CHIEF COMPLAINT: Bladder cancer.

PRESENT ILLNESS: Patient is a 75 year-old gentleman who has been followed for
nonmuscle invasive
bladder cancer for several years. He has received 2 rounds of
intravesical therapy including BCG, alpha interferon,
gemcitabine and Adriamycin. Most recent urine cytology in [**Month (only) 205**]
of [**2169**] was positive for malignant cells. Patient
subsequently underwent cystoscopy and bladder biopsy. Biopsy
revealed high grade urothelial carcinoma with lamina propria
invasion but without muscle invasive disease. However, there was
a significant degree of micropapillary invasion which was noted
to be high risk for invasion. Given that risk factor
the patient was counseled as to the risks and benefits of
surgery versus watchful waiting and the decided to opt for
surgical intervention prior to development of muscle invasive
disease.

MEDICAL HISTORY: 1.   Hypertension.
2.   Elevated cholesterol (LDL 122).
3.   Obstructive sleep apnea.
4.   Degenerative joint disease.
5.   Obesity.
6.   Sciatica.
.
PSHx: TURBTx8, hemrrhoidectomy, Nasal septal surgery.

MEDICATION ON ADMISSION: Nolol,nifedipine, flonase, lovastatin, zoloft, asprin,
rabeprazole, nitrostat prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Patient resting comforable in bed.

FAMILY HISTORY: FAMILY HISTORY:  Brother with hypertension, father with a
history of a myocardial infarction at the age of 75.

SOCIAL HISTORY: SOCIAL HISTORY:  The patient drinks approximately [**3-11**] alcohol
beverages a week, denies smoking tobacco.
Malignant neoplasm of other specified sites of bladder,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Anemia, unspecified,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Percutaneous transluminal coronary angioplasty status,Esophageal reflux,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Malig neo bladder NEC,Ac diastolic hrt failure,Ac kidny fail, tubr necr,Pleural effusion NOS,Hyperosmolality,Chronic kidney dis NOS,Anemia NOS,Obstructive sleep apnea,Obesity NOS,Osteoarthros NOS-unspec,Status-post ptca,Esophageal reflux,Hy kid NOS w cr kid I-IV
Admission Date:  [**2169-8-14**]              Discharge Date:   [**2169-9-1**]

Date of Birth:  [**2093-10-8**]             Sex:   M

Service: UROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Bladder cancer.

Major Surgical or Invasive Procedure:
1. Radical cystoprostatectomy.
2. Ileal conduit.
3. Pelvic lymph node dissection


History of Present Illness:
 Patient is a 75 year-old gentleman who has been followed for
nonmuscle invasive
bladder cancer for several years. He has received 2 rounds of
intravesical therapy including BCG, alpha interferon,
gemcitabine and Adriamycin. Most recent urine cytology in [**Month (only) 205**]
of [**2169**] was positive for malignant cells. Patient
subsequently underwent cystoscopy and bladder biopsy. Biopsy
revealed high grade urothelial carcinoma with lamina propria
invasion but without muscle invasive disease. However, there was
a significant degree of micropapillary invasion which was noted
to be high risk for invasion. Given that risk factor
the patient was counseled as to the risks and benefits of
surgery versus watchful waiting and the decided to opt for
surgical intervention prior to development of muscle invasive
disease.

Past Medical History:
1.   Hypertension.
2.   Elevated cholesterol (LDL 122).
3.   Obstructive sleep apnea.
4.   Degenerative joint disease.
5.   Obesity.
6.   Sciatica.
.
PSHx: TURBTx8, hemrrhoidectomy, Nasal septal surgery.


Social History:
SOCIAL HISTORY:  The patient drinks approximately [**3-11**] alcohol
beverages a week, denies smoking tobacco.


Family History:
FAMILY HISTORY:  Brother with hypertension, father with a
history of a myocardial infarction at the age of 75.


Physical Exam:
Patient resting comforable in bed.

VS: 99.7/71 174/68 94%RA
I/O: 640 PO/SL  O: 700 urostomy/several bm.

HEENT: unshaven, soft/supple, PEERLA.
Chest: CTABL
CV: RRR S1S2
Abd: Midline incision with steri strips covering incision.
Minor erythema.  Large abdomen: soft/nontender/no rebound/no
guarding/no rigidity.  +BS.  Urostomy tube in place.
Neuro: Grossly intact.
Extrm: +1 pitting ankle edema.

Pertinent Results:
[**2169-8-25**] 08:45AM BLOOD WBC-19.0* RBC-2.89* Hgb-8.6* Hct-26.1*
MCV-90 MCH-29.7 MCHC-32.9 RDW-15.5 Plt Ct-323
[**2169-8-24**] 03:30PM BLOOD WBC-16.6* RBC-3.07* Hgb-8.8* Hct-27.1*
MCV-88 MCH-28.7 MCHC-32.5 RDW-15.6* Plt Ct-318
[**2169-8-24**] 01:38AM BLOOD WBC-13.7* RBC-2.76* Hgb-8.3* Hct-24.5*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.3 Plt Ct-248
[**2169-8-23**] 02:11AM BLOOD Neuts-91.3* Lymphs-5.6* Monos-2.1 Eos-0.7
Baso-0.3
[**2169-8-25**] 08:45AM BLOOD Plt Ct-323
[**2169-8-25**] 08:45AM BLOOD PT-17.0* PTT-28.6 INR(PT)-1.6*
[**2169-8-24**] 03:30PM BLOOD Plt Ct-318
[**2169-8-25**] 08:45AM BLOOD Glucose-109* UreaN-67* Creat-2.7* Na-149*
K-3.1* Cl-117* HCO3-19* AnGap-16
[**2169-8-24**] 03:30PM BLOOD Glucose-133* UreaN-60* Creat-2.2* Na-146*
K-3.3 Cl-115* HCO3-20* AnGap-14
[**2169-8-24**] 01:38AM BLOOD Glucose-149* UreaN-56* Creat-2.1* Na-145
K-3.5 Cl-115* HCO3-19* AnGap-15
[**2169-8-23**] 04:59PM BLOOD Glucose-118* UreaN-55* Creat-2.1* Na-147*
K-3.4 Cl-115* HCO3-21* AnGap-14
[**2169-8-23**] 04:59PM BLOOD Glucose-113* UreaN-53* Creat-1.9* Na-141
K-GREATER TH Cl-126* HCO3-21*
[**2169-8-20**] 08:20AM BLOOD ALT-12 AST-31 AlkPhos-84 Amylase-107*
TotBili-1.2
[**2169-8-20**] 03:14AM BLOOD ALT-8 AST-30 AlkPhos-79 Amylase-104*
TotBili-1.3
[**2169-8-20**] 08:20AM BLOOD Lipase-107*
[**2169-8-25**] 08:45AM BLOOD Albumin-2.7* Calcium-7.3* Phos-2.5*
Mg-2.1
[**2169-8-24**] 03:30PM BLOOD Calcium-7.6* Phos-2.2* Mg-2.0 Iron-18*
[**2169-8-24**] 01:38AM BLOOD Calcium-7.2* Phos-2.4* Mg-2.1
[**2169-8-24**] 03:30PM BLOOD calTIBC-131* Ferritn-1155* TRF-101*
[**2169-8-25**] 08:45AM BLOOD Triglyc-163*
[**2169-8-24**] 03:30PM BLOOD PTH-107*
[**2169-8-25**] 08:45AM BLOOD CRP-226.0*
[**2169-8-22**] 04:09AM BLOOD Type-ART pO2-76* pCO2-42 pH-7.38
calTCO2-26 Base XS-0
[**2169-8-21**] 05:30PM BLOOD Type-ART pO2-178* pCO2-33* pH-7.44
calTCO2-23 Base XS-0
[**2169-8-21**] 05:30PM BLOOD Glucose-144*
[**2169-8-21**] 06:28AM BLOOD Glucose-112* Lactate-0.9
[**2169-8-15**] 03:32AM BLOOD Hgb-11.1* calcHCT-33
[**2169-8-14**] 06:07PM BLOOD Hgb-12.0* calcHCT-36 O2 Sat-98 COHgb-1
[**2169-8-21**] 06:28AM BLOOD freeCa-1.05*
[**2169-8-15**] 03:32AM BLOOD freeCa-1.29
[**2169-8-25**] 08:45AM BLOOD PREALBUMIN-PND

  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-8-31**] 06:25AM    11.5* 2.92* 8.8* 25.1* 86 30.3 35.2*
16.0* 325
[**2169-8-30**] 06:40AM    12.3* 3.26* 9.2* 28.6* 88 28.2 32.1 16.2*
380
[**2169-8-29**] 05:20PM    13.2* 3.34* 9.9* 30.0* 90 29.5 32.9 15.9*
379
[**2169-8-29**] 05:50AM    13.3* 3.23* 9.2* 28.2* 87 28.4 32.6 16.1*
351
[**2169-8-28**] 04:55PM    12.9* 3.30* 9.7* 29.7* 90 29.4 32.6 16.0*
303
[**2169-8-28**] 07:25AM    13.4* 3.13* 9.1* 28.0* 89 29.2 32.7 16.2*
322
[**2169-8-27**] 05:40AM    17.5* 3.64* 10.1* 32.3* 89 27.6 31.2
16.3* 345
[**2169-8-26**] 05:55AM    19.5* 3.11* 9.3* 27.6* 89 29.9 33.7 15.8*
305

  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2169-8-31**] 06:25AM        325
[**2169-8-30**] 06:40AM        380
[**2169-8-30**] 06:40AM    16.1* 28.3   1.5*
[**2169-8-29**] 05:20PM        379
[**2169-8-29**] 05:20PM    15.7*     1.4*
[**2169-8-29**] 05:50AM        351
[**2169-8-29**] 05:50AM    16.3* 29.2   1.5*
[**2169-8-28**] 04:55PM        303
[**2169-8-28**] 07:25AM        322
[**2169-8-28**] 07:25AM    16.2* 27.6   1.5*
[**2169-8-27**] 05:40AM        345
[**2169-8-27**] 05:40AM    16.0* 29.1   1.5*
[**2169-8-26**] 05:55AM        305

  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-8-31**] 06:25AM    91 48* 2.0* 139 3.9 112* 19* 12
[**2169-8-30**] 06:40AM    135* 57* 2.3* 137 3.9 110* 18* 13
[**2169-8-29**] 05:20PM    112* 62* 2.3* 144 4.2 116* 17* 15
[**2169-8-29**] 05:50AM    107* 68* 2.5* 143 3.8 115* 19* 13
[**2169-8-28**] 04:55PM    118* 73* 2.5* 143 4.0 116* 15* 16
[**2169-8-28**] 07:25AM    101 74* 2.7* 144 3.9 116* 17* 15
[**2169-8-27**] 05:00PM    115* 79* 2.8* 143 3.6 114* 17* 16
[**2169-8-27**] 05:40AM    122* 79* 2.9* 144 3.3 111* 18* 18
[**2169-8-26**] 02:45PM    95 80* 3.1* 145 3.1* 113* 18* 17
[**2169-8-26**] 05:55AM    101 78* 2.9* 152*1 3.2* 119* 20* 16

[**2169-8-30**] 6:28 pm STOOL     CONSISTENCY: SOFT      Source: Stool.


                            **FINAL REPORT [**2169-8-31**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2169-8-31**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.

.

[**2169-8-22**] 11:19 pm URINE

                            **FINAL REPORT [**2169-8-24**]**

   URINE CULTURE (Final [**2169-8-24**]):    <10,000 organisms/ml.
.
[**2169-8-21**] 5:12 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2169-8-23**]**

   MRSA SCREEN (Final [**2169-8-23**]):    NO STAPHYLOCOCCUS AUREUS
ISOLATED.
.
[**2169-8-18**] 4:02 pm BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2169-8-20**]**

   GRAM STAIN (Final [**2169-8-18**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.

   RESPIRATORY CULTURE (Final [**2169-8-20**]):
      10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
.
[**2169-8-17**] 10:41 pm SPUTUM     Site: EXPECTORATED
      Source: Expectorated.

                            **FINAL REPORT [**2169-8-20**]**

   GRAM STAIN (Final [**2169-8-18**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2169-8-20**]):
      MODERATE GROWTH OROPHARYNGEAL FLORA.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2169-8-15**] 3:27
AM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] CC6B [**2169-8-15**]
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 94998**]
Reason: Eval ET position

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man with bladder CA s/p cystectomy w/ ileoconduit
   REASON FOR THIS EXAMINATION:
Eval ET position



Final Report
INDICATION:  Evaluation of endotracheal tube.

Portable AP view of the chest.

Comparison is  available from yesterday.

FINDINGS:  Heart is mildly enlarged.  Mediastinal contour is
widened and
stable and hilar contour is normal.  left pleural effusion and
left basilar
atelectasis are unchanged .  The remainder of both lungs is
clear.  The
endotracheal tube is 4.3 cm above carina.  NG tube has its tip
in the stomach.

IMPRESSION:  Unchanged left basilar atelectasis and small
effusion.
Endotracheal tube stable in satisfactory position.
 .
Radiology Report RENAL U.S. PORT Study Date of [**2169-8-15**] 10:56 AM



[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] CC6B [**2169-8-15**]
RENAL U.S. PORT   Clip # [**Clip Number (Radiology) 94999**]
Reason: ?ureteral obstruction

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man POD 1 s/p cystectomy & ileal conudit with low
urine output
   REASON FOR THIS EXAMINATION:
?ureteral obstruction



Final Report
RENAL ULTRASOUND, PORTABLE

INDICATION:  Low urine output.  Rule out obstruction.

FINDINGS:  The right kidney is normal in echotexture.  There is
no evidence of
hydronephrosis, stones, or masses.  A small simple cyst is
visualized in the
upper pole of the right kidney measuring 1.3 x 1.4 x 1.2 cm.
The right kidney
measures 10.0 cm in diameter.  Limited views of the left kidney
show normal
echotexture.  There is no hydronephrosis or stones present.
There is a
suspicious mass on the lateral aspect of the left kidney
measuring 1.6 x 2.4
cm.  Comparison is made with the CT exam dated [**2169-7-8**].  This
density most
likely represents extension of the renal cortex, however, a
follow up
ultrasound at 6 months is recommended.

A small pleural effusion is noted on the left.  There is no
evidence of
pleural effusion on the right.

IMPRESSION:
1.  No evidence of hydronephrosis.

2.  Small, mildly suspicious area in the mid-left kidney noted,
probably a
pseudonodule since no lesion is seen on a recent single phase CT
scan, but
followup ultrasound recommended at 6 months.
 .
Cardiology Report ECG Study Date of [**2169-8-20**]  10:18:10 AM


Sinus rhythm
Lead(s) unsuitable for analysis: V4


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] T.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 186 86 346/384.42 45 22 46
 .
Radiology Report CHEST (PORTABLE AP) Study Date of [**2169-8-21**] 3:54
AM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] CC6B [**2169-8-21**]
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 95000**]
Reason: tachypnea

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man with bladder CA s/p cystectomy w/ ileoconduit.
n/w tachypnea
s/p extubation
   REASON FOR THIS EXAMINATION:
tachypnea



Final Report
PORTABLE UPRIGHT CHEST on [**2169-8-21**].

INDICATION:  Tachypnea.

COMPARISON:  [**2169-8-20**] chest x-ray.

Left subclavian catheter remains in standard position.  Cardiac
silhouette is
enlarged but stable.  Multifocal areas of consolidation are
again demonstrated
with slight worsening in the right upper and left lower lobes,
concerning for
multifocal pneumonia, although a component of pulmonary edema is
also
possible.
.
Radiology Report VIDEO OROPHARYNGEAL SWA Study Date of [**2169-8-24**]
1:24 PM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-24**]
VIDEO OROPHARYNGEAL SWALLOW   Clip # [**Clip Number (Radiology) 95001**]
Reason: Pt had a bedside evaluation, and was reccomended to have
a v

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man s/p cystectomy and ileal loop diversion.

   REASON FOR THIS EXAMINATION:
Pt had a bedside evaluation, and was reccomended to have a video
eval. Pt has
been transfered from the [**Hospital Ward Name **] to [**Hospital Ward Name **]; would like
to start pt on
a regular diet, but would like to be cleared by Swallowing
study.



Final Report
INDICATION:  Video assisted oropharyngeal fluoroscopic
evaluation was
performed.  The patient was administered barium of various
consistencies
including thin liquid, nectar thick puree, and solid barium
coated cookie.
Oral phase was severely impaired with difficulty in bolus
formation and
manipulation.  Swallow was associated with poor laryngeal
elevation and absent
epiglottic deflection resulting in moderate/significant
vallecular residue.
Thin liquid was accompanied by silent aspiration at which it
could not be
alleviated with chin tuck maneuvers.

IMPRESSION:  Silent aspiration with thin liquids and valleculae
and piriform
sinus residue.
 .
Radiology Report CHEST (PA & LAT) Study Date of [**2169-8-25**] 8:11 AM



[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-25**]
CHEST (PA & LAT)   Clip # [**Clip Number (Radiology) 95002**]
Reason: Signs of gastric aspiration/infection?

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man with TCC s/p cystectomy, ileal loop diversion
   REASON FOR THIS EXAMINATION:
Signs of gastric aspiration/infection? To be done STAT.



Final Report
CLINICAL INFORMATION:  History of transitional cell carcinoma
status post
cystectomy and ileal loop diversion.  Evaluate for gastric
aspiration versus
infection.

PA AND LATERAL CHEST RADIOGRAPH:

Comparison is made to chest radiographs obtained from [**8-20**]
through [**8-22**].  Multifocal pulmonary consolidation seen diffusely
throughout both lungs
appear more confluent compared to prior film.  The cardiac
silhouette is
mildly enlarged but stable.  There may be small bilateral
pleural effusions.
The left subclavian central line has been removed in the
interval time.

IMPRESSION:  Multifocal pulmonary consolidation, appearing more
confluent
compared to last film, however, similar to appearance to [**8-22**] film
acquired at 05:28 hours, which is likely secondary to a
combination of
multifocal pneumonia and pulmonary edema.
.
[**Known lastname 7327**],[**Known firstname 54344**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 95003**]
FINAL REPORT

INDICATION: 75-year-old male, postop day 13 status post
cystectomy with ileal
conduit with persistent elevated creatinine. Evaluate for
evidence of
ureteral obstruction.

COMPARISON: CT scan from [**2169-8-7**].

TECHNIQUE: Contiguous axial images were obtained from the lung
bases to the
pubic symphysis with coronal and sagittal reformatted images.

CONTRAST: No oral or intravenous contrast was administered.

CT OF THE ABDOMEN WITHOUT CONTRAST: There are bilateral
consolidative
opacities at the lung bases. There are small bilateral pleural
effusions,
greater on the right. There may be a small amount of pericardial
fluid.

There is limited evaluation of solid organs without intravenous
contrast,
however, the liver, spleen, stomach, pancreas, adrenal glands,
and gallbladder
appear stable in appearance. There is ascites, around the liver
and spleen.
No pathologically enlarged retroperitoneal or mesenteric
lymphadenopathy is
seen. There is limited evaluation of bowel without oral or IV
contrast,
however, there is no evidence of bowel dilatation.

There is no evidence of perinephric fluid. There may be mild
pelvic fullness,
however, there is no frank hydronephrosis or hydroureter. The
ileal conduit
is seen in the right lower quadrant and is not distended.
Post-surgical clips
are seen in the region of surgery and bladder resection.

Calcification is seen within the aortic wall, without any
evidence of
aneurysmal dilatation.

CT OF THE PELVIS WITHOUT CONTRAST: Post-surgical changes are
seen within the
pelvis, including clips and bladder resection. There is a small
amount of
free fluid. The rectum and distal colon are normal in
appearance. There are
multiple scattered colonic diverticula. There is a fluid
containing left
inguinal hernia.

BONE WINDOWS: There has been no interval change in comparison to
the prior
study. The previously noted sclerotic focus within the mid
sacrum is
unchanged. Degenerative changes are seen within the thoracic
spine.

IMPRESSION:
1. The patient is status post cystectomy. There is no
hydroureter or
dilatation of the ileal conduit, or perinephric fluid.
2. There are bilateral consolidative opacities at the lung
bases. This may
represent an infectious etiology, or aspiration.
3. Small bilateral pleural effusions, and a small amount of
pericardial
fluid. There is also ascites surrounding the liver and spleen.

These results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95004**] at 12 pm
on [**8-27**]/6.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.

DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]

DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]


Approved: MON [**2169-8-28**] 3:03 PM
Procedure Date:[**2169-8-27**]

    Radiology Report LUNG SCAN Study Date of [**2169-8-27**]


[**Last Name (LF) **], [**First Name3 (LF) 275**] C.     [**2169-8-27**]
LUNG SCAN   Clip # [**Clip Number (Radiology) 95005**]
Reason: 75M S/P RADICAL CYSTECTOMY W/PERSISTENT HYPOXEMIA AND
INCREASED TACHYPNEA. CXR DOES NOT SHOW WORSENED PULMONARY




Final Report

RADIOPHARMECEUTICAL DATA:
   5.0 mCi Tc-[**Age over 90 **]m MAA;
   40.0 mCi Tc-99m DTPA Aerosol;
HISTORY: 75 year old man post cystectomy with persistent hypoxia
and tachypnea.
Bilateral patchy infiltrates on chest radiograph. Patient is not
a candidate for
CTA given elevated creatinine.

INTERPRETATION:  Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views
demonstrate  considerable central airway deposition of tracer
and several areas
of reduced tracer deposition within the parenchyma of both
lungs.

Perfusion images in the same 8 views show relatively preserved
perfusion
throughout the parenchyma of both lungs (compared to the
ventilation images).
There are subsegemental scattered areas of reduced tracer
activity.

Given the chest radiograph appearance, the above findings are
consistent with an
intermediate probability of pulmonary embolism. Central
deposition of tracer on
the ventilation study is suggestive of an airway turbulence.

IMPRESSION: Intermediate probability of pulmonary embolism.
Given the multiple
bilateral patchy infiltrates on chest radiograph and
corresponding areas of
reduced tracer deposition on the ventilation portion of the
study, perfusion
appears relatively preserved in comparison.  Given the chest
X-ray findings,
pulmonary embolism cannot be ruled out; however, there are no
findings which a
particularly suggestive of that diagnosis.


[**First Name11 (Name Pattern1) 714**] [**Last Name (NamePattern4) 95006**], M.D.


[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D.

Approved: MON [**2169-8-28**] 2:24 PM

    Radiology Report CT ABDOMEN W/O CONTRAST Study Date of
[**2169-8-27**] 11:47 AM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-27**]
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST   Clip #
[**Clip Number (Radiology) 95007**]
Reason: Please assess for evidence of ureteral obstruction
(although
Field of view: 44

   [**Hospital 93**] MEDICAL CONDITION:
75M POD13 s/p cystectomy w/ ileal conduit with persistently
elevated creatinine
(currently 2.9).
   REASON FOR THIS EXAMINATION:
Please assess for evidence of ureteral obstruction (although
some mild fullness
might be expected, given refluxing anastamoses) or fluid leak.
   CONTRAINDICATIONS for IV CONTRAST:
elevated creatinine



Final Report
INDICATION:  75-year-old male, postop day 13 status post
cystectomy with ileal
conduit with persistent elevated creatinine.  Evaluate for
evidence of
ureteral obstruction.

COMPARISON:  CT scan from [**2169-8-7**].

TECHNIQUE:  Contiguous axial images were obtained from the lung
bases to the
pubic symphysis with coronal and sagittal reformatted images.

CONTRAST:  No oral or intravenous contrast was administered.

CT OF THE ABDOMEN WITHOUT CONTRAST:  There are bilateral
consolidative
opacities at the lung bases.  There are small bilateral pleural
effusions,
greater on the right.  There may be a small amount of
pericardial fluid.

There is limited evaluation of solid organs without intravenous
contrast,
however, the liver, spleen, stomach, pancreas, adrenal glands,
and gallbladder
appear stable in appearance.  There is ascites, around the liver
and spleen.
No pathologically enlarged retroperitoneal or mesenteric
lymphadenopathy is
seen.  There is limited evaluation of bowel without oral or IV
contrast,
however, there is no evidence of bowel dilatation.

There is no evidence of perinephric fluid.  There may be mild
pelvic fullness,
however, there is no frank hydronephrosis or hydroureter.  The
ileal conduit
is seen in the right lower quadrant and is not distended.
Post-surgical clips
are seen in the region of surgery and bladder resection.

Calcification is seen within the aortic wall, without any
evidence of
aneurysmal dilatation.

CT OF THE PELVIS WITHOUT CONTRAST:  Post-surgical changes are
seen within the
pelvis, including clips and bladder resection.  There is a small
amount of
free fluid.  The rectum and distal colon are normal in
appearance.  There are
multiple scattered colonic diverticula. There is a fluid
containing left
inguinal hernia.

BONE WINDOWS:  There has been no interval change in comparison
to the prior
study.  The previously noted sclerotic focus within the mid
sacrum is
unchanged.  Degenerative changes are seen within the thoracic
spine.

IMPRESSION:
1.  The patient is status post cystectomy.  There is no
hydroureter or
dilatation of the ileal conduit, or perinephric fluid.
2.  There are bilateral consolidative opacities at the lung
bases.  This may
represent an infectious etiology, or aspiration.
3.  Small bilateral pleural effusions, and a small amount of
pericardial
fluid.  There is also ascites surrounding the liver and spleen.

These results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 95004**] at 12 pm
on [**8-27**]/6.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: MON [**2169-8-28**] 3:03 PM

    Radiology Report CHEST (PORTABLE AP) Study Date of [**2169-8-27**]
7:31 PM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-27**]
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 95008**]
Reason: ? cause

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man with bladder CA s/p cystectomy w/ ileoconduit.
n/w
tachypnea s/p extubation with mild resp distress now with
increased RR to
36
   REASON FOR THIS EXAMINATION:
? cause



Final Report
HISTORY:  Bladder CA, increased respiratory rate, question
cause.

CHEST, SINGLE AP PORTABLE VIEW.

There are dense diffuse patchy bilateral alveolar opacities
throughout both
lungs, similar to the chest x-ray on [**2169-8-25**].  There is very
slight
obscuration of the right hemidiaphragm.  No gross effusion.

IMPRESSION:  Diffuse patchy alveolar opacities in both lungs
similar to
[**2169-8-25**], possibly minimally improved.  Differential diagnoses
includes CHF,
multifocal pneumonia, or combination of the two.  In the
appropriate clinical
setting, this could reflect the presence of ARDS.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: TUE [**2169-8-29**] 10:59 AM

    Radiology Report UNILAT UP EXT VEINS US  Study Date of
[**2169-8-28**] 9:52 AM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-28**]
UNILAT UP EXT VEINS US LEFT   Clip # [**Clip Number (Radiology) 95009**]
Reason: SWELLING ASSESS FOR CLOT IN LEFT CUBITAL FOSSA

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man with 1 day hx. of shortness of breath and
metabolic acidosis.
   REASON FOR THIS EXAMINATION:
r/o clot in left cubital fossa



Final Report
INDICATION:  One-day history of shortness of breath, metabolic
acidosis.

COMPARISONS:  None.

LEFT UPPER EXTREMITY ULTRASOUND:  2D, color, and Doppler
waveform imaging was
obtained of the left internal jugular, subclavian, axillary,
brachial, and
basilic veins.  Normal compressibility, waveforms, and
augmentation were
demonstrated.  No intraluminal thrombus was identified.  Imaging
of the
cephalic vein in the upper arm showed an occlusive thrombus.
Thrombus was not
seen extending into the axillary vein.

IMPRESSION:
1.  Occlusive thrombus identified within the left cephalic vein.

2.  No evidence of deep venous thrombosis within the left upper
extremity.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: MON [**2169-8-28**] 4:47 PM


    Radiology Report BILAT LOWER EXT VEINS Study Date of
[**2169-8-28**] 9:52 AM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2169-8-28**]
BILAT LOWER EXT VEINS   Clip # [**Clip Number (Radiology) 95010**]
Reason: POSSIBLE PE ASSESS FOR DVT

   [**Hospital 93**] MEDICAL CONDITION:
75 year old man with 1 day hx. of shortness of breath and
metabolic acidosis.
Patient has very poor renal fxn. and could not undergo CT angio.
V/Q done.
   REASON FOR THIS EXAMINATION:
r/o dvt.



Final Report
INDICATION:  Shortness of breath, metabolic acidosis.

COMPARISONS:  None.

BILATERAL LOWER EXTREMITY ULTRASOUND:  2D, color, and Doppler
waveform imaging
was obtained of bilateral common femoral, superficial femoral,
and popliteal
veins.  Normal compressibility, waveforms, and augmentation were
demonstrated.
No intraluminal thrombus is identified.

IMPRESSION:  No evidence of lower extremity deep vein
thrombosis, bilaterally.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: MON [**2169-8-28**] 4:47 PM



Brief Hospital Course:
Mr [**Known lastname **] is a 74 year old man  with a 3 year history of
transitional cell carcinoma. He was admitted to [**Hospital1 18**] on [**8-14**], [**2169**] for his procedure. He was prepared and consented as per
standard; all risks and benefits of his surgery were discussed
and it was ensured that he understood all potential
compolications.
In the operating room, the total estimated blood loss was
3500cc. The total procedure time was 12 hours. He received 10L
of crystaloid, 800 Hespan, and 6 Units of packed red blood
cells.
.
Mr [**Known lastname **] was sent to the Surgery ICU (SICU) upon completion of
his surgery. He had an NGT, CVL, urostomy, JP drain and ETT in
place. He was given a total of 3 doses of Ancef in the next 24
hours. His INR at this point was 1.2. His chest film on [**8-15**]
read as: "Heart is mildly enlarged.  Mediastinal contour is
widened and
stable and hilar contour is normal.  left pleural effusion and
left basilar
atelectasis are unchanged .  The remainder of both lungs is
clear.  The
endotracheal tube is 4.3 cm above carina.  NG tube has its tip
in the stomach."
.
On [**8-16**], a chest film was read as: "There is a left lower lobe
retrocardiac atelectasis with large consolidation. ____ and NG
tube in standard positions." He had a sputum culture which was
also negative. His [**Location (un) 1661**]-[**Location (un) 1662**] drainage continued to be high,
and hence, a JP creatinine level and a Urine creatinine level
was sought in order to rule-out a urine leak within the abdomen.
The levels were repeated 3 times in the next 6 days, and on all
three occassions, it was determined that a urine leak was not
present.
.
On [**8-17**], Mr [**Known lastname **] was started on anticoagulation medications.
He received 5mg of coumadin this evening. A chst film was read
as: "An ET tube is seen with the tip in the mid trachea.  There
is a left subclavian line, with the tip in the lower SVC.
There is an NG tube, with the tip in the stomach.  Again seen is
left
retrocardiac opacity, which is unchanged.  The right lung is
clear.  Pulmonary
vasculature is within normal limits." He also had a urine
culture today, for febrile episodes during the day, which was
negative. His sputum culture was also negative on this day.
.
On [**8-18**], Mr [**Known lastname **] had a BAL, whose result is as follows:
[**2169-8-18**] 4:02 pm BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2169-8-20**]**

   GRAM STAIN (Final [**2169-8-18**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.

   RESPIRATORY CULTURE (Final [**2169-8-20**]):
      10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
He received 5mg of coumadin this evening.
.

.
On [**8-19**], Mr [**Known lastname **] was extuabted. His NGT was removed later in
the evening. He received 1mg of coumadin this morning. He was
also started on levofloxacin. A chest film was read as: "A
single AP view of the chest is obtained on [**2169-8-19**] at 0534 hours
and compared with the prior radiograph of [**2169-8-17**].  Tubes and
lines appear
unchanged in position.  Retrocardiac opacity consistent with
airspace disease
is unchanged.  There does, however, now appear to be increased
opacity in the
left mid lung zone and the right lower lung zone consistent with
worsening
airspace disease." Mr [**Known lastname **] was in distress overnight, and
required a dose of Haldol. He was restless and agitated. He was
able to tolerate sips, as he bad started to pass flatus earlier
in the day. Dr [**Last Name (STitle) 261**] spoke with the family over the phone in
the afternoon; there was discussion about determining whether Mr
[**Known lastname **] sister would be able to care for her brother at home.
In addition, the ostomy nurse [**First Name (Titles) **] [**Name (NI) 653**] in order to teach Mr
[**Name (NI) **] regarding ostomy care once he is transfered to the floor.
.
On [**8-20**], Mr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was removed. He
received 1mg of coumadin this morning. At midnight, his fluids
were stopped. A morning chest film was read as: "A single AP
view of the chest is obtained on [**2169-8-20**] at 05:42 hours and
compared with the prior day's radiograph.  Again is seen patchy
multifocal
airspace disease which appears unchanged on the left side but it
is worse on
the right side.  The patient has been extubated.  A left-sided
subclavian line
is unchanged in position.  No large pleural effusion is
present."
.
On [**8-21**], Mr [**Known lastname **] INR was 3.6. His coumadin was held this
evening. A repeat chest xray this morning read as: "Left
subclavian catheter remains in standard position.  Cardiac
silhouette is enlarged but stable.  Multifocal areas of
consolidation are again demonstrated with slight worsening in
the right upper and left lower lobes, concerning for multifocal
pneumonia, although a component of pulmonary edema is also
possible." He continued to require oxygen at 12L. LAter in the
day, he was switched to CPAP. He was also started on a Lasix IV
drip, and given albumin 25% to help with diuresis. His
antibiotic (Levo) was stopped.
.
On [**8-22**], the Lasix drip continued, as did the 25% albumin. Mr
[**Known lastname **] started to tolerate oral intake. It was decided Mr [**Known lastname **]
was able to be transfered to the floor (his orders were put in
and he was awaiting a bed). A cardiology consult was called, and
en echo done which showed:
"The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis
is not present. No aortic regurgitation is seen. The mitral
valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is
an anterior space which most likely represents a fat pad.
Compared with the report of the prior study (images unavailable
for review) of  [**2163-12-20**], mild pulmonary artery systolic
hypertension is now suggested.  Biventricular systolic function
appears similar." Overnight, Mr [**Known lastname **] had some episodes of
respiratory distress. He also had episodes of chest pain - a
12-lead EKG was done which did not show any abnormalities. He
also spiked a temperature of 101.5, and was pancultured. Mr
[**Known lastname **] was given 2.5mg of Vitamin K overnight due to his INR
level.
.
On [**8-23**], Mr [**Known lastname **] was given another 2.5mg PO of Vitamin K. His
chest pain had resolved and he was no longer having breathing
difficulties. His Lasix drip was continued at 5mg/hr. Overnight,
he had some episodes of respiratory distress for which his
oxygen level was increased.
.
On [**8-24**], Mr [**Known lastname **] was transfered to the floor (12 [**Hospital Ward Name 1827**]). He
had a video surveillance study to assess his risk for gastric
aspiration, and it was determined he would require a thickened
diet due to some risk of aspiration. In addition, it was advised
to keep him off whole pills. Mr [**Known lastname **] had no other complaints
and was seen by a physical therapist. He was given a bolus of
Lasix on the floor, and another unit of blood. His central
venous line was removed. In the evening, Mr [**Known lastname **] was given 1
unit of packed red blood cells. After starting administration,
he had an allergic reaction to the product and his blood
pressure elevated and his temperature went up to 103. This
product was stopped, and his temperature and blood pressure came
down. Overnight, he had no other issues.
.
On [**8-25**], Mr [**Known lastname **] was seen for a rehabilitation screening. He
was also visited by the physical therapist, who stated he would
need some physical therapy in order to regain his strength. He
had no new medical issues today.
.
On [**8-26**],

On [**8-27**], the patient underwent a trigger event.
Neuro: Off all pain meds.  On home seroquel.

CV: Intermittently hypertensive over weekend (SBP 130-180).
Increased lopressor
to 62.5 tid (along w/ PRN hydralazine).  Still off home
nifedipine b/c can't
crush the pill.  Consider touching base w/ cardiology about
recommended
alternative [**Doctor Last Name 360**] if still intermittently hypertensive.

PULM: Was on RA by Saturday PM.  Then increasingly tachypnic
today PM (rate
25-40).  ABG and PM lytes c/w metabolic acidosis w/ respiratory
compensation as
well as some degree of primary respiratory hypoxemia.  CXR
stable from 2 days
prior.  Pulmonary previously consulted and felt hypoxemia likely
due to
multifocal aspiration PNA (no ABx treatment if no fever spikes).
 Renal and pulm
felt that fluid overload from IVF over weekend might have helped
trigger events
today PM.  Plan to observe off IVF and on O2.  Consider repeat
ABG in AM.  Will
also obtain VQ Scan overnight per Dr. [**Last Name (STitle) **] to assess for PE
(although
radiologist states that utility w/ inderlying parenchymal
disease is minimal).
Pulmonary following.

GI: Currently on limited diet per speech/swallow.  Albumin
Sunday 2.5.  On
calorie counts and followed by nutrition.  Must get
speech/swallow reassessment
(specifically about prognosis for return to full swallowing
function) Monday.
If poor prognosis for PO intake ability, we should consider PICC
for peripheral
nutrition/boluses or J-tube for feeds.  Protonix [**Hospital1 **] via IV
until can tolerate
pills.

GU: Severely hypernatremic and intravascularly contracted
Saturday AM.  Renal
reconsulted.  Presumed ATN and intravascular depletion from poor
oncotic
pressure with low albumin (secondary to poor nutrition) and
previous lasix for
days while in SICU.  Recommended 24h of D5W at 150 cc/h.  Today
they recommended
HLIV and observation, but we elected to continue IVF at 150 cc/h
(until they
were HLIV when tachypnea presented).  Renal following.  Even
with everything
today PM, Dr. [**Last Name (STitle) **] would like to restart IVF at 75 cc/h Monday
PM if it
appears patient can tolerate.  CT A/P Sunday w/o evidence of
obstruction.

ID: WBC peaked at 19.5, currently 17.5.  Afebrile.  No ABx.  F/U
Cx (just about
everything is NGF).  CT A/P Sunday shows evidence of known PNA.

H: On coumadin 1hs [**First Name8 (NamePattern2) **] [**Doctor Last Name **].  INR 1.5-1.6 over weekend.

E: Blessedly, no issues.

T/L/D: PIV (maybe).  Ureteral stent removed Saturday AM.  [**Month (only) 116**]
need PICC stat in
AM for access (PIV blew just now).

OTHER: Labs to check in AM.  PT/OT following.  Currently being
screened for
rehab.  Ostomy nurse needs to come by on Monday (ostomy
appliance leaking like a
seive all weekend).

On [**8-28**], the patient was still on the the floor (12 [**Hospital Ward Name 1827**]) on
2L of oxygen.  He wife comment that his breathing was no
different since he left the ICU.  The V/Q scan from the previous
day did not show a pulmonary embolism, but it was indeterminant.
 The doppler of the lower extremities did not show any DVT
either and respiratory had now new recs.  Speech and swallow
were consulted again about his swallowing status.  An solid
answer was not obtained and they will be [**Hospital Ward Name 653**] again on
Tuesday.  The nutrition team also made some recs about inserting
a Dobhoff tube and feeding the patient at night, but with his
reflux, this is not a good idea.  His urostomy appliance leaked
over the weekend and it continued to do so today despite the
nurse fixing it.  Cardiology was also [**Name (NI) 653**] about his
hypertenstion and they recommended going up on the lopressor to
75-100 mg TID with prn hydralazine.  His pain is well
controlled.  His IV fluids were restarted originally with D5 [**1-9**]
NS with 1 amp of bicarb.  This was changed to D5W with 1 amp of
bicarb.  His coumadin was also increased to 2 mg this eveing.
He had no pain and has no other major issues.

On [**8-29**], patient still on floor (12 [**Hospital Ward Name 1827**]) off of oxygen.
Overnight, the patient had some difficulty sleeping and was very
frustrated with his current situation at hand.  Speech and
swallow were [**Hospital Ward Name 653**] again and asked specifically when his
swallowing would recover.  Therapist believes that it will
recover, but it may take several weeks for this to happen.  In
the mean time, aspiration precautions should not preven the
patient from going to rehab.   Recommends pureed diet so that it
takes less energy to eat which has been ordered.  He also got
1,200 calories and 47 grams of protein.  With the concerns about
ascietes, liver enzymes were drawn and gastroenterology was
curbsided.  They were unimpressed by his current enzyme levels
and recommended a right upper quadrant ultrasound if concerned.
Additionally, patient's appliance continued to leak last night
and the stoma nurse came by today and changed it again.

On [**8-30**], patient still on the floor (12 [**Hospital Ward Name 1827**]) off oxygen.
Overnight, the patient did better and got some rest.  The
hospitalist does not recommend anticoagulating this patient for
the clot in his left arm.  They do not want any blood draws from
that arm.  The Gastroenterologists commented that the ascites
has not contributed to the difficult fluid management.  The
renal team is signing off and they recommend that he stay on
Bicitra 30mg PO BID for the indefinate future.  He tolerated
clear fluids very well with no coughing.  He continues to
dislike the food and his wife was encouraged to bring in food
for the patient.  The dischage coordinator was [**Hospital Ward Name 653**] and
several care facilites are reviewing his chart for admission.
Dr. [**Last Name (STitle) 261**] saw the patient and agress with the current plan of
care.  Staples to come out tomorrow am and due for dischgare if
things are well.

On [**8-31**], patient still on the floor (12 [**Hospital Ward Name 1827**]) off oxygen.
Overnight, there were no issues.  He recieved his dose of
coumadin last night and it was d/c today.  The staples were
removed and steri strips were applied to the wound.  The nurse
communicated her concern about the lower part of the wound as it
maybe infected.  The intern communicated this to the resident
and he came to look at it.  The wound is erythematous, but there
was no purulent discharge or tenderness.  Keflex was prescribed
at 500 mg QID x7 days.  Awaiting to hear from discharge
planners.  Patient will need to f/u with all consult teams that
saw him. Patient due for discharge back to [**State 1727**] this afternoon.
 He will recive 1 unit of blood for low hematocrit this
afternoon.


Medications on Admission:
Nolol,nifedipine, flonase, lovastatin, zoloft, asprin,
rabeprazole, nitrostat prn

ALLERGIES:  The patient has no known drug allergies.

Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
4. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: 3.5 Tablets PO TID (3
times a day).
10. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig:
Thirty (30) ML PO BID (2 times a day).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day. Capsule, Delayed
Release(E.C.)(s)
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-13**]
hours as needed for pain: hold if O2 sat less than 93% or
oversedated.
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO every twelve
(12) hours for 2 days.
15. Outpatient Lab Work
Please recheck chem 7 as patient was put on new renal
medication.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 24402**], ME

Discharge Diagnosis:
Bladder cancer.


Discharge Condition:
Stable.


Discharge Instructions:
You are being prescribed a narcotic pain medication. DO NOT
DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION.
IT [**Month (only) **] MAKE YOU DROWSY.

Contact a physician for fever >100.5, bleeding or increasing
redness from incisions, difficulty swallowing or breathing,
headache, nausea or vomiting, double or blurry vision, or any
other concerns.

Please continue all home medications and those given to you by
your surgeon.

Followup Instructions:
Please arrange a follow-up appointment with Dr. [**Last Name (STitle) 261**] by
calling ([**Telephone/Fax (1) 4276**].  The rehab facility needs to call on
Friday ([**2169-9-1**]) to arrange for follow up.

Please arrange for follow up with your cardiologist at home in
[**State 1727**] as you need to go back on your Nifedipine.  Please have
the rehab facility arrange this for you.  You can also contact
one of our cardiologists here at ([**Telephone/Fax (1) 2037**].

Please arrange a follow up with the nephrology team by calling
them at([**Telephone/Fax (1) 773**].  You can also have your primary care
doctor arrange an appointment for you with a nephrologist up in
[**State 1727**].

Please arrange to have an ultrasound scan done on your left arm
in 7 days to make sure the blood clot has resolved.



Completed by:[**2169-8-31**]
{'Malignant neoplasm of other specified sites of bladder,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Anemia, unspecified,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Percutaneous transluminal coronary angioplasty status,Esophageal reflux,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Bladder cancer.

PRESENT ILLNESS: Patient is a 75 year-old gentleman who has been followed for
nonmuscle invasive
bladder cancer for several years. He has received 2 rounds of
intravesical therapy including BCG, alpha interferon,
gemcitabine and Adriamycin. Most recent urine cytology in [**Month (only) 205**]
of [**2169**] was positive for malignant cells. Patient
subsequently underwent cystoscopy and bladder biopsy. Biopsy
revealed high grade urothelial carcinoma with lamina propria
invasion but without muscle invasive disease. However, there was
a significant degree of micropapillary invasion which was noted
to be high risk for invasion. Given that risk factor
the patient was counseled as to the risks and benefits of
surgery versus watchful waiting and the decided to opt for
surgical intervention prior to development of muscle invasive
disease.

MEDICAL HISTORY: 1.   Hypertension.
2.   Elevated cholesterol (LDL 122).
3.   Obstructive sleep apnea.
4.   Degenerative joint disease.
5.   Obesity.
6.   Sciatica.
.
PSHx: TURBTx8, hemrrhoidectomy, Nasal septal surgery.

MEDICATION ON ADMISSION: Nolol,nifedipine, flonase, lovastatin, zoloft, asprin,
rabeprazole, nitrostat prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Patient resting comforable in bed.

FAMILY HISTORY: FAMILY HISTORY:  Brother with hypertension, father with a
history of a myocardial infarction at the age of 75.

SOCIAL HISTORY: SOCIAL HISTORY:  The patient drinks approximately [**3-11**] alcohol
beverages a week, denies smoking tobacco. 

### Response:
{'Malignant neoplasm of other specified sites of bladder,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Anemia, unspecified,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Percutaneous transluminal coronary angioplasty status,Esophageal reflux,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
