day + Glyburide 5mg once a day + Lipitor 10mg + Lantus 5-6 units before breakfast. Novolog [**11-27**] units before +each meal + Midodrine 5mg three times a day + Protonix 40mg daily + Prednisone 1mg 3 3 tablets once a day + lasix 20mg twice daily + + +Discharge Medications: +1. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) +Tablet, Chewable PO DAILY (Daily). +3. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY +(Daily). +4. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 +times a day). +Disp:*180 Tablet(s)* Refills:*2* +5. Lasix 80 mg Tablet Sig: One (1) Tablet PO three times a day. +Disp:*90 Tablet(s)* Refills:*2* +6. Insulin Glargine 100 unit/mL Solution Sig: 5-6 units +Subcutaneous QAM: Resume your home dosing. +7. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours: As +needed for seizure, discomfort. +Disp:*30 Tablet(s)* Refills:*0* +8. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO q1 +hour PRN: PRN shortness of breath, discomfort. +9. Insulin Aspart 100 unit/mL Solution Sig: [**11-27**] units +Subcutaneous before meals: Please resume your home dosing. + + +Discharge Disposition: +Home With Service + +Facility: +[**Location (un) **] Nursing Services + +Discharge Diagnosis: +Primary diagnoses: +- Acute on chronic renal failure +- Hyponatremia + +Secondary diagnoses: +- Diabetes Mellitus +- Renal transplant +- Gastroparesis +- Neuropathy +- Retinopathy +- GERD + + +Discharge Condition: +Fair, alert, oriented. + + +Discharge Instructions: +You were admitted from an outside hospital for management of +your renal failure, low sodium, mild shortness of breath, +fatigue, and swelling of your extremities. It was recommended +that you undergo dialysis or have other treatments for your low +sodium, however you declined these treatments. The psychiatry +team helped evaluate you, and they were in agreement that you +understood the risks and benefits of this decision. The +palliative care team and case management helped to arrange for a +discharge home with Hospice services. +. +Please call your primary care physician if you have any pain, +worsening shortness of breath, or other concerns that need +attention. +. +You should take 80 mg of lasix three times a day in addition to +[**11-27**] salt tabs 3 times a day. Please continue all of your other +medications as directed or appropriate. A foley catheter has +been placed for comfort and should be left in unless otherwise +directed. + +Followup Instructions: +You decided that you wanted to go home with Hospice. Please +contact your primary care physician or other providers for any +needs you may have outside of Hospice services. + + + +","this patient is a 65 y/o m with history of dmix35 years (a1c 6.7), kidney tx in [**2165**], transferred from [**hospital3 2089**] ed where he presented with fatigue x5 days, worsening edema and mild dyspnea on exertion. he was was in the er to have acute on chronic renal failure with a creatinine of 5.6, hyponatremia to 113 and ? pna on chest xray. patient reports feeling extremely week for the past 5 days. he c/o extreme fatigue preventing him from getting up on his own. he denies fevers, chills. he complains of some difficulty breathing and orthopnea for the past week. he has been nauseated with dry heave for the past 5 days. he has also noticed increased scrotal edema x1 month and periorbital edema occassionally for the past month. he has had worsening le edema since [**month (only) 807**] and was started on lasix in the beginning of [**month (only) **]. he reports no change in his urination, denies frequency or burning. no changed in the color. his stool has changed, as he goes about 3 times a day now, and previously he was constipated. he also reports decreased po intake his issues started around last [**month (only) **] when he had an epsidode of vomitting in the setting of 4 days of constipation. this resolved, but he remained weak since then. he went to [**state 2090**] for a week at the end of [**month (only) 51**] and that is when he first noticed swelling in his feet. he recalls that the swelling has been getting worse slowly since then. he finally called his nephrologist dr. [**first name (stitle) 2091**] in the middle of [**month (only) **] who scheduled an echo and requested him to have his labs drawn. he also adjusted the dosages of his tacro. the patient went to [**hospital3 2089**] [**7-22**] or low blood sugar and again [**2177-7-28**] because he was feeling very weak. at that time he was found to have low sodium and chloride and low blood count and was given 2 units of blood and 2 bags of ns (according to wife). he felt much better after this admission, was able to take long walks with his wife, and his appetite returned. this last until 5 days ago when he started with the above symptoms. in the ed his blood pressure ranged from 151-208/77-106, t 97, hr 65-79, rr 16 sat 100% ra. he was fiven levaquin 750mg iv, lasix 80mg iv, labetolol 10mg iv, compazine 10mg iv. he put out 1300 cc lasix","patient is a 65 year old male with type one diabetes mellitus, renal transplant in [**2165**], gastroparesis, who presented with fatigue, hyponatremia, worsening edema, dyspnea on exertion, and worsening renal insufficiency who was transferred from an outside hospital for further management.","this patient is a 65 y/o m with history of dmix35 years (a1c 6.7), kidney tx in [**2165**], transferred from [**hospital3 2089**] ed where he presented with fatigue x5 days, worsening edema and mild dyspnea on exertion. he c/o extreme fatigue preventing him from getting up on his own. he reports no change in his urination, denies frequency or burning. his stool has changed, as he goes about 3 times a day now, and previously he was constipated. he also reports decreased po intake his issues started around last [**month (only) **] when he had an epsidode of vomitting in the setting of 4 days of constipation. he went to [**state 2090**] for a week at the end of [**month (only) 51**] and that is when he first noticed swelling in his feet. at that time he was found to have low sodium and chloride and low blood count and was given 2 units of blood and 2 bags of ns (according to wife). this last until 5 days ago when he started with the above symptoms. he was fiven levaquin 750mg iv, lasix 80mg iv, labetolol 10mg iv, compazine 10mg iv.",['The patient was in the ER for a week at the end of the month.\nHe has had severe pain and numbness for the past 5 days.\nHas had severe diarrhea and mild dyspnea.\nIs a 65 y/o molar and has a history of renal failure.\nWas in the ED for a month at the beginning of the year.\nHad a gastric band removed and a colonoscopy.\nThe patient has been vomiting for the last 5 days and is now feeling very tired.'],"patient is 65 y/o m with history of dmix35 years (a1c 6.7), kidney tx in [**2165**]. he was in the er to have acute on chronic renal failure with a creatinine of 5.6, hyponatremia to 113 and? pna on chest xray. patient reports feeling extremely week for the past 5 days.","['a 65-year old man with chronic kidney failure has been admitted to hospital for severe fatigue and dyspneal on exertion. the patient is now recovering at home after being given lasix, which helped him get through his symptoms of leukemia in less than two weeks!']","this patient is a 65 y/o m with history of dmix35 years (a1c 6.7), kidney tx in [**2165**], transferred from [**hospital3 2089**] ed where he presented with fatigue x5 days, worsening edema and mild dyspnea on exertion. +patient reports feeling extremely week for the past 5 days. +he has had worsening le edema since [**month (only) 807**] and was started on lasix in the beginning of [**month (only) **]. +he also reports decreased po intake his issues started around last [**month (only) **] when he had an epsidode of vomitting in the setting of 4 days of constipation. +the patient went to [**hospital3 2089**] [**7-22**] or low blood sugar and again [**2177-7-28**] because he was feeling very weak.","this patient is a 65 y/o m with history of dmix35 years (a1c 6.7), kidney tx in [**2165**], transferred from [**hospital3 2089**] ed where he presented with fatigue x5 days, worsening edema and mild dyspnea on exertion.he was was in the er to have acute on chronic renal failure with a creatinine of 5.6, hyponatremia to 113 and ? pna on chest xray.patient reports feeling extremely week for the past 5 days.he c/o extreme fatigue preventing him from getting up on his own.he complains of some difficulty breathing and orthopnea for the past week.he has been nauseated with dry heave for the past 5 days.he has also noticed increased scrotal edema x1 month and periorbital edema occassionally for the past month.he has had worsening le edema since [**month (only) 807**] and was started on lasix in the beginning of [**month (only) **].","[{'rouge-1': {'r': 0.4594594594594595, 'p': 0.1297709923664122, 'f': 0.20238094894628686}, 'rouge-2': {'r': 0.175, 'p': 0.03763440860215054, 'f': 0.061946899741561735}, 'rouge-l': {'r': 0.40540540540540543, 'p': 0.11450381679389313, 'f': 0.17857142513676308}}]","[{'rouge-1': {'r': 0.2972972972972973, 'p': 0.20754716981132076, 'f': 0.24444443960246923}, 'rouge-2': {'r': 0.025, 'p': 0.013157894736842105, 'f': 0.01724137479191557}, 'rouge-l': {'r': 0.21621621621621623, 'p': 0.1509433962264151, 'f': 0.17777777293580263}}]","[{'rouge-1': {'r': 0.2702702702702703, 'p': 0.2222222222222222, 'f': 0.24390243407198106}, 'rouge-2': {'r': 0.025, 'p': 0.019230769230769232, 'f': 0.02173912551984988}, 'rouge-l': {'r': 0.21621621621621623, 'p': 0.17777777777777778, 'f': 0.19512194626710305}}]","[{'rouge-1': {'r': 0.24324324324324326, 'p': 0.2, 'f': 0.21951219016954204}, 'rouge-2': {'r': 0.05, 'p': 0.045454545454545456, 'f': 0.047619042630386015}, 'rouge-l': {'r': 0.1891891891891892, 'p': 0.15555555555555556, 'f': 0.17073170236466406}}]","[{'rouge-1': {'r': 0.4594594594594595, 'p': 0.2, 'f': 0.2786885203641495}, 'rouge-2': {'r': 0.175, 'p': 0.061946902654867256, 'f': 0.09150326411209381}, 'rouge-l': {'r': 0.40540540540540543, 'p': 0.17647058823529413, 'f': 0.24590163511824786}}]","[{'rouge-1': {'r': 0.4594594594594595, 'p': 0.17346938775510204, 'f': 0.2518518478727024}, 'rouge-2': {'r': 0.175, 'p': 0.051094890510948905, 'f': 0.07909604169938411}, 'rouge-l': {'r': 0.43243243243243246, 'p': 0.16326530612244897, 'f': 0.23703703305788754}}]",0.459459459,0.129770992,0.202380949,0.175,0.037634409,0.0619469,0.405405405,0.114503817,0.178571425,0.297297297,0.20754717,0.24444444,0.025,0.013157895,0.017241375,0.216216216,0.150943396,0.177777773,0.27027027,0.222222222,0.243902434,0.025,0.019230769,0.021739126,0.216216216,0.177777778,0.195121946,0.243243243,0.2,0.21951219,0.05,0.045454545,0.047619043,0.189189189,0.155555556,0.170731702,0.459459459,0.2,0.27868852,0.175,0.061946903,0.091503264,0.405405405,0.176470588,0.245901635,0.459459459,0.173469388,0.251851848,0.175,0.051094891,0.079096042,0.432432432,0.163265306,0.237037033 +13306,188375,6828,"Chief Complaint: shortness of breath, lower extremity swelling, + ""dizziness"" + HPI: + Mr. [**Known lastname 5243**] is a 49 year old male with a PMH of COPD (FEV1 1.7 [**3-16**]), CAD + s/p IMI, HTN, DMII, OSA on CPAP who presents with increasing shortness + of breath, dizzyness, and bilateral lower extremity swelling over the + past 2 weeks. The patient felt like he was fighting a cold 2 weeks ago + and took Airborne. His symptoms improved, but then he developed a runny + nose and post nasal drainage and began coughing grey-[**Known lastname **] sputum from + his lungs. His dyspnea occurs primarily with movement/exertion, not at + rest. Over this time period he has also developed worsening bilateral + lower extremity edema that has been painful at times at the ankles. He + denies any prior history of lower extremity edema. He has also been + waking up at night sitting up on the side of his bed with his CPAP mask + off and feeling somewhat confused. He has had a decreased appetite for + the last 3-4 days with decreased PO intake. He has also felt ""dizzy"" + and when asked to clarify this states that he has felt lightheaded, as + if he would faint, at times. + . + He presented to the [**Hospital 319**] clinic earlier today and was noted to have a + heart rate of 120 with an 02 sat of 78%. He was sent to the ED for + further evaluation. Vitals on presentation to the ED were T 99.1, BP + 136/90, HR 100, O2sat of 96% on a non-rebreather mask. He received + aspirin 325 mg PO, Levofloxacin 750 mg IV, and Lasix 10 mg IV. + . + ROS: As above. In addition he also endorses diarrhea yesterday only + that has since resolved. He chronically sleeps on 2 pillows at night + and has to sleep on his left side as he cannot breathe if he lays on + his back. He also uses CPAP at night. He has had no fevers, chills, + vertigo, headache, chest pain, melena, BRBPR, myalgias, arthralgias, or + dysuria. + Patient admitted from: [**Hospital1 54**] [**Hospital1 55**] + History obtained from [**Hospital 85**] Medical records + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Advair 250/50 1 puff [**Hospital1 **] + Lisinopril 10 mg PO daily + Metformin 500 mg PO BID + Metoprolol 50 mg PO BID + Nitroglycerin 0.4 mg prn + Spiriva 1 cap daily + Tolterodine SR 4 mg daily + Aspirin 325 mg PO daily + Melatonin 3 mg QPM + MVI with minerals daily + *pt. was prescribed Rosuvastatin 40 mg but is not currently taking this + medication due to insurance issues. + Past medical history: + Family history: + Social History: + # CAD: 2VD s/p inferior STEMI & BMS->LCX [**2183**] + - cath [**5-15**]: 30% prox LAD, 60% mid-LCx before patent OM1 stent, 100% + RCA occlusion with good L->R collaterals + # PVD s/p stenting of the right common iliac artery, [**2183**] + # CHF, preserved EF on MIBI [**4-14**], ECHO [**1-12**] + # COPD, FEV1 1.7 [**3-16**] + # OSA on CPAP + # Diabetes mellitus, type 2, HbA1c 6.2 in [**3-16**] + # Hypercholesterolemia + # Hypertension + # Obesity + Father died at 59 in his sleep, had COPD. Mother died at 79 and had + breast cancer. He has a sister with ""heart disease"" and a stroke. + Occupation: works in shipping and receiving + Drugs: past marijuana + Tobacco: quit [**2190**], former 2 ppd smoker for many years + Alcohol: occasional + Other: + Review of systems: + Constitutional: No(t) Fever + Cardiovascular: Edema, No(t) Tachycardia, Orthopnea + Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze + Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, + No(t) Diarrhea, No(t) Constipation + Genitourinary: No(t) Dysuria + Musculoskeletal: No(t) Myalgias + Neurologic: No(t) Headache + Pain: No pain / appears comfortable + Flowsheet Data as of [**2193-1-9**] 04:38 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: 85 (74 - 95) bpm + BP: 88/54(62) {88/54(62) - 108/71(78)} mmHg + RR: 15 (15 - 17) insp/min + SpO2: 91% + Heart rhythm: SR (Sinus Rhythm) + Total In: + PO: + TF: + IVF: + Blood products: + Total out: + 1,450 mL + 201 mL + Urine: + 800 mL + 201 mL + NG: + Stool: + Drains: + Balance: + -1,450 mL + -201 mL + Respiratory + O2 Delivery Device: Other + Ventilator mode: MMV/PSV/AutoFlow + Vt (Set): 501 (501 - 501) mL + Vt (Spontaneous): 911 (911 - 911) mL + PS : 15 cmH2O + RR (Set): 10 + RR (Spontaneous): 15 + PEEP: 5 cmH2O + FiO2: 60% + PIP: 21 cmH2O + SpO2: 91% + ABG: 7.29/81.[**Numeric Identifier 253**]/71//9 + Ve: 4.5 L/min + PaO2 / FiO2: 118 + Physical Examination + General Appearance: Overweight / Obese, tachypneic + Head, Ears, Nose, Throat: Normocephalic, BiPAP + Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy + Cardiovascular: (S1: Normal), (S2: Normal) + Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: + Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) + Respiratory / Chest: (Breath Sounds: Diminished: ) + Abdominal: Soft, Non-tender, Bowel sounds present, Obese + Extremities: Right: 3+, Left: 3+ + Skin: Warm, Rash: Multiple non-blanching, petechiae-like red dots on + the anterior lower legs bilaterally. Erythematous, blanching, slightly + scaly macular rash over abdomen, thighs, and back, blanching. + Neurologic: Attentive, Follows simple commands, Responds to: Verbal + stimuli, Oriented (to): person, place, time, Movement: Purposeful, + Tone: Normal, Moving all extremities. Sensation intact throughout + Labs / Radiology + 217 + 117 + 0.7 + 14 + 40 + 98 + 4.5 + 141 + 56.3 + 8.8 + [image002.jpg] + [**2190-2-8**] + 2:33 A12/3/[**2192**] 12:20 AM + [**2190-2-12**] + 10:20 P12/3/[**2192**] 12:33 AM + [**2190-2-13**] + 1:20 P + [**2190-2-14**] + 11:50 P + [**2190-2-15**] + 1:20 A + [**2190-2-16**] + 7:20 P + 1//11/006 + 1:23 P + [**2190-3-11**] + 1:20 P + [**2190-3-11**] + 11:20 P + [**2190-3-11**] + 4:20 P + TropT + 0.05 + TC02 + 41 + Other labs: CK / CKMB / Troponin-T:58//0.05 + Imaging: CXR - AP upright portable chest radiograph is obtained. There + is + persistent elevation of the left hemidiaphragm. There is increased + density at the left lung base which may reflect effusion and + atelectasis though pneumonia cannot be excluded. Pulmonary vascularity + is stable allowing for diminished lung volumes with crowding of + bronchovasculature at the lung bases noted. + Cardiomediastinal silhouette is stable. There is no overt CHF. No + pneumothorax is present. Osseous structures are stable. + IMPRESSION: + Limited study with increased left basilar density, which may reflect + atelectasis and effusion though pneumonia cannot be excluded. + Correlation with lateral view may aid in diagnosis. + [**2192-5-8**] Cardiac cath - 1. Coronary angiography in this right dominant + system demonstrated an LMCA without angiographically apparent disease. + The LAD had a 30% proximal lesion. The LCX had a 60% mid-vessel lesion + just before the patent stent in OM1. The RCA had a 100% proximal lesion + with very good left to right collaterals. + 2. Pressure wire of the LCX lesion revealed an FFR of 0.81, and the + lesion was not stented. + 3. Limited resting hemodynamics revealed elevated pulmonary arterial + pressures. + [**2192-4-18**] P-MIBI: + No anginal type symptoms or ischemic EKG changes. Nuclear report sent + separately. + 1. Partially reversible, large, moderate severity perfusion defect + involving the PDA territory. + 2. Partially reversible, small, moderate severity perfusion defect + involving the LAD territory. + 3. Increased left ventricular cavity size with normal systolic + function. Compared with the study of [**2184-5-27**], the defects are new. + [**2192-3-28**] spirometry - Impression: + FEV1 1.7(44%), FVC 3.14 (59%), FEV1/FVC 55 (76%) + Moderate obstructive ventilatory defect. The reduced DLCO suggests a + perfusion limitation. Compared to the prior study of [**2191-9-13**] the FVC + has increased by 0.36 L (13%) and the FEV1 has increased by 0.26 L + (18%). + [**2191-1-10**] ECHO - The left atrium is mildly elongated. Left ventricular + wall thickness, cavity size, and systolic function are normal + (LVEF>55%). Due to suboptimal technical quality, a focal wall motion + abnormality cannot be fully excluded. The right ventricular cavity is + mildly dilated. Free wall motion is depressed (?mild). The aortic valve + leaflets are mildly thickened. There is no aortic valve stenosis. No + aortic regurgitation is seen. The mitral valve is grossly normal. No + mitral regurgitation is seen. There is mild pulmonary artery systolic + hypertension. There is no pericardial effusion. + IMPRESSION: Right ventricular cavity enlargement with free wall + hypokineiss. Pulmonary artery systolic hypertension. Preserved global + left ventricular systolic function. Is there a history to suggest a + primary pulmonary process (e.g., pulmonary embolism, COPD, + bronchospasm, etc.) + ECG: NSR at 97, RAD. IVCD. TWI in III, TEF in II, aVF. Compared to + prior [**2192-5-8**], no significant change. + Assessment and Plan + 49 year old male with COPD (FEV1 1.7 [**3-16**]), CAD, HTN, DMII, OSA on CPAP + who presents with SOB and LE swelling transferred to the unit for + hypercarbic and hypoxic respiratory failure. + . + # respiratory failure: combined hypercarbic and hypoxic respiratory + failure. Etiology unclear. Chronically elevated Hct suggests some + level of chronic hypoxia, likely d/t combination of COPD and OSA. pH of + 7.3 with pCO2 of 82 suggests chronic respiratory acidosis with + metabolic compensation. BL pCO2 likely ~ 70. Unclear cause of current + decline. No prodrome of fevers or myalgias to suggest flu. No obvious + infection on CXR to suggest profound pna. Increased LE edema and + elevated BNP raises ? of CHF. ? ischemic contribution. MBI elevated but + ECG without dramatic ischemic changes and trop normal. Could also have + COPD exacerbation in setting of infection. + - levofloxacin 750 mg x 5 day course + - continue home advair + - albuterol/atrovent nebs, Q2-4H prn + - hold spiriva + - solumedrol 125 mg IV Q8H + - strict I/Os, daily weights, goal negative 1L. Can repeat lasix prn + - Noninvasive mechanical ventilation for now and trend ABGs. Monitor + mental status. If does note continue to improve will need intubation + - serial CEs to rule out MI as etiology of CHF exacerbation + - check ECHO in am to eval for new WMA + . + # Dizziness/lightheadedness: Unclear cause. Potentially due to + significant hypoxia as was in 70s on RA at outpt appointment today. + - tele + - treat respiratory status as above + - further work up if persistent symptoms following resolution of + respiratory failure + . + # Diabetes: well controlled according to most recent HbA1C. On + metformin as outpt. + - hold metformin for now + - FABG with ISS + . + # Hypertension: Continue home regimen of lisinopril and metoprolol. + . + # CAD: s/p IMI in past by report and prior stenting. Large reversible + defect in inferior wall in [**3-16**] but no intervenable CAD on cath in + [**5-15**]. No chest pain currently. + - cycle CEs + - cont asa + - simvastatin for now + - check lipids in am + - cont beta blocker with holding parameters + . + # OSA: will transition to CPAP once acute respiratory issues resolved. + . + # Hypertension: current BPs low normal. Will follow + - cont metoprolol + . + # FEN: low salt, cardiac, diabetic diet + . + # PPx: heparin sc tid, bowel regimen + . + # CODE: presumed full + . + # COMM: with patient + . + # DISP: medical floor until oxygenation returns to baseline + . + ICU Care + Nutrition: + Glycemic Control: insulin ss + Lines: + 18 Gauge - [**2193-1-8**] 11:19 PM + Prophylaxis: + DVT: heparin sc + Stress ulcer: PPI while on steroids + VAP: n/a + Communication: patient + Code status: FULL + Disposition: ICU level of care +","Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-15**] + +Date of Birth: [**2143-2-1**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 4654**] +Chief Complaint: +hypoxia and hypercarbia + +Major Surgical or Invasive Procedure: +none + +History of Present Illness: +Mr. [**Known lastname 174**] is a 49 year old male with a PMH of HTN, DMII, OSA, +COPD, CAD s/p IMI and stenting who presents with increasing +shortness of breath, dizzyness, and bilateral lower extremity +swelling over the past 2 weeks. The patient felt like he was +fighting a cold 2 weeks ago and took Airborne. His symptoms +improved, but then he developed a runny nose and post nasal +drainage and began coughing grey-[**Known lastname **] sputum from his lungs. +His dyspnea occurs primarilly with movement/exertion, not at +rest. Over this time period he has also developed worsening +bilateral lower extremity edema that has been painful at times +at the ankles. He denies any prior history of lower extremity +edema. He has also been waking up at night sitting up on the +side of his bed with his CPAP mask off and feeling somewhat +confused. He has had a decreased appetite for the last 3-4 days +with decreased PO intake. He has also felt ""dizzy"" and when +asked to clarify this states that he has felt lightheaded, as if +he would faint, at times. +. +He presented to the [**Hospital 191**] clinic earlier today and was noted to +have a heart rate of 120 with an 02 sat of 78%. He was sent to +the ED for further evaluation. Vitals on presentation to the ED +were T 99.1, BP 136/90, HR 100, O2sat of 92% 2L. He received +aspirin 325 mg PO, Levofloxacin 750 mg IV, and Lasix 10 mg IV. +On initial presentation on the floor, the patient was +comfortable, in no distress, able speak and relate history +easily, 92%4L. On falling asleep w/o his usual home BiPap w/ 3L, +he desaturated to 78%RA. He was triggered due to hypoxia. On +arousing the patient up, the patient was awake, alert, not +complaining of SOB, but drowsy. Initially, his O2 sat rose to +89% on 4L. Respiratory therapy was called to arrange for +patient's BiPap. He was also given lasix 20mg IV to which he +promptly urinated 650cc. He also received a combivent. His +clinical status continued to deteriorate with 02 sat 80-85% on +10L. ABG was 7.42/90/45. He was placed on CPAP and transfered to +the ICU. +. +ROS: As above. In addition he also endorses diarrhea yesterday +only that has since resolved. He chronically sleeps on 2 pillows +at night and has to sleep on his left side as he cannot breathe +if he lays on his back. He also uses CPAP at night. He has had +no fevers, chills, vertigo, headache, chest pain, melena, BRBPR, +myalgias, arthralgias, or dysuria. + + +Past Medical History: +# CAD: 2VD s/p inferior STEMI & BMS->LCX [**2183**] +- cath [**5-15**]: 30% prox LAD, 60% mid-LCx before patent OM1 stent, +100% RCA occlusion with good L->R collaterals +# PVD s/p stenting of the right common iliac artery, [**2183**] +# CHF, preserved EF on MIBI [**4-14**], ECHO [**1-12**] +# COPD, FEV1 1.7 [**3-16**] +# OSA on CPAP +# Diabetes mellitus, type 2, HbA1c 6.2 in [**3-16**] +# Hypercholesterolemia +# Hypertension +# Obesity + +Social History: +He works in shipping & receiving, was formerly a machinist. He +quit smoking in [**2190**], but formerly smoked ~ 2ppd x many years. +Has a couple of beers per month. Past history of marijuana use +many years ago, but none currently. No IVDU. + +Family History: +Father died at 59 in his sleep from MI, had COPD. Mother died at +79 and had breast cancer. He has a sister with ""heart disease"" +and a stroke in her 30s. + +Physical Exam: +Vitals: T 98.1, BP 106/80, HR 100, RR 22, 93% on 4L NC +Gen: Obese caucasian male sitting up in bed in NAD +HEENT: Clear OP, MMM +NECK: Supple, No LAD, No JVD +CV: RRR. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**] +LUNGS: Decreased breath sounds bilaterally, no wheezes, +crackles, or rhronchi +ABD: normo-active BS, soft, NT, ND. +EXT: 3+ edema in the feet bilaterally, 2+ to mid shins +bilaterally. DP pulses not palpable. +SKIN: Multiple non-blanching, petechiae-like red dots on the +anterior lower legs bilaterally. Erythematous, blanching, +slightly scaly maculopapular rash over abdomen, thighs, and +back, blanching. +NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength +throughout. [**2-8**]+ reflexes, equal BL. +PSYCH: Listens and responds to questions appropriately, pleasant + + + +Pertinent Results: +[**2193-1-8**] 01:20PM PLT SMR-NORMAL PLT COUNT-217 +[**2193-1-8**] 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL +POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL +POLYCHROM-NORMAL +[**2193-1-8**] 01:20PM NEUTS-72* BANDS-0 LYMPHS-17* MONOS-8 EOS-3 +BASOS-0 ATYPS-0 METAS-0 MYELOS-0 +[**2193-1-8**] 01:20PM WBC-8.8 RBC-6.05 HGB-18.3* HCT-56.3* MCV-93 +MCH-30.3 MCHC-32.6 RDW-13.1 +[**2193-1-8**] 01:59PM CK-MB-12* MB INDX-11.8* proBNP-1797* +[**2193-1-8**] 01:59PM cTropnT-0.03* +[**2193-1-8**] 01:59PM CK(CPK)-102 +[**2193-1-8**] 01:59PM estGFR-Using this +[**2193-1-8**] 01:59PM GLUCOSE-117* UREA N-14 CREAT-0.7 SODIUM-141 +POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-40* ANION GAP-8 +[**2193-1-8**] 03:50PM PT-14.4* PTT-26.0 INR(PT)-1.3* +[**2193-1-8**] 05:15PM URINE URIC ACID-OCC +[**2193-1-8**] 05:15PM URINE HYALINE-0-2 +[**2193-1-8**] 05:15PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE +EPI-0 +[**2193-1-8**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 +GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG +[**2193-1-8**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 +[**2193-1-8**] 10:36PM O2 SAT-75 +[**2193-1-8**] 10:36PM LACTATE-0.7 +[**2193-1-8**] 10:36PM TYPE-ART PO2-45* PCO2-94* PH-7.27* TOTAL +CO2-45* BASE XS-11 INTUBATED-NOT INTUBA COMMENTS-CPAP +[**2193-1-8**] 10:54PM LACTATE-0.9 +[**2193-1-8**] 10:54PM TYPE-ART PO2-59* PCO2-94* PH-7.28* TOTAL +CO2-46* BASE XS-13 INTUBATED-NOT INTUBA COMMENTS-CPAP 15L +. +EKG ([**2193-1-8**]): Sinus rhythm at the upper limits of normal rate. +Right inferior axis. RSR' pattern in lead V1. Borderline +intraventricular conduction delay. Low precordial voltage. Since +the previous tracing of [**2192-5-8**] the inferior Q waves are less +prominent now. Early precordial ST segment elevations are no +longer present. Clinical correlation is suggested. +. +CXR ([**2193-1-8**]): Limited study with increased left basilar +density, which may reflect atelectasis and effusion though +pneumonia cannot be excluded. Correlation with lateral view may +aid in diagnosis. +. +CXR ([**2193-1-9**]): In comparison with the study of [**1-8**], there is +again blunting of the left costophrenic angle with opacification +at the base. Again, there is asymmetry of the density of the +lungs with the left being somewhat darker. Mild prominence of +interstitial markings persists that could represent some +asymmetric pulmonary edema. +. +TTE ([**2193-1-9**]): The left atrium is dilated. 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 normal (LVEF>55%). There is no ventricular +septal defect. The right ventricular cavity is mildly dilated +with mild global free wall hypokinesis. 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. There is mild +pulmonary artery systolic hypertension. There is no pericardial +effusion. IMPRESSION: poor technical quality due to patient's +body habitus. Left ventricular function is probably normal, a +focal wall motion abnormality cannot be fully excluded. The +right ventricleappears mildly dilated and hypokinetic. No +pathologic valvular abnormality seen. Mild pulmonary artery +systolic pressure hypertension. + +Brief Hospital Course: +49 year old male with COPD (FEV1 1.7 [**3-16**]), CAD, HTN, DMII, OSA +on CPAP who presents with SOB and LE swelling transferred to the +unit for hypercarbic and hypoxic respiratory failure. +. +Respiratory failure: Transferred from floor to ICU for combined +hypercarbic and hypoxic respiratory failure. Etiology unclear +but likely a combination of chronic lung disease and mild CHF. +Chronically elevated Hct suggested chronic hypoxia, likely due +to a combination of COPD and OSA. pH of 7.3 with pCO2 of 82 +suggests chronic respiratory acidosis with metabolic +compensation. BL pCO2 likely ~ 70. No obvious infection on CXR +to suggest pna. Increased LE edema and elevated BNP raised +possibility of CHF. He ruled out for acute MI and TTE was +limited but LV function was thought to be normal with mild RV +dilation and hypokinesis. He initially required noninvasive +positive pressure ventilation which was weaned off on hospital +day #2. He was treated for COPD exacerbation with IV solumedrol +which was transitioned to oral prednisone on hospital day # 3. +He received levofloxacin for possible atypical pneumonia for a 5 +day course. He was continued on his home Advair and received +albuterol and atrovent nebulizers. He diuresed well with IV +lasix. He remained relatively hypoxic requiring 5L via nasal +cannula to maintain O2 sats in the 90s and required noninvasive +mechanical ventilation overnight to maintain oxygenation. Both +bipap and noninvasive cpap were used during his stay however the +patient could not tolerate bipap despite trying on different +masks. He preferred to stay on O2 NC which at 5L maintained O2 +saturations from mid 80s to low 90s. It was felt the patient +would benefit from pulmonary rehabilitation and at the patient's +preference he was given contact information to schedule this as +an outpatient. The patient was newly started on furosemide 10mg +daily. He was counselled to weigh himself daily, call his PCP +for any weight increase >3lbs and to adhere to a low salt diet. +The patient ambulated with PT the day prior to discharge and +maintained an oxygen saturation of >90% on oxygen, 4L by NC. +. +Dizziness/lightheadedness: Unclear cause. Potentially due to +significant hypoxia as was in 70s on RA at outpt appointment on +admission. He had no further symptoms throughout his +hospitalization. No arrhythmias on telemetry. Symptoms did not +recur during his stay. +. +Erythrocytosis. The patient was found to have profound +erythrocytosis to Hct of 60. He was evaluated by the heme-onc +consult service who felt this most likely represented secondary +polycythemia due to chronic hypoxia. Epo level was sent and is +pending at the time of discharge. Due to the marked elevation in +Hct, the patient was felt to be at risk for symptoms associated +with his condition. He was initiated on phlebotomy and underwent +1U removal with Hct decline to 57. He will follow-up in the +hematology clinics for ongoing care of this issue including +ongoing phlebotomy with likely goal Hct 55. It is possible +though unlikely that the patient will experience hypoxia +associated with this loss in oxygen carrying capacity. +. +Diabetes: well controlled according to most recent HbA1C. On +metformin as outpt. Metformin was held during admission and he +was controlled with insulin sliding scale. He was restarted on +metformin prior to discharge. +. +Hypertension: Patient was normotensive throughout admission with +low normal SBPs in 90s with sleep. He was continued on his home +regimen of lisinopril and metoprolol. +. +CAD: s/p IMI in past by report and prior stenting. Large +reversible defect in inferior wall in [**3-16**] but no intervenable +CAD on cath in [**5-15**]. No chest pain on history and he ruled out +for MI with serial enzymes. He was continued on asa, statin, +beta blocker, and ace inhibitor. +. +Diastolic heart failure. As described above, the patient was +confirmed on TTE to have diastolic heart failure. He was started +on simvastatin for this issue as well his history of CAD. +. +OSA: As above, required noninvasive mechanical ventilation +overnight to maintain oxygenation. +. +Code: The patient is full code. + +Medications on Admission: +Advair 250/50 1 puff [**Hospital1 **] +Lisinopril 10 mg PO daily +Metformin 500 mg PO BID +Metoprolol 50 mg PO BID +Nitroglycerin 0.4 mg prn +Spiriva 1 cap daily +Tolterodine SR 4 mg daily +Aspirin 325 mg PO daily +Melatonin 3 mg QPM +MVI with minerals daily +*pt. was prescribed Rosuvastatin 40 mg but is not currently +taking this medication due to insurance issues. + +Discharge Medications: +1. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO once a day. +2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO +DAILY (Daily). +4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) 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 for constipation. +7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: +One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). +8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +Disp:*30 Tablet(s)* Refills:*4* +9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. +10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device +Sig: One (1) capsule Inhalation once a day. +11. Melatonin 3 mg Tablet Sig: One (1) Tablet PO qpm. +12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation +every four (4) hours as needed for shortness of breath or +wheezing. +13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) +Sublingual once a day as needed for chest pain: Take one pill +every 3-5 minutes for chest pain. If you are taking this +medication you should call your doctor or 911. +Disp:*15 tabs* Refills:*3* +14. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*4* +15. Outpatient pulmonary rehab +Attend outpatient pulmonary rehab for ongoing care. + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Primary: +1. COPD exacerbation +2. Acute on chronic diastolic heart failure +3. Obstructive sleep apnea +4. Secondary polycythemia +. +Secondary: +1. Coronary artery disease +2. Peripheral vascular disease +3. Diabetes mellitus, type 2 +4. Hypercholesterolemia +5. Hypertension +6. Obesity + + +Discharge Condition: +Stable + + +Discharge Instructions: +You were admitted to the hospital for shortness of breath and +you were found to have low oxygen levels. You were given +diuretics (water pills) to help remove fluid from your lungs and +you were given steroids and antibiotics for an exacerbation of +your COPD. You improved with these treatments but continued to +require supplemental oxygen at night while sleeping. You do not +need to continue use of your CPAP machine at night. Please +follow-up with with your primary care doctor and your +pulmonologist for further care of this issue. +. +You were also found to have extremely high blood counts. This is +likely due to chronic low oxygen levels in the blood. You must +follow-up in the hematology clinics as scheduled for ongoing +care of this issue including regular blood removal. +. +Take all medications as prescribed. New medications that you +should take every day are furosemide and simvastatin. Adhere to +a low salt diet (less than 2grams/day) and weigh yourself daily. +Call your doctor for any increase in weight greater than 3 lbs. +. +Call your doctor or return to the hospital for any new or +worsening shortness of breath, chest pain, swelling in the +ankles or weight gain >3lbs. + +Followup Instructions: +Primary care: Dr. [**First Name (STitle) **] on [**1-21**] at 3pm. + +Hematology: Dr. [**Last Name (STitle) 6944**] ([**Telephone/Fax (1) **]) [**2193-1-23**] at +2:20PM. + +Pulmonology: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) Monday [**2193-2-4**] 11:00AM. Call your primary care doctor's office to obtain +insurance referral for this visit. + +You have an appointment with Dr [**First Name (STitle) **] in Vascular Medicine on +[**2-8**] at 9:40am. This appointment was scheduled to discuss +your symptoms of peripheral vascular disease. + +You have a follow up appointment with Dr. [**Last Name (STitle) **] in podiatry on +Monday [**2-18**] at 11am. + +Please call ([**Telephone/Fax (1) 9525**] to schedule a follow up appointment +with your sleep doctor [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. + +Please keep all other appointments as listed below: + +Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] +Date/Time:[**2193-3-28**] 11:20 + +Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION +BILLING Date/Time:[**2193-4-3**] 1:00 + +Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] +Date/Time:[**2193-4-3**] 1:00 + + + [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] + +","mr. [**known lastname 5243**] is a 49 year old male with a pmh of copd (fev1 1.7 [**3-16**]), cad s/p imi, htn, dmii, osa on cpap who presents with increasing shortness of breath, dizzyness, and bilateral lower extremity swelling over the past 2 weeks. the patient felt like he was fighting a cold 2 weeks ago and took airborne. his symptoms improved, but then he developed a runny nose and post nasal drainage and began coughing grey-[**known lastname **] sputum from his lungs. his dyspnea occurs primarily with movement/exertion, not at rest. over this time period he has also developed worsening bilateral lower extremity edema that has been painful at times at the ankles. he denies any prior history of lower extremity edema. he has also been waking up at night sitting up on the side of his bed with his cpap mask off and feeling somewhat confused. he has had a decreased appetite for the last 3-4 days with decreased po intake. he has also felt ""dizzy"" and when asked to clarify this states that he has felt lightheaded, as if he would faint, at times. he presented to the [**hospital 319**] clinic earlier today and was noted to have a heart rate of 120 with an 02 sat of 78%. he was sent to the ed for further evaluation. vitals on presentation to the ed were t 99.1, bp 136/90, hr 100, o2sat of 96% on a non-rebreather mask. he received aspirin 325 mg po, levofloxacin 750 mg iv, and lasix 10 mg iv. ros: as above. in addition he also endorses diarrhea yesterday only that has since resolved. he chronically sleeps on 2 pillows at night and has to sleep on his left side as he cannot breathe if he lays on his back. he also uses cpap at night. he has had no fevers, chills, vertigo, headache, chest pain, melena, brbpr, myalgias, arthralgias, or dysuria. patient admitted from: [**hospital1 54**] [**hospital1 55**] history obtained from [**hospital 85**] medical records","49 year old male with copd (fev1 1.7 [**3-16**]), cad, htn, dmii, osa on cpap who presents with sob and le swelling transferred to the unit for hypercarbic and hypoxic respiratory failure.","known lastname 5243**] is a 49 year old male with a pmh of copd (fev1 1.7 [**3-16**]), cad s/p imi, htn, dmii, osa on cpap who presents with increasing shortness of breath, dizzyness, and bilateral lower extremity swelling over the past 2 weeks. the patient felt like he was fighting a cold 2 weeks ago and took airborne. his dyspnea occurs primarily with movement/exertion, not at rest. he has also been waking up at night sitting up on the side of his bed with his cpap mask off and feeling somewhat confused. he has also felt ""dizzy"" and when asked to clarify this states that he has felt lightheaded, as if he would faint, at times. he received aspirin 325 mg po, levofloxacin 750 mg iv, and lasix 10 mg iv. he chronically sleeps on 2 pillows at night and has to sleep on his left side as he cannot breathe if he lays on his back.","[""The 49-year-old man has a urinary incontinence that has been painful for him for the last 2 weeks.\nHe has also been experiencing a runny nose and a rung of dizziness.\nHas also been waking up at night with his cappuccino mask off and his cp is off.\nThe condition is not treatable and he has been prescribed antibiotics.\nBut he has also had no fever or vomiting and is now feeling 'lightheaded'\nHe is also having a low blood pressure and is having a blood clot.\nHis condition is so bad that he has had to have""]","a 49 year old male with a pmh of copd presents with increasing shortness of breath, dizzyness, and bilateral lower extremity swelling. he has also developed worsening bilateral lower extremity edema that has been painful at times at the ankles. he was sent to the ed for further evaluation.","['a 49 year old male with an amh of copd presents to the hospital for evaluation. his symptoms have improved, but then developed worsening bilateral lower extremity swelling at times in this time period and denies any prior history or treatment options were available on prescriptions from other health care providers (employment centers).']","[**known lastname 5243**] is a 49 year old male with a pmh of copd (fev1 1.7 [**3-16**]), cad s/p imi, htn, dmii, osa on cpap who presents with increasing shortness of breath, dizzyness, and bilateral lower extremity swelling over the past 2 weeks. +over this time period he has also developed worsening bilateral lower extremity edema that has been painful at times at the ankles. +he denies any prior history of lower extremity edema.","[**known lastname 5243**] is a 49 year old male with a pmh of copd (fev1 1.7 [**3-16**]), cad s/p imi, htn, dmii, osa on cpap who presents with increasing shortness of breath, dizzyness, and bilateral lower extremity swelling over the past 2 weeks.the patient felt like he was fighting a cold 2 weeks ago and took airborne.his symptoms improved, but then he developed a runny nose and post nasal drainage and began coughing grey-[**known lastname **] sputum from his lungs.his dyspnea occurs primarily with movement/exertion, not at rest.over this time period he has also developed worsening bilateral lower extremity edema that has been painful at times at the ankles.he denies any prior history of lower extremity edema.he has also been waking up at night sitting up on the side of his bed with his cpap mask off and feeling somewhat confused.he has also felt ""dizzy"" and when asked to clarify this states that he has felt lightheaded, as if he would faint, at times.he chronically sleeps on 2 pillows at night and has to sleep on his left side as he cannot breathe if he lays on his back.","[{'rouge-1': {'r': 0.6774193548387096, 'p': 0.19626168224299065, 'f': 0.3043478226034447}, 'rouge-2': {'r': 0.46875, 'p': 0.1, 'f': 0.16483516193696418}, 'rouge-l': {'r': 0.6774193548387096, 'p': 0.19626168224299065, 'f': 0.3043478226034447}}]","[{'rouge-1': {'r': 0.16129032258064516, 'p': 0.07936507936507936, 'f': 0.10638297430285215}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.12903225806451613, 'p': 0.06349206349206349, 'f': 0.08510637855817135}}]","[{'rouge-1': {'r': 0.3870967741935484, 'p': 0.3076923076923077, 'f': 0.34285713792244904}, 'rouge-2': {'r': 0.1875, 'p': 0.13043478260869565, 'f': 0.1538461490072322}, 'rouge-l': {'r': 0.3870967741935484, 'p': 0.3076923076923077, 'f': 0.34285713792244904}}]","[{'rouge-1': {'r': 0.41935483870967744, 'p': 0.24074074074074073, 'f': 0.30588234830726646}, 'rouge-2': {'r': 0.15625, 'p': 0.09433962264150944, 'f': 0.11764705412871992}, 'rouge-l': {'r': 0.3548387096774194, 'p': 0.2037037037037037, 'f': 0.2588235247778547}}]","[{'rouge-1': {'r': 0.6451612903225806, 'p': 0.3333333333333333, 'f': 0.43956043506822845}, 'rouge-2': {'r': 0.46875, 'p': 0.21428571428571427, 'f': 0.2941176427527874}, 'rouge-l': {'r': 0.6451612903225806, 'p': 0.3333333333333333, 'f': 0.43956043506822845}}]","[{'rouge-1': {'r': 0.6774193548387096, 'p': 0.17073170731707318, 'f': 0.2727272695117221}, 'rouge-2': {'r': 0.46875, 'p': 0.08196721311475409, 'f': 0.13953488118723636}, 'rouge-l': {'r': 0.6774193548387096, 'p': 0.17073170731707318, 'f': 0.2727272695117221}}]",0.677419355,0.196261682,0.304347823,0.46875,0.1,0.164835162,0.677419355,0.196261682,0.304347823,0.161290323,0.079365079,0.106382974,0,0,0,0.129032258,0.063492063,0.085106379,0.387096774,0.307692308,0.342857138,0.1875,0.130434783,0.153846149,0.387096774,0.307692308,0.342857138,0.419354839,0.240740741,0.305882348,0.15625,0.094339623,0.117647054,0.35483871,0.203703704,0.258823525,0.64516129,0.333333333,0.439560435,0.46875,0.214285714,0.294117643,0.64516129,0.333333333,0.439560435,0.677419355,0.170731707,0.27272727,0.46875,0.081967213,0.139534881,0.677419355,0.170731707,0.27272727 +58287,178918,8928,"TITLE: + Chief Complaint: [**Hospital 3353**] transfer from [**Hospital1 **]-[**Location (un) 250**] ED + HPI: Ms. [**Known lastname 347**] is a 70 y/o female with dilated cardiomyopathy (EF 20%), + T2DM, HTN, and hypothyroidism who presented to [**Hospital1 **] [**Location (un) 250**] ED with 2 + days of worsening dyspnea and chest pain. Pt also reported 2-3 days of + intermitttent, diffuse back pain. + . + Upon arrival to the ED, vitals were BP 164/77, HR 92, RR 34, 71% O2 sat + on RA. She reported 1-2 days of worsening dyspnea and [**11-12**] SSCP, no + radiation or associated symptoms. Sats improved to 100% on NRB. She was + given 1 SL nitro, which decreased her CP to [**6-12**] but also dropped her + BP to 83/42. EKG without any acute ST changes, evidence of AV pacing. + She was given Lasix 40 mg IV x 1 with marked improvement in her + symptoms and able to wean her oxygen to 4L NC, satting 98%. Foley was + placed. CXR reportedly revealed pulmonary edema but report did not + accompany patient. She was given another 40 mg of IV Lasix. She was + also given ASA 325 mg. The decision was made to transfer to [**Hospital1 19**] CCU + for further diuresis in the setting of hypotension. + . + Upon arrival to the CCU, she was in NAD and hemodynmically stable. BP + was 106/54 and HR 72, satting 100% on 4L NC, quickly weaned to 2L NC. + She still complained of [**5-13**] chest pain. + . + Upon further questioning, she explained that there were no recent + changes in her medication regimen. She admits to using salt on her food + but not a large amount. Followed by a cardiologist at [**Location (un) 2544**]-[**Location (un) 3354**]. + She saw him about 3 weeks ago and per her report no changes were made + to her medications. Denies F/C. Denies N/V/D/abdominal pain. Denies + urinary symptoms. Denies palpitations or PND. Usually sleeps at an + incline so difficult to know if orthopnea worsened. No recent travel. + ROS otherwise N/C. Of note, pt is a poor historian. + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Furosemide (Lasix) - 20 mg/hour + Other ICU medications: + Heparin Sodium (Prophylaxis) - [**2156-12-10**] 08:41 AM + Furosemide (Lasix) - [**2156-12-10**] 10:45 AM + Home medications: + Toprol XL 50 mg PO daily + Lasix 80 mg PO QAM, 40 mg PO QPM + ASA 81 mg PO daily + Amiodarone 200 mg PO daily + Iron 325 mg PO daily + Lantus 10 units QAM + HISS + Levoxyl 75 mcg PO daily + Vitamin B12 + Allopurinol 100 mg PO daily + Ramipril 5 mg PO daily + Past medical history: + Family history: + Social History: + Dilated cardiomyopathy, recent EF 20%, cath in 200 which revealed no + CAD, mild MR, and EF of 35%, s/p pacer/ICD placement (unsure what kind + of pacer/when placed/when was last interrogated + T2DM + HTN + Hypothyroidism + N/C + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: + Review of systems: + Flowsheet Data as of [**2156-12-10**] 12:05 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 36.7 +C (98 + Tcurrent: 36.7 +C (98 + HR: 72 (71 - 75) bpm + BP: 106/57(70) {97/54(66) - 116/70(82)} mmHg + RR: 21 (16 - 21) insp/min + SpO2: 96% + Heart rhythm: V Paced + Height: 63 Inch + Total In: + 451 mL + PO: + 355 mL + TF: + IVF: + 96 mL + Blood products: + Total out: + 0 mL + 1,660 mL + Urine: + 660 mL + NG: + Stool: + Drains: + Balance: + 0 mL + -1,209 mL + Respiratory + O2 Delivery Device: Nasal cannula + SpO2: 96% + ABG: ///23/ + Physical Examination + General: WD/WN 70 y/o female in NAD. + HEENT: NC/AT. MMM. OP clear. + Neck: +JVD + CV: Normal S1, S2 without any m/r/g. + Pulm: Bibasilar crackles, no wheezes. + Abd: Soft, NT/ND with normoactive BS. + Ext: No c/c/e. + Skin: No rash. + Neuro: A/O x 3. CNs II-XII grossly intact. Good ROM and strength in all + 4 extremities. Sensation intact. No spinal tenderness. Mild lumbar + paraspinal TTP. + Labs / Radiology + 216 K/uL + 9.9 g/dL + 183 mg/dL + 1.8 mg/dL + 24 mg/dL + 23 mEq/L + 106 mEq/L + 4.4 mEq/L + 139 mEq/L + 31.5 % + 7.3 K/uL + [image002.jpg] + [**2154-2-4**] + 2:33 A11/7/[**2156**] 06:09 AM + [**2154-2-8**] + 10:20 P + [**2154-2-9**] + 1:20 P + [**2154-2-10**] + 11:50 P + [**2154-2-11**] + 1:20 A + [**2154-2-12**] + 7:20 P + 1//11/006 + 1:23 P + [**2154-3-7**] + 1:20 P + [**2154-3-7**] + 11:20 P + [**2154-3-7**] + 4:20 P + WBC + 7.3 + Hct + 31.5 + Plt + 216 + Cr + 1.8 + TropT + <0.01 + Glucose + 183 + Other labs: PT / PTT / INR:12.2/29.1/1.0, CK / CKMB / + Troponin-T:31//<0.01, ALT / AST:13/15, Alk Phos / T Bili:107/0.3, + Differential-Neuts:84.6 %, Lymph:9.9 %, Mono:5.0 %, Eos:0.2 %, Ca++:8.4 + mg/dL, Mg++:1.7 mg/dL, PO4:4.2 mg/dL + Cardiac Cath [**2148**]: + Left heart cath: Coronary arteries normal. + Right heart cath: PAP 30/14/21 and LVEDP 13 + LV gram with global hypokinesis and anterolateral akinesis, EF 30%, + 1+MR. + . + EKG: + [**Hospital1 **] [**Location (un) 250**] [**3-12**]: AV paced at 67, frequent VPBs, no acute ST changes. + [**Hospital1 **] [**Location (un) 250**] [**2156-12-10**]: Paced with frequent VPBs, no acute ST changes, poor + baseline. + . + [**Hospital1 19**] EKG: + Mostly V-paced, occasional PVCs, no acute ST changes, + . + CXR at OSH: Per report, pulm edema + . + [**Location (un) 250**] Labs: + . + WBC 9.4, HCT 34.9, PLT 269 + INR 0.9 + CMP with glucose 353, BUN 23, creatinine 1.9 + CPK-MB 39, Troponin T 0.019 + BNP [**Numeric Identifier 3355**] + U/A negative + Assessment and Plan + 70 F with idiopathic cardiomyopathy (EF 20% in [**6-10**]), T2DM, HTN, and + hypothyrodism who presents with worsening DOE and chest pain. + . + # DYSPNEA - Basilar crackles, JVD, OSH CXR with volume o/l, and + elevated BNP suggest symptoms are [**3-6**] CHF exacerbation. Given chest + pain and hypotension might also represent cardiac ischemia. No + suspicion of PE at this time. Outpatient PFTs show mild restrictive + pattern but no COPD. No evidence for right-sided failure on exam. 1L + negative at OSH with 40 mg IV Lasix x 2. Unclear what precipitated + exacerbation, DDx includes ischemia, medication noncompliance, or + dietary indiscretion. + - serial EKGs, cycle CEs, continue telemetry + - Lasix gtt for now given SBPs in the 90s-100s for further removal of + fluid, continue Foley for now with goal UOP >60 cc/hr as tolerated by + blood pressure. Goal 1-2L diuresis. + - half dose BB, hold ACEI + - continue amiodarone + - repeat chest x-ray here + - touch base with outpatient cardiologist/PCP [**Last Name (NamePattern4) **]: changes in meds, last + TTE/cath/interrogation of pacer, what type of pacer + - wean O2 as tolerated + - no evidence of suggest PNA or other etiology for pt's symptoms + - once BP improves, will add back ACEI + - Echo to evaluate EF. + . + # CHEST PAIN - [**Month (only) 51**] be ischemic as improved with NTG, however no + convincing evidence of ACS by EKG or troponins. + - SL NTG or morphine if BPs tolerate. + - cycle CEs, serial EKGs, monitor on telemetry + . + # Hypotension - Likely has low pressures as outpatient given low EF but + will be limiting to diuresis. At OSH had SBP of 160 on presentation. + - Hold outpatient betablocker and lisinopril for now, gentle diuresis + with Lasix gtt + . + # CHRONIC KIDNEY DISEASE - Baseline creatine around 2, 1.9 at OSH. + - renally dose meds. Trend Cr. + . + # LUMBAR BACK PAIN - Has been going for two days and is improved now. + Exam consistent with MSK etiology, no abnormalities on exam. + - Tylenol for pain control + . + # T2 DIABETES - On insulin at home with glargine 10-20 mg daily. + - start at 10 mg glargine with humalog ss. + - monitor FSBG + . + # HYPOTHYROIDISM - Will repeat TSH as hypothyroidism can exacerbate + CHF. + - continue synthroid + . + # FEN - Low salt, diabetic + . + # PPX - SC Heparin + . + # DISPO - Likely to floor today if BP stable + . + # FULL CODE + . + # CONTACT - husband, son ([**Telephone/Fax (1) 3356**] + 1. Allopurinol 100 mg PO DAILY Order date: [**12-10**] @ 0619 + 8. Furosemide 10-20 mg/hr IV DRIP INFUSION + Titrate to UOP>60cc/hr. Hold for MAP < 55. Order date: [**12-10**] @ 1020 + 2. Amiodarone 200 mg PO DAILY Order date: [**12-10**] @ 0619 + 9. Heparin 5000 UNIT SC TID Order date: [**12-10**] @ 0557 + 3. Aspirin 325 mg PO DAILY Order date: [**12-10**] @ 0619 + 10. Influenza Virus Vaccine 0.5 mL IM ASDIR + Follow Influenza Protocol Document administration in POE Order date: + [**12-10**] @ 0547 + 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: [**12-10**] @ 0557 + 11. Insulin SC (per Insulin Flowsheet) + Sliding Scale & Fixed Dose Order date: [**12-10**] @ 0619 + 5. Docusate Sodium 100 mg PO BID Order date: [**12-10**] @ 0557 + 12. Levothyroxine Sodium 75 mcg PO DAILY Order date: [**12-10**] @ 0619 + 6. Ferrous Sulfate 325 mg PO DAILY Order date: [**12-10**] @ 0619 + 13. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**12-10**] @ + 0547 + 7. Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: [**12-10**] @ 1020 + 14. Senna 1 TAB PO BID:PRN Order date: [**12-10**] @ 0557 +","Admission Date: [**2156-12-10**] Discharge Date: [**2156-12-16**] + +Date of Birth: [**2086-9-17**] Sex: F + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 7651**] +Chief Complaint: +Dyspnea + +Major Surgical or Invasive Procedure: +None + + +History of Present Illness: +Ms. [**Known lastname **] is a 70 y/o female with dilated cardiomyopathy (EF +20%), T2DM, HTN, and hypothyroidism who presented to [**Hospital1 **] [**Location (un) 620**] +ED with 2 days of worsening dyspnea and chest pain. Pt also +reported 2-3 days of intermitttent, diffuse back pain. + +Upon arrival to the ED, vitals were BP 164/77, HR 92, RR 34, 71% +O2 sat on RA. She reported 1-2 days of worsening dyspnea and +[**11-12**] SSCP, no radiation or associated symptoms. Sats improved +to 100% on NRB. She was given 1 SL nitro, which decreased her CP +to [**6-12**] but also dropped her BP to 83/42. EKG without any acute +ST changes. There was AV pacing. She was given Lasix 40 mg IV x +1 with marked improvement in her symptoms and able to wean her +oxygen to 4L NC, satting 98%. Foley was placed. CXR reportedly +revealed pulmonary edema but report did not accompany patient. +She was given another 40 mg of IV Lasix. She was also given ASA +325 mg. The decision was made to transfer to [**Hospital1 18**] CCU for +further diuresis in the setting of hypotension. + +Upon arrival to the CCU, she was in NAD and hemodynmically +stable. BP was 106/54 and HR 72, satting 100% on 4L NC, quickly +weaned to 2L NC. She still complained of [**5-13**] chest pain. + +Upon further questioning, she explained that there were no +recent changes in her medication regimen. She admits to using +salt on her food but not a large amount. Followed by a +cardiologist at [**Location (un) 745**]-[**Location (un) 3678**]. She had recently had a course +of steroids for gout flare which was perhaps responsible for +fluid retention. Denies F/C. Denies N/V/D/abdominal pain. Denies +urinary symptoms. Denies palpitations or PND. Usually sleeps at +an incline so difficult to know if orthopnea worsened. No recent +travel. ROS otherwise N/C. Of note, pt is a poor historian. + + +Past Medical History: +Dilated cardiomyopathy, recent EF 20%, cath in 200 which +revealed no CAD, mild MR, and EF of 35%, s/p pacer/ICD placement +(unsure what kind of pacer/when placed/when was last +interrogated +T2DM +HTN +Hypothyroidism + +Social History: +No prior history of smoking or alcohol use. + +Family History: +Non-contributory + +Physical Exam: +T 97.2 BP 106/54 HR 74 RR 20 98% 2L NC +General: WD/WN 70 y/o female in NAD. +HEENT: NC/AT. MMM. OP clear. +Neck: +JVD +CV: Normal S1, S2 without any m/r/g. +Pulm: Bibasilar crackles, no wheezes. +Abd: Soft, NT/ND with normoactive BS. +Ext: No c/c/e. +Skin: No rash. +Neuro: A/O x 3. CNs II-XII grossly intact. Good ROM and strength +in all 4 extremities. Sensation intact. No spinal tenderness. +Mild lumbar paraspinal TTP. + +Pertinent Results: +[**2156-12-16**] 05:35AM BLOOD WBC-4.2 RBC-3.01* Hgb-9.4* Hct-29.4* +MCV-98 MCH-31.2 MCHC-31.9 RDW-16.6* Plt Ct-252 +[**2156-12-10**] 06:09AM BLOOD Neuts-84.6* Lymphs-9.9* Monos-5.0 Eos-0.2 +Baso-0.3 +[**2156-12-13**] 05:45AM BLOOD PT-11.9 PTT-41.1* INR(PT)-1.0 +[**2156-12-16**] 05:35AM BLOOD Glucose-88 UreaN-42* Creat-2.3* Na-138 +K-5.3* Cl-102 HCO3-29 AnGap-12 +[**2156-12-10**] 06:09AM BLOOD ALT-13 AST-15 CK(CPK)-31 AlkPhos-107 +TotBili-0.3 +[**2156-12-10**] 03:46PM BLOOD CK-MB-NotDone cTropnT-<0.01 +[**2156-12-15**] 09:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.3 +[**2156-12-12**] 06:03AM BLOOD TSH-8.9* +[**2156-12-12**] 06:03AM BLOOD T4-5.7 T3-53* +[**2156-12-14**] 07:06PM URINE Hours-RANDOM UreaN-188 Creat-58 Na-71 + +ECHO [**12-10**]: +The left atrium is moderately dilated. Left ventricular wall +thicknesses are normal. The left ventricular cavity is +moderately dilated. There is severe global left ventricular +hypokinesis (LVEF = 15-20%). Right ventricular chamber size is +normal. with mild global free wall hypokinesis. 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. There is at +least mild pulmonary artery systolic hypertension. There is no +pericardial effusion. + +IMPRESSION: Severe global left ventricular systolic dysfunction +with elevated LVEDP. Mild aortic regurgitation. Mild mitral +regurgitation. At least mild pulmonary hypertension. + +CXR [**12-10**]: +1. Right basilar area of consolidation concerning for pneumonia +or +aspiration. Left basilar atelectasis. +2. Moderate cardiomegaly. +3. No sign of failure or effusion. + + +Brief Hospital Course: +[**Hospital1 18**] EKG: +Mostly V-paced, occasional PVCs, no acute ST changes, + +70 F with idiopathic cardiomyopathy (EF 20% in [**6-10**]), T2DM, HTN, +and hypothyrodism who presents with worsening DOE and chest +pain. + +# DYSPNEA - On transfer, in the setting of pt's history, exam +(basilar crackles, JVD) and laboratory findings (OSH CXR with +volume overload, and elevated BNP), etiology of pt's dyspnea was +thought to be secondary to left sided CHF exacerbacion. Etiology +of exacerbation was thought to be partly dietary indiscretion +and more importantly a recent course of prednisone. Pt was +diuresed aggresively with IV lasix drip. CXR confirmed fluid +overload and ruled out infection. BP meds were held while +diuresing and restarted once tolerated. Pt's oxygen +supplementation was weaned as she was diuresed. + +# CHEST PAIN - Not thought to be ischemic based on EKG and +cardiac enzymes. + +# Hypotension - Thought to be chronic due to low EF. Pt's +beta-blocker and ace-inhibitor were initially held while +aggresively diuresing and restarted slowly prior to discharge. + +# CHRONIC KIDNEY DISEASE - Pt's creatinine fluctuated around her +baseline with diuresis. She was asked to have her renal function +checked on follow up with PCP. + +# DIABETES type 2 - Pt's blood sugars were controlled with +standing glarging and humalog sliding scale. + +# HYPOTHYROIDISM - Pt's TSH was elevated and repeated due to +concern for contribution to CHF, but T3 and T4 were within +appropriate range, thus suggesting sick euthyroid. She was +continued on her outpt dose of levothyroxine. + +# ARRHYTHMIA - Pt initially had frequent ectopy with PVCs +alternating with paced beats. Her PVCs were not perfusing and +thus her effective pulse was 40s while being paced at 70s. Pt +remained asymptomatic but EP was consulted and recommended +increasing beta-blockade to suppress ectopy. On discharge pt's +perfusing pulse was in the 70s on Toprol. + + +Medications on Admission: +ASA 81mg po daily +Toprol XL 50mg po daily +Amiodarone 200mg po daily +Ramipril 5mg po daily +Allopurinol 100mg po daily +Lasix 80mg po QAM, 40mg QPM +*Humalin 15/12 units SC AM/PM--Pt states recently she has been +taking 10 AM, 15 PM (3am glucose 70s, 8am glucose 240s) +*Levothyroxine 75mcg po daily + 2 tabs on saturday and tuesday +*Vitamin B12 50mcg po qd +*Prednisone 20mg po qd--Self DC'd + +Discharge Medications: +1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) +Tablet PO DAILY (Daily). +3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable +PO DAILY (Daily). +6. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous +once a day. +7. Humalog 100 unit/mL Solution Sig: per sliding scale +Subcutaneous twice a day. +8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a +day. +9. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). + +10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) +Tablet PO once a day. +11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO every +morning. +12. Furosemide 80 mg Tablet Sig: 0.5 Tablet PO at 6 pm. +13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr +Sig: One (1) Tablet Sustained Release 24 hr PO once a day. +Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* +14. Outpatient Lab Work +Please check BUN,Creatinine, Hct, K, Na when you see Dr. [**Known lastname **]. + + +Discharge Disposition: +Home With Service + +Facility: +[**Hospital 2255**] [**Name (NI) 2256**] + +Discharge Diagnosis: +Dilated Cardiomyopathy +Daibetes Mellitus Type 2 +Hypertension +Acute on Chronic systolic Congestive Heart Failure. +Bradycardia with Ventricular Ectopy + + +Discharge Condition: +bun=42 +creat=2.3 +hct=29.4 +k=5.3 + + +Discharge Instructions: +You had a congestive heart failure exacerbation that may have +been caused by a high sodium diet. it is important that you stay +active and get as much activity as you can. We gave you +intravenous furosemide to remove the fluid. Your kidney function +declined temporarily because of the stress of the fluid removal. +You should get your kidney function checked in the next week. +. +Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day +or 6 pounds in 3 days. +Adhere to 2 gm sodium diet, information regarding this was +discussed with you and given to you on discharge. +Fluid Restriction: 1.5 Liters, about 7 eight ounce cups per day. + +. +Medication changes: +Your Metoprolol was changed to 100mg daily (long acting +medicine) + +Followup Instructions: +Primary Care: +[**Known lastname **],[**First Name3 (LF) **] M Phone: [**Telephone/Fax (1) 6163**] Date/Time: Monday [**12-20**] 12:00pm +. +Cardiology: +[**Name6 (MD) 31011**] [**Name8 (MD) **], MD Phone: ([**Telephone/Fax (1) 31012**] Date/Time: [**12-22**] +at 2:15pm. + + + +Completed by:[**2156-12-21**]","ms. [**known lastname 347**] is a 70 y/o female with dilated cardiomyopathy (ef 20%), t2dm, htn, and hypothyroidism who presented to [**hospital1 **] [**location (un) 250**] ed with 2 days of worsening dyspnea and chest pain. pt also reported 2-3 days of intermitttent, diffuse back pain. upon arrival to the ed, vitals were bp 164/77, hr 92, rr 34, 71% o2 sat on ra. she reported 1-2 days of worsening dyspnea and [**11-12**] sscp, no radiation or associated symptoms. sats improved to 100% on nrb. she was given 1 sl nitro, which decreased her cp to [**6-12**] but also dropped her bp to 83/42. ekg without any acute st changes, evidence of av pacing. she was given lasix 40 mg iv x 1 with marked improvement in her symptoms and able to wean her oxygen to 4l nc, satting 98%. foley was placed. cxr reportedly revealed pulmonary edema but report did not accompany patient. she was given another 40 mg of iv lasix. she was also given asa 325 mg. the decision was made to transfer to [**hospital1 19**] ccu for further diuresis in the setting of hypotension. upon arrival to the ccu, she was in nad and hemodynmically stable. bp was 106/54 and hr 72, satting 100% on 4l nc, quickly weaned to 2l nc. she still complained of [**5-13**] chest pain. upon further questioning, she explained that there were no recent changes in her medication regimen. she admits to using salt on her food but not a large amount. followed by a cardiologist at [**location (un) 2544**]-[**location (un) 3354**]. she saw him about 3 weeks ago and per her report no changes were made to her medications. denies f/c. denies n/v/d/abdominal pain. denies urinary symptoms. denies palpitations or pnd. usually sleeps at an incline so difficult to know if orthopnea worsened. no recent travel. ros otherwise n/c. of note, pt is a poor historian.","[**hospital1 18**] ekg: mostly v-paced, occasional pvcs, no acute st changes, 70 f with idiopathic cardiomyopathy (ef 20% in [**6-10**]), t2dm, htn, and hypothyrodism who presents with worsening doe and chest pain.","known lastname 347**] is a 70 y/o female with dilated cardiomyopathy (ef 20%), t2dm, htn, and hypothyroidism who presented to [**hospital1 **] [**location (un) 250**] ed with 2 days of worsening dyspnea and chest pain. pt also reported 2-3 days of intermitttent, diffuse back pain. she was given lasix 40 mg iv x 1 with marked improvement in her symptoms and able to wean her oxygen to 4l nc, satting 98%. the decision was made to transfer to [**hospital1 19**] ccu for further diuresis in the setting of hypotension. bp was 106/54 and hr 72, satting 100% on 4l nc, quickly weaned to 2l nc. she still complained of [**5-13**] chest pain. usually sleeps at an incline so difficult to know if orthopnea worsened.","[""The 70-year-old woman, who has dilated cardiomyopathy, was given lisdexamfetamine, which reduced her blood pressure to 83/77.\nShe was given a syringe, which she was given as a supplement, and was given an ibuprofen, which decreased her blood flow to her liver.\nThe doctor who treated her said she was not suffering from any underlying symptoms.\nBut she admitted to using salt on her food but did not report any changes to her medication.\n'I was very concerned about the health of my family,' she said.""]","ms. [**known last name 347**] is a 70 y/o female with dilated cardiomyopathy. she was given lasix 40 mg iv x 1 with marked improvement in her symptoms. she was able to wean her oxygen to 4l nc, satting 98%.","['pt is diagnosed with dysphagia, chest pain and intermittent back problems. she was given lasix 40 mg in the past week; her symptoms improved significantly after that time period of treatment for hypotension (cxr).']","[**known lastname 347**] is a 70 y/o female with dilated cardiomyopathy (ef 20%), t2dm, htn, and hypothyroidism who presented to [**hospital1 **] [**location (un) 250**] ed with 2 days of worsening dyspnea and chest pain. +pt also reported 2-3 days of intermitttent, diffuse back pain. +she reported 1-2 days of worsening dyspnea and [**11-12**] sscp, no radiation or associated symptoms. +she was given lasix 40 mg iv x 1 with marked improvement in her symptoms and able to wean her oxygen to 4l nc, satting 98%. +she saw him about 3 weeks ago and per her report no changes were made to her medications.","[**known lastname 347**] is a 70 y/o female with dilated cardiomyopathy (ef 20%), t2dm, htn, and hypothyroidism who presented to [**hospital1 **] [**location (un) 250**] ed with 2 days of worsening dyspnea and chest pain.pt also reported 2-3 days of intermitttent, diffuse back pain.upon arrival to the ed, vitals were bp 164/77, hr 92, rr 34, 71% o2 sat on ra.she reported 1-2 days of worsening dyspnea and [**11-12**] sscp, no radiation or associated symptoms.sats improved to 100% on nrb.she was given 1 sl nitro, which decreased her cp to [**6-12**] but also dropped her bp to 83/42.ekg without any acute st changes, evidence of av pacing.she was given lasix 40 mg iv x 1 with marked improvement in her symptoms and able to wean her oxygen to 4l nc, satting 98%.she was given another 40 mg of iv lasix.upon arrival to the ccu, she was in nad and hemodynmically stable.","[{'rouge-1': {'r': 0.43333333333333335, 'p': 0.13541666666666666, 'f': 0.20634920272108848}, 'rouge-2': {'r': 0.16129032258064516, 'p': 0.04201680672268908, 'f': 0.06666666338755572}, 'rouge-l': {'r': 0.43333333333333335, 'p': 0.13541666666666666, 'f': 0.20634920272108848}}]","[{'rouge-1': {'r': 0.06666666666666667, 'p': 0.03333333333333333, 'f': 0.044444440000000446}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.06666666666666667, 'p': 0.03333333333333333, 'f': 0.044444440000000446}}]","[{'rouge-1': {'r': 0.13333333333333333, 'p': 0.11428571428571428, 'f': 0.12307691810650907}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13333333333333333, 'p': 0.11428571428571428, 'f': 0.12307691810650907}}]","[{'rouge-1': {'r': 0.16666666666666666, 'p': 0.14285714285714285, 'f': 0.1538461488757398}, 'rouge-2': {'r': 0.03225806451612903, 'p': 0.029411764705882353, 'f': 0.03076922577988246}, 'rouge-l': {'r': 0.13333333333333333, 'p': 0.11428571428571428, 'f': 0.12307691810650907}}]","[{'rouge-1': {'r': 0.4666666666666667, 'p': 0.175, 'f': 0.25454545057851247}, 'rouge-2': {'r': 0.16129032258064516, 'p': 0.05102040816326531, 'f': 0.07751937619373854}, 'rouge-l': {'r': 0.4, 'p': 0.15, 'f': 0.21818181421487606}}]","[{'rouge-1': {'r': 0.5666666666666667, 'p': 0.15178571428571427, 'f': 0.23943661638563776}, 'rouge-2': {'r': 0.22580645161290322, 'p': 0.04827586206896552, 'f': 0.07954545164320775}, 'rouge-l': {'r': 0.5, 'p': 0.13392857142857142, 'f': 0.21126760230113076}}]",0.433333333,0.135416667,0.206349203,0.161290323,0.042016807,0.066666663,0.433333333,0.135416667,0.206349203,0.066666667,0.033333333,0.04444444,0,0,0,0.066666667,0.033333333,0.04444444,0.133333333,0.114285714,0.123076918,0,0,0,0.133333333,0.114285714,0.123076918,0.166666667,0.142857143,0.153846149,0.032258065,0.029411765,0.030769226,0.133333333,0.114285714,0.123076918,0.466666667,0.175,0.254545451,0.161290323,0.051020408,0.077519376,0.4,0.15,0.218181814,0.566666667,0.151785714,0.239436616,0.225806452,0.048275862,0.079545452,0.5,0.133928571,0.211267602 +86146,112417,8935,"Chief Complaint: seizures + HPI: + PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3876**] + . + HPI: 56 yo M with PMH of alcohol abuse and alcohol withdrawal seizures + who presents s/p seizures at home. Patient is Spanish speaking only so + most of history obtained from his wife and some from patient as well. + . + Patient says he drinks vodka but says he last drink was Monday (6 days + prior to presentation). His wife confirms she believes this is true. + She reports that she came home from work yesterday and the patient had + a black eye on the right which he told her was from a fall. He also may + have vomited yesterday although this history is not clear. Then today + she and her daughter witnessed him seizing. Whole body shaking with all + limbs moving. No loss of bowel or bladder continence. Lasted about one + min then stopped. Then started again for another min. She reports he + was confused and did not know who she was afterwards. She called EMS to + bring him to the ED. She reports he had this about 6 months ago and was + told it was from alcohol use. She also reports that he has not been + eating well secondary to his esophageal stricture which was recently + dilated by GI here. + . + In the ED, his initial vital signs were T 98.7, BP 131/80, HR 86, RR + 18, O2sat 100% RA. He was given potassium, magnesium, banana bag and + ativan per CIWA scale (about 6-8mg total). Neurology was consulted in + the ED as well. He had a trauma work up for CT c-spine, head and + maxillary/mandible all of which were negative for fracture. CXR was + unchanged with no acute process. He was sent to the ICU for further + care. + Patient admitted from: [**Hospital1 19**] ER + History obtained from Patient, Family / [**Hospital 75**] Medical records + Patient unable to provide history: Language barrier, post -ictal + Allergies: + Penicillins + Unknown; + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + none + Past medical history: + Family history: + Social History: + per OMR and pt's wife + -ETOH abuse c/b withdrawal seizures + -Chronic liver disease c/b pancytopenia-f/up unclear + -esophageal stricture recently dilated by Dr. [**Last Name (STitle) 2269**] + [**Name (STitle) 3877**] c/b pneumothoraces in [**2094**]. He completed antibiotic regimen per + notes. + unknown + Occupation: works in a kitchen + Drugs: denies + Tobacco: smokes cigars + Alcohol: drinks 1pint per day of vodka. had seizures in past from + withdrawal. Unclear when his last drink was- he says it was 6 days + prior to admission + Other: married with daughters + Review of systems: + [**Name (NI) **], [**Name (NI) 3618**], Throat: Dry mouth + Cardiovascular: No(t) Chest pain, No(t) Palpitations + Nutritional Support: NPO + Respiratory: No(t) Cough, No(t) Dyspnea + Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, + No(t) Diarrhea, No(t) Constipation + Flowsheet Data as of [**2103-12-16**] 11:40 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 37.7 +C (99.8 + Tcurrent: 37.7 +C (99.8 + HR: 108 (87 - 108) bpm + BP: 127/77(90) {100/74(83) - 127/97(103)} mmHg + RR: 22 (19 - 22) insp/min + SpO2: 99% + Heart rhythm: ST (Sinus Tachycardia) + Total In: + 883 mL + PO: + TF: + IVF: + 883 mL + Blood products: + Total out: + 0 mL + 295 mL + Urine: + 295 mL + NG: + Stool: + Drains: + Balance: + 0 mL + 588 mL + Respiratory + O2 Delivery Device: None + SpO2: 99% + ABG: ///28/ + Physical Examination + General: thin, malnurished male in NAD, but tremulous. Not diaphoretic. + HEENT: Has hematoma and ecchymosis over right eye which is shut. PERRL, + anicteric sclera. non-injected conjunctiva. OP clear but dry MM + CV: RRR soft 1/6 SEM but distant heart sounds + Lungs: CTAB no w/r/r + Abdomen: +BS, soft, NTND + Ext: no e/c/c + Neuro: difficult to assess given language difficulty. Strength seems + full throughout. no neck tenderness with FROM. +asterixis. Toes mute. + Reflexes in tact. + Labs / Radiology + 92 mg/dL + 0.6 mg/dL + 8 mg/dL + 28 mEq/L + 93 mEq/L + 3.2 mEq/L + 135 mEq/L + [image002.jpg] + [**2101-1-24**] + 2:33 A11/23/[**2103**] 06:00 PM + [**2101-1-28**] + 10:20 P11/23/[**2103**] 10:21 PM + [**2101-1-29**] + 1:20 P + [**2101-1-30**] + 11:50 P + [**2101-1-31**] + 1:20 A + [**2101-2-1**] + 7:20 P + 1//11/006 + 1:23 P + [**2101-2-24**] + 1:20 P + [**2101-2-24**] + 11:20 P + [**2101-2-24**] + 4:20 P + Cr + 0.6 + TropT + <0.01 + Glucose + 92 + Other labs: CK / CKMB / Troponin-T:219/4/<0.01, Ca++:8.3 mg/dL, + Mg++:1.8 mg/dL, PO4:2.9 mg/dL + Fluid analysis / Other labs: + IN ED: + Trop-T: <0.01 CK: 219 MB: 3 + Trop-T: <0.01 CK: 219 MB: Pnd + . + Color Amber AppearClear SpecGr 1.027 pH 9.0 Urobil12 BiliNeg + Leuk Tr Bld Neg Nitr Neg Prot Tr GluNeg Ket 50 RBC 2 WBC + 2 Bact Few Yeast None Epi 0-2 Amorph Few + Comments: URINE Color: Abn Color [**Month (only) 51**] Affect Dipstick + Other Urine Counts + Sperm: Occ + . + 137 89 9 169 AGap=16 + ------------< + 2.7* 35 0.6 repeat K was 3.2 + . + estGFR: >75 (click for details) + . + Ca: 9.3 Mg: 1.1 P: 2.2 + ALT: 21 AP: 124 Tbili: 2.2 Alb: + AST: 70 LDH: 329 + . + Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative + . + WBC 6.9 Hgb 12.7 HCT 36.2 PLT 114 MCV 97 + N:70.8 L:22.9 M:5.6 E:0.2 Bas:0.5 + Imaging: CXR: IMPRESSION: + 1. Small nodular opacities within the left mid lung field, which were + present on the previous chest CT, may be slightly improved. Findings + may represent small airways infection or aspiration. + 2. Post-surgical changes, right lung. + . + CT Cspine: + IMPRESSION: + 1. No acute fracture or spondylolisthesis. Multilevel degenerative + changes as described above. + 2. Left apical bleb. + . + CT head: + IMPRESSION: + 1. Limited study due to motion artifact demonstrating no acute + intracranial pathology. + 2. Soft tissue injury as described above. + . + CT sinus: CT Sinus/Mandible/Maxillofacial W/O Contrast -- IMPRESSION: + No evidence of acute fracture. Soft tissue injury as described above. + . + ECG: NSR with rate in 80s. Nl axis, biphasic TW in V2-3 + Assessment and Plan + 56 yo M with PMH of alcohol abuse and withdrawal seizures who presents + with likely withdrawal seizures. + . + # seizures: two witnessed seizures at home. Likely from alcohol + withdrawal. He has had them before. Says it has been 6 days since his + last drink, but unclear. ETOH was negative in tox screen. + -CIWA scale with diazepam + -seizure precautions + -appreciated neurology recs from ED- they recommend outpatient EEG + . + # alcohol abuse: long history of alcohol abuse. + -thiamine, folate, MVI + -SW consult/addiction consult + -PPI + . + # elevated bilirubin: likely secondary to underlying liver disease from + alcohol. He has elevated bili (mild) and mild thrombocytopenia and + anemia. + . + # liver nodules: follow up as outpatient. In [**Month (only) **] it was recommended + that he have an MRI given suggestion of liver nodule vs HCC.He had MRI + in [**10-1**] which showed hemangioma and no suggestion of HCC. + . + # esophageal stricture: recently dilated by GI as outpatient. Will need + outpatient follow up. His EGD in [**10-1**] suggested lesion on distal + esophagus. Biopsy just showed inflammation. Unclear if this was + followed further. + . + # h/o TB s/p pneumothoraces: per old notes, this was fully treated with + antibiotics. + . + # FEN: NPO for now. IVF for hydration. Replete lytes prn. + . + # PPX: seizure precautions, withdrawal precautions, heparin SQ for DVT + ppx, bowel reg, PPI given alcohol use + . + # Code: full + . + # communication with wife and patient. + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2103-12-16**] 07:26 PM + 22 Gauge - [**2103-12-16**] 07:29 PM + Prophylaxis: + DVT: SQ UF Heparin + Stress ulcer: PPI + VAP: + Comments: + Communication: Patient discussed on interdisciplinary rounds , Family + meeting held , ICU consent signed Comments: + Code status: Full code + Disposition: ICU +","Admission Date: [**2103-12-16**] Discharge Date: [**2103-12-21**] + +Date of Birth: [**2047-1-31**] Sex: M + +Service: MEDICINE + +Allergies: +Penicillins + +Attending:[**First Name3 (LF) 2641**] +Chief Complaint: +seizures + +Major Surgical or Invasive Procedure: +none + +History of Present Illness: +56 yo M with PMH of alcohol abuse and alcohol withdrawal +seizures who presents s/p seizures at home. Patient is Spanish +speaking only so most of history obtained from his wife and some +from patient as well. +. +Patient says he drinks vodka but says he last drink was Monday +(6 days prior to presentation). His wife confirms she believes +this is true. She reports that she came home from work yesterday +and the patient had a black eye on the right which he told her +was from a fall. He also may have vomited yesterday although +this history is not clear. Then today she and her daughter +witnessed him seizing. Whole body shaking with all limbs moving. +No loss of bowel or bladder continence. Lasted about one min +then stopped. Then started again for another min. She reports he +was confused and did not know who she was afterwards. She called +EMS to bring him to the ED. She reports he had this about 6 +months ago and was told it was from alcohol use. She also +reports that he has not been eating well secondary to his +esophageal stricture which was recently dilated by GI here. +. +In the ED, his initial vital signs were T 98.7, BP 131/80, HR +86, RR 18, O2sat 100% RA. He was given potassium, magnesium, +banana bag and ativan per CIWA scale (about 6-8mg total). +Neurology was consulted in the ED as well. He had a trauma work +up for CT c-spine, head and maxillary/mandible all of which were +negative for fracture. CXR was unchanged with no acute process. +He was sent to the ICU for further care. + + +Past Medical History: +-ETOH abuse c/b withdrawal seizures +-Chronic liver disease c/b pancytopenia-f/up unclear +-esophageal stricture recently dilated by Dr. [**Last Name (STitle) 174**] +[**Name (STitle) 31040**] c/b pneumothoraces in [**2094**]. He completed antibiotic regimen +per notes. + +Social History: +The patient immigrated from [**Country 7192**] in [**2078**]. Married with +daughters. Smokes cigars. Drinks at vodka per him and his wife, +at least a pint a day. Prior notes comment on rum as well. + +Family History: +unknown + +Physical Exam: +General: thin, malnurished male in NAD, but tremulous. Not +diaphoretic. +HEENT: Has hematoma and ecchymosis over right eye which is shut. +PERRL, anicteric sclera. non-injected conjunctiva. OP clear but +dry MM +CV: RRR soft 1/6 SEM but distant heart sounds +Lungs: CTAB no w/r/r +Abdomen: +BS, soft, NTND +Ext: no e/c/c +Neuro: difficult to assess given language difficulty. Strength +seems full throughout. no neck tenderness with FROM. +asterixis. +Toes mute. Reflexes in tact. + +Pertinent Results: +[**2103-12-16**] 10:09AM BLOOD WBC-6.9 RBC-3.71* Hgb-12.7* Hct-36.2* +MCV-97 MCH-34.1* MCHC-35.0 RDW-12.7 Plt Ct-114* +[**2103-12-16**] 10:09AM BLOOD Neuts-70.8* Lymphs-22.9 Monos-5.6 Eos-0.2 +Baso-0.5 +[**2103-12-18**] 03:21AM BLOOD PT-13.4 PTT-48.8* INR(PT)-1.2* +[**2103-12-16**] 10:09AM BLOOD Glucose-169* UreaN-9 Creat-0.6 Na-137 +K-2.7* Cl-89* HCO3-35* AnGap-16 +[**2103-12-16**] 10:09AM BLOOD ALT-21 AST-70* LD(LDH)-329* CK(CPK)-219* +AlkPhos-124* TotBili-2.2* +[**2103-12-16**] 10:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG +Bnzodzp-NEG Barbitr-NEG Tricycl-NEG +. +Head CT [**2103-12-16**]: The study is limited due to motion artifact. +There is no intracranial mass lesion, hydrocephalus, shift of +normally midline structures, major vascular territorial infarct, +or intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter +differentiation is preserved. The study is limited due to motion +artifact for the evaluation of the orbits; however, no displaced +fracture is identified. There is a large right periorbital +hematoma. The ocular globes appear intact. +. +CT Mandible, Sinus [**2103-12-16**]: The cribriform plate appears +intact. The nasal septum is mildly deviated to the right. There +is a small air-fluid level in the right maxillary sinus. No +acute fracture is identified. Right periorbital soft tissue +hematoma is seen. +. +CT C-Spine [**2103-12-16**]: There is no prevertebral soft tissue +swelling. The +alignment is maintained without spondylolisthesis. No acute +fracture is +identified. The odontoid process is intact. Multilevel +degenerative changes, worse at the level of C5-6 and C6-7. The +visualized lung apices demonstrate a left apical bleb. Bilateral +apical pleural thickening. The visualized paranasal sinuses +demonstrate minimal opacification of the right maxillary sinus. +Soft tissue density in both external auditory canals may +represent cerumen. Clinical correlation is recommended. +. +Chest X-ray [**2103-12-16**]: 1. Small nodular opacities within the left +mid lung field, which were present on the previous chest CT, may +be slightly improved. Findings may represent small airways +infection or aspiration. +2. Post-surgical changes, right lung. +. +Barium Swallow [**2103-12-21**] (preliminary read): No esophageal +diverticulum seen. Narrowing of distal esophagus with holdup of +13 mm barium tablet, without holdup of barium. No dysmotility or +reflux seen. +. +Pending studies at the time of discharge: +Final read of Barium swallow study + +Brief Hospital Course: +1. SEIZURES +Mr. [**Known lastname **] was admitted to the MICU after having 2 witnessed +seizures in the setting of alcohol withdrawal. He said that it +had been 6 days since his last drink and had a history of +seizures 6 months prior in the setting of alcohol withdrawal. +His ETOH level was negative on tox screen. Neurology was +consulted in the ED and recommended and outpatient EEG. He was +put on a CIWA protocol and given Diazepam PO to treat his +withdrawal. He required IV Ativan initially to control his +symptoms but then was given PO Diazepam. His withdrawal +sytmptoms were controlled and he had no witness seizures during +this hospital stay. He was given thiamine, folate and a +multivitamin and was put on a PPI. He was transferred to the +medicine floor on [**2103-12-19**]. He continued to have no seizures +for the remainder of his hospital course. He was scheduled for +outpatient neurology follow-up and will be called by the EEG lab +regarding scheduling of an outpatient EEG. +. +2. ALCOHOL ABUSE +Mr. [**Known lastname **] was given IV Ativan initially for withdrawal and this +was later changed to PO Diazepam. He required no further +benzodiazepines after [**2103-12-19**]. He was seen by the addiction +social worker who suggested inpatient rehab program but he +preferred to seek help at outpatient treatment centers and was +given a list of programs prior to discharge. He was advised not +to drink alcohol. His liver function tests were normal through +his hospital course. +. +3. DYSPHAGIA +Mr. [**Known lastname **] had a history of dysphagia and prior EGDs with +dilation. Several prior biopsies had shown no evidence of +cancer. On admission he stated that he had dysphagia to thick +meats such as steak. He was evaluated by a barium swallow study +which showed hold-up of a 13mm barium tablet but no hold-up of +the liquid barium and no diverticulum. His outpatient +gastroenterologist, Dr. [**Last Name (STitle) 174**] was contact[**Name (NI) **] and suggested +outpatient follow-up for this problem with another EGD and +possibe sugerical referral in the future. Mr. [**Known lastname **] was given +an appointment to see Dr. [**Last Name (STitle) 174**] in [**Month (only) 404**]. He was evaluated by +speech and swallow who stated that he had no difficulty in +swallowing above the epiglottis. He was advised not to eat +steak and to seek medical attension if he had pain with +swallowing or the feeling of food getting stuck in his throat. +He was advised to seek medical attention if he could not +maintain his weight properly with foods. +. +4. PROPHYLAXIS +Mr. [**Known lastname **] was put on SC heparin for DVT prophylaxis, a PPI and a +bowel regimen during his hospital course. He was given a +prescription for a PPI as an outpatient. +. +Prior to discharge, Mr. [**Known lastname **] was evaluated by PT who +recommended outpatient PT for [**2-25**] more days and ambulation with +a cane, as the patient was not entirely steady on his feet. + +Medications on Admission: +none + +Discharge Medications: +1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +3. Multivitamin 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). +Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* +5. Outpatient Physical Therapy +Diagnosis: Alcohol Withdrawal, ambulate with LRAD, 1-2 visits + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Primary Diagnosis: +1. Alcohol Withdrawal Seizures +. +Secondary Diagnoses: +2. Dysphagia +3. Alcohol Abuse +4. Fatty Liver Disease + + +Discharge Condition: +afebrile, hemodynamically stable + + +Discharge Instructions: +You were admitted to the hospital with seizures in the setting +of alcohol withdrawal. You were given benzodiazepines to treat +your withdrawal symptoms. Your symptoms improved and you did +not require benzodiazepines any longer prior to discharge. You +were evaluated by neurology for your seizures who felt that they +were due to alcohol withdrawal and you should have outpatient +follow-up. You had an x-ray to evaluate your esophagus during +this admission. +. +You were started on a multivitamin, thiamine and folate during +this admission. You should continue to take these at home and +can buy them over-the-counter. You should take also take a +proton-pump inhibitor. +. +You had an esophageal barium swallow study to evaluate your +dysphagia. You should follow-up with Dr. [**Last Name (STitle) 174**] for this as +described below. +. +You should follow-up with Neurology with an EEG and appointment +with Dr. [**Last Name (STitle) 2340**] as described below. The EEG will be scheduled +by Neurology and they will contact you on monday to schedule +this. You should follow-up with your primary care physician, +[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] regarding treatment for your alcoholism and further +care. You were provided with phone numbers for outpatient +substance abuse treatment centers on discharge. +. +You should call your doctor or come to the emergency room for +any fevers > 100.4, chills, night sweats, seizures, weakness or +numbness in any parts of your body, severe headache, vision +changes, vomiting, abdominal pain or any other symptoms that +concern you. Please call Dr.[**Name (NI) 31041**] office if you have any +difficulty swallowing or feeling of food getting stuck in your +throat. + +Followup Instructions: +Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] +Date/Time:[**2103-12-31**] 10:30 +Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) 8618**] Phone:[**Telephone/Fax (1) 44**] +Date/Time:[**2104-1-16**] 2:00 +. +Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 174**] (Gastroenterology) [**2103-1-27**] at 1:45pm. Rhabb +building [**Location (un) 453**]. [**Telephone/Fax (1) 463**] + + + +","pcp: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **]. [**telephone/fax (1) 3876**] . 56 yo m with pmh of alcohol abuse and alcohol withdrawal seizures who presents s/p seizures at home. patient is spanish speaking only so most of history obtained from his wife and some from patient as well. patient says he drinks vodka but says he last drink was monday (6 days prior to presentation). his wife confirms she believes this is true. she reports that she came home from work yesterday and the patient had a black eye on the right which he told her was from a fall. he also may have vomited yesterday although this history is not clear. then today she and her daughter witnessed him seizing. whole body shaking with all limbs moving. no loss of bowel or bladder continence. lasted about one min then stopped. then started again for another min. she reports he was confused and did not know who she was afterwards. she called ems to bring him to the ed. she reports he had this about 6 months ago and was told it was from alcohol use. she also reports that he has not been eating well secondary to his esophageal stricture which was recently dilated by gi here. in the ed, his initial vital signs were t 98.7, bp 131/80, hr 86, rr 18, o2sat 100% ra. he was given potassium, magnesium, banana bag and ativan per ciwa scale (about 6-8mg total). neurology was consulted in the ed as well. he had a trauma work up for ct c-spine, head and maxillary/mandible all of which were negative for fracture. cxr was unchanged with no acute process. he was sent to the icu for further care. patient admitted from: [**hospital1 19**] er history obtained from patient, family / [**hospital 75**] medical records patient unable to provide history: language barrier, post -ictal",1,"pcp: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **]. [** 56 yo m with pmh of alcohol abuse and alcohol withdrawal seizures who presents s/p seizures at home. patient is spanish speaking only so most of history obtained from his wife and some from patient as well. patient says he drinks vodka but says he last drink was monday (6 days prior to presentation). his wife confirms she believes this is true. she also reports that he has not been eating well secondary to his esophageal stricture which was recently dilated by gi here. in the ed, his initial vital signs were t 98.7, bp 131/80, hr 86, rr 18, o2sat 100% ra.",['Patient says he drinks vodka but says he last drank on Monday.\nHe has not been eating well since the morning and is not eating well.\nHis wife and daughter have been unable to provide a full account of his illness.\nShe says he has not eaten well since he was told he had a fall.\nThe doctor has not given a cause of death for the fall.'],56 yo m with pmh of alcohol abuse and alcohol withdrawal seizures who presents s/p seizures at home. patient is spanish speaking only so most of history obtained from his wife and some from patient as well. his wife confirms she believes this is true.,"[""56-year old with pmh of alcohol abuse and . drinking withdrawal seizures presents at home in spain, but his wife confirms she believes this is true as well so most history obtained from her husband'emirati family members are spanish speaking only; patient says last drink was monday (6 days prior to presentation)""]","patient is spanish speaking only so most of history obtained from his wife and some from patient as well. +she reports that she came home from work yesterday and the patient had a black eye on the right which he told her was from a fall. +he also may have vomited yesterday although this history is not clear. +she reports he had this about 6 months ago and was told it was from alcohol use.","pcp: [**name10 (nameis) **],[**name11 (nameis) **] [**name initial (nameis) **].56 yo m with pmh of alcohol abuse and alcohol withdrawal seizures who presents s/p seizures at home.patient is spanish speaking only so most of history obtained from his wife and some from patient as well.patient says he drinks vodka but says he last drink was monday (6 days prior to presentation).his wife confirms she believes this is true.she reports that she came home from work yesterday and the patient had a black eye on the right which he told her was from a fall.he also may have vomited yesterday although this history is not clear.then today she and her daughter witnessed him seizing.whole body shaking with all limbs moving.she also reports that he has not been eating well secondary to his esophageal stricture which was recently dilated by gi here.","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]","[{'rouge-1': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.0, 'p': 0.0, 'f': 0.0}}]",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0 +86146,128337,8936,"Chief Complaint: EtOH withdrawal w/ seizure + HPI: This is a 57 year-old Spanish-speaking only male with h/o DTs and + withdrawal seizures who presents with witnessed seizure by son at home. + He reports that his last drink was Friday and he did not drink Sat/Sun + because he did not have any alcohol available. Tremulous, diaphoretic + at home over the weekend; then had a tonic-clonic seizure reported by + son. + In the ED, vitals upon presentation T 97.3 HR 116 BP 131/86 RR 18 + 97%RA. He was given 20mg IV valium then 10 mg IV valium, vomited once. + Afebrile. Also received KCl 40mEq PO and 40 mEQ IV and MgSO4 2gm IV in + the ED. He was started on a banana bag and admitted to the ICU for + further management. + ROS: Denies F/C. Denies CP or SOB. Denies hematemesis. Denies melena or + hematochezia. Denies urinary symptoms. Admits to diffuse, mild + abdominal pain. + Upon arrival to the ICU, he was hemodynamically stable. History and + physical exam done with a Spanish interpreter present. + Patient admitted from: [**Hospital1 19**] ER + History obtained from Patient, [**Hospital 1330**] Medical records + Allergies: + Penicillins + Unknown; + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Home medications: + MVI + Past medical history: + Family history: + Social History: + ETOH abuse c/b withdrawal seizures + Chronic liver disease c/b pancytopenia - f/up unclear + Esophageal stricture likely related to GERD dilated here in [**9-/2103**] + TB c/b pneumothoraces in [**2094**]. He completed antibiotic regimen per + notes. + N/C + Occupation: Unemployed + Drugs: None + Tobacco: None + Alcohol: At least one pint of vodka daily for 20 years + Other: + Review of systems: + Constitutional: Fatigue, No(t) Fever, No(t) Weight loss + Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema, + No(t) Tachycardia, No(t) Orthopnea + Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze + Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) 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 + Heme / Lymph: Anemia + Neurologic: Headache, Seizure + Pain: [**1-25**] Minimal + Pain location: Abdomen + Flowsheet Data as of [**2104-2-4**] 03:48 PM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 36.9 +C (98.4 + Tcurrent: 36.9 +C (98.4 + HR: 91 (90 - 95) bpm + BP: 125/80(90) {119/77(87) - 128/87(97)} mmHg + RR: 14 (13 - 18) insp/min + SpO2: 99% + Heart rhythm: SR (Sinus Rhythm) + Total In: + 1,644 mL + PO: + 240 mL + TF: + IVF: + 404 mL + Blood products: + Total out: + 0 mL + 825 mL + Urine: + 825 mL + NG: + Stool: + Drains: + Balance: + 0 mL + 819 mL + Respiratory + O2 Delivery Device: None + SpO2: 99% + Physical Examination + General Appearance: No acute distress, Thin + Eyes / Conjunctiva: PERRL + Head, Ears, Nose, Throat: Normocephalic + Cardiovascular: (PMI Normal), (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 : ) + Abdominal: Soft, Bowel sounds present, Tender: Diffuse mild tenderness, + no rebound or guarding + Extremities: Right: Absent, Left: Absent + Skin: Warm, No(t) Rash: , No(t) Jaundice + Neurologic: Attentive, Follows simple commands, Responds to: Not + assessed, Oriented (to): person, place, time, Movement: Not assessed, + Tone: Not assessed + Labs / Radiology + 77 + 11.5 + 165 + 0.5 + 11 + 22 + 92 + 2.6 + 138 + 32.1 + 7.8 + [image002.jpg] + Other labs: PT / PTT / INR:13.6/28.7/1.2, ALT / AST:20/64, Alk Phos / T + Bili:91/1.2, Differential-Neuts:62.9, Band:0, Lymph:32.3, Mono:4.1, + Eos:0.3, Ca++:9, Mg++:1, PO4:3.6 + Fluid analysis / Other labs: BAL 62 + Imaging: CXR - WNL + Microbiology: None + ECG: ST at 120, normal axis and intervals, no acute ST changes + Assessment and Plan + This is a 57 year-old male with alcoholism and history of withdrawal + seizures who presents after s/sx alcohol withdrawal including seizure + this morning, 3 days after most recent drink. + # Alcohol withdrawal: clinical history c/w alcohol withdrawal (recently + stopped drinking) in pt with history of significant alcohol use and + history of alcohol withdrawal seizures; additionally, withdrawal + symptoms and signs with a positive alcohol level place pt at very high + risk for DTs or further seizures. + - diazepam 30mg po q1h prn CIWA >10 + - IV thiamine, folate, oral MVI + - ICU cardiac monitoring + # Hypokalemia and hypomagnesemia + - aggressive lyte repletion, monitor on telemetry + # Thrombocytopenia/Anemia - Per past admissions, pt with anemia, HCT + around 30-35. Has had thrombocytopenia, although this admission has + been his lowest value. Most likely related to his chronic use. No + clinical evidence to indicate hemolysis or other etiology at this time. + - will give pneumoboots for DVT PPx + - monitor PLT count daily + # FEN: banana bag and IVF as needed, regular diet, aggressive lyte + repletion + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2104-2-4**] 12:59 PM + 20 Gauge - [**2104-2-4**] 01:00 PM + Prophylaxis: + DVT: Boots(Systemic anticoagulation: None) + Stress ulcer: + VAP: + Comments: + Communication: Comments: + Code status: Full code + Disposition: ICU +","Admission Date: [**2104-2-4**] Discharge Date: [**2104-2-19**] + +Date of Birth: [**2047-1-31**] Sex: M + +Service: MEDICINE + +Allergies: +Penicillins + +Attending:[**First Name3 (LF) 1253**] +Chief Complaint: +Delirum Tremens s/p seizure + +Major Surgical or Invasive Procedure: +EGD with dilatation + + +History of Present Illness: +This is a 57 year-old Spanish-speaking only male with h/o DTs +and withdrawal seizures who presents with witnessed seizure by +son at home. He reports that his last drink was Friday and he +did not drink Sat/Sun because he did not have any alcohol +available. Tremulous, diaphoretic at home over the weekend; then +had a tonic-clonic seizure reported by son. +. +In the ED, vitals upon presentation T 97.3 HR 116 BP 131/86 RR +18 97%RA. He was given 20mg IV valium then 10 mg IV valium, +vomited once. Afebrile. Also received KCl 40mEq PO and 40 mEQ IV +and MgSO4 2gm IV in the ED. He was started on a banana bag and +admitted to the ICU for further management. +. +ROS: Denies F/C. Denies CP or SOB. Denies hematemesis. Denies +melena or hematochezia. Denies urinary symptoms. Admits to +diffuse, mild abdominal pain. +. +Upon arrival to the ICU, he was hemodynamically stable. History +and physical exam done with a Spanish interpreter present. + + +Past Medical History: +ETOH abuse c/b withdrawal seizures +-Chronic liver disease c/b pancytopenia - f/up unclear +-Esophageal stricture likely related to GERD dilated here in +[**9-/2103**] +-TB c/b pneumothoraces in [**2094**]. He completed antibiotic regimen + +per notes. + + +Social History: +The patient immigrated from [**Country 7192**] in [**2078**]. Married but lives +alone. Smokes cigars. Drinks vodka, at least a pint a day. Has +been drinking heavily for 15-20 years. + +Family History: +NC + +Physical Exam: +VS: 98.5 87/63 78 20 98RA +GEN: NAD, no tremor. +HEENT: EOMI, PERRLA, sclera anicteric, MMM. +COR: RRR, no M/G/R, normal S1 S2, radial pulses +2. +PULM: Lungs CTAB, no W/R/R. +ABD: Soft, NT/ND. Normoactive BS. No rebound or guarding. +EXT: No C/C/E, no palpable cords. +NEURO: Oriented to person, place, and time. CN II ?????? XII grossly +intact. Moves all 4 extremities. +SKIN: No jaundice, cyanosis. No ecchymoses. + + +Pertinent Results: +[**2104-2-4**] 07:23PM GLUCOSE-73 UREA N-5* CREAT-0.5 SODIUM-134 +POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14 +[**2104-2-4**] 07:23PM CALCIUM-7.7* PHOSPHATE-2.1* MAGNESIUM-2.1 +[**2104-2-4**] 09:40AM GLUCOSE-165* UREA N-11 CREAT-0.5 SODIUM-138 +POTASSIUM-2.6* CHLORIDE-92* TOTAL CO2-22 ANION GAP-27* +[**2104-2-4**] 09:40AM ALT(SGPT)-20 AST(SGOT)-64* CK(CPK)-49 ALK +PHOS-91 TOT BILI-1.2 +[**2104-2-4**] 09:40AM cTropnT-<0.01 +[**2104-2-4**] 09:40AM CK-MB-NotDone +[**2104-2-4**] 09:40AM ALBUMIN-4.5 CALCIUM-9.0 PHOSPHATE-3.6 +MAGNESIUM-1.0* +[**2104-2-4**] 09:40AM ASA-NEG ETHANOL-62* ACETMNPHN-NEG +bnzodzpn-NEG barbitrt-NEG tricyclic-NEG +[**2104-2-4**] 09:40AM NEUTS-62.9 LYMPHS-32.3 MONOS-4.1 EOS-0.3 +BASOS-0.4 +[**2104-2-4**] 09:40AM PLT SMR-VERY LOW PLT COUNT-77* +[**2104-2-4**] 09:40AM PT-13.6* PTT-28.7 INR(PT)-1.2* +. + +[**2104-2-18**] 08:00AM BLOOD WBC-9.5 RBC-3.54* Hgb-11.6* Hct-34.3* +MCV-97 MCH-32.6* MCHC-33.7 RDW-12.8 Plt Ct-640* +[**2104-2-18**] 08:00AM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-142 K-4.1 +Cl-101 HCO3-33* AnGap-12 + +[**2104-2-18**] 08:00AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.8 +. +EGD Biopsy: +DIAGNOSIS: +""Gastroesophageal junction stricture"" biopsy: + +1) Focal ulcer of squamous epithelium with granulation tissue. + +2) Cardiac-type mucosa without intestinal metaplasia. + +3) No viral inclusions or tumor seen. +. +CXR: +IMPRESSION: Interval development of opacification within the +left lower lobe that is suggestive of aspiration. +. + +EKG [**2-7**]: +Sinus rhythm. Probably a normal tracing but baseline artifact +makes +assessment difficult. Since the previous tracing of [**2104-2-4**] +sinus +tachycardia is absent and ST-T wave changes have decreased. + + +Brief Hospital Course: +57 year-old male with alcoholism and history of withdrawal +seizures who presented after s/sx alcohol withdrawal including +seizure on [**2104-2-4**] with admission to [**Hospital Unit Name 153**], 3 days after most +recent drink. Treated with valim po and iv per CIWA scale (note +high benzo doses during this time period with valium 30mg given +on this ciwa scale). Patient also became acutely hypoxic after +likley aspiration event and briefly required a non-rebreather +while being transfered to floor with plan prior to treat for +aspiration PNA. Completed 7 day course of levo/flagyl. +. +# PNA, aspiration: +Had fever to 102, no leukocytosis, though infiltrate on CXR, +with suspected aspiration PNA upon transfer from [**Hospital Unit Name 153**]. Pt was +initially treated with Vanc and Levo, and he completed treatment +for aspiration pneumonia with levo/flagyl. Pt remained afebrile +after treatment, and without respiratory complaints. + +# Alcohol withdrawal/Etoh dependency: +Patient was admitted with withdrawal seizure, initially +monitored closely in ICU with valium 30 mg PO Q1 hour with CIWA +checks. He received a total of 280 mg of valium. Patient cleared +from withdrawal within the hospital. +- contin thiamine, folate and MVI as an outpatient +. +# Esophageal stricture: During his hospital stay the patient had +an episode of a soft piece of [**Country 1073**] getting stuck in his lower +esophagus. Thankfully it eventually passed. the GI team was +contacated and they took him for EGD the following day. His +lower esophagus was succesfully dilated. His diet was advanced +back to soft after that and he tolerateed it well. He is +followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] for his stricture. He recommended +an outpatient [**Last Name (NamePattern1) 2963**] which will be arranged by his team. +. + +# Orthostatic hypotension: The patient was noted to have +orthostatic hypotension during his hospitalization. His BP did +respond to IVF although he did not appear clinically dehydrated. +The patient may have autonomic neuropathy, likely due to alcohol +abuse. A cosyntropin stim test was within normal limits. Pt was +started on florinef. +- contin florinef as an outpt +. +# Anemia: Hct remained stable. Likely ETOH related. +. + +# Hypokalemia and hypomagnesemia: repleted as necessary. +Stabilized and did not require further repletion by the end of +the hospitalization. + +. +FEN: recommend soft solids d/t hx of stricture + +Dispo - to home today. + + +Medications on Admission: +1. Thiamine HCl 100 mg PO daily +2. Folic Acid 1 mg PO daily +3. Multivitamin +4. Pantoprazole 40 mg PO daily + + +Discharge Medications: +1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily). +2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). + +4. 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:*2* +5. Fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY +(Daily). +Disp:*60 Tablet(s)* Refills:*2* + + +Discharge Disposition: +Home With Service + +Facility: +[**Hospital 119**] Homecare + +Discharge Diagnosis: +# Alcohol Withdrawal with seizures +# Alcohol dependency +# gait instability +# Anemia +# esophageal stricture + + +Discharge Condition: +stable + + +Discharge Instructions: +Please take your medications as prescribed and importantly to +completely avoid alcohol. If you start feeling the urge to +re-start drinking please contact your provider as soon as +possible and use the resources that will be given to you by your +detox program. +
+ +If you notice your unsteadiness worsening please contact your +provider to be [**Name9 (PRE) 31042**]. + +Followup Instructions: +1. Please arrange a follow-up appointment 2-3 weeks following +your discharge from rehab with your PCP: [**Name10 (NameIs) 14919**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. +[**Telephone/Fax (1) 14918**] to re-assess your memory questions. +
+ +2. Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] +Date/Time:[**2104-3-17**] 1:30 +Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] +Date/Time:[**2104-3-17**] 3:00 - for follow-up for your esophageal +stricture. +. +Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] +Date/Time:[**2104-3-4**] 9:30 +Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2104-3-4**] 9:30 + + + +","this is a 57 year-old spanish-speaking only male with h/o dts and withdrawal seizures who presents with witnessed seizure by son at home. he reports that his last drink was friday and he did not drink sat/sun because he did not have any alcohol available. tremulous, diaphoretic at home over the weekend; then had a tonic-clonic seizure reported by son. in the ed, vitals upon presentation t 97.3 hr 116 bp 131/86 rr 18 97%ra. he was given 20mg iv valium then 10 mg iv valium, vomited once. afebrile. also received kcl 40meq po and 40 meq iv and mgso4 2gm iv in the ed. he was started on a banana bag and admitted to the icu for further management. ros: denies f/c. denies cp or sob. denies hematemesis. denies melena or hematochezia. denies urinary symptoms. admits to diffuse, mild abdominal pain. upon arrival to the icu, he was hemodynamically stable. history and physical exam done with a spanish interpreter present. patient admitted from: [**hospital1 19**] er history obtained from patient, [**hospital 1330**] medical records","57 year-old male with alcoholism and history of withdrawal seizures who presented after s/sx alcohol withdrawal including seizure on [**2104-2-4**] with admission to [**hospital unit name 153**], 3 days after most recent drink.","this is a 57 year-old spanish-speaking only male with h/o dts and withdrawal seizures who presents with witnessed seizure by son at home. tremulous, diaphoretic at home over the weekend; then had a tonic-clonic seizure reported by son. he was started on a banana bag and admitted to the icu for further management. patient admitted from: [**hospital1 19**] er history obtained from patient, [**hospital 1330**] medical records",['The 57-year-old is a spiny-speaking only male with h/o/o ds.\nHe has a tonic-clonic seizure and has a speech impediment.\nThe only thing he has to do is to get a spina bifida.\nHis last drink was a banana bag and he was told to drink it.\nIt was a good thing he was able to get the hang of it.'],"a spanish-speaking only male with h/o dts and withdrawal seizures presents at home. he was given 20mg iv valium then 10 mg iv valium, vomited once. he was started on a banana bag and admitted to the icu for further management.","[""spanish-speaking only male with h/o seizures and withdrawal symptoms presents at home to son's seizure. patient was given 20mg of valine, 10 mg devalium; vomited once in the first week after presentation by his father on friday night (fris). admitted for further management following banana bag treatment but is hemodynamically stable upon arrival into hospital1 19**""]","this is a 57 year-old spanish-speaking only male with h/o dts and withdrawal seizures who presents with witnessed seizure by son at home. +he was started on a banana bag and admitted to the icu for further management. +history and physical exam done with a spanish interpreter present.","this is a 57 year-old spanish-speaking only male with h/o dts and withdrawal seizures who presents with witnessed seizure by son at home.he reports that his last drink was friday and he did not drink sat/sun because he did not have any alcohol available.tremulous, diaphoretic at home over the weekend; then had a tonic-clonic seizure reported by son.in the ed, vitals upon presentation t 97.3 hr 116 bp 131/86 rr 18 97%ra.he was given 20mg iv valium then 10 mg iv valium, vomited once.also received kcl 40meq po and 40 meq iv and mgso4 2gm iv in the ed.he was started on a banana bag and admitted to the icu for further management.denies cp or sob.upon arrival to the icu, he was hemodynamically stable.","[{'rouge-1': {'r': 0.43333333333333335, 'p': 0.23214285714285715, 'f': 0.3023255768523526}, 'rouge-2': {'r': 0.125, 'p': 0.0625, 'f': 0.08333332888888913}, 'rouge-l': {'r': 0.43333333333333335, 'p': 0.23214285714285715, 'f': 0.3023255768523526}}]","[{'rouge-1': {'r': 0.23333333333333334, 'p': 0.175, 'f': 0.19999999510204094}, 'rouge-2': {'r': 0.03125, 'p': 0.017857142857142856, 'f': 0.022727268099174493}, 'rouge-l': {'r': 0.2, 'p': 0.15, 'f': 0.1714285665306124}}]","[{'rouge-1': {'r': 0.23333333333333334, 'p': 0.19444444444444445, 'f': 0.21212120716253455}, 'rouge-2': {'r': 0.0625, 'p': 0.05128205128205128, 'f': 0.05633802321761599}, 'rouge-l': {'r': 0.23333333333333334, 'p': 0.19444444444444445, 'f': 0.21212120716253455}}]","[{'rouge-1': {'r': 0.3333333333333333, 'p': 0.17857142857142858, 'f': 0.23255813499188757}, 'rouge-2': {'r': 0.03125, 'p': 0.01818181818181818, 'f': 0.022988501096579086}, 'rouge-l': {'r': 0.26666666666666666, 'p': 0.14285714285714285, 'f': 0.18604650708491086}}]","[{'rouge-1': {'r': 0.4, 'p': 0.2857142857142857, 'f': 0.33333332847222225}, 'rouge-2': {'r': 0.125, 'p': 0.0851063829787234, 'f': 0.10126581796506992}, 'rouge-l': {'r': 0.36666666666666664, 'p': 0.2619047619047619, 'f': 0.30555555069444446}}]","[{'rouge-1': {'r': 0.4666666666666667, 'p': 0.1414141414141414, 'f': 0.21705425999639447}, 'rouge-2': {'r': 0.125, 'p': 0.03225806451612903, 'f': 0.051282048021039}, 'rouge-l': {'r': 0.43333333333333335, 'p': 0.13131313131313133, 'f': 0.2015503840274023}}]",0.433333333,0.232142857,0.302325577,0.125,0.0625,0.083333329,0.433333333,0.232142857,0.302325577,0.233333333,0.175,0.199999995,0.03125,0.017857143,0.022727268,0.2,0.15,0.171428567,0.233333333,0.194444444,0.212121207,0.0625,0.051282051,0.056338023,0.233333333,0.194444444,0.212121207,0.333333333,0.178571429,0.232558135,0.03125,0.018181818,0.022988501,0.266666667,0.142857143,0.186046507,0.4,0.285714286,0.333333328,0.125,0.085106383,0.101265818,0.366666667,0.261904762,0.305555551,0.466666667,0.141414141,0.21705426,0.125,0.032258065,0.051282048,0.433333333,0.131313131,0.201550384 +92872,175600,8945,"Chief Complaint: Seizure + Reason for MICU admission: Hyponatremia + HPI: + History was obtained from ED and medical records as patient arrived to + somnolent to answer questions. + 31 yo female with hx of seizure disorder, EtOH abuse and medication + non-compliance who presents to the ED after having a seizure at work. + Patient states she has been very stressed out both at home and at work, + states she has not been sleeping well. She has been drinking a lot of + water and alcohol lately, and not eating very well. While at work she + had a generalized tonic clonic seizure of unknown duration with + eyewitnesses. Her last seizure prior to that was in [**Month (only) 8**], again patient + attributes this to increased stress and poor sleep. + . + In the ED, initial vs were: 98.2 110 166/100 18 99%. She was noted to + be hyponatremic and felt to be hypovolemic as well. She was given 1.5 + L of NS with correction of Na from 124 to 130. Additionally she + received 4 mg of lorazepam for witnessed seizure with symptoms of eye + deviation, body stiffening, followed by post-ictal phase. Neurology + saw her and feels her current seizures are from the hyponatremia. They + recommended ICU admission for close monitoring during Na correction and + she was loaded with 1 gm of Keppra IV. + . + On the floor, Patient is noted to be somnolent with slow responses to + questions. + . + Review of sytems: + (+) Per HPI + (-) Unable to respond to ROS + . + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + - Clonazepam 0.5mg [**Hospital1 **] prn + - Oxcarbazepine 600mg [**Hospital1 **], has taken irregularly. + Past medical history: + Family history: + Social History: + - Migraines (triggers - menstrual cycle, stress, and sleep deprivation) + - Seizures, in setting of being very stressed out at school, sleep + deprivation and she missed some doses + - EtOH abuse + - Anxiety + . + Seizures - second degree relative + HTN - father + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: Lives in [**Location **]. Works as waitress. Lives with partner, + feels safe at home. Lots of financial and family stress. + Tobacco - 1ppd x 5 years + EtOH - 4-6 beers per day + Drug use - denies + Review of systems: + Flowsheet Data as of [**2131-6-11**] 12:14 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 36.7 +C (98 + Tcurrent: 36.7 +C (98 + HR: 82 (75 - 82) bpm + BP: 144/84(98) {144/84(98) - 144/84(98)} mmHg + RR: 20 (15 - 20) insp/min + SpO2: 98% + Heart rhythm: SR (Sinus Rhythm) + Total In: + PO: + TF: + IVF: + Blood products: + Total out: + 400 mL + 0 mL + Urine: + 400 mL + NG: + Stool: + Drains: + Balance: + -400 mL + 0 mL + Respiratory + SpO2: 98% + Physical Examination + Vitals: T: 98 BP: 144/84 P: 82 R: 18 O2: 98% on RA + General: Patient somnolent, but 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, 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: Patient somnolent, PERRL, reflexes sluggish, Gag not vigoruous + . + Labs / Radiology + 341 + 135 + 0.7 + 8 + 20 + 88 + 4.7 + 124 + 40.8 + 10.0 + [image002.jpg] + Osms:261 + Carbamaz: <1.0 + Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc + Negative + Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne + Negative + Color + Yellow + Appear + Clear + SpecGr + 1.009 + pH + 5.0 + Urobil + Neg + Bili + Neg + Leuk + Neg + Bld + Sm + Nitr + Neg + Prot + 30 + Glu + Neg + Ket + 15 + RBC + 0-2 + WBC + 0-2 + Bact + Occ + Yeast + None + Epi + 0-2 + Assessment and Plan + HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY) + SEIZURE, WITHOUT STATUS EPILEPTICUS + 30 F with seizure disorder, EtOH abuse who presents after a seizure and + found to have hyponatremia. + . + # Hyponatremia: Hypoosmotic. DDx includes poor PO intake due to + stress, primary polydypsia, or less likely SIADH or reset osmostat. + Was intially given 1.5 L NS in ED with rapid correction of Na to 130. + Unclear if ataxic gait in ED may be [**1-1**] to demyelination or lorazempam + effect. Patient arrived somnolent, but still with 5/5 strength and + able to be arroused. + - Na Checks Q4-6 hrs + - Hold IVF for now as she has rapidly corrected in first 3 hrs. + - measure urine osms and lytes + - TSH + - neuro checks Q2 hrs + - treat seizures as below. + - re-image head if mental status deteriorates + . + # Seizures: One withnessed in ED with gaze deviation. Multiple possible + causes of seizures including hyponatremia, medication non-compliance, + and EtOH withdrawal. Recieved several doses of ativan in ED but more + related to anxiety and desire to leave rather than be admitted. + - Appreciate Neuro recs + - Seizure precautions for any acute seizure activity, 2 mg IV lorazepam + - Loaded with Keppra 1 gm IV, + - 500 mg [**Hospital1 **] + - hold trileptal and f/u level sent in ED + - treat hyponatremia as above + . + # EtOH Abuse: Patient states she has been drinking more often due to + stress in her life. Last drink PM of [**2131-6-9**]. Unclear if withdrawal is + contributing to siezures, but currently without + tachycardia/hypertension or other signs of withdrawal. + - Check LFTs + - Social work consult for substance abuse treatment. + . + # Anion gap acidosis: likely related to ketosis with ketones in urine. + - monitor with hydration and re-feeding. + . + # Anxiety: Patient initially refusing admission to MICU due to + ""personal problems"". [**Name2 (NI) **] staff noted her to be very anxious. + - Hold clonazepam 0.5mg TID PRN as patient is somnolent + . + FEN: No IVF, regular diet + Prophylaxis: Subutaneous heparin + Access: peripherals + Code: Full (discussed with patient) + Communication: Patient, Mother [**Telephone/Fax (1) 7662**] + Disposition: pending clinical improvement + ICU Care + Nutrition: NPO + Glycemic Control: + Lines: + 18 Gauge - [**2131-6-10**] 11:06 PM + Prophylaxis: + DVT: Boots + Stress ulcer: Not indicated + VAP: HOB elevation + Comments: + Communication: Comments: + Code status: Full code + Disposition: ICU + ------ Protected Section ------ + I have seen and examined the patient with the resident and agree with + the assessment and plan as above with the following emphasis/addendum: + 31 year old female history of seizure disorder, ETOH abuse, who + presented to the ED after having a seizure. In the ED, she had a + second seizure and was given lorazepam. She was found to be + hyponatremic (124) and was given normal saline. Neurology had + evaluated the patient and were concerned that seizures were secondary + to hyponatremia. Patient was loaded with Keppra. During ED course, + patient refusing to stay but ultimately agreed to admission + had + received additional ativan for anxiety and possible withdrawal and + currently she is sleepy and unable to provide further history. + PE: T 36.7 BP 144/84 P 82 R 20 O2 Saturation: 98% RA + Gen: sleepy but arousable, conversant briefly, and protecting airway + Chest: CTA bilaterally + Cor: S1 S2 reg + Abd: soft NT ND + Ext: no edema + Neuro: Arousable with verbal stimuli +moves all extremities and no focal + neuro findings although limited exam given her lethargy that is likely + secondary to benzodiazepams. + Labs: + Na 124 -> 130 -> 137 + Alcohol: negative + Bicarb: 20 + Ketones in urine + HCT: Negative + 1: Seizure: differential includes seizure related to alcohol + withdrawal, hyponatremia (less likely given that level was 124 in + chronic alcoholic but still possible), medication non-compliance, + primary seizure disorder + - loaded with Keppra and given ativan in the ED + - Neurology following and will continue Keppra + 2: Hyponatremia: essentially corrected on arrival to ICU + correction + was quick so will monitor mental status when she awakes to make sure + there are no signs of CPM though unlikely given level of 124. Will not + provide any further correction given level is currently 137. Etiology + likely secondary to alcohol (beer potomania), dehydration (hypovolemic, + hyponatremia), or polydipsia. Other etiologies less likely but if + recurs, can investigate. + 3- Alcoholism: + - Monitor for signs of withdrawal and CIWA as needed + - thiamine, folate, and B-vitamins + Time Spent: 35 minutes (patient is critically ill) + ------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD + on:[**2131-6-11**] 00:42 ------ + S: No overnight events. + PE: VS stable. Exam unchanged. + Labs: Na 139 + Imaging: CXR normal + Addendem to plan as updated on AM rounds: + 30 F with seizure disorder, EtOH abuse who presents after a seizure and + found to have hyponatremia. + . + # Hyponatremia: Hypoosmotic. Likely [**1-1**] decreased po intake, primary + polydipsia on trileptal (can also be primary effect of drug itself), + with possible component from beer potomania (few beers daily). Less + likely [**1-1**] EtOH withdrawal. CXR nl. Corrected rapidly but neuro exam + stably intact. + - F/u TSH + - D/c +d trileptal; seizure management per Neuro + - No IV fluids + . + # Seizures: Underlying seizure d/o with acute [**Last Name (un) **] likely in setting of + hyponatremia. + - Appreciate Neuro recs + - Cont keppra + - Outpatient f/u with neurologist tmrw + . + # EtOH Abuse: Patient states she has been drinking more often due to + stress in her life. Last drink PM of [**2131-6-9**]. Withdrawal seizure less + likely. + - LFTs nl + - Received MVI/folate/thiamine; will d/c on MVI daily + - Social work consulted for substance abuse treatment. + . + # Anion gap acidosis: Likely related to ketosis with ketones in urine. + Now resolved. + # Anxiety: Patient initially refusing admission to MICU due to + ""personal problems"". [**Name2 (NI) **] staff noted her to be very anxious. + - Resume home clonazepam. + . + FEN: No IVF, regular diet + Prophylaxis: Subcutaneous heparin + Access: peripherals + Code: Full (discussed with patient) + Communication: Patient, Mother [**Telephone/Fax (1) 7662**] + Disposition: D/c home from ICU today + ------ Protected Section Addendum Entered By:[**Name (NI) 197**] [**Last Name (NamePattern1) 6865**], MD + on:[**2131-6-11**] 09:00 ------ +","Admission Date: [**2131-6-10**] Discharge Date: [**2131-6-11**] + +Date of Birth: [**2100-2-7**] Sex: F + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 338**] +Chief Complaint: +Seizure +Reason for MICU admission: Hyponatremia + + +Major Surgical or Invasive Procedure: +None + +History of Present Illness: +History was obtained from ED and medical records as patient +arrived to somnolent to answer questions. +31 yo female with hx of seizure disorder, EtOH abuse and +medication non-compliance who presents to the ED after having a +seizure at work. Patient states she has been very stressed out +both at home and at work, states she has not been sleeping well. + She has been drinking a lot of water and alcohol lately, and +not eating very well. While at work she had a generalized tonic +clonic seizure of unknown duration with eyewitnesses. Her last +seizure prior to that was in [**Month (only) 116**], again patient attributes this +to increased stress and poor sleep. +. +In the ED, initial vs were: 98.2 110 166/100 18 99%. She was +noted to be hyponatremic and felt to be hypovolemic as well. +She was given 1.5 L of NS with correction of Na from 124 to 130. + Additionally she received 4 mg of lorazepam for witnessed +seizure with symptoms of eye deviation, body stiffening, +followed by post-ictal phase. Neurology saw her and feels her +current seizures are from the hyponatremia. They recommended +ICU admission for close monitoring during Na correction and she +was loaded with 1 gm of Keppra IV. +. +On the floor, Patient is noted to be somnolent with slow +responses to questions. +. +Review of sytems: +(+) Per HPI +(-) Unable to respond to ROS +. + + +Past Medical History: +- Migraines (triggers - menstrual cycle, stress, and sleep +deprivation) +- Seizures, in setting of being very stressed out at school, +sleep deprivation and she missed some doses +- EtOH abuse +- Anxiety + +Social History: +Lives in [**Location **]. Works as waitress. Lives with partner, +feels safe at home. Lots of financial and family stress. +Tobacco - 1ppd x 5 years +EtOH - 4-6 beers per day +Drug use - denies +. + +Family History: +Seizures - second degree relative +HTN - father +. + +Physical Exam: +Upon arrival to the MICU: +Vitals: T: 98 BP: 144/84 P: 82 R: 18 O2: 98% on RA +General: Patient somnolent, but 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, 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: Patient somnolent, PERRL, reflexes sluggish, Gag not +vigoruous +. + + +Pertinent Results: +[**2131-6-10**] 03:25PM WBC-10.0 RBC-4.38 HGB-14.6 HCT-40.8 MCV-93 +MCH-33.2* MCHC-35.7* RDW-12.6 +[**2131-6-10**] 03:25PM NEUTS-87.4* LYMPHS-8.4* MONOS-3.7 EOS-0.3 +BASOS-0.3 +[**2131-6-10**] 03:25PM PLT COUNT-341 +. +[**2131-6-10**] 03:25PM GLUCOSE-135* UREA N-8 CREAT-0.7 SODIUM-124* +POTASSIUM-4.7 CHLORIDE-88* TOTAL CO2-20* ANION GAP-21* +[**2131-6-10**] 03:25PM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-2.1 +. +[**2131-6-10**] 03:25PM OSMOLAL-261* +. +[**2131-6-10**] 11:30PM ALT(SGPT)-17 AST(SGOT)-22 LD(LDH)-153 ALK +PHOS-67 TOT BILI-0.6 +. +Na Trend: +124 +130 +137 +. +[**2131-6-10**] 11:30PM BLOOD TSH-3.0 +. +[**2131-6-10**] 09:15PM BLOOD TRILEPTAL-PND +. +CT head: IMPRESSION: No acute intracranial process. +. +CXR: IMPRESSION: Lungs fully expanded and clear. Heart size top +normal. No +pleural abnormality or evidence of central adenopathy. + + +Brief Hospital Course: +30 F with seizure disorder, EtOH abuse who presents after a +seizure and found to have hyponatremia. +. +# Hyponatremia: Hypoosmotic. Likely [**1-1**] decreased po intake, +primary polydipsia on trileptal (can also be primary effect of +drug itself), with possible component from beer potomania (few +beers daily). Less likely [**1-1**] EtOH withdrawal. CXR and TSH nl. +Trileptal discontinued. Was intially given 1.5 L NS in ED with +rapid correction of Na to 130 and subsequently to 139 with no +further intervention. Ataxic gait in ED likely [**1-1**] lorazepam +effect rather than demyelination as neuro exam remained intact +and ambulating well on discharge. +. +# Seizures: One witnessed in the ED with gaze deviation. Has +underlying seizure d/o with this episode likely in the setting +of hyponatremia, likely medication +noncompliance, and alcohol use. Seen by Neuro who recommended +discontinuing Trileptal and loading with keppra, then +discharging on once daily dosing of Keppra XR 2000mg. Counseled +against EtOH abuse and instructed not to drive for 6 months. Pt +to follow up with Dr. [**Last Name (STitle) **] tomorrow ([**2131-6-12**]). If her +anxiety worsens while on Keppra, could consider transitioning to +long acting Lamictal as an outpatient. +*Trileptal level pending on discharge.* +. +# EtOH Abuse: Patient states she has been drinking more often +due to stress in her life, at least 2-4 beers daily. Last drink +PM of [**2131-6-9**]. Did not appear to be in EtOH withdrawal. Did +receive banana bag. Counseled against EtOH use and discharged on +daily MVI. +. +# Anion gap acidosis: Likely related to ketosis given ketonuria. +Improved in AM after hydration and reinitiation of po diet. +. +# Anxiety: Patient initially refusing admission to MICU due to +""personal problems"". [**Name2 (NI) **] staff noted her to be very anxious and +received ativan there. Discharged on home clonazepam 0.5mg TID +PRN. +. +FEN: No IVF, regular diet +Prophylaxis: Subcutaneous heparin +Access: peripherals +Code: Full (discussed with patient) +Communication: Patient, Mother [**Telephone/Fax (1) 31070**] + +Medications on Admission: +- Clonazepam 0.5mg [**Hospital1 **] prn +- Oxcarbazepine 600mg [**Hospital1 **], has taken irregularly. + +Discharge Medications: +1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times +a day) as needed for anxiety. +2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). + +3. Keppra XR 500 mg Tablet Sustained Release 24 hr Sig: Four (4) +Tablet Sustained Release 24 hr PO once a day. +Disp:*120 Tablet Sustained Release 24 hr(s)* Refills:*2* + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Primary: +Hyponatremia, possibly secondary to primary polydypsia +Seizure disorder + + +Discharge Condition: +good, hemodynamically stable, no neural deficits. + + +Discharge Instructions: +You were admitted for seizure and found to have a low sodium +level. This is thought to be due to multiple factors including +possible side effect of trileptal, increased water intake with +decreased food intake, or possibly increase intake of beer, +which has no sodium. The lower sodium puts you at risk for more +frequent seizures. Your sodium corrected rapidly without any +neurologic problems. [**Name (NI) **] were given Keppra to prevent seizures +in the future. +. +Due to the fact that you had a seizure, you may NOT drive for 6 +months. Please see your neurologist tomorrow as described below. +. +Medication changes: +- Please STOP taking trileptal +- Please take 1 tab of Keppra 500 mg tonight ([**2131-6-11**]), then +start Keppra XR +- Please take Keppra XR as prescribed. +- Please take a multivitamin daily +- Please take your other medications as prescribed. +. +seizures, confusion, dizzyness, fevers, chills, nausea, +vomiting, diarrhea, or other concerns. + +Followup Instructions: +You have the following scheduled appointment with your +Date/Time:[**2131-6-12**] 2:30 + + + +Completed by:[**2131-6-12**]","history was obtained from ed and medical records as patient arrived to somnolent to answer questions. 31 yo female with hx of seizure disorder, etoh abuse and medication non-compliance who presents to the ed after having a seizure at work. patient states she has been very stressed out both at home and at work, states she has not been sleeping well. she has been drinking a lot of water and alcohol lately, and not eating very well. while at work she had a generalized tonic clonic seizure of unknown duration with eyewitnesses. her last seizure prior to that was in [**month (only) 8**], again patient attributes this to increased stress and poor sleep. in the ed, initial vs were: 98.2 110 166/100 18 99%. she was noted to be hyponatremic and felt to be hypovolemic as well. she was given 1.5 l of ns with correction of na from 124 to 130. additionally she received 4 mg of lorazepam for witnessed seizure with symptoms of eye deviation, body stiffening, followed by post-ictal phase. neurology saw her and feels her current seizures are from the hyponatremia. they recommended icu admission for close monitoring during na correction and she was loaded with 1 gm of keppra iv. on the floor, patient is noted to be somnolent with slow responses to questions. review of (-) unable to respond to ros .","30 f with seizure disorder, etoh abuse who presents after a seizure and found to have hyponatremia.","history was obtained from ed and medical records as patient arrived to somnolent to answer questions. in the ed, initial vs were: 98.2 110 166/100 18 99%. she was given 1.5 l of ns with correction of na from 124 to 130. neurology saw her and feels her current seizures are from the hyponatremia. on the floor, patient is noted to be somnolent with slow responses to questions.","['31yo female with hc of seizure disorder, ay of pain and medication non-compliance.\nShe has been drinking a lot of water and alcohol lately.\nHas been drinking water and drinking water moderately.\nWas given 1.5 litre of kepra ib.\nHad a somnolence and was not eating well.\nAlso had a seizure and was in a coma.']","31 yo female with hx of seizure disorder, etoh abuse and medication non-compliance. patient states she has been very stressed out both at home and at work. she has been drinking a lot of water and alcohol lately, and not eating well.","['ed records show patient has had hyponatremia and was given 1.5l of naproxen for seizures at work. she is noted to be somnolent with slow responses on the floor, but does not respond well when asked about her condition or medication use disorder in general; this may have been due stress from working so hard during that time period as opposed being sleepy after having an epilepsy (see below).']","patient states she has been very stressed out both at home and at work, states she has not been sleeping well. +her last seizure prior to that was in [**month (only) 8**], again patient attributes this to increased stress and poor sleep.","history was obtained from ed and medical records as patient arrived to somnolent to answer questions.31 yo female with hx of seizure disorder, etoh abuse and medication non-compliance who presents to the ed after having a seizure at work.patient states she has been very stressed out both at home and at work, states she has not been sleeping well.she has been drinking a lot of water and alcohol lately, and not eating very well.while at work she had a generalized tonic clonic seizure of unknown duration with eyewitnesses.her last seizure prior to that was in [**month (only) 8**], again patient attributes this to increased stress and poor sleep.in the ed, initial vs were: 98.she was noted to be hyponatremic and felt to be hypovolemic as well.5 l of ns with correction of na from 124 to 130.on the floor, patient is noted to be somnolent with slow responses to questions.","[{'rouge-1': {'r': 0.25, 'p': 0.07407407407407407, 'f': 0.11428571075918378}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.25, 'p': 0.07407407407407407, 'f': 0.11428571075918378}}]","[{'rouge-1': {'r': 0.3125, 'p': 0.12195121951219512, 'f': 0.17543859245306256}, 'rouge-2': {'r': 0.1875, 'p': 0.05660377358490566, 'f': 0.08695651817685376}, 'rouge-l': {'r': 0.3125, 'p': 0.12195121951219512, 'f': 0.17543859245306256}}]","[{'rouge-1': {'r': 0.4375, 'p': 0.20588235294117646, 'f': 0.27999999564800004}, 'rouge-2': {'r': 0.1875, 'p': 0.07692307692307693, 'f': 0.10909090496528942}, 'rouge-l': {'r': 0.4375, 'p': 0.20588235294117646, 'f': 0.27999999564800004}}]","[{'rouge-1': {'r': 0.375, 'p': 0.08450704225352113, 'f': 0.13793103148104116}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.1875, 'p': 0.04225352112676056, 'f': 0.06896551423966191}}]","[{'rouge-1': {'r': 0.1875, 'p': 0.08823529411764706, 'f': 0.11999999564800015}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.1875, 'p': 0.08823529411764706, 'f': 0.11999999564800015}}]","[{'rouge-1': {'r': 0.6875, 'p': 0.1111111111111111, 'f': 0.1913043454306238}, 'rouge-2': {'r': 0.3125, 'p': 0.03333333333333333, 'f': 0.060240962113514346}, 'rouge-l': {'r': 0.6875, 'p': 0.1111111111111111, 'f': 0.1913043454306238}}]",0.25,0.074074074,0.114285711,0,0,0,0.25,0.074074074,0.114285711,0.3125,0.12195122,0.175438592,0.1875,0.056603774,0.086956518,0.3125,0.12195122,0.175438592,0.4375,0.205882353,0.279999996,0.1875,0.076923077,0.109090905,0.4375,0.205882353,0.279999996,0.375,0.084507042,0.137931031,0,0,0,0.1875,0.042253521,0.068965514,0.1875,0.088235294,0.119999996,0,0,0,0.1875,0.088235294,0.119999996,0.6875,0.111111111,0.191304345,0.3125,0.033333333,0.060240962,0.6875,0.111111111,0.191304345 +65449,187354,9517,"TITLE: + Chief Complaint: SOB, LE swelling + HPI: + Mr. [**Known lastname 10185**] is a 24 year old man with a history of non-ischemic + cardiomypathy (EF 15-20%) and morbid obesity who presents with + shortness of breath, lower extremity edema and abdominal distention for + the past 2 weeks. He states that on the day of admission ([**2191-12-24**]) he + felt short of breath and a chest tightness described as ""pulling"" + sensation in the center of his chest, worse with deep inspiration. He + reports decreased expercise tolerance and is only able to ambulate [**12-22**] + a block (previously could ambulate several blocks). He can climb 1 + flight of stairs. He denies dietary indiscretion and states he has + been taking all medications as prescribed. He has 3 pillow orthopnea + which has worsened in the past few weeks. He denies overt chest pain, + PND, diarrhea, constipation, fever, chills, night sweats, nausea, + vomiting, dysuria. ROS is positive for chronic cough x 1 year. + . + 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. + . + Cardiac review of systems is notable for absence of chest pain, + paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, + syncope or presyncope. + . + In the ED, initial vitals were 99.6 63 146/95 32 95% RA. He triggered + in the ED for tachypnea with a RR of 32 and his HR was 110-120s and + sinus during his ED stay. He received 1 SL NTG, ASA 325mg and Lasix + 40mg IV x 1, to which he put out 850ml of urine and reported feeling + improvement in symptoms. + Patient admitted from: [**Hospital1 1**] ER + History obtained from Patient + Allergies: + Cozaar (Oral) (Losartan Potassium) + Cough; + Spironolactone + Rash; + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Past medical history: + Family history: + Social History: + 1. Idiopathic dilated cardiomyopathy, EF 20% (echo [**9-28**]) + - diagnosed [**11-27**] when he presented to [**Hospital1 1**] with cough, fever, and + increasing SOB. Chest CT showed bilateral lung infiltrates and enlarged + mediastinal lymph nodes consistent with multifocal pneumonia, and + echocardiography showed moderate to severe global left ventricular + hypokinesis (LVEF = 25-30 %), with normal valve function, and no + pericardial effusion. Lab work for HIV, RSV, influenza, EBV, CMV, Lyme + and multiple blood cultures were unremarkable. Repeated echo 10 months + later confirms severely depressed and dilated LV with LVEF of [**10-4**]%, + and LVEDD of 7.8 cm + - last hospitalized [**5-29**] for CHF exacerbation, treated with IV lasix + - evaluated [**2192-11-1**] by ED (Dr. [**Last Name (STitle) 2363**] for ICD placement, recommended + general anesthesia for EPS and ICD placement + 2. Childhood asthma + 3. Morbid obesity + 4. Sleep apnea - on CPAP but has not been using it + 5. Moderate pulmonary hypertension (46 mmHg [**9-28**] + Father is 65 year-old and mother is 55 year-old. + Both have diabetes. He has 4 healthy older sisters. There is no + family history of SCD or cardiomyopathy. + Occupation: wrestling coach + Drugs: none currently, hx of cocaine use + Tobacco: none + Alcohol: none currently + Other: + Review of systems: + Constitutional: No(t) Fever + Eyes: No(t) Blurry vision + Ear, Nose, Throat: No(t) Epistaxis + Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, + Tachycardia, Orthopnea + Respiratory: Cough, Dyspnea, Tachypnea + Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, + No(t) Diarrhea, No(t) Constipation + Genitourinary: No(t) Dysuria + Musculoskeletal: No(t) Joint pain + Integumentary (skin): No(t) Jaundice + Heme / Lymph: No(t) Anemia, No(t) Coagulopathy + Neurologic: No(t) Headache, No(t) Seizure + Psychiatric / Sleep: No(t) Agitated + Flowsheet Data as of [**2192-12-24**] 01:39 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since [**94**] AM + Tmax: 36.3 +C (97.3 + Tcurrent: 36.3 +C (97.3 + HR: 114 (114 - 114) bpm + BP: 136/61(66) {136/61(66) - 136/61(66)} mmHg + RR: 23 (23 - 23) insp/min + SpO2: 97% + Heart rhythm: ST (Sinus Tachycardia) + Height: 69 Inch + Total In: + PO: + TF: + IVF: + Blood products: + Total out: + 0 mL + 850 mL + Urine: + NG: + Stool: + Drains: + Balance: + 0 mL + -850 mL + Respiratory + O2 Delivery Device: Nasal cannula + SpO2: 97% + Physical Examination + General Appearance: Overweight / Obese + Eyes / Conjunctiva: PERRL, No(t) Sclera edema + Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL + Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3, + No(t) S4, (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: Clear : ) + Abdominal: Soft, Non-tender, Bowel sounds present, Distended + Extremities: Right lower extremity edema: 4+, Left lower extremity + edema: 4+ + Musculoskeletal: No(t) Muscle wasting + Skin: Not assessed, No(t) Rash: + Neurologic: Attentive, Follows simple commands, Responds to: Not + assessed, Movement: Not assessed, Tone: Not assessed + Labs / Radiology + [image002.jpg] + Imaging: . + 2D-ECHOCARDIOGRAM: + [**2192-10-29**]: The left atrium is moderately dilated. No atrial septal + defect is seen by 2D or color Doppler. Left ventricular wall + thicknesses are normal. The left ventricular cavity is severely + dilated. Overall left ventricular systolic function is severely + depressed (LVEF= 15-20 %) with global near akinesis. No masses or + thrombi are seen in the left ventricle. Tissue Doppler imaging suggests + an increased left ventricular filling pressure (PCWP>18mmHg). There is + no ventricular septal defect. with depressed free wall contractility. + The diameters of aorta at the sinus, ascending and arch levels are + normal. The aortic valve leaflets (3) appear structurally normal with + good leaflet excursion and no aortic regurgitation. The mitral valve + leaflets are not well seen. The left ventricular inflow pattern + suggests a restrictive filling abnormality, with elevated left atrial + pressure. There is moderate pulmonary artery systolic hypertension. + There is a small pericardial effusion. There are no echocardiographic + signs of tamponade. + . + CXR [**2191-12-24**] (prelim read): limited by portable technique, poor + penetration. Heart is quite enlarged but stable in size. Prominence of + pulmonary vasculary which may be accentuated by low lung volumes. + Retrocardiac consolidation with atelectasis. No pleural effusion on the + right; however effusion on the left cannot be excluded. Impression: + cardiomegaly with volume overload; retrocardiac atelectasis. + Assessment and Plan + ASSESSMENT AND PLAN: + Mr. [**Known lastname 10185**] is a 24 year old man with a history of non-ischemic + cardiomyopathy, NYH Class II CHF, EF 15-20% who presents with acute on + chronic CHF exacerbation. + . + 1. Acute on Chronic CHF Exacerbation: Underlying etiology was presumed + to be viral in origin. All lab testing negative, including HIV, EBV, + CMV, Lyme, RPR. Current exacerbation due to poor compliance as patient + does not weigh himself. Appears to be taking medications as prescribed + and does not report missing any doses. No current evidence of ischemic + event. + - will continue diuresis with Lasix, additional 40mg IV now + - monitor Is/Os; goal negative 1-2 liters/day + - electrolyte repletion + - fluid restrict 2000ml + - continue b-blockade with Toprol XL 75mg PO BID per Dr.[**Name (NI) 10186**] note + - continue rule out with cardiac enzymes + - full dose aspirin for LV thrombus prevention + - continue Digoxin, will re-load due to low Digoxin level with 0.5mg X + 1, then 0.25mg + - ECG in AM + . + 2. Tachycardia: Sinus rhythm. Per prior records, this is likely + chronic. CHF exacerbation may be contributing. + - continue home dose of Metoprolol for sinus tachycardia + . + 3. Leukocytosis: No evidence of infection based on exam. Appears + chronic compared to prior levels. Likely stress response. + - continue to monitor + . + FEN: cardiac, low sodium diet; fluid restrict 2000ml + . + ACCESS: PIV's + . + PROPHYLAXIS: + -DVT ppx with SC Heparin + -Bowel regimen with colace, senna + . + CODE: Full, confirmed on admission + . + COMM: patient + . + DISPO: CCU for now + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2192-12-24**] 01:15 AM + Prophylaxis: + DVT: SQ UF Heparin + Stress ulcer: + VAP: + Comments: + Communication: ICU consent signed Comments: + Code status: Full code + Disposition: +","Admission Date: [**2192-12-23**] Discharge Date: [**2192-12-26**] + +Date of Birth: [**2168-10-28**] Sex: M + +Service: MEDICINE + +Allergies: +Cozaar / Spironolactone + +Attending:[**First Name3 (LF) 4765**] +Chief Complaint: +SOB/DOE + +Major Surgical or Invasive Procedure: +none + +History of Present Illness: +Mr. [**Known lastname 32362**] is a 24 year old man with a history of non-ischemic +cardiomypathy (EF 15-20%) and morbid obesity who presents with +shortness of breath, lower extremity edema and abdominal +distention for the past 2 weeks. He states that on the day of +admission ([**2191-12-24**]) he felt short of breath and a chest tightness +described as ""pulling"" sensation in the center of his chest, +worse with deep inspiration. He reports decreased expercise +tolerance and is only able to ambulate [**12-22**] a block (previously +could ambulate several blocks). He can climb 1 flight of stairs. +He denies dietary indiscretion and states he has been taking all +medications as prescribed. He has 3 pillow orthopnea which has +worsened in the past few weeks. He denies overt chest pain, PND, +diarrhea, constipation, fever, chills, night sweats, nausea, +vomiting, dysuria. ROS is positive for chronic cough x 1 year. +He was supposed to have an EP study with or without AICD +placement on [**11-20**] that was postponed to [**2193-1-2**] for symptoms +akin to a cold. (No record in chart) + +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. + +Cardiac review of systems is notable for absence of chest pain, +paroxysmal nocturnal dyspnea, orthopnea, ankle edema, +palpitations, syncope or presyncope. + +In the ED, initial vitals were 99.6 63 146/95 32 95% RA. He +triggered in the ED for tachypnea with a RR of 32 and his HR was +110-120s and sinus during his ED stay. He received 1 SL NTG, ASA +325mg and Lasix 40mg IV x 1, to which he put out 850ml of urine +and reported feeling improvement in symptoms + + +Past Medical History: +1. Presumed Idiopathic dilated cardiomyopathy, EF 15-20% (echo +[**9-28**]) +- diagnosed [**11-27**] when he presented to [**Hospital1 18**] with cough, fever, +and increasing SOB. Chest CT showed bilateral lung infiltrates +and enlarged mediastinal lymph nodes consistent with multifocal +pneumonia, and echocardiography showed moderate to severe +global left ventricular hypokinesis (LVEF = 25-30 %), with +normal valve function, and no pericardial effusion. Lab work +for RSV was positive, while HIV, influenza, EBV, CMV, Lyme and +multiple blood cultures were unremarkable. Repeated echo 10 +months later confirms severely depressed and dilated LV with +LVEF of [**10-4**]%, and LVEDD of 7.8 cm +- last hospitalized [**5-29**] for CHF exacerbation, treated with IV +lasix +- evaluated [**2192-11-1**] by ED (Dr. [**Last Name (STitle) **] for ICD placement, +recommended general anesthesia for EPS and ICD placement +2. Childhood asthma +3. Morbid obesity +4. Sleep apnea - on CPAP but has not been using it +5. Moderate, Worsening pulmonary hypertension (46 mmHg [**9-28**]) +(20-28 in [**4-28**]) +6. Fatty Liver by CT. Obese and hx of EtOH. INR 1.4-1.7 since +[**5-29**]; Bili 1.7; HCV neg; HBV immune. + +Social History: +He is unmarried and lives at home with his parents. He works as +a high school wrestling coach and in security. He never smoked. +He drank ""a lot"" in college, previously quoting 6 beer/weekend +but not elaborting this time; started drinking in [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32363**] +high school. He has a history of cocaine use, ""a great deal"" in +sophmore year. Drinks an occasional glass of wine. + +Family History: +Father is 65 year-old and mother is 55 year-old. +Both have diabetes. He has 4 healthy older sisters. There is no +family history of SCD or cardiomyopathy. + +Physical Exam: +VS: T= 97.3 BP= 136/61 HR=114 RR= 23 O2 sat= 97% 3L +GENERAL: Obese African-American man 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 without appreciable JVP, although cannot currently +assess due to body habitus. Dark Acanthosis nigricans +bilaterally +CARDIAC: PMI located in 5th intercostal space, midclavicular +line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or +S4. +LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp +were unlabored, no accessory muscle use. CTAB, crackles at Right +base, no wheezes or rhonchi. +ABDOMEN: Obese with diffuse anasarca and tense skin. No pain on +palpation. Positive bowel sounds. +EXTREMITIES: 3+ pitting edema to mid-abodmen. Dry skin of lower +extremities with changes of venous stasis. +SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. +Skin: dry, cool. Acanthosis as above. +Neurologic: Cn 2-12 intact, full strength globally + + +Pertinent Results: +ADMISSION LABLS + WBC-12.3* RBC-5.33 Hgb-12.7* Hct-38.8* MCV-73* MCH-23.8* +MCHC-32.8 RDW-19.1* Plt Ct-284 + Glucose-136* UreaN-15 Creat-1.0 Na-136 K-4.2 Cl-102 HCO3-23 +AnGap-15 + ALT-15 AST-25 CK(CPK)-97 AlkPhos-82 TotBili-1.7* + PT-17.3* PTT-27.9 INR(PT)-1.6* + CK-MB-2 cTropnT-<0.01 proBNP-2319* + CK-MB-NotDone cTropnT-0.01 + Digoxin-0.3* +[**2192-12-24**] 03:52AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.9 Iron-PND + +IRON +calTIBC-503* Ferritn-47 TRF-387* Iron-36* + +Liver +[**2192-12-23**] PT-17.3* PTT-27.9 INR(PT)-1.6* +[**2192-12-25**] PT-16.1* PTT-28.9 INR(PT)-1.4* +[**2192-12-23**] ALT-15 AST-25 CK(CPK)-97 AlkPhos-82 TotBili-1.7* +[**2192-12-26**] TotBili-1.9* DirBili-1.0* IndBili-0.9 + + +Brief Hospital Course: +Mr. [**Known lastname 32362**] is a 24 year old man with a history of non-ischemic +cardiomyopathy, NYH Class II CHF, EF 15-20% who presents with +DOE/SOB over one month, acutely over one week. He was treated +for acute on chronic CHF exacerbation. He was diuresed with IV +and then PO lasix, achieving a net negative balance of ~ 7 +litres. He was discharged to optimize his fluid status prior to +an AICD placement + +By Problem +1. Acute on Chronic CHF Exacerbation: Underlying etiology for +patient's chronic heart failure was presumed to be viral in +origin, could also be related to cocaine use in years prior to +diagnosis or alcohol abuse. All lab testing negative except for +RSV, including HIV, EBV, CMV, Lyme, RPR. Current exacerbation +likely due to poor dietary compliance as patient does not weigh +himself daily and could easily become overloaded particularly in +the context of the Holidays. He denied any medication +noncompliance. The patient was aggressively diuresed with iV +furosemide and by time of discharge he was 7 litres net negative +and sent home on 40 mg of PO furosemide [**Hospital1 **]. + +2. Tachycardia: The patient had CHF with rates around 100-130 at +presentation. This appears to be a chronic problem per previous +notes. This improved somewhat with diuresis and improvement of +his respiratory status. Doses of metoprolol were increased over +hospitalization without change in heart rate (100-120 on +telemetry). The patient should have an AICD for purposes of +primary prevention given his low EF. Plans are underway to +finish this as an outpatient. He was discharged on 100 mg +Toprol XL [**Hospital1 **] + +3. Iron Deficiency Anemia: The patient continued to be +microcytic with indices suggestive of iron deficiency. He is +also hemoglobin AC which could explain some microcytosis. No +signs of active bleeding and previous CT [**Last Name (un) **] was negative. He +was discharged on iron TID with ascorbic acid for absorption and +senna/colace for constipation + +4: Hyperbilirubinemia/ Liver Dysfunction: Patient had a slightly +elevated INR and bilirubin at presentation with normal +transaminases. Both of these parameters were slightly above his +previous values though he doe have a known element of +non-alcoholic steatohepatitis (defined by ALT/AST and US/CT +evidence of fatty infiltration). Given his two presumptive +diagnoses (NAFLD/NASH and Congestive Hepatolpathy) he is at +increased risk of fibrosis. His negative transaminases and +elevated bilirubin (half direct, half indirect) were likely in +the setting of hepatic congestion and decreased cardiac output +during his heart failure exacerbation. His bilirubin was +elevated at the time of discharge, but this would not be +expected to fall quickly. It ought to be followed. + +5. Pulmonary Hypertension: The patient was mildly hypoxic at +presentation presumably due to exacerbation of his CHF. With +diuresis this improved. ULtimately, plan is for outpatient +right heart cath. The patient was also encouraged to use his +CPAP at home and continue the diuresis begun in house. + +6. Leukocytosis: The patient had a mild leukocytosis that was +trending down at the time of discharge. He had no fevers or +signs of acute infection. + +[**Telephone/Fax (3) 32364**] +TO BE FOLLOWED IMMEDIATELY +1) Needs BMP to evaluate response to Lasix 40 mg [**Hospital1 **] +2) Needs Weight Check, was 192 Kg standing on scale at d/c +EVENTUALLY +3) CBC, iron studies to follow progress on iron repletion +4) Ultimately, follow bilirubin, INR, assess liver status +[**Telephone/Fax (3) **] + +Medications on Admission: +Diovan 40mg PO qday +Acetaminophen + Codeine 300mg/30mg PO q4H PRN cough +ASA 325mg PO qday +Furosemide 20mg PO BID - of note, pt is not sure if he takes +20mg or 40mg [**Hospital1 **] +Digoxin 250mcg PO qday +Metoprolol Succinate ER 75mg PO BID - pt is not sure of dose +(this is per Dr.[**Name (NI) 8996**] last note) + + +Discharge Medications: +1. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*2* +3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*2* +4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) +Tablet PO TID (3 times a day). +Disp:*90 Tablet(s)* Refills:*2* +5. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, +Chewable PO three times a day. +Disp:*90 Tablet, Chewable(s)* Refills:*2* +6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a +day). +Disp:*60 Tablet(s)* Refills:*2* +7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) +Tablet Sustained Release 24 hr PO twice a day: Take one pill in +the morning and one at night. +Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* +8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: +for constipation. +Disp:*60 Capsule(s)* Refills:*2* +9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as +needed for constipation. +Disp:*30 Capsule(s)* Refills:*2* +10. Outpatient Lab Work +Check Na, K, BUN, Cr on Monday [**2192-12-31**] + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Primary Diagnosis: +Acute exacerbation of chronic systolic congestive heart failure +Iron Deficiency Anemia +Morbid obesity + + +Discharge Condition: +Good, not hypoxic on room air +Ambulating without assistance +Alert and Oriented *3 + +Discharge Instructions: +Mr [**Known lastname 32362**], it was pleasure to participate in your care. You were +admitted because you had increased swelling in your legs and +difficulty breathing. This was due to an exacerbation of your +heart failure. The reasons for this exacerbation are unclear +though it may have been partially driven by more salty food over +the Holidays or more subtle diet changes. In the hospital you +received IV diuretics to help remove this fluid. You lost more +than 7 litres of fluid by the time you were discharged. This is +more than 15 pounds! It is crucial that you continue this +progress at home by being very careful with diet, fluid intake +and medication use. + +Your medications have been changed. You have been started on +iron supplementation as your low iron seems to be contributing +to your persistently low blood counts. Take your iron pills with +vitamin c or fruit juice. If you get constipated on iron, you +can take Colace twice daily or Senna; these are medications that +you can get at the pharmacy. Please continue to take your other +medications as previously described. + +Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more +than 3 lbs. + +MEDICATIONS +1) LASIX/FUROSEMIDE - Take 40mg tablets in the morning when you +wake and again at 4pm, or a few hours before you go to sleep. +You must take it twice daily. Your cardiologist may change this +dose. You must follow up with your PCP for [**Name Initial (PRE) **] lab test while on +this dose +2) Toprol XL - 100 mg, twice daily - this is a new dose of your +heart rate medication. TAKE THIS MEDICATION TONIGHT. +3) Aspirin 325 mg, this is to prevent a clot in your heart +4) Iron, Vitamin C - you are very low on iron and vitamin c aids +in absorption +5) Colace and Senna - medications for constipation, if that +becomes an issue + + +Followup Instructions: +You need to have your labs checked at your PCP office +We have scheduled an appointment for monday +[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2192-12-31**] +12:30 + +You have a pre-op evaluation on the [**1-2**]. +Provider: [**Name10 (NameIs) **] RM 1 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2193-1-2**] +9:30 +Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] +Date/Time:[**2193-1-10**] 11:20 + + +Completed by:[**2192-12-26**]","mr. [**known lastname 10185**] is a 24 year old man with a history of non-ischemic cardiomypathy (ef 15-20%) and morbid obesity who presents with shortness of breath, lower extremity edema and abdominal distention for the past 2 weeks. he states that on the day of admission ([**2191-12-24**]) he felt short of breath and a chest tightness described as ""pulling"" sensation in the center of his chest, worse with deep inspiration. he reports decreased expercise tolerance and is only able to ambulate [**12-22**] a block (previously could ambulate several blocks). he can climb 1 flight of stairs. he denies dietary indiscretion and states he has been taking all medications as prescribed. he has 3 pillow orthopnea which has worsened in the past few weeks. he denies overt chest pain, pnd, diarrhea, constipation, fever, chills, night sweats, nausea, vomiting, dysuria. ros is positive for chronic cough x 1 year. 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. cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. in the ed, initial vitals were 99.6 63 146/95 32 95% ra. he triggered in the ed for tachypnea with a rr of 32 and his hr was 110-120s and sinus during his ed stay. he received 1 sl ntg, asa 325mg and lasix 40mg iv x 1, to which he put out 850ml of urine and reported feeling improvement in symptoms. patient admitted from: [**hospital1 1**] er history obtained from patient","mr. [**known lastname 32362**] is a 24 year old man with a history of non-ischemic cardiomyopathy, nyh class ii chf, ef 15-20% who presents with doe/sob over one month, acutely over one week.","known lastname 10185**] is a 24 year old man with a history of non-ischemic cardiomypathy (ef 15-20%) and morbid obesity who presents with shortness of breath, lower extremity edema and abdominal distention for the past 2 weeks. he states that on the day of admission ([**2191-12-24**]) he felt short of breath and a chest tightness described as ""pulling"" sensation in the center of his chest, worse with deep inspiration. he denies dietary indiscretion and states he has been taking all medications as prescribed. 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. all of the other review of systems were negative. patient admitted from: [**hospital1 1**] er history obtained from patient","['The 24-year-old man has a history of non-ischemic heart disease.\nHe has a blood clot, patella, diastema, constipation, nausea, vomiting, dizziness, and abdominal pain.\nThe condition is not treatable with medication.\nHis doctor says he has been taking all medications as prescribed.']","a 24-year-old man with a history of non-ischemic cardiomypathy presents with shortness of breath, lower extremity edema and abdominal distention. he denies overt chest pain, pnd, diarrhea, constipation, fever, chills, night sweats, nausea, vomiting, dysuria. he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism.","[""a 24-year-old man with history of nonischemic cardiomypathy has shortness and abdominal distention for the past 2 weeks. patient denies overt chest pain, diarrhea or constipation; alleges recent fevers/chill'd sweating (x 1 year).""]","[**known lastname 10185**] is a 24 year old man with a history of non-ischemic cardiomypathy (ef 15-20%) and morbid obesity who presents with shortness of breath, lower extremity edema and abdominal distention for the past 2 weeks. +he denies overt chest pain, pnd, diarrhea, constipation, fever, chills, night sweats, nausea, vomiting, dysuria. +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.","[**known lastname 10185**] is a 24 year old man with a history of non-ischemic cardiomypathy (ef 15-20%) and morbid obesity who presents with shortness of breath, lower extremity edema and abdominal distention for the past 2 weeks.he states that on the day of admission ([**2191-12-24**]) he felt short of breath and a chest tightness described as ""pulling"" sensation in the center of his chest, worse with deep inspiration.he reports decreased expercise tolerance and is only able to ambulate [**12-22**] a block (previously could ambulate several blocks).he can climb 1 flight of stairs.he denies dietary indiscretion and states he has been taking all medications as prescribed.he has 3 pillow orthopnea which has worsened in the past few weeks.he denies overt chest pain, pnd, diarrhea, constipation, fever, chills, night sweats, nausea, vomiting, dysuria.all of the other review of systems were negative.cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.he triggered in the ed for tachypnea with a rr of 32 and his hr was 110-120s and sinus during his ed stay.","[{'rouge-1': {'r': 0.4482758620689655, 'p': 0.125, 'f': 0.19548871839448248}, 'rouge-2': {'r': 0.3870967741935484, 'p': 0.08759124087591241, 'f': 0.14285713984764745}, 'rouge-l': {'r': 0.4482758620689655, 'p': 0.125, 'f': 0.19548871839448248}}]","[{'rouge-1': {'r': 0.2413793103448276, 'p': 0.175, 'f': 0.20289854585171196}, 'rouge-2': {'r': 0.0967741935483871, 'p': 0.07317073170731707, 'f': 0.08333332842978425}, 'rouge-l': {'r': 0.2413793103448276, 'p': 0.175, 'f': 0.20289854585171196}}]","[{'rouge-1': {'r': 0.2413793103448276, 'p': 0.17073170731707318, 'f': 0.19999999514693892}, 'rouge-2': {'r': 0.1935483870967742, 'p': 0.13333333333333333, 'f': 0.15789473201177298}, 'rouge-l': {'r': 0.2413793103448276, 'p': 0.17073170731707318, 'f': 0.19999999514693892}}]","[{'rouge-1': {'r': 0.13793103448275862, 'p': 0.11764705882352941, 'f': 0.1269841220156213}, 'rouge-2': {'r': 0.06451612903225806, 'p': 0.06060606060606061, 'f': 0.062499995004883215}, 'rouge-l': {'r': 0.13793103448275862, 'p': 0.11764705882352941, 'f': 0.1269841220156213}}]","[{'rouge-1': {'r': 0.4827586206896552, 'p': 0.1917808219178082, 'f': 0.2745097998519801}, 'rouge-2': {'r': 0.41935483870967744, 'p': 0.15853658536585366, 'f': 0.23008849159370356}, 'rouge-l': {'r': 0.4827586206896552, 'p': 0.1917808219178082, 'f': 0.2745097998519801}}]","[{'rouge-1': {'r': 0.4827586206896552, 'p': 0.10687022900763359, 'f': 0.17499999703203128}, 'rouge-2': {'r': 0.41935483870967744, 'p': 0.07262569832402235, 'f': 0.12380952129297057}, 'rouge-l': {'r': 0.4827586206896552, 'p': 0.10687022900763359, 'f': 0.17499999703203128}}]",0.448275862,0.125,0.195488718,0.387096774,0.087591241,0.14285714,0.448275862,0.125,0.195488718,0.24137931,0.175,0.202898546,0.096774194,0.073170732,0.083333328,0.24137931,0.175,0.202898546,0.24137931,0.170731707,0.199999995,0.193548387,0.133333333,0.157894732,0.24137931,0.170731707,0.199999995,0.137931034,0.117647059,0.126984122,0.064516129,0.060606061,0.062499995,0.137931034,0.117647059,0.126984122,0.482758621,0.191780822,0.2745098,0.419354839,0.158536585,0.230088492,0.482758621,0.191780822,0.2745098,0.482758621,0.106870229,0.174999997,0.419354839,0.072625698,0.123809521,0.482758621,0.106870229,0.174999997 +65449,169230,9518,"Chief Complaint: failure to extubate + HPI: + Mr. [**Known lastname 10185**] is a 24 yo M with non-ischemic cardiomyopathy (EF 25% in + [**9-28**]) who was admitted for right heart cardiac catherization and AICD + placement today. He is being transferred to the CCU after difficulty + with extubation s/p cath. Patient was recently admitted to the CCU from + [**2192-12-23**] - [**2192-12-26**] with acute congestive heart failure in the setting of + dietary non-compliance. He was scheduled to have his AICD placed today + under general anesthesia per recommendation by Dr. [**Last Name (STitle) 2363**]. Per + anesthesia, patient was a difficult intubation due to his body habitus, + and was maintained on a phenylephrine gtt in order to maintain his + blood pressures during the procedure (SBPs in 100s-120s). He underwent + RHC which showed elevated wedge, PA, RV, and RA pressures (see + hemodynamics below). He had a [**Company **] single chamber ICD + placed through cutdown of left cephalic vein without complication. He + was continued on a neo gtt which was weaned at 5 pm, and remained off + pressors for 4 hours prior to CCU transfer. Patient was transitioned to + PS [**9-29**] in an attempt at extubation in the PACU, but these attempts + were unsuccessful due to tachypnea and secretions requring continuous + secretions. Patient was also noted to be difficult to sedate during + ventilation and was maintained on propofol 70 mcg/kg/min. A-lines + attempts in both radial arteries by anesthesia were unsuccessful. It + was thought that the failure to extubate was due to body habitus and + pulmonary edema. Prior to transfer to CCU, VS were 98.6 112/48 110 20 + 100% on CPAP with PEEP of 10 and FiO2 of 50%. He received 20 mg of IV + lasix in the PACU and was transferred to the CCU for further + management. + . + ROS unable to be obtained due to patient being intubated and sedated. + Allergies: + Cozaar (Oral) (Losartan Potassium) + Cough; + Spironolactone + Rash; itching; + Lisinopril + Cough; + Last dose of Antibiotics: + Infusions: + Furosemide (Lasix) - 5 mg/hour + Propofol - 70 mcg/Kg/min + Other ICU medications: + Other medications: + . Valsartan 40 mg PO DAILY + 2. Aspirin 325 mg PO DAILY + 3. Digoxin 250 mcg PO DAILY + 4. Ferrous Sulfate 325 mg PO TID + 5. Ascorbic Acid 250 mg Tablet PO TID + 6. Furosemide 40 mg PO BID + 7. Toprol XL 100 mg Tablet Sustained Release PO BID + 8. Colace 100 mg PO BID + 9. Senna 8.6 mg PO daily:PRN constipation + Past medical history: + Family history: + Social History: + 1. Presumed Idiopathic dilated cardiomyopathy, EF 15-20% (echo + [**9-28**]) + - diagnosed [**11-27**] when he presented to [**Hospital1 1**] with cough, fever, + and increasing SOB. Chest CT showed bilateral lung infiltrates + and enlarged mediastinal lymph nodes consistent with multifocal + pneumonia, and echocardiography showed moderate to severe + global left ventricular hypokinesis (LVEF = 25-30 %), with + normal valve function, and no pericardial effusion. Lab work + for RSV was positive, while HIV, influenza, EBV, CMV, Lyme and + multiple blood cultures were unremarkable. Repeated echo 10 + months later confirms severely depressed and dilated LV with + LVEF of [**10-4**]%, and LVEDD of 7.8 cm + - last hospitalized [**5-29**] and [**12-30**] for CHF exacerbation, treated with IV + lasix + 2. Childhood asthma + 3. Morbid obesity + 4. Sleep apnea - on CPAP but has not been using it + 5. Moderate, Worsening pulmonary hypertension (46 mmHg [**9-28**]) + (20-28 in [**4-28**]) + 6. Fatty Liver by CT. Obese and hx of EtOH. INR 1.4-1.7 since + [**5-29**]; Bili 1.7; HCV neg; HBV immune. + Father is 65 year-old and mother is 55 year-old. + Both have diabetes. He has 4 healthy older sisters. There is no + family history of SCD or cardiomyopathy. + Occupation: + Drugs: + Tobacco: + Alcohol: + Other: He is unmarried and lives at home with his parents. He works as + a high school wrestling coach and in security. He never smoked. + He drank ""a lot"" in college, previously quoting 6 beer/weekend + but not elaborting this time; started drinking in [**First Name5 (NamePattern1) 10484**] [**Last Name (NamePattern1) 10485**] + high school. He has a history of cocaine use, ""a great deal"" in + sophmore year. Drinks an occasional glass of wine. + Review of systems: + Flowsheet Data as of [**2193-1-9**] 01:44 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since [**94**] AM + Tmax: 38.5 +C (101.3 + Tcurrent: 38.5 +C (101.3 + HR: 98 (91 - 104) bpm + BP: 73/42(52) {73/42(52) - 78/44(55)} mmHg + RR: 23 (23 - 33) insp/min + SpO2: 94% + Heart rhythm: ST (Sinus Tachycardia) + Total In: + 236 mL + 247 mL + PO: + TF: + IVF: + 236 mL + 247 mL + Blood products: + Total out: + 40 mL + 0 mL + Urine: + 40 mL + NG: + Stool: + Drains: + Balance: + 196 mL + 247 mL + Respiratory + O2 Delivery Device: Endotracheal tube + Ventilator mode: CMV/ASSIST/AutoFlow + Vt (Set): 550 (550 - 550) mL + Vt (Spontaneous): 335 (335 - 335) mL + PS : 0 cmH2O + RR (Set): 16 + RR (Spontaneous): 0 + PEEP: 10 cmH2O + FiO2: 40% + PIP: 30 cmH2O + Plateau: 27 cmH2O + Compliance: 35.3 cmH2O/mL + SpO2: 94% + ABG: 7.36/49/111/24/1 + Ve: 12.4 L/min + PaO2 / FiO2: 277 + Physical Examination + VS: T= 101.2 BP= 98/48 (A-line 75/46) HR= 98 RR= 20 O2 sat= 92% on CPAP + PEEP 12, FiO2 50%. + GENERAL: obese M intubated, sedated + HEENT: NCAT. PERRL, EOMI. + NECK: unable to assess JVP due to body habitus. + CARDIAC: PMI laterally displaced. RR, normal S1, S2. No m/r/g. No + thrills, lifts. No S3 or S4. + LUNGS: ventilated breath sounds + ABDOMEN: obese, NTND. No HSM or tenderness. Abd aorta not enlarged by + palpation. No abdominial bruits. + EXTREMITIES: [**12-22**]+ pitting edema bilaterally. +venous stasis changes and + dirt noted over bilateral extremities. + SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. + PULSES: + Right: DP 2+ PT 2+ + Left: DP 2+ PT 2+ + Labs / Radiology + 229 K/uL + 11.7 g/dL + 84 mg/dL + 1.7 mg/dL + 20 mg/dL + 24 mEq/L + 104 mEq/L + 4.2 mEq/L + 141 mEq/L + 36.9 % + 11.8 K/uL + [image002.jpg] + [**2188-12-22**] + 2:33 A1/19/[**2192**] 10:32 PM + [**2188-12-26**] + 10:20 P1/19/[**2192**] 10:50 PM + [**2188-12-27**] + 1:20 P + [**2188-12-28**] + 11:50 P + [**2188-12-29**] + 1:20 A + [**2188-12-30**] + 7:20 P + 1//11/006 + 1:23 P + [**2189-1-22**] + 1:20 P + [**2189-1-22**] + 11:20 P + [**2189-1-22**] + 4:20 P + WBC + 11.8 + Hct + 36.9 + Plt + 229 + Cr + 1.7 + TC02 + 29 + Glucose + 81 + 84 + Other labs: PT / PTT / INR:16.4/26.4/1.5, Ca++:8.3 mg/dL, Mg++:2.0 + mg/dL + Fluid analysis / Other labs: CARDIAC CATH: ([**2193-1-8**]): + HEMODYNAMICS: + PCPW: 36 mm Hg + PA: (51/13 mean 38) 65/35 + RV: (57/14 mean 36) 65/14 + RA: 41/18 mean 32 mm Hg + . + LABORATORY DATA: + 7.36/49/111/29 + Na:139 K:4.1 Cl:101 Glu:81 O2Sat: 96 + Imaging: The left atrium is moderately dilated. No atrial septal defect + is seen by 2D or color Doppler. Left ventricular wall thicknesses are + normal. The left ventricular cavity is severely dilated. Overall left + ventricular systolic function is severely depressed (LVEF= 15-20 %) + with global near akinesis. No masses or thrombi are seen in the left + ventricle. Tissue Doppler imaging suggests an increased left + ventricular filling pressure (PCWP>18mmHg). There is no ventricular + septal defect. with depressed free wall contractility. The diameters of + aorta at the sinus, ascending and arch levels are normal. The aortic + valve leaflets (3) appear structurally normal with good leaflet + excursion and no aortic regurgitation. The mitral valve leaflets are + not well seen. The left ventricular inflow pattern suggests a + restrictive filling abnormality, with elevated left atrial pressure. + There is moderate pulmonary artery systolic hypertension. There is a + small pericardial effusion. There are no echocardiographic signs of + tamponade. + . + Compared with the prior study (images reviewed) of [**2192-6-6**], no + change. The LVEF was overestimated on the prior study. + ECG: EKG: sinus tachycardia. +LAD. normal intervals; poor R-wave + progression precordial leads. no acute ischemic changes. + Assessment and Plan + CARDIOMYOPATHY, OTHER + 24 yo M with non-ischemic cardiomyopathy admitted to CCU after failure + to extubate s/p elective AICD placement and right heart cath. + . + # Failure to extubate: Patient was unable to be extubated in the PACU + s/p cardiac catherization. Likely in setting of extrapulmonary + restriction (morbid obesity/large body habitus) and poor lung + compliance due to volume overload from patient's systolic and diastolic + heart failure, leading to elevated elastic pressures. ABG shows chronic + respiratory acidosis with appropriate metabolic compensation, may be + due to obesity hypoventilation/Pickwickian syndrome. + - initial diuresis with lasix gtt (40 mg IV bolus x1), but held in the + setting of hypotension + - propofol for sedation + - consider checking P-plateau to assess for elastic pressures + - switch to AC overnight + - wean ventilator as tolerated after diuresis with attempt at + extubation in AM + . + # Fever: Pt with T to 101.2 in the ED and rising leukocytosis. Likely + febrile in setting of recent procedure. Hypotension, although more + likely due to sedation/intubation is somewhat concerning for possible + sepsis. + - check WBC diff + - blood cultures + - u/a, urine cultures + - CXR + - tylenol prn: fever (< 2 grams daily) + - minimize lines + - IV abx for ICD placement (see below) + . + # Hypotension: Patient had pre-procedure SBP of 140s. Placement of + A-line showed SBPs of 70s, indicating relative hypotension. Etiologies + include sedation/mechanical ventilation versus sepsis given recent + diagnosis of cellulitis treated with 10 days of keflex, fever noted on + CCU admission, hypotension, and decreased urine output. + - neo gtt run peripherally for MAP > 65 + - hold lasix gtt + - hold placement of CVL for now given possible extubation in AM; will + place if pressor requirements increase. + - f/u blood and urine cultures + - check c. diff toxin assay + - consider broadening abx to Vancomycin if spikes fever again. + . + # Acute renal failure: Cre up to 1.7 (baseline 1.1). [**Month (only) 11**] be pre-renal + in setting of hypotension during the procedure due to + sedation/intubation, leading to ATN (intrarenal). Other etiologies + (though less likely) include poor forward flow in setting of depressed + EF% versus overdiuresis with PO lasix at home. No recent contrast + administration. Patient relatively oliguric on admission to the CCU + with only 40 ccs of dark urine output to 20 of IV lasix administered in + the PACU. + - bladder scan to assess for post renal obstruction + - hold lasix gtt for now + - renally dose all meds, avoid nephrotoxins + - check digoxin level in AM to avoid toxicity + - hold [**Last Name (un) 284**] for now + - check u/a, urine electrolytes to calculate FeUrea, urine eos + - consider renal consult in AM if renal failure worsens + . + # CORONARIES: No known hx of CAD. + - continue ASA, beta-blocker + - hold [**Last Name (un) 284**] in setting acute renal failure + . + # PUMP: Non-ischemic dilated cardiomyopathy, thought to be viral in + etiology. Likely has chronic systolic and diastolic heart failure (EF + 25% on [**9-28**].) Elevated left and right heart pressures noted on RHC + today with severe pulmonary hypertension. Patient received lasix 20 mg + IV x1 in PACU and 40 IV x1 in CCU followed by lasix gtt, which was then + held in the setting of hypotension noted on A-line readings, which were + ~20 pts lower than non-invasive readings. + - hold lasix gtt for now + - fluid restriction, low Na diet, strict Is and Os, foley, daily + weights + - continue BB, digoxin + . + # RHYTHM: Patient is s/p AICD placement for primary prevention of + tachyarrythmias given non-ischemic cardiomyopathy EF of 25%. One + episode of NSVT in the CCU. + - CXR in AM to confirm AICD placement + - EP to interrogate pacer in AM + - replete K > 4 Mg > 2 + - continue beta-blocker and digoxin + - check digoxin level in AM + - IV Ancef x1, followed by Keflex x3 days to prevent infection s/p AICD + placement + . + # Asthma: + - albuterol inhaler prn + . + # Fatty Liver: Patient sedated with propofol overnight given quick + on/off for sedation. Patient received fentanyl and versed but was + reportedly not well sedated during the procedure on this regimen, + resulting in switch to propofol. Per discussion with pharmacy, OK to + sedate with propofol temporarily overnight (12 hours) if extubation + planned in AM. + - trend LFTs daily + . + # Anemia: Known iron deficiency anemia. Trend Hct. Continue iron + supplements with bowel regimen and vitamin C once able to take PO. + . + # OSA: restart/encourage nocturnal CPAP at home once extubated. + . + ICU Care + Nutrition: NPO + Glycemic Control: + Lines: + 20 Gauge - [**2193-1-8**] 10:00 PM + 18 Gauge - [**2193-1-8**] 10:56 PM + Prophylaxis: + DVT: SQ UF Heparin + Stress ulcer: + VAP: HOB elevation, Mouth care, Daily wake up, RSBI + Need for restraints reviewed + Comments: + Communication: Comments: + Code status: Full code + Disposition: ICU +","Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-21**] + +Date of Birth: [**2168-10-28**] Sex: M + +Service: MEDICINE + +Allergies: +Cozaar / Spironolactone / Lisinopril + +Attending:[**Last Name (NamePattern1) 1167**] +Chief Complaint: +failure to extubate + +Major Surgical or Invasive Procedure: +Internal Cardiac Defibrillator Implantation + + +History of Present Illness: +Mr. [**Known lastname 32362**] is a 24 yo M with non-ischemic cardiomyopathy (EF 25% +in [**9-28**]) who was admitted for right heart cardiac catherization +and AICD placement today. He is being transferred to the CCU +after difficulty with extubation s/p cath. Patient was recently +admitted to the CCU from [**2192-12-23**] - [**2192-12-26**] with acute congestive +heart failure in the setting of dietary non-compliance. He was +scheduled to have his AICD placed today under general anesthesia +per recommendation by Dr. [**Last Name (STitle) **]. Per anesthesia, patient was a +difficult intubation due to his body habitus, and was maintained +on a phenylephrine gtt in order to maintain his blood pressures +during the procedure (SBPs in 100s-120s). He underwent RHC which +showed elevated wedge, PA, RV, and RA pressures (see +hemodynamics below). He had a [**Company 2267**] single chamber +ICD placed through cutdown of left cephalic vein without +complication. Received 1.2 L of LR in the OR. He was continued +on a neo gtt which was weaned at 5 pm, and remained off pressors +for 4 hours prior to CCU transfer. Patient was transitioned to +PS [**9-29**] in an attempt at extubation in the PACU, but these +attempts were unsuccessful due to tachypnea and secretions +requring continuous secretions. Patient was also noted to be +difficult to sedate during ventilation and was maintained on +propofol 70 mcg/kg/min. A-lines attempts in both radial arteries +by anesthesia were unsuccessful. It was thought that the failure +to extubate was due to body habitus and pulmonary edema. Prior +to transfer to CCU, VS were 98.6 112/48 110 20 100% on CPAP with +PEEP of 10 and FiO2 of 50%. He received 20 mg of IV lasix in the +PACU and was transferred to the CCU for further management. +. +ROS unable to be obtained due to patient being intubated and +sedated. +. + + +Past Medical History: +1. Presumed Idiopathic dilated cardiomyopathy, EF 15-20% (echo +[**9-28**]) +- diagnosed [**11-27**] when he presented to [**Hospital1 18**] with cough, fever, + +and increasing SOB. Chest CT showed bilateral lung infiltrates +and enlarged mediastinal lymph nodes consistent with multifocal + +pneumonia, and echocardiography showed moderate to severe +global left ventricular hypokinesis (LVEF = 25-30 %), with +normal valve function, and no pericardial effusion. Lab work +for RSV was positive, while HIV, influenza, EBV, CMV, Lyme and +multiple blood cultures were unremarkable. Repeated echo 10 +months later confirms severely depressed and dilated LV with +LVEF of [**10-4**]%, and LVEDD of 7.8 cm +- last hospitalized [**5-29**] and [**12-30**] for CHF exacerbation, treated +with IV lasix +2. Childhood asthma +3. Morbid obesity +4. Sleep apnea - on CPAP but has not been using it +5. Moderate, Worsening pulmonary hypertension (46 mmHg [**9-28**]) +(20-28 in [**4-28**]) +6. Fatty Liver by CT. Obese and hx of EtOH. INR 1.4-1.7 since +[**5-29**]; Bili 1.7; HCV neg; HBV immune. + + +Social History: +He is unmarried and lives at home with his parents. He works as +a high school wrestling coach and in security. He never smoked. +He drank ""a lot"" in college, previously quoting 6 beer/weekend +but not elaborting this time; started drinking in [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32363**] +high school. He has a history of cocaine use, ""a great deal"" in +sophmore year. Drinks an occasional glass of wine. + +Family History: +Father is 65 year-old and mother is 55 year-old. +Both have diabetes. He has 4 healthy older sisters. There is no +family history of SCD or cardiomyopathy. + +Physical Exam: +VS: T= 101.2 BP= 98/48 (A-line 75/46) HR= 98 RR= 20 O2 sat= 92% +on CPAP PEEP 12, FiO2 50%. +GENERAL: obese M intubated, sedated +HEENT: NCAT. PERRL, EOMI. +NECK: unable to assess JVP due to body habitus. +CARDIAC: PMI laterally displaced. RR, normal S1, S2. No m/r/g. +No thrills, lifts. No S3 or S4. +LUNGS: ventilated breath sounds +ABDOMEN: obese, NTND. No HSM or tenderness. Abd aorta not +enlarged by palpation. No abdominial bruits. +EXTREMITIES: [**12-22**]+ pitting edema bilaterally. +venous stasis +changes and dirt noted over bilateral extremities. +SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. +PULSES: +Right: DP 2+ PT 2+ +Left: DP 2+ PT 2+ + +Discharge exam: vitals stable +pulmonary exam: clear to auscultation bilaterally. +Otherwise unchanged. + +Pertinent Results: +CXR [**1-8**]: In comparison with the study of [**12-23**], there is again +huge +enlargement of the cardiac silhouette with evidence of pulmonary +vascular +congestion. It is difficult to determine whether there are +layering +effusions, because of extensive scattered radiation related to +the body +habitus of the patient. The ICD line is poorly seen, though it +appears to +extend to the region of the apex of the right ventricle. + +CXR [**1-9**]: In comparison with the study of [**1-8**], there are very +low lung +volumes. Huge enlargement of the cardiac silhouette persists. +Pulmonary +vessels are difficult to evaluate, though they do not appear to +be especially engorged. The AICD line extends to the region of +the apex of the right ventricle. The area behind the hugely +enlarged heart cannot be evaluated for the possible presence of +pneumonia or effusion. + +ECHO [**1-9**]: + +[**2193-1-8**] 10:50PM BLOOD WBC-11.8* RBC-4.95 Hgb-11.7* Hct-36.9* +MCV-75* MCH-23.5* MCHC-31.6 RDW-20.4* Plt Ct-229 +[**2193-1-9**] 04:16AM BLOOD WBC-12.4* RBC-5.10 Hgb-12.1* Hct-37.9* +MCV-74* MCH-23.6* MCHC-31.8 RDW-20.6* Plt Ct-275 +[**2193-1-9**] 04:16AM BLOOD Neuts-77.9* Lymphs-15.9* Monos-5.3 +Eos-0.6 Baso-0.3 +[**2193-1-8**] 10:50PM BLOOD PT-16.4* PTT-26.4 INR(PT)-1.5* +[**2193-1-8**] 10:50PM BLOOD Glucose-84 UreaN-20 Creat-1.7* Na-141 +K-4.2 Cl-104 HCO3-24 AnGap-17 +[**2193-1-9**] 04:16AM BLOOD Glucose-89 UreaN-24* Creat-2.1* Na-140 +K-4.4 Cl-104 HCO3-25 AnGap-15 +[**2193-1-9**] 04:16AM BLOOD ALT-19 AST-51* AlkPhos-97 TotBili-2.7* +DirBili-2.0* IndBili-0.7 +[**2193-1-9**] 04:16AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.3 +[**2193-1-8**] 10:32PM BLOOD Type-ART pO2-111* pCO2-49* pH-7.36 +calTCO2-29 Base XS-1 +[**2193-1-9**] 09:26AM BLOOD Type-ART pO2-88 pCO2-45 pH-7.35 +calTCO2-26 Base XS-0 +[**2193-1-9**] 07:43AM BLOOD Lactate-1.4 + +[**2193-1-21**] 07:08AM BLOOD WBC-12.5* RBC-5.60 Hgb-13.5* Hct-41.4 +MCV-74* MCH-24.0* MCHC-32.5 RDW-20.8* Plt Ct-295 +[**2193-1-18**] 04:56AM BLOOD Neuts-85.8* Lymphs-8.0* Monos-3.8 Eos-2.2 +Baso-0.2 +[**2193-1-21**] 07:08AM BLOOD Glucose-103* UreaN-18 Creat-0.7 Na-140 +K-4.1 Cl-103 HCO3-29 AnGap-12 + +AP CHEST, 8:24 A.M. [**1-19**] + +HISTORY: Intubated. Multilobar collapse or infection, assess +change. + +IMPRESSION: AP chest compared to [**1-15**] and 28. + +Severe cardiomegaly has improved since [**1-15**], subsequently +stable. +Previous mild pulmonary edema has also improved, though +pulmonary vascular +engorgement remains. Left lower lobe is consolidated, but has +probably +improved since [**1-15**] and since there was previously ipsilateral +mediastinal +shift much of that is probably atelectasis. The course of the +transvenous +right ventricular pacemaker lead is obscured in the heart by +cardiac motion. + +[**2193-1-18**] CT chest/[**Last Name (un) 103**]/pelvis + +Final Report +INDICATION: 24-year-old man with persistent fever after ICD +placement. Study +is to evaluate for source of infection. + +TECHNIQUE: MDCT images were acquired from the thoracic inlet +through the +pubic symphysis without administration of IV contrast. +Multiplanar +reformatted images were provided, essential in delineating +anatomy and +pathology. + +CT CHEST WITHOUT CONTRAST: There is complete collapse of the +left lower lobe +and partial collapse of right lower lobe, with an endotracheal +tube in place. +This probably represent atelectasis, although underlying +infection cannot be +excluded particularly in the setting of fever and leukocytosis. +Examination +of fine parenchymal detail or small nodules is severely limited +by motion +artifact as well as image quality. There is no pericardial or +pleural +effusion. + +Visualization of the thyroid gland is limited by motion, +however, a small +hypodensity with central hyperattenuation is seen in the +posterior left lobe +of the thyroid (2, 3), measuring approximately 8 mm. There is +moderate-to- +severe cardiomegaly. Patient is status post a left-sided ICD +placement with +metallic leads terminating in the right atrium and right +ventricle. Small +mediastinal and axillary lymph nodes do not meet CT criteria for +pathologic +enlargement. + +CT ABDOMEN WITHOUT CONTRAST: A nasogastric tube is in place with +its tip +terminating in mid stomach. Small amorphous echogenic material +layering along +the posterior fundal stomach probably represents ingested +material. Within +limitation of non-contrast technique, the liver, spleen, adrenal +glands, and +kidneys appear unremarkable. The gallbladder is not visualized. +A 2cm +hypodense area in the head of pancreas (2,73; 103b,41) may +represent a cyst. +There is no nephrolithiasis or hydronephrosis. There is no free +air or free +fluid. A few small focal areas of soft tissue thickening in the +right +abdominal adipose tissue are of uncertain etiology, for example, +series 2, +image 87. + +CT PELVIS WITHOUT CONTRAST: The bladder is decompressed with a +Foley catheter +which is in place. The rectum and sigmoid colon are collapsed. +Uterus is not +well seen. A 12mm right iliac lymph node is noted (2, 118), +non-specific. +Additional small scattered inguinal and pelvic sidewall lymph +nodes do not +meet CT criteria for pathologic enlargement. There is no free +fluid in the +pelvis. + +OSSEOUS FINDINGS: No suspicious lytic or blastic lesions. + +IMPRESSION: +1. Endotracheal tube in place with complete and partial collapse +of left and +right lower lobes probably represent atelectasis. However, +underlying +infection cannot be excluded given clinical presentation. + +2. No fluid collection or abscess identified in the abdomen or +pelvis. + +3. 8-mm left thyroid cyst or nodule can be further evaluated by +ultrasound. + +4. 2-cm hypoattenuating area in pancreatic head may represent a +cyst. +Further evaluation as clinically indicated. + +5. Cardiomegaly with ICD in place. + +6. Isolated 12mm right iliac lymph node is non-specific. + +The study and the report were reviewed by the staff radiologist. + + + +Brief Hospital Course: +24 yo M with non-ischemic cardiomyopathy admitted to CCU after +failure to extubate s/p elective AICD placement and right heart +cath. This failure was related to pulmonary edema, pneumonia +(serratia) and atelectasis. Over 10 days of ventillation, the +patient's I/O's were 8 L negative. In this time he had a +swan-ganz catheter placed and a myocardial biopsy. His course +was complicated by fevers which may have been related to +atelecatisis or a drug reaction (he had a bilateral blanching +erythematous rash) and/or serratia in his sputum. He was +extubated and swiftly transferred to the floor. He was +discharged to rehab______ + +#. Failure to extubate: Patient was unable to be extubated in +the PACU s/p ICD placement. Likely in setting of extrapulmonary +restriction (morbid obesity/large body habitus) and poor lung +compliance due to volume overload from patient's systolic and +diastolic heart failure, leading to elevated elastic pressures. +Mr. [**Known lastname 32362**] required 8 litres of measured diuresis and an +antibiotic course over 10 days to become suitable for extubation +(he was, until that point, hypercarbic on pressure support). +Pulmonary was consulted. A Chest CT on the day before extubation +highlighted atelecatasis. After extubation, he saturated at +91-94% on room air. +. +#. Non-ischemic dilated cardiomyopathy: His EF is 10% or less. +This is the indication for his ICD placement. Etiology thought +to be related to obesity, post-viral or related to distant +history drug use. A myocardial biopsy was unrevealing. His has +chronic systolic and diastolic heart failure. He required +invasive monitoring (SGC) and lasix, metolazone, diamox diuresis +to 8 measured litres negative. He will need a transplant work +up. He was discharged on metoprolol, [**Last Name (un) **], digoxin, lasix and +eplerinone. +. +#. Fever: Pt with T to 101.2 in the PACU and rising +leukocytosis. Likely febrile in setting of recent procedure. He +also had a bilateral, blanching, confluent erythematous rash +from his toes to umbillicus that gradually fades. His urine was +positive for Eosinophils. Blood cultures with coag negative +staph. C Diff negative. His Fever waxed and waned, peaking at +104.0 on ventillator day 8. He was placed under a cooling +blanket and given round-the-clock tylenol. A CT chest +underscored atelectasis but could not rule out pna. He slowly +defervesced while on antibiotics, so he continued on a full +course for VAP. +. +#. Acute renal failure: Mr. [**Known lastname 32362**] had two episodes of ARF. On +admission his Cr was up to 1.7 (baseline 1.1), which was likely +related to hypotension intraoperatively. This resolved. Later, +as his diuresis reached goal, his creatinine bumped to 2.4. +Renal was consulted and felt this was related to diuresis and +[**Last Name (un) **] therapy. This too resolved. During the workup, he was found +to have urine eos. +. +#. Hyperbilirubinemia: Patient had hyperbilirubinemia to 2.7 +with direct fraction of 2.0. When previously admitted for CHF +exacerbation, he had bilirubin elevations to 2.0. This is likely +related to congestive hepatopathy. As he diureses, these numbers +improve. He received an unremarkable RUQ US which commented on +the non-visualization of his gallbladder, which cannot be seen +on his CT's. This has not been confirmed by any direct +visualization. His CT abdomen this admission described a normal +appearing liver, while a prior exam described fatty infiltration +with nodularity. +. +#. Anemia, Microcytic: Mr. [**Known lastname 32362**] has Known iron deficiency +anemia s/p normal CT colonography. He has hemorrhoids and HbAC +(benign but gives microcytosis). He was maintained on iron with +vitamin C. + +# Asthma: It is the reason he wasn't started on carvedilol. +Patient states he had childhood asthma, and hasn't had asthma +symptoms since high school. Albuterol inhaler prn was given. + +#. OSA: Patient would benefit from CPAP, but he refused CPAP +here in the hospital after extubation. + + + +Medications on Admission: +1. Valsartan 40 mg PO DAILY +2. Aspirin 325 mg PO DAILY +3. Digoxin 250 mcg PO DAILY +4. Ferrous Sulfate 325 mg PO TID +5. Ascorbic Acid 250 mg Tablet PO TID +6. Furosemide 40 mg PO BID +7. Toprol XL 100 mg Tablet Sustained Release PO BID +8. Colace 100 mg PO BID +9. Senna 8.6 mg PO daily:PRN constipation + + +Discharge Medications: +1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr +Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a +day). +3. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO TID (3 +times a day). +4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 +times a day). +5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) +Tablet PO TID (3 times a day). +6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +7. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a +day) as needed for constipation. +8. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO once a day. +Disp:*90 Tablet(s)* Refills:*2* +9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One +(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for +1 months. +Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* +10. Eplerenone 25 mg Tablet Sig: Two (2) Tablet PO DAILY +(Daily). +Disp:*60 Tablet(s)* Refills:*2* +11. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO TID (3 times +a day). +12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) +Tablet PO TID (3 times a day). +14. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr +Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a +day). +16. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*2* +17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 +days. +Disp:*14 Tablet(s)* Refills:*0* + + +Discharge Disposition: +Home With Service + +Facility: +[**Location (un) 86**] VNA + +Discharge Diagnosis: +Non-Ischemic Dilated Cardiomyopathy +Morbid Obesity +Obstructive Sleep Apnea + + +Discharge Condition: +Mental Status:Clear and coherent +Level of Consciousness:Alert and interactive +Activity Status:Ambulatory - Independent + +VS: Within normal limits +Lungs: clear +Wound: clean +CV: regular +Ext: no edema + + +Discharge Instructions: +It was a pleasure to be involved in your care, Mr. [**Known lastname 32362**]. You +were admitted to [**Hospital1 69**] Cardiac +Care Unit after an defibrillator was placed. You had an +internal defibrillator implanted for primary prevention of +sudden cardiac death in the setting of a non-ischemic dilated +cardiomyopathy. After the defibrillator was placed, you were +intubated for 10 days because of difficulties to extubate you. +You were aggressively diuresed with IV lasix, and you were also +treated with antibiotics for pneumonia. You were extubated on +[**1-18**], and since then you recovered rapidly. + +Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up +more than 3 lbs.in 2 days or 5 pounds in 5 days. + +Your medications have been changed: +You have been started on 20mg torsemide daily +Your valsartan has been increased to 120mg daily +You have been started on eplernone 50mg daily +You have been started on an antibiotic ciprofloxacin 500mg twice +daily for 3 days. +You have beens started on pantoprazole 40mg daily for 1 month + +Followup Instructions: +You have the following follow-up appointments + +Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] +Date/Time:[**2193-1-29**] 11:00 +Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-2-11**] +10:00 + + + +Completed by:[**2193-1-22**]","mr. [**known lastname 10185**] is a 24 yo m with non-ischemic cardiomyopathy (ef 25% in [**9-28**]) who was admitted for right heart cardiac catherization and aicd placement today. he is being transferred to the ccu after difficulty with extubation s/p cath. patient was recently admitted to the ccu from [**2192-12-23**] - [**2192-12-26**] with acute congestive heart failure in the setting of dietary non-compliance. he was scheduled to have his aicd placed today under general anesthesia per recommendation by dr. [**last name (stitle) 2363**]. per anesthesia, patient was a difficult intubation due to his body habitus, and was maintained on a phenylephrine gtt in order to maintain his blood pressures during the procedure (sbps in 100s-120s). he underwent rhc which showed elevated wedge, pa, rv, and ra pressures (see hemodynamics below). he had a [**company **] single chamber icd placed through cutdown of left cephalic vein without complication. he was continued on a neo gtt which was weaned at 5 pm, and remained off pressors for 4 hours prior to ccu transfer. patient was transitioned to ps [**9-29**] in an attempt at extubation in the pacu, but these attempts were unsuccessful due to tachypnea and secretions requring continuous secretions. patient was also noted to be difficult to sedate during ventilation and was maintained on propofol 70 mcg/kg/min. a-lines attempts in both radial arteries by anesthesia were unsuccessful. it was thought that the failure to extubate was due to body habitus and pulmonary edema. prior to transfer to ccu, vs were 98.6 112/48 110 20 100% on cpap with peep of 10 and fio2 of 50%. he received 20 mg of iv lasix in the pacu and was transferred to the ccu for further management. ros unable to be obtained due to patient being intubated and sedated.",24 yo m with non-ischemic cardiomyopathy admitted to ccu after failure to extubate s/p elective aicd placement and right heart cath.,"known lastname 10185**] is a 24 yo m with non-ischemic cardiomyopathy (ef 25% in [**9-28**]) who was admitted for right heart cardiac catherization and aicd placement today. he is being transferred to the ccu after difficulty with extubation s/p cath. patient was transitioned to ps [**9-29**] in an attempt at extubation in the pacu, but these attempts were unsuccessful due to tachypnea and secretions requring continuous secretions. a-lines attempts in both radial arteries by anesthesia were unsuccessful. prior to transfer to ccu, vs were 98.6 112/48 110 20 100% on cpap with peep of 10 and fio2 of 50%. he received 20 mg of iv lasix in the pacu and was transferred to the ccu for further management.",['The 24yo Japanese man was admitted for right heart catheterisation and a biopsy.\nHe was initially admitted for a cardiac catheter but was later transferred to a cyst.\nThe patient was a difficult to sedate during the procedure.\nIt was thought that the failure to exhale was due to body habitus and pulmonary edema.\nThis is when the patient is prone to breathing difficulties.'],mr. [**known lastname 10185**] is a 24 yo m with non-ischemic cardiomyopathy. he was admitted to the ccu from [**2192-12-23**] - [**2192-12-26**] with acute congestive heart failure in the setting of dietary non-compliance. he was scheduled to have his aicd placed today under general anesthesia.,"['mr. [**known lastname 10185*] is being transferred to the hospital after difficulty with extubation today under general anesthesia and without complications, but was discharged on sunday morning from his home in north carolina for treatment of acute congestive heart failure (ef 25%)']","patient was recently admitted to the ccu from [**2192-12-23**] - [**2192-12-26**] with acute congestive heart failure in the setting of dietary non-compliance. +per anesthesia, patient was a difficult intubation due to his body habitus, and was maintained on a phenylephrine gtt in order to maintain his blood pressures during the procedure (sbps in 100s-120s). +patient was transitioned to ps [**9-29**] in an attempt at extubation in the pacu, but these attempts were unsuccessful due to tachypnea and secretions requring continuous secretions.","[**known lastname 10185**] is a 24 yo m with non-ischemic cardiomyopathy (ef 25% in [**9-28**]) who was admitted for right heart cardiac catherization and aicd placement today.he is being transferred to the ccu after difficulty with extubation s/p cath.patient was recently admitted to the ccu from [**2192-12-23**] - [**2192-12-26**] with acute congestive heart failure in the setting of dietary non-compliance.he was scheduled to have his aicd placed today under general anesthesia per recommendation by dr.per anesthesia, patient was a difficult intubation due to his body habitus, and was maintained on a phenylephrine gtt in order to maintain his blood pressures during the procedure (sbps in 100s-120s).he underwent rhc which showed elevated wedge, pa, rv, and ra pressures (see hemodynamics below).he had a [**company **] single chamber icd placed through cutdown of left cephalic vein without complication.he was continued on a neo gtt which was weaned at 5 pm, and remained off pressors for 4 hours prior to ccu transfer.patient was also noted to be difficult to sedate during ventilation and was maintained on propofol 70 mcg/kg/min.he received 20 mg of iv lasix in the pacu and was transferred to the ccu for further management.","[{'rouge-1': {'r': 0.85, 'p': 0.19767441860465115, 'f': 0.32075471391954435}, 'rouge-2': {'r': 0.4, 'p': 0.07079646017699115, 'f': 0.12030074932443896}, 'rouge-l': {'r': 0.75, 'p': 0.1744186046511628, 'f': 0.2830188648629406}}]","[{'rouge-1': {'r': 0.3, 'p': 0.13043478260869565, 'f': 0.18181817759412314}, 'rouge-2': {'r': 0.1, 'p': 0.031746031746031744, 'f': 0.04819276742633211}, 'rouge-l': {'r': 0.3, 'p': 0.13043478260869565, 'f': 0.18181817759412314}}]","[{'rouge-1': {'r': 0.6, 'p': 0.3, 'f': 0.3999999955555556}, 'rouge-2': {'r': 0.3, 'p': 0.13953488372093023, 'f': 0.1904761861426053}, 'rouge-l': {'r': 0.55, 'p': 0.275, 'f': 0.3666666622222223}}]","[{'rouge-1': {'r': 0.3, 'p': 0.14285714285714285, 'f': 0.19354838272632682}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.2, 'p': 0.09523809523809523, 'f': 0.12903225369406884}}]","[{'rouge-1': {'r': 0.35, 'p': 0.11666666666666667, 'f': 0.17499999625000007}, 'rouge-2': {'r': 0.05, 'p': 0.013157894736842105, 'f': 0.020833330034722746}, 'rouge-l': {'r': 0.25, 'p': 0.08333333333333333, 'f': 0.12499999625000012}}]","[{'rouge-1': {'r': 0.9, 'p': 0.13432835820895522, 'f': 0.2337662315061562}, 'rouge-2': {'r': 0.5, 'p': 0.05319148936170213, 'f': 0.09615384441568049}, 'rouge-l': {'r': 0.8, 'p': 0.11940298507462686, 'f': 0.2077922055321302}}]",0.85,0.197674419,0.320754714,0.4,0.07079646,0.120300749,0.75,0.174418605,0.283018865,0.3,0.130434783,0.181818178,0.1,0.031746032,0.048192767,0.3,0.130434783,0.181818178,0.6,0.3,0.399999996,0.3,0.139534884,0.190476186,0.55,0.275,0.366666662,0.3,0.142857143,0.193548383,0,0,0,0.2,0.095238095,0.129032254,0.35,0.116666667,0.174999996,0.05,0.013157895,0.02083333,0.25,0.083333333,0.124999996,0.9,0.134328358,0.233766232,0.5,0.053191489,0.096153844,0.8,0.119402985,0.207792206 +62707,169169,9531,"Chief Complaint: Hematemesis + HPI: + Mrs. [**Known lastname 8317**] is a very pleasant 69 year old female with past medical + history of esophageal and breast cancer. She is currently undergoing + treatment with cisplatin, 5-FU, and radiation. Her last treatment was + [**2178-9-21**], and her OMED team has been treating her for nausea, fatigue, + and poor PO intake. + . + [**Hospital Unit Name 10**] team was called for evaluation on [**2178-9-24**] after patient had + episode of hematemesis. Patient reports that she was sleeping and awoke + with substernal chest discomfort. Shortly thereafter, she vomitted + approximately 150 cc of bright red bloody emesis. She was noted to be + slightly tachycardic with a heart rate to the 110's. Of note, her + platelet count was 19,000 on morning of hematemesis. The moonlighter + discussed the patient with her oncology attending; it was felt that + transfer to the [**Hospital Unit Name 10**] was appropriate given that her short term + prognosis was felt to be favorable. OMED moonlighter initiated IV + PPI/H2 blocker, transfusion of 2 units of platelets, morphine for pain + control, and stat laboratories to check CBC and coags. An EKG + demonstrated ST elevation in aVR/V1. + . + Upon evaluation on the floor, patient was laying quietly. She reported + that at the moment, she felt well, though could still sense some of the + pain. + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Other ICU medications: + Other medications: + Past medical history: + Family history: + Social History: + - Breast cancer: Stage III, right-side, diagnosed in [**2169**]. She has had + a right mastectomy and adjuvant chemotherapy, followed by five years of + tamoxifen and extended adjuvant endocrine therapy with letrozole in + [**12/2174**] until present, with biposy of T6 vertebral body suspsicious for + metastasis (eitehr breast or esophageal). + - Esophageal cancer: Diagnosed in [**6-/2178**], squamous cell carcinoma. + - Hypertension + Non-contributory + Patient is married, does not smoke (quit over 15 years ago, smoked 1 + PPD for 20 years). Social alcohol use, no ilicit drug use. + Review of systems: + As noted above. Patient has had nausea and poor PO intake. + Dry + heaves, + substernal chest pain, + discomfort with eating and drinking, + improved after GI cocktail. + Currently denies SOB, CP + Flowsheet Data as of [**2178-9-24**] 07:41 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Total In: + PO: + TF: + IVF: + Blood products: + Total out: + 0 mL + 0 mL + Urine: + NG: + Stool: + Drains: + Balance: + 0 mL + 0 mL + Respiratory + Physical Examination + General: Pleasant female laying quietly in bed, NAD, slightly pale + HEENT: NC/AT, slightly dry mucous membranes, no scleral icterus + Lungs: CTAB no w/r/r + Cardiac: Regular, S1, S2, no m/g/r + Abdomen: soft, NT, ND, no focal tenderness, guarding, rebound + tenderness + Extr: Warm, no c/c/e + Neuro: A&Ox3 + Vasc: radial/DP/PT 2+ bilaterally + Labs / Radiology + [image002.jpg] + Assessment and Plan + Mrs. [**Known lastname 8317**] is 69 year old with history of esophageal cancer and + breast, currently undergoing Cycle 2 of therapy with cisplatin and 5-FU + as well as radiation therapy, who is transfered to the [**Hospital Unit Name 10**] for + hematemesis. + . + #) Hematemesis: Suspect this is likely due to radiation esophagitis + coupled with mucositis due to chemotherapy leading to + [**Doctor First Name 331**]-[**Doctor Last Name **]-like tears with heaving. In setting of thrombocytopenia, + this is a set-up for hematemesis. This would fit with her substernal + discomfort that accompanied the episode. Other possibilities include + peptic ulcer disease, bleeding from malignancy, vascular malformation, + fistula, among other causes. + - Continue IV BID PPI, H2 blocker + - Getting 2 units of platelets now, will follow up post-transfusion + counts, transfuse to goal of 30 K if possible + - Follow up HCT now, q6-8 hours + - Access: PIV and port in place + - GI cockail + - Pain control with morphine + - Anti-emetics PRN + - If [**Last Name (LF) 8318**], [**First Name3 (LF) 116**] discuss if any other potential treatment options are + appropriate with GI aside from supportive care, as unsure what role + upper endoscopy would have + - Checking coagulation studies + - NPO for now with maintenance IVF + - Adding on cardiac enzymes, follow up EKG + . + #) Esophageal cancer, breast cancer: Currently on cycle 2 of therapy; + this is her expected nadir of counts. + - Continue supportive transfusions as needed (HCT goal >25, Plt >30) + - Appreciate oncology recommendations + - Pain control and anti-emetics PRN + . + #) Neutropenia: Expected as counts nadir. + Continue to monitor for fever and initiate antibiotics as appropriate + - Follow ANC + - Neutropenic precautions + - Neupogen 300 mcg per oncology recommendations + . + #) Prophylaxis: PPI/H2 blocker, holding heparin given thrombocytopenia + . + #) FEN: NPO for now, IVF for maintenance, replete electrolytes PRN + . + ICU Care + Nutrition: NPO for now + Glycemic Control: Insulin sliding scale if needed + Lines: + Prophylaxis: Pneumoboots, no heparin SQ given bleeding and low counts + DVT: Pneumoboots + Stress ulcer: + VAP: + Comments: + Communication: Comments: + Code status: Full + Disposition: ICU for now, though if remains hemodynamically stable and + no further episodes, would consider transfer back to floor +","Admission Date: [**2178-9-12**] Discharge Date: [**2178-10-8**] + +Date of Birth: [**2108-10-8**] Sex: F + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 3276**] +Chief Complaint: +Nausea + +Major Surgical or Invasive Procedure: +EGD + + +History of Present Illness: +69 yo woman with ho Stage III esophogeal carcinoma on on day 6 +of cycle 2 of cisplatin/5-FU, presents with nausea, fatigue, +poor PO intake. Describes symptoms coinciding with chemotherapy +initiation. Denies vomitting but reports dry heaves. Patient +describes herself as very weak. Patient also reports +intermittent upper substernal CP, associated only with +eating/swallowing and relieved with GI coctail. The patient +denies associated SOB, fevers, chills, cough. Also denies +abdominal pain, diarrhea, significant weight changes, back pain. +Reports dysphagia, constipation, and decreased appetite. + +Past Medical History: + +PAST ONCOLOGIC HISTORY: +====================== +Stage III right breast cancer, diagnosed in [**2169**]. She was +treated with a right mastectomy and adjuvant chemotherapy. She +then completed five years of tamoxifen and began extended +adjuvant endocrine therapy with letrozole in [**12/2174**] until +present +. +[**7-16**] Bone, T6 vertebral body, needle core biopsy: +Highly suspicious for metastatic carcinoma (see note). +. +[**7-16**] Vertebral bone (T6), fine needle aspirate and touch prep of + +core biopsy: +ATYPICAL. +Rare atypical single cells in a background of hematopoietic +elements. +. +[**6-16**]: +A. Esophageal tumor: +Poorly differentiated invasive carcinoma, consistent with +squamous cell carcinoma. +B. Proximal edge of esophageal tumor at 30 cm: +Poorly differentiated invasive carcinoma, consistent with +squamous cell carcinoma. +C. Antrum: +Antral mucosa with mild regenerative changes suggestive of +chemical gastropathy. +. +Unclear if T6 biopsy, breast cancer or esophageal cancer. Tx +presumptively for esophageal cancer given it is so aggressive +. +PAST MEDICAL HISTORY: +==================== +Onc history as detailed above +HL +HTN, no longer requires antihypertensive medications + + +Social History: +Married 46 yrs, lives with husband. +EtOH: one drink a night before dinner +Tobacco: quit 15 yrs ago, smoked 20 yrs, 1PPD = 20 packyears +No illicits + + +Family History: +Noncontributory + +Physical Exam: +97.5 110/80 82 18 98-100%RA +GEN: Pleasant, thin elderly woman in NAD, occasionally heaving +during interview +HEENT: No LAD, oropharynx clear, MMM wo erythema or thrush. +PERRLA. +CV: RRR, no RMG +PULM: CTAB, no WRR +ABD: Soft, NTND, +BS, no rebound or guarding, no organomegaly +EXT: No edema + +Pertinent Results: +GLUCOSE-172* UREA N-21* CREAT-1.2* SODIUM-129* POTASSIUM-3.7 +CHLORIDE-91* TOTAL CO2-26 ANION GAP-16 +CALCIUM-8.0* PHOSPHATE-2.0* MAGNESIUM-1.3* + +WBC-4.9 HCT-34.5* MCV-92 PLT COUNT-204 + +LACTATE-2.4* + +URINE +BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-NEG +BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG COLOR-Yellow +APPEAR-Clear SP [**Last Name (un) 155**]-1.010 + +CHEST (PA & LAT) Study Date of [**2178-9-12**] +Compared to the prior study, there has been no significant +interval change. A left subclavian Port-A-Cath is again seen +with tip in the proximal superior vena cava. The lungs are clear +without infiltrate or effusion. + +EKG: Sinus tachycardia, LAD, TW inversions in III and aVF, +unchanged from prior EKG from [**2178-8-22**]. + + +Brief Hospital Course: +69 yo woman with ho Stage III esophogeal carcinoma on day 6 of +cycle 2 of cisplatin/5-FU, presents with nausea, fatigue, poor +PO intake. + +# Esophagitis: Patient with signicant esophagitis. In setting of +radiation tx, thrombocytopenia, pt vomitted 150cc of frank +bloody emesis and was admitted to [**Hospital Unit Name 153**] for observation. Pt was +transfused 1 unit PRBCs and 3 units platelets and an EGD showed +erosive esophagitis, likely radiation induced. Patient's +dysphagia improved with iv pantoprazole. + +# Pancytopenia: Pt with severe thrombocytopenia requiring +multiple transfusions of platelets, PRBCs, and was started on +neupogen which resolved her neutropenia. Patient remained +afebrile. + +# Nausea: Most likely combination of cisplatinum chemotoxicity +causing central nausea along with constipation possibly induced +by narcotics and zofran. Pt is afebrile and without other sx or +signs of infection. Nausea was refractory and severe and needed +standing Zofran 8 mg IV Q8H, Prochlorperazine 10 mg IV Q6H and +Reglan with eventual resolution. Patient's nausea required +nighttime doses which also helped her AM nausea. + +# CP: Most likely caused by esophogitis given association with +eating and resolution with GI coctail. EKG normal. Pt with +modified Well's score of 1 and low risk for PE. Cardiac enzymes +negative. Continued home GI coctail with good effect. + +# Dehydration: Most likely due to poor PO intake mostly related +to chemotoxicity and dysphagia and probable component of +esophogeal malignancy. Pt on IVF, and this was eventually weaned +off once PO intake improved. + +# Constipation: Likely related to morphine and zofran. Resolved +with aggressive bowel regimen. + +# Hypokalemia/Hypomagnesemia: Persisted despite resolution of +nausea/vomitting, likely secondary to chemotoxicity. Pt +instructed to return to clinic within the week to check lytes. + + +Medications on Admission: +(All medications reconciled with patient and patient's husband). + +ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once +a week +FENTANYL - 25 mcg/hour Patch 72 hr - Apply to skin every 72 +hours As of [**2178-9-2**] patient using two 25 mcg/hr patches for a +total of 50 mcg/hr. +LETROZOLE - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day +LIDOCAINE HCL - 20 mg/mL Solution - Apply topically q2-4 h PRN +LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] - 400 +mg-400 mg-40 mg-25 mg-200 mg/30 mL Mouthwash - use as directed +before meals as needed for mouth sores. +MORPHINE - 15 mg Tablet - [**1-9**] Tablet(s) by mouth every 4-6 hours +as needed for pain +NYSTATIN - 100,000 unit/mL Suspension - one teaspoon by mouth +four times a day retain in mouth as long as possible then +swallow +ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth +q8-12hrs as needed for prn nausea/vomiting +ORAL WOUND CARE PRODUCTS [GELCLAIR] - Gel in Packet - 1 Gel(s) +three times a day as needed for Mucositis +POLYETHYLENE GLYCOL 3350 - 100 % Powder - 1 Powder(s) by mouth +DAILY (Daily) hold for lose stool +POTASSIUM CHLORIDE [KLOR-CON M20] - 20 mEq Tab Sust.Rel. +Particle/Crystal - 4 Tab(s) by mouth qd x 2 days followed by 2 +tabs qd x 2 days +PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth +every six (6) hours as needed for nausea +ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg +Tablet - 1 Tablet(s) by mouth once a day + +Medications - OTC +ASCORBIC ACID - 1,000 mg Tablet - 1 (One) Tablet(s) by mouth +NOT TAKING WHILE HAVING CHEMO AND RADIATION THERAPY +CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - Dosage +uncertain +CORTISONE - 1 % Cream - 1 Cream(s) four times a day as needed +for rash do not use on face +DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 to 2 Capsule(s) by +mouth once a day as needed +OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 +Capsule(s) by mouth once a day +SENNOSIDES [SENOKOT] - 8.6 mg Tablet - 1 to 2 Tablet(s) by mouth +once a day as needed + + +Discharge Medications: +1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a +day) as needed for constipation. +Disp:*90 Tablet(s)* Refills:*2* +2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr +Transdermal Q72H (every 72 hours). +Disp:*10 Patch 72 hr(s)* Refills:*2* +3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) +Tablet, Chewable PO TID (3 times a day). +4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) +Tablet PO DAILY (Daily). +5. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN +(as needed) as needed for Mouth pain. +Disp:*5 containers* Refills:*2* +6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 +times a day) as needed for constipation. +Disp:*90 * Refills:*2* +7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H +(every 8 hours) as needed for Constipation. +Disp:*3 Bottles* Refills:*2* +8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) +Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for +constipation. +Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* +9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, +Chewable PO TID (3 times a day) as needed for indigestion, acid +reflux. +Disp:*60 Tablet, Chewable(s)* Refills:*2* +10. Petrolatum Ointment Sig: One (1) Appl Topical TID (3 +times a day) as needed for xrt burn. +Disp:*30 Containers* Refills:*2* +11. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: One (1) +PO three times a day as needed for heartburn. +12. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO +Q6H (every 6 hours) as needed for nausea. +Disp:*90 Tablet(s)* Refills:*2* +13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS +(4 times a day (before meals and at bedtime)). +Disp:*90 Tablet(s)* Refills:*2* +14. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, +Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. +Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2* +15. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO once a day. +16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) +Capsule, Delayed Release(E.C.) PO once a day. +17. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). +Disp:*30 Tablet(s)* Refills:*2* +18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal +Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 +days. +Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* +19. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. + +20. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as +needed for pain. + + +Discharge Disposition: +Home + +Discharge Diagnosis: +Primary: +1) Esophagitis +2) Pancytopenia +3) Neutropenia +4) Dehydration + +Secondary: +Metastatic esophogeal cancer + + +Discharge Condition: +Stable, afebrile + + +Discharge Instructions: +It was a pleasure to take care of you during your +hospitalization. + +You were admitted to the hospital for nausea, vomitting, and +dehydration due to chemotoxicity. You continued to receive +radiation to your esophagus during your hospital stay. You +developed bloody vomitus and an upper GI scope revealed severe +esophagitis secondary to radiation injury. Your blood counts +also suffered from the chemotherapy. We gave you platelets, red +blood cells, and neupogen to stimulate your bone marrow to make +neutrophils, an important white blood cell. Over time your cell +counts stabilized. Fortunately, your ability to swallow, nausea, +and vomitting improved throughout your hospital stay and you +were able to take in sufficient oral intake. You also had a +slightly fast heart rate. A medicaiton, Atenolol, was started to +control your heart rate. You also had low potassium. Please take +potassium as it perscribed below. You are to be discharged to +home with home VNA services following. + +We have made the following changes to your medications: +1) Potassium tablet 20mEQ by mouth every day for 7 days or until +you see your oncologist. +2) Atenolol 25mg by mouth every day. +3) Bisacody 10mg by mouth every day as needed for constipation +4) Lactulose 30mL every 8 hours as needed for constipation +4) Ondansetron ODT 8mg by mouth every 8 hours for nausea +5) Prochlorperazine 10mg by mouthe very 6 hours for nausea +6) Metoclopramide 10mg by mouth four times a day with meals and +at bedtime for nausea + +If you experience chest pain, shortness of breath, high fevers, +please come to the emergency department. + +Followup Instructions: +Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**] +Date/Time:[**2178-10-13**] 3:00 + +You have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD +Phone:[**0-0-**] Date/Time:[**2178-10-22**] 2:00 + +You have an appointment with Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD +Phone:[**0-0-**] Date/Time:[**2178-10-22**] 2:30 + +You have an appointment with Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. +Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2178-11-13**] 12:30 + + + [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] + +Completed by:[**2178-10-12**]","mrs. [**known lastname 8317**] is a very pleasant 69 year old female with past medical history of esophageal and breast cancer. she is currently undergoing treatment with cisplatin, 5-fu, and radiation. her last treatment was [**2178-9-21**], and her omed team has been treating her for nausea, fatigue, and poor po intake. [**hospital unit name 10**] team was called for evaluation on [**2178-9-24**] after patient had episode of hematemesis. patient reports that she was sleeping and awoke with substernal chest discomfort. shortly thereafter, she vomitted approximately 150 cc of bright red bloody emesis. she was noted to be slightly tachycardic with a heart rate to the 110's. of note, her platelet count was 19,000 on morning of hematemesis. the moonlighter discussed the patient with her oncology attending; it was felt that transfer to the [**hospital unit name 10**] was appropriate given that her short term prognosis was felt to be favorable. omed moonlighter initiated iv ppi/h2 blocker, transfusion of 2 units of platelets, morphine for pain control, and stat laboratories to check cbc and coags. an ekg demonstrated st elevation in avr/v1. upon evaluation on the floor, patient was laying quietly. she reported that at the moment, she felt well, though could still sense some of the pain.","69 yo woman with ho stage iii esophogeal carcinoma on day 6 of cycle 2 of cisplatin/5-fu, presents with nausea, fatigue, poor po intake.","known lastname 8317**] is a very pleasant 69 year old female with past medical history of esophageal and breast cancer. she is currently undergoing treatment with cisplatin, 5-fu, and radiation. patient reports that she was sleeping and awoke with substernal chest discomfort. shortly thereafter, she vomitted approximately 150 cc of bright red bloody emesis. the moonlighter discussed the patient with her oncology attending; it was felt that transfer to the [**hospital unit name 10**] was appropriate given that her short term prognosis was felt to be favorable.","[""The 69-year-old woman is currently undergoing treatment with citalopram, morphine for pain control.\nShe vomited approximately 150cc of blood.\nThe op was described as'very pleasant' and'very sedating'\nShe was also noted to be very tachycardic.""]","mrs. [**known lastname 8317**] is a very pleasant 69 year old female. she is currently undergoing treatment with cisplatin, 5-fu, and radiation. her omed team has been treating her for nausea, fatigue, and poor po intake.","['omed team evaluated patient after she had episode of bloody epilepsy, reported discomfort in bed and was slightly shaken up by the pain. platelet count 19,000 on mornings her disease occurred; prognoses were favorable for short term patients with medical history cancerous breast or stomach problems (ecb)']","[**hospital unit name 10**] team was called for evaluation on [**2178-9-24**] after patient had episode of hematemesis. +omed moonlighter initiated iv ppi/h2 blocker, transfusion of 2 units of platelets, morphine for pain control, and stat laboratories to check cbc and coags.","[**known lastname 8317**] is a very pleasant 69 year old female with past medical history of esophageal and breast cancer.she is currently undergoing treatment with cisplatin, 5-fu, and radiation.her last treatment was [**2178-9-21**], and her omed team has been treating her for nausea, fatigue, and poor po intake.[**hospital unit name 10**] team was called for evaluation on [**2178-9-24**] after patient had episode of hematemesis.patient reports that she was sleeping and awoke with substernal chest discomfort.shortly thereafter, she vomitted approximately 150 cc of bright red bloody emesis.she was noted to be slightly tachycardic with a heart rate to the 110's.of note, her platelet count was 19,000 on morning of hematemesis.the moonlighter discussed the patient with her oncology attending; it was felt that transfer to the [**hospital unit name 10**] was appropriate given that her short term prognosis was felt to be favorable.upon evaluation on the floor, patient was laying quietly.","[{'rouge-1': {'r': 0.13636363636363635, 'p': 0.04477611940298507, 'f': 0.06741572661532655}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13636363636363635, 'p': 0.04477611940298507, 'f': 0.06741572661532655}}]","[{'rouge-1': {'r': 0.13636363636363635, 'p': 0.08823529411764706, 'f': 0.10714285237244918}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13636363636363635, 'p': 0.08823529411764706, 'f': 0.10714285237244918}}]","[{'rouge-1': {'r': 0.3181818181818182, 'p': 0.21212121212121213, 'f': 0.2545454497454546}, 'rouge-2': {'r': 0.13043478260869565, 'p': 0.08571428571428572, 'f': 0.1034482710761001}, 'rouge-l': {'r': 0.3181818181818182, 'p': 0.21212121212121213, 'f': 0.2545454497454546}}]","[{'rouge-1': {'r': 0.13636363636363635, 'p': 0.06382978723404255, 'f': 0.08695651739550536}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13636363636363635, 'p': 0.06382978723404255, 'f': 0.08695651739550536}}]","[{'rouge-1': {'r': 0.13636363636363635, 'p': 0.08108108108108109, 'f': 0.1016949105774205}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.13636363636363635, 'p': 0.08108108108108109, 'f': 0.1016949105774205}}]","[{'rouge-1': {'r': 0.4090909090909091, 'p': 0.08737864077669903, 'f': 0.14399999709952008}, 'rouge-2': {'r': 0.13043478260869565, 'p': 0.02027027027027027, 'f': 0.03508771697000803}, 'rouge-l': {'r': 0.4090909090909091, 'p': 0.08737864077669903, 'f': 0.14399999709952008}}]",0.136363636,0.044776119,0.067415727,0,0,0,0.136363636,0.044776119,0.067415727,0.136363636,0.088235294,0.107142852,0,0,0,0.136363636,0.088235294,0.107142852,0.318181818,0.212121212,0.25454545,0.130434783,0.085714286,0.103448271,0.318181818,0.212121212,0.25454545,0.136363636,0.063829787,0.086956517,0,0,0,0.136363636,0.063829787,0.086956517,0.136363636,0.081081081,0.101694911,0,0,0,0.136363636,0.081081081,0.101694911,0.409090909,0.087378641,0.143999997,0.130434783,0.02027027,0.035087717,0.409090909,0.087378641,0.143999997 +95186,169330,9540,"TITLE: + Chief Complaint: CP + HPI: + 72 y/o M with h/o [** **] '[**82**] s/p BMS x 2 to mid-LAD who presented to OSH + with chest pain. Patient awoke from his sleep at approx 11pm [**12-14**] + with 10/10 chest pain that prompted him to seek EMS. Patient describes + as a pressure across his chest with radiation to both of his arms. + Reports associated SOB, Nausea and states that presentation is similar + to his [**Month/Year (2) **] in [**2182**]. + Patient's initial vitals at OSH were BP 148/100, HR 94, 99%RA. Patient + was found to have anterior ST elevations on ECG and was given ASA + 325mg, plavix loaded, and started on NTG and Eptifibatide gtts. + Patient's nausea was controlled with zofran, and given lopressor 5mg IV + x 1. The patient was transferred to [**Hospital1 5**] for cardiac + catheterization. On transfer, patient's BP was 124/74 on NTG gtt. + Patient was not started on heparin gtt at OSH as there was concern for + widened mediastinum. + . + During cardiac catheterization, patient was found to have proximal + mid-LAD late stent thrombosis. Patient had thrombectomy and had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] + 1 placed overlapping prior proximal BMS. D1 with 70% lesion, distal + 50% LAD lesion that appears old. RCA with mild luminal irregularies. + The patient was continued on integrillin. + . + 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. + . + Cardiac review of systems is notable for current resolution chest + pain. Denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, + palpitations, syncope or presyncope. + Allergies: + No Known Drug Allergies + Last dose of Antibiotics: + Infusions: + Eptifibatide (Integrilin) - 2 mcg/Kg/min + Other ICU medications: + Other medications: + Atenolol 12.5mg daily + Simvastatin 20mg daily (dose limited by myalgias) + ASA 81mg daily + ***Prednisone Taper x 1 wk for Gout (completed course) + ***Indomethacin - x 1 wk for Gout + Past medical history: + Family history: + Social History: + 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension + 2. CARDIAC HISTORY: + - s/p [**Last Name (Prefixes) **] [**2182**] + -CABG: + -PERCUTANEOUS CORONARY INTERVENTIONS: + [**8-/2182**]: 95% mid LAD lesion with clot with adjacent 90% lesion as well as + 50% distal LAD lesion. s/p PTCA and BMS x 2 (overlapping) to mid LAD. + ---D1 w/ 70% stenosis, RCA had 30% smooth stenoses in the proximal and + mid-portions. There was a 30% proximal PDA stenosis + ---Systolic dysfunction in 8/00 by LV gram + . + -PACING/ICD: + 3. OTHER PAST MEDICAL HISTORY: + - s/p multiple back surgeries + No family history of early MI, arrhythmia, cardiomyopathies, or sudden + cardiac death; otherwise non-contributory. + -Tobacco history: 50 pack year, quit 9 years ago + -ETOH: Drinks 1 beer/[**Doctor Last Name 34**] daily + -Illicit drugs: None + Review of systems: + Flowsheet Data as of [**2191-12-15**] 04:43 AM + Vital Signs + Hemodynamic monitoring + Fluid Balance + 24 hours + Since 12 AM + Tmax: 35.2 +C (95.3 + Tcurrent: 35.2 +C (95.3 + HR: 62 (62 - 76) bpm + BP: 127/92(99) {108/68(77) - 127/92(99)} mmHg + RR: 13 (13 - 19) insp/min + SpO2: 96% + Heart rhythm: SR (Sinus Rhythm) + Height: 69 Inch + Total In: + 129 mL + PO: + 50 mL + TF: + IVF: + 79 mL + Blood products: + Total out: + 0 mL + 500 mL + Urine: + 500 mL + NG: + Stool: + Drains: + Balance: + 0 mL + -371 mL + Respiratory + O2 Delivery Device: Nasal cannula + SpO2: 96% + Physical Examination + VS: 95.3, 70, 127/83, 19, 94% 3LNC + 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 JVP 6 cm (near fully recumbent) + CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, + normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. + LUNGS: CTA anterolaterally, no crackles, wheezes or rhonchi. + ABDOMEN: Soft, NT. Mild Distention. 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+ Femoral 2+ DP 1+ PT 1+ + Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ + Labs / Radiology + 204 K/uL + 13.9 g/dL + 42.2 % + 14.4 K/uL + [image002.jpg] + EKG: + [**2191-12-14**] 2352: NSR @ 72. Nl Acisn, NL intervals. 2-3mm STE in V1-4, + peaked Ts laterally. + . + [**2191-12-15**] 0017: NSR @ 79. NL Axis, NL intervals. 3.5mm ST elevations + in V2-3. 1-2mm STEs in V5-6. Compared to EKG on [**2191-12-14**] @ 2352, + lateral involvement is present. + . + TELEMETRY: + . + 2D-ECHOCARDIOGRAM: + [**2-20**]: LVEF 60%, Interferior wall HK. 1+ TR/MR + [**2188-1-21**] + 2:33 A11/26/[**2191**] 04:00 AM + [**2188-1-25**] + 10:20 P + [**2188-1-26**] + 1:20 P + [**2188-1-27**] + 11:50 P + [**2188-1-28**] + 1:20 A + [**2188-1-29**] + 7:20 P + 1//11/006 + 1:23 P + [**2188-2-21**] + 1:20 P + [**2188-2-21**] + 11:20 P + [**2188-2-21**] + 4:20 P + WBC + 14.4 + Hct + 42.2 + Plt + 204 + Assessment and Plan + Patient is a 72 y/o M w/ CAD, HTN, HPL who presents with [**Year (4 digits) **]. + . + # CORONARIES: s/p [**Year (4 digits) **] with proximal late stent thrombosis of old BMS + placed in [**2182**]. The patient is s/p thrombectomy and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 placed + overlapping proximal old BMS stent. Patient is hemodynamically + stable. + - Continue ASA 325mg daily, Plavix 150mg daily x 7 days, 75mg + thereafter + - Integrillin x 18hrs + - If BP/HR tolerates, start Lopressor 12.5mg [**Hospital1 **], uptitrate as + tolerated. + . + # PUMP: Appears euvolemic on examination. Patient's LV gram from [**8-/2182**] + with systolic dysfunction (EF 30%), likely secondary to Myocardial + stunning. EF on [**2183**] echocardiogram preserved, however no recent echo. + - Formal Echocardiogram on Friday [**12-16**] + . + # RHYTHM: NSR currently. + - Monitor on tele + - EKG in AM + . + # HTN: BP 107/70. Pt's HR is in 60s. + - Monitor for now, if HR is elevated > 70s, will start lopressor. + . + # HPL: Had previously been taking Simvastatin 20mg, dose limited by + myopathy according to patient. Given [**Initials (NamePattern4) 508**] [**Last Name (NamePattern4) **], [**First Name3 (LF) 124**] switch to + Atorvastatin 80mg daily and monitor LFTs and for myopathy. + . + # h/o Gout: Resolved. Patient had been taking + Indomethacin/Prednisone to treat gout flare over the past week. No + active lesions for now. Will avoid NSAIDs in patient. + . + FEN: Sips until able to sit up, Cardiac diet thereafter. + . + ACCESS: PIV's + . + PROPHYLAXIS: + -DVT ppx with Heparin gtt + -Bowel regimen with colace/senna + . + CODE: Full Code + . + COMM: Wife [**Name (NI) 8968**] [**Telephone/Fax (1) 10165**] + . + DISPO: CCU for now + ICU Care + Nutrition: + Glycemic Control: + Lines: + 18 Gauge - [**2191-12-15**] 04:19 AM + 20 Gauge - [**2191-12-15**] 04:21 AM + Prophylaxis: + DVT: + Stress ulcer: + VAP: + Comments: + Communication: Comments: + Code status: + Disposition: +","Admission Date: [**2191-12-15**] Discharge Date: [**2191-12-19**] + +Date of Birth: [**2119-8-25**] Sex: M + +Service: MEDICINE + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:[**First Name3 (LF) 1145**] +Chief Complaint: +CP + +Major Surgical or Invasive Procedure: +cardiac catheterization with drug eluting stent to left anterior +descending artery. + + +History of Present Illness: +72 y/o M with h/o STEMI '[**82**] s/p BMS x 2 to mid-LAD who presented +to OSH with chest pain. Patient awoke from his sleep at approx +11pm [**12-14**] with 10/10 chest pain that prompted him to seek EMS. +Patient describes as a pressure across his chest with radiation +to both of his arms. Reports associated SOB, Nausea and states +that presentation is similar to his STEMI in [**2182**]. + +Patient's initial vitals at OSH were BP 148/100, HR 94, 99%RA. +Patient was found to have anterior ST elevations on ECG and was +given ASA 325mg, plavix loaded, and started on NTG and +Eptifibatide gtts. Patient's nausea was controlled with zofran, +and given lopressor 5mg IV x 1. The patient was transferred to +[**Hospital1 18**] for cardiac catheterization. On transfer, patient's BP +was 124/74 on NTG gtt. Patient was not started on heparin gtt +at OSH as there was concern for widened mediastinum. + +During cardiac catheterization, patient was found to have +proximal mid-LAD late stent thrombosis. Patient had +thrombectomy and had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 placed overlapping prior proximal +BMS. D1 with 70% lesion, distal 50% LAD lesion that appears +old. RCA with mild luminal irregularies. The patient was +continued on integrillin. + +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. + +Cardiac review of systems is notable for current resolution +chest pain. Denies paroxysmal nocturnal dyspnea, orthopnea, +ankle edema, palpitations, syncope or presyncope. + +Past Medical History: +1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension + + +2. CARDIAC HISTORY: +- s/p STEMI [**2182**] +-CABG: +-PERCUTANEOUS CORONARY INTERVENTIONS: +[**8-/2182**]: 95% mid LAD lesion with [**Month/Year (2) 7388**] with adjacent 90% lesion as +well as 50% distal LAD lesion. s/p PTCA and BMS x 2 +(overlapping) to mid LAD. +---D1 w/ 70% stenosis, RCA had 30% smooth stenoses in the +proximal and mid-portions. There was a 30% proximal PDA +stenosis +---Systolic dysfunction in 8/00 by LV gram + +-PACING/ICD: +3. OTHER PAST MEDICAL HISTORY: +- s/p multiple back surgeries + + +Social History: +-Tobacco history: 50 pack year, quit 9 years ago +-ETOH: Drinks 1 beer/[**Doctor Last Name 6654**] daily +-Illicit drugs: None + +Family History: +No family history of early MI, arrhythmia, cardiomyopathies, or +sudden cardiac death; otherwise non-contributory. + +Physical Exam: +VS: 95.3, 70, 127/83, 19, 94% 3LNC +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 JVP 6 cm (near fully recumbent) +CARDIAC: PMI located in 5th intercostal space, midclavicular +line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or +S4. +LUNGS: CTA anterolaterally, no crackles, wheezes or rhonchi. +ABDOMEN: Soft, NT. Mild Distention. 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+ Femoral 2+ DP 1+ PT 1+ +Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ + +Pertinent Results: +[**2191-12-17**] 05:50AM BLOOD WBC-12.4* RBC-3.44* Hgb-11.1* Hct-32.8* +MCV-95 MCH-32.2* MCHC-33.8 RDW-13.9 Plt Ct-205 +[**2191-12-16**] 07:00AM BLOOD Glucose-95 UreaN-40* Creat-0.7 Na-139 +K-4.4 Cl-108 HCO3-23 AnGap-12 +[**2191-12-16**] 07:00AM BLOOD CK(CPK)-286* +[**2191-12-15**] 06:42PM BLOOD CK(CPK)-760* +[**2191-12-15**] 04:00AM BLOOD ALT-61* AST-65* CK(CPK)-407* +[**2191-12-16**] 07:00AM BLOOD CK-MB-47* MB Indx-16.4* +[**2191-12-15**] 06:42PM BLOOD CK-MB-124* MB Indx-16.3* +[**2191-12-15**] 02:14PM BLOOD CK-MB-160* MB Indx-17.8* +[**2191-12-15**] 04:00AM BLOOD CK-MB-68* MB Indx-16.7* cTropnT-1.22* +[**2191-12-16**] 07:00AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.3 +[**2191-12-15**] 04:00AM BLOOD Triglyc-115 HDL-55 CHOL/HD-2.4 LDLcalc-56 + +HCT TREND: +[**2191-12-15**] 04:00AM Hct-42.2 +[**2191-12-16**] 07:00AM Hct-35.2* +[**2191-12-17**] 05:50AM Hct-32.8* +[**2191-12-17**] 09:45AM Hct-29.7* +[**2191-12-17**] 06:06PM Hct-35.2* +[**2191-12-18**] 12:29AM Hct-31.4* +[**2191-12-18**] 05:40AM Hct-32.6* +[**2191-12-18**] 01:16PM Hct-32.2* +[**2191-12-19**] 07:00AM Hct-31.6* + +ECHO +The left atrium and right atrium are normal in cavity size. +There is mild symmetric left ventricular hypertrophy with normal +cavity size. There is mild regional left ventricular systolic +dysfunction with hypokinesis of the anterior septum, anterior +wall and apex. 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 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 a trivial/physiologic pericardial effusion. There is an +anterior space which most likely represents a fat pad. + +IMPRESSION: Mild symmetric left ventricular hypertrophy with +mild focal LV systolic dysfunction, consistent with CAD (LAD +territory). No significant valvular abnormality seen. + +DISCHARGE LABS [**2191-12-19**]: +[**2191-12-19**] 07:00AM BLOOD WBC-12.3* RBC-3.42* Hgb-11.0* Hct-31.6* +MCV-92 MCH-32.0 MCHC-34.7 RDW-13.7 Plt Ct-168 +[**2191-12-19**] 07:00AM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-137 +K-4.2 Cl-103 HCO3-25 AnGap-13 +[**2191-12-19**] 07:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 UricAcd-7.5* + + +Brief Hospital Course: +In brief this a 72 year old man with CAD, HTN and hyperlipidemia +who presented with STEMI and noted to have stenosis of the LAD. +He is status post thrombectomy and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. He remained +hemodynamically stable during and post procedure. His post MI +TTE showed left ventricular systolic dysfunction with +hypokinesis of the anterior septum, anterior wall and apex and +an EF of 40%. He remained in sinus rhythm during his stay. His +medical regimen on discharge inludes ASA, clopidrogel, +simvastatin, lisinopril and metoprolol. He should be on +clopidrogel for at least one year post stent. NSAIDs should be +avoided to prevent interaction with ASA. He has a history of +myopathy related to statins - he developed hand pain during +hospitalization on Atorvastatin 80mg, so he was switched to +Simvastatin 20mg prior to discharge. + +#. GI Bleed: The [**Hospital 228**] hospital course was complicated by +UGIB on [**12-17**]. He was noted to have HCT drop to 29.7, in +addition to black stool, guaiac positive. He was transfused 1 +unit pRBCs with appropriate response in HCT. He declined upper +endoscopy during this hospitalization and preferred to f/u with +his GI physician as an outpatient. HCT was stable upon discharge +at 31.6 with no further evidence of bleeding. He was discharged +on PPI [**Hospital1 **]. + +#. Gouty flare: The patient developed pain in his toes during +his hospitalization. He was started on colchicine prior to +discharge. NSAIDs should be avoided to prevent interaction with +ASA, as well as in the setting of recent GI bleed. + + + +Medications on Admission: +Atenolol 12.5mg daily +Simvastatin 20mg daily (dose limited by myalgias) +ASA 81mg daily +***Prednisone Taper x 1 wk for Gout (completed course) +***Indomethacin - x 1 wk for Gout + +Discharge Medications: +1. Outpatient Lab Work +Please check CBC and call results to Dr. [**Last Name (STitle) 5310**] at ([**Telephone/Fax (1) 32399**] on [**2191-12-23**]. +2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) +Tablet, Delayed Release (E.C.) PO DAILY (Daily). +3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY +(Daily): Do not stop taking unless Dr. [**Last Name (STitle) 5310**] tells you to. +Disp:*30 Tablet(s)* Refills:*11* +4. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO once a day. +Disp:*45 Tablet(s)* Refills:*2* +5. 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:*2* +6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr +Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). +Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* +7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. +8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 +hours) as needed for foot pain: Stop taking once you have +diarrhea. Do not take simvastatin with this medicine. . +Disp:*6 Tablet(s)* Refills:*0* + + +Discharge Disposition: +Home + +Discharge Diagnosis: +ST elevation Myocardial Infarction +Gout flare +Upper Gastrointestinal Bleed + + +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 chest pain. You were +found to have a heart attack - there was a blood [**Last Name (STitle) 7388**] in the +stent that was placed in your artery 8 years ago. You underwent +cardiac catheterization - the doctors removed the [**Name5 (PTitle) 7388**] in your +artery and placed another stent to help keep the artery open. +You had some bleeding from your upper intestines that was +treated with an acid blocking medicine. You will continue on +that medicine twice daily. +. +Medication changes: +1. Stop taking Atenolol +2. Start taking Metoprolol XL, a beta blocker +3. Increase your aspirin to 325 mg daily for at least 2 months, +Dr. [**Last Name (STitle) 5310**] will decrease the dose as soon as possible +4. Start taking Plavix to keep the stent open. You will need to +take this every day for one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop +taking Plavix unless Dr. [**Last Name (STitle) 5310**] tells you to. +5. Start taking Lisinopril, a medicine that decreases your blood +pressure and helps your heart recover from the heart attack. +6. Start taking Pantoprazole, a medicine that will help to +prevent bleeding in your stomach. +7. Start taking colchicine for your gout flare. Do not take +colchicine and Simvastatin together. You can restart the +Simvastatin after you stop the colchicine as per Dr. +[**Last Name (STitle) 5310**]. +. +Please get a blood pressure cuff at home and check your blood +pressure daily. Keep a log of blood pressures to give to Dr. +[**Last Name (STitle) 5310**]. +. +You are scheduled for an endoscopy at [**Hospital3 3583**] at +10:00am. Do not eat or drink anything after midnight, you can +take all of your medicines with a small amount of water. +. +Please ask Dr. [**Last Name (STitle) 5310**] about a Rheumatologist in [**Location (un) 3320**] +that you can go to. +. +Please speak to Dr. [**Last Name (STitle) 5310**] about a primary care provider +you can go to. +. +Weigh yourself every morning, call Dr. [**Last Name (STitle) 5310**] if weight +goes up more than 3 lbs in 1 day or 6 pounds in 3 days. +Follow a low sodium diet. + +Followup Instructions: +Cardiology: +Dr. [**Last Name (STitle) 5310**] Phone: ([**Telephone/Fax (1) 5319**] Date/time: [**12-27**] at +2:20pm. +. +Rheumatology: +Dr. [**Last Name (STitle) 12434**] Phone: ([**Telephone/Fax (1) 1668**] [**Hospital 32400**] Medical Building, [**Last Name (NamePattern1) 12939**]. [**Hospital Ward Name 517**] [**Hospital1 18**]. [**12-20**] at 3:30pm. +. +Gastroenterology: +Dr. [**First Name (STitle) 32277**] (partner of Dr. [**Last Name (STitle) 2520**] Phone: ([**Telephone/Fax (1) 32401**] +Date/time: Wednesday [**12-21**] at 10:00 at the endoscopy clinic at +[**Hospital3 3583**] (where you had your colonoscopy) +. + + + +","72 y/o m with h/o [** **] '[**82**] s/p bms x 2 to mid-lad who presented to osh with chest pain. patient awoke from his sleep at approx 11pm [**12-14**] with 10/10 chest pain that prompted him to seek ems. patient describes as a pressure across his chest with radiation to both of his arms. reports associated sob, nausea and states that presentation is similar to his [**month/year (2) **] in [**2182**]. patient's initial vitals at osh were bp 148/100, hr 94, 99%ra. patient was found to have anterior st elevations on ecg and was given asa 325mg, plavix loaded, and started on ntg and eptifibatide gtts. patient's nausea was controlled with zofran, and given lopressor 5mg iv x 1. the patient was transferred to [**hospital1 5**] for cardiac catheterization. on transfer, patient's bp was 124/74 on ntg gtt. patient was not started on heparin gtt at osh as there was concern for widened mediastinum. during cardiac catheterization, patient was found to have proximal mid-lad late stent thrombosis. patient had thrombectomy and had [**name prefix (prefixes) **] [**last name (prefixes) **] 1 placed overlapping prior proximal bms. d1 with 70% lesion, distal 50% lad lesion that appears old. rca with mild luminal irregularies. the patient was continued on integrillin. 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. cardiac review of systems is notable for current resolution chest pain. denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.","in brief this a 72 year old man with cad, htn and hyperlipidemia who presented with stemi and noted to have stenosis of the lad.","72 y/o m with h/o [** **] '[**82**] s/p bms x 2 to mid-lad who presented to osh with chest pain. patient describes as a pressure across his chest with radiation to both of his arms. patient's initial vitals at osh were bp 148/100, hr 94, 99%ra. patient was found to have anterior st elevations on ecg and was given asa 325mg, plavix loaded, and started on ntg and eptifibatide gtts. the patient was transferred to [**hospital1 5**] for cardiac catheterization. the patient was continued on integrillin. he denies exertional buttock or calf pain. denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.","['Patient woke from his sleep at 11pm with 10/10 chest pain.\nHe was given asa 325mg, placenta loaded, and started on nt 1st.\nPatient was not started on heparin gt at oshox, but was given a dose of \xa0pregnant\xa0pals.\nThe patient was not starting on hepatin gt, but had a lower mid-throndrial thrombosis.\nThis is a condition that affects the heart, lungs, and liver.\nIt is not known if the patient had any underlying health conditions']","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.","[""awoke from his sleep at 11pm with 10/10 chest pain that prompts him to seek an emergency room appointment for treatment. patient'd denies any prior history of stroke, blood pressure or bleeding during surgery; all other reviews were negative and the patients are now on medication-free diet pills (emg)""]","72 y/o m with h/o [** **] '[**82**] s/p bms x 2 to mid-lad who presented to osh with chest pain. +during cardiac catheterization, patient was found to have proximal mid-lad late stent thrombosis. +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. +cardiac review of systems is notable for current resolution chest pain.","72 y/o m with h/o [** **] '[**82**] s/p bms x 2 to mid-lad who presented to osh with chest pain.patient awoke from his sleep at approx 11pm [**12-14**] with 10/10 chest pain that prompted him to seek ems.patient describes as a pressure across his chest with radiation to both of his arms.reports associated sob, nausea and states that presentation is similar to his [**month/year (2) **] in [**2182**].patient's initial vitals at osh were bp 148/100, hr 94, 99%ra.patient was found to have anterior st elevations on ecg and was given asa 325mg, plavix loaded, and started on ntg and eptifibatide gtts.patient's nausea was controlled with zofran, and given lopressor 5mg iv x 1.the patient was transferred to [**hospital1 5**] for cardiac catheterization.on transfer, patient's bp was 124/74 on ntg gtt.patient was not started on heparin gtt at osh as there was concern for widened mediastinum.","[{'rouge-1': {'r': 0.43478260869565216, 'p': 0.12195121951219512, 'f': 0.1904761870548753}, 'rouge-2': {'r': 0.08333333333333333, 'p': 0.019801980198019802, 'f': 0.0319999968972803}, 'rouge-l': {'r': 0.391304347826087, 'p': 0.10975609756097561, 'f': 0.17142856800725628}}]","[{'rouge-1': {'r': 0.21739130434782608, 'p': 0.08620689655172414, 'f': 0.12345678605700364}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.21739130434782608, 'p': 0.08620689655172414, 'f': 0.12345678605700364}}]","[{'rouge-1': {'r': 0.08695652173913043, 'p': 0.07407407407407407, 'f': 0.07999999503200031}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.08695652173913043, 'p': 0.07407407407407407, 'f': 0.07999999503200031}}]","[{'rouge-1': {'r': 0.21739130434782608, 'p': 0.10204081632653061, 'f': 0.1388888845408952}, 'rouge-2': {'r': 0.0, 'p': 0.0, 'f': 0.0}, 'rouge-l': {'r': 0.17391304347826086, 'p': 0.08163265306122448, 'f': 0.11111110676311746}}]","[{'rouge-1': {'r': 0.34782608695652173, 'p': 0.12121212121212122, 'f': 0.1797752770660271}, 'rouge-2': {'r': 0.08333333333333333, 'p': 0.02666666666666667, 'f': 0.040404036730946155}, 'rouge-l': {'r': 0.34782608695652173, 'p': 0.12121212121212122, 'f': 0.1797752770660271}}]","[{'rouge-1': {'r': 0.4782608695652174, 'p': 0.10576923076923077, 'f': 0.17322834349060703}, 'rouge-2': {'r': 0.08333333333333333, 'p': 0.013513513513513514, 'f': 0.023255811552190624}, 'rouge-l': {'r': 0.43478260869565216, 'p': 0.09615384615384616, 'f': 0.15748031199454401}}]",0.434782609,0.12195122,0.190476187,0.083333333,0.01980198,0.031999997,0.391304348,0.109756098,0.171428568,0.217391304,0.086206897,0.123456786,0,0,0,0.217391304,0.086206897,0.123456786,0.086956522,0.074074074,0.079999995,0,0,0,0.086956522,0.074074074,0.079999995,0.217391304,0.102040816,0.138888885,0,0,0,0.173913043,0.081632653,0.111111107,0.347826087,0.121212121,0.179775277,0.083333333,0.026666667,0.040404037,0.347826087,0.121212121,0.179775277,0.47826087,0.105769231,0.173228343,0.083333333,0.013513514,0.023255812,0.434782609,0.096153846,0.157480312