CHIEF COMPLAINT: fall

PRESENT ILLNESS: This is a 70M h/o cdCHF, CAD, COPD, IDDM2 transferred to [**Hospital1 **]
from OSH with C6 fx s/p near syncopal fall.

MEDICAL HISTORY: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 80 mg PO DAILY
2. ranolazine *NF* 1,000 mg Oral [**Hospital1 **]
3. Pantoprazole 40 mg PO Q12H
4. Venlafaxine XR 75 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Aspirin 325 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 150 mg PO BID
10. Lisinopril 5 mg PO DAILY
11. Furosemide 40 mg PO BID
hold for sbp < 100
12. Polyethylene Glycol 17 g PO DAILY
13. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
hold for sbp < 100
14. Amitriptyline 25 mg PO DAILY
15. Glargine 70 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: #ADMISSION PHYSICAL EXAM:
VS: T 97.9, BP 117/54, HR 69, RR 18, SpO2 94% on RA
Gen: Elderly male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Cervical collar in place.  Unable to asses JVP or nodes.
CV: RRR with normal S1, S2.  No M/R/G appreciated.
Chest: CTAB on limited anterolateral exam without crackles,
wheezes, or rhonchi.
Abd: Hypoactive bowel sounds. Soft, NT, ND.
Ext: WWP.  Digital cap refill <2 sec.  No C/C/E.  Distal pulses
intact radial 2+, DP 2+, PT 2+.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.

FAMILY HISTORY: Adopted, unknown

SOCIAL HISTORY: Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA.
Closed fracture of sixth cervical vertebra,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Disruption of external operation (surgical) wound,Acute posthemorrhagic anemia,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Morbid obesity,Other specified forms of chronic ischemic heart disease,Sinoatrial node dysfunction,Old myocardial infarction,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Esophageal reflux,Depressive disorder, not elsewhere classified,Aortocoronary bypass status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of insulin,Unspecified fall,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other antihypertensive agents causing adverse effects in therapeutic use
Fx c6 vertebra-closed,Pneumonia, organism NOS,Subendo infarct, initial,Ac on chr diast hrt fail,DMII oth uncntrld,Disrup-external op wound,Ac posthemorrhag anemia,Hyperpotassemia,Chr airway obstruct NEC,Morbid obesity,Chr ischemic hrt dis NEC,Sinoatrial node dysfunct,Old myocardial infarct,Hypertension NOS,Obstructive sleep apnea,Hyperlipidemia NEC/NOS,Esophageal reflux,Depressive disorder NEC,Aortocoronary bypass,Hx TIA/stroke w/o resid,Long-term use of insulin,Fall NOS,Abn react-artif implant,Adv eff antihyperten agt
Admission Date:  [**2118-7-30**]              Discharge Date:   [**2118-8-15**]

Date of Birth:  [**2047-9-30**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
1.) C3-T1 posterior fusion with laminectomy on [**2118-8-4**]


History of Present Illness:
This is a 70M h/o cdCHF, CAD, COPD, IDDM2 transferred to [**Hospital1 **]
from OSH with C6 fx s/p near syncopal fall.

Pt was in USOH until 2 days ago. He was boating with his family
when he began to feel light-headed, similar to prior episodes of
hypoglycemia (notably, his insulin regimen was recently changed
with labile sugars). While getting out of the boat, the pt fell
backwards, struck his head with 30sec LOC. Given candy bars
after with improved LH but c/o pain in his back. No excess
mobility afterwards; slept on the boat that night and went to
PCP the following day (day prior to admit) who referred the pt
to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]. He was found to have an unstable C6 fracture
through the vertebral body into the disc. Notably, his head CT
was negative.
.
Initial vitals in ED triage were T 98.1, HR 70, BP 112/52, RR
16, and SpO2 95% on RA.  EKG showed sinus rhythm at 65 bpm with
no STE.  CBC showed anemia with Hct 32.3 above recent baseline.
Chemistry panel showed elevated creatinine 1.9 (baseline 1.1)
and glucose 303.  His CK was elevated to 907 with CKMB 8 and
Troponin 0.02, thought to be from a non-cardiac muscle source
.
Spine consult was called, and recommended [**Location (un) 2848**] J collar,
admission to Medicine, and MRI C-spine.  He was given Aspirin
325 mg PO.  He was given Humalog 15 units for his elevated
glucose (per his home regimen).  He received Morphine 5 mg IV
for pain control.
.
He was admitted to Medicine for further management of recent
syncope and cervical fracture.  Vitals prior to floor transfer
were T 98.7, HR 69, BP 108/43, RR 16, and SpO2 95% on RA.  On
reaching the floor, he reported ongoing lower neck pain and dry
mouth. Upon meeting the patient, he complained of sharp chest
pain radiating down the arms similar to episodes he has
previously identified as anginal. An EKG was obtained which did
now show interval change. MB and troponin were due in with
morning labs as they were mildly elevated when he presented to
the ED. Pt had a difficult time articulating the difference
between back and chest pain so SL nitro x1 was given. His chest
pain resolved, and his back/arm pain persisted. This was treated
with Dilaudid.

He denied acute SOB, diaphoresis, N/V, incontinence, weakness,
sensory loss. ROS was otherwise NC.

Past Medical History:
CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

Social History:
Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA.


Family History:
Adopted, unknown


Physical Exam:
#ADMISSION PHYSICAL EXAM:
VS: T 97.9, BP 117/54, HR 69, RR 18, SpO2 94% on RA
Gen: Elderly male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Cervical collar in place.  Unable to asses JVP or nodes.
CV: RRR with normal S1, S2.  No M/R/G appreciated.
Chest: CTAB on limited anterolateral exam without crackles,
wheezes, or rhonchi.
Abd: Hypoactive bowel sounds. Soft, NT, ND.
Ext: WWP.  Digital cap refill <2 sec.  No C/C/E.  Distal pulses
intact radial 2+, DP 2+, PT 2+.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.

#DISCHARGE PHYSICAL EXAM:
O:  AF 97.9  BP 118/56  HR 69   sat 95% RA
GENERAL - Alert, interactive, well-appearing in NAD.
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - bibasilar crackles, CTAB, no wheezes, no rales.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no clubbing or cyanosis, 2+ pitting edema b/l
in lower extremities, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact, C-collar in
place, cervical surgical site c/d/i s/p dressing change by ortho
spine this AM.


Pertinent Results:
#ADMISSION LABS:
[**2118-7-29**] 11:57PM BLOOD WBC-10.3 RBC-3.71* Hgb-10.6* Hct-32.3*
MCV-87 MCH-28.5 MCHC-32.8 RDW-18.9* Plt Ct-199
[**2118-7-29**] 11:57PM BLOOD Neuts-77.3* Lymphs-14.5* Monos-3.8
Eos-4.0 Baso-0.3
[**2118-7-29**] 11:57PM BLOOD Plt Ct-199
[**2118-7-29**] 11:57PM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.1
[**2118-7-29**] 11:57PM BLOOD Glucose-303* UreaN-48* Creat-1.9* Na-130*
K-5.9* Cl-94* HCO3-27 AnGap-15
[**2118-7-29**] 11:57PM BLOOD CK(CPK)-907*
[**2118-7-29**] 11:57PM BLOOD CK-MB-8 cTropnT-0.02*

#[**Hospital 40963**] HOSPITAL COURSE LABS:
[**2118-8-15**] 09:10AM BLOOD WBC-8.4 RBC-3.19* Hgb-9.3* Hct-28.8*
MCV-90 MCH-29.0 MCHC-32.2 RDW-17.3* Plt Ct-185
[**2118-8-14**] 08:42AM BLOOD WBC-12.5* RBC-3.42* Hgb-10.0* Hct-31.0*
MCV-91 MCH-29.2 MCHC-32.2 RDW-17.2* Plt Ct-246
[**2118-8-12**] 06:08AM BLOOD WBC-8.0 RBC-3.19* Hgb-9.2* Hct-28.2*
MCV-88 MCH-28.8 MCHC-32.6 RDW-17.3* Plt Ct-176
[**2118-8-10**] 01:01AM BLOOD WBC-8.2 RBC-3.38* Hgb-9.6* Hct-30.1*
MCV-89 MCH-28.5 MCHC-32.1 RDW-17.4* Plt Ct-186
[**2118-8-8**] 02:04AM BLOOD WBC-5.6 RBC-2.83* Hgb-8.3* Hct-25.4*
MCV-90 MCH-29.2 MCHC-32.5 RDW-17.9* Plt Ct-124*
[**2118-8-5**] 10:35AM BLOOD WBC-12.0*# RBC-3.89*# Hgb-11.2*
Hct-34.8*# MCV-89 MCH-28.8 MCHC-32.2 RDW-17.8* Plt Ct-222
[**2118-8-4**] 06:40AM BLOOD WBC-6.4 RBC-3.71* Hgb-10.8* Hct-33.1*
MCV-89 MCH-29.0.MCHC-32.6 RDW-18.1* Plt Ct-187
[**2118-8-2**] 07:10AM BLOOD WBC-8.6 RBC-3.73* Hgb-10.7* Hct-33.2*
MCV-89 MCH-28.9 MCHC-32.3 RDW-18.2* Plt Ct-223#
[**2118-8-1**] 06:45AM BLOOD WBC-9.4 RBC-3.97* Hgb-11.3* Hct-35.7*
MCV-90 MCH-28.6 MCHC-31.7 RDW-18.4* Plt Ct-145*
[**2118-7-30**] 10:10AM BLOOD WBC-8.6 RBC-3.55* Hgb-10.2* Hct-31.1*
MCV-88 MCH-28.8 MCHC-32.9 RDW-18.8* Plt Ct-183
[**2118-8-11**] 08:15AM BLOOD Neuts-79.2* Lymphs-11.2* Monos-4.2
Eos-5.1* Baso-0.3
[**2118-8-7**] 01:34AM BLOOD Neuts-81.2* Lymphs-11.3* Monos-3.5
Eos-3.9 Baso-0.1
[**2118-8-6**] 02:05AM BLOOD Neuts-88.0* Lymphs-7.3* Monos-3.1 Eos-1.3
Baso-0.3
[**2118-8-5**] 10:35AM BLOOD Neuts-93.9* Lymphs-3.0* Monos-1.9*
Eos-1.0 Baso-0.1
[**2118-8-9**] 02:19AM BLOOD PT-14.3* PTT-30.3 INR(PT)-1.3*
[**2118-8-8**] 02:04AM BLOOD PT-14.5* PTT-44.8* INR(PT)-1.4*
[**2118-8-7**] 01:34AM BLOOD PT-15.1* PTT-37.7* INR(PT)-1.4*
[**2118-8-6**] 02:05AM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.3*
[**2118-8-1**] 06:45AM BLOOD PT-11.9 PTT-21.9* INR(PT)-1.1
[**2118-8-15**] 09:10AM BLOOD Glucose-128* UreaN-48* Creat-1.4* Na-139
K-5.0 Cl-105 HCO3-27 AnGap-12
[**2118-8-13**] 09:50AM BLOOD Glucose-121* UreaN-54* Creat-1.9* Na-139
K-4.8 Cl-101 HCO3-26 AnGap-17
[**2118-8-12**] 06:08AM BLOOD Glucose-106* UreaN-46* Creat-1.5* Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
[**2118-8-10**] 01:01AM BLOOD Glucose-121* UreaN-34* Creat-1.2 Na-142
K-3.8 Cl-102 HCO3-30 AnGap-14
[**2118-8-5**] 08:02PM BLOOD Glucose-245* UreaN-22* Creat-1.5* Na-141
K-4.6 Cl-104 HCO3-26 AnGap-16
[**2118-8-4**] 05:30PM BLOOD Glucose-120* UreaN-18 Creat-1.1 Na-140
K-4.9 Cl-105 HCO3-28 AnGap-12
[**2118-8-2**] 07:10AM BLOOD Glucose-152* UreaN-27* Creat-1.1 Na-136
K-4.7 Cl-99 HCO3-31 AnGap-11
[**2118-7-31**] 07:15AM BLOOD Glucose-193* UreaN-35* Creat-1.4* Na-138
K-5.4* Cl-102 HCO3-31 AnGap-10
[**2118-7-30**] 10:10AM BLOOD Glucose-216* UreaN-46* Creat-1.5* Na-135
K-4.9 Cl-99 HCO3-27 AnGap-14
[**2118-8-10**] 01:01AM BLOOD CK(CPK)-66
[**2118-8-7**] 01:34AM BLOOD CK(CPK)-165
[**2118-8-6**] 10:52AM BLOOD CK(CPK)-393*
[**2118-8-6**] 02:05AM BLOOD CK(CPK)-614*
[**2118-8-5**] 10:19AM BLOOD CK(CPK)-207
[**2118-8-4**] 05:30PM BLOOD CK(CPK)-140
[**2118-8-3**] 06:30AM BLOOD CK(CPK)-66
[**2118-7-30**] 10:10AM BLOOD CK(CPK)-565*
[**2118-8-10**] 01:01AM BLOOD CK-MB-3 cTropnT-2.19*
[**2118-8-9**] 02:19AM BLOOD CK-MB-4 cTropnT-1.95*
[**2118-8-8**] 02:04AM BLOOD CK-MB-4 cTropnT-1.66*
[**2118-8-7**] 01:34AM BLOOD CK-MB-11* MB Indx-6.7* cTropnT-1.49*
[**2118-8-6**] 06:34PM BLOOD CK-MB-17* MB Indx-7.9* cTropnT-1.72*
[**2118-8-6**] 10:52AM BLOOD CK-MB-35* MB Indx-8.9* cTropnT-1.78*
[**2118-8-6**] 02:05AM BLOOD CK-MB-67* MB Indx-10.9* cTropnT-1.84*
[**2118-8-5**] 08:02PM BLOOD cTropnT-1.11*
[**2118-8-5**] 10:19AM BLOOD CK-MB-8 cTropnT-0.10*
[**2118-8-3**] 06:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-7-31**] 07:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2118-7-30**] 10:10AM BLOOD CK-MB-5 cTropnT-<0.01
[**2118-8-15**] 09:10AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.5
[**2118-8-13**] 09:50AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.3
[**2118-8-11**] 06:46PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2
[**2118-8-11**] 08:15AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3
[**2118-8-8**] 01:47PM BLOOD Calcium-8.1* Phos-3.3 Mg-2.1
[**2118-8-6**] 02:05AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.4
[**2118-8-4**] 06:40AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.4
[**2118-8-1**] 06:45AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.7*
[**2118-7-31**] 07:15AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.6
[**2118-7-30**] 10:10AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3
[**2118-8-2**] 07:10AM BLOOD VitB12-345
[**2118-8-1**] 06:45AM BLOOD %HbA1c-7.6* eAG-171*
[**2118-8-2**] 07:10AM BLOOD TSH-4.6*
[**2118-8-7**] 06:45AM BLOOD Vanco-10.3
[**2118-8-9**] 02:36AM BLOOD Type-ART pO2-92 pCO2-53* pH-7.35
calTCO2-30 Base XS-1
[**2118-8-8**] 10:18PM BLOOD Type-ART pH-7.37
[**2118-8-8**] 02:22AM BLOOD Type-ART pO2-80* pCO2-48* pH-7.39
calTCO2-30 Base XS-2
[**2118-8-7**] 06:45PM BLOOD Type-ART pO2-95 pCO2-37 pH-7.46*
calTCO2-27 Base XS-2
[**2118-8-6**] 02:21AM BLOOD Type-ART pO2-87 pCO2-41 pH-7.45
calTCO2-29 Base XS-3
[**2118-8-5**] 03:59PM BLOOD Type-ART Temp-38.3 pO2-122* pCO2-53*
pH-7.30* calTCO2-27 Base XS-0
[**2118-8-5**] 02:13AM BLOOD Type-ART pO2-118* pCO2-49* pH-7.40
calTCO2-31* Base XS-4
[**2118-8-4**] 03:09PM BLOOD Type-ART Tidal V-500 FiO2-60 O2 Flow-6
pO2-249* pCO2-51* pH-7.36 calTCO2-30 Base XS-2 Intubat-INTUBATED
Vent-CONTROLLED
[**2118-8-4**] 01:43PM BLOOD Type-ART pO2-442* pCO2-50* pH-7.39
calTCO2-31* Base XS-4
[**2118-8-3**] 06:56AM BLOOD Type-ART pO2-65* pCO2-53* pH-7.33*
calTCO2-29 Base XS-0
[**2118-8-9**] 02:36AM BLOOD Glucose-285* K-4.1
[**2118-8-8**] 05:11PM BLOOD Glucose-248*
[**2118-8-4**] 03:09PM BLOOD Glucose-89 Lactate-1.0 Na-137 K-4.7
Cl-106
[**2118-8-9**] 02:36AM BLOOD freeCa-1.21
[**2118-8-8**] 10:18PM BLOOD freeCa-1.11*
[**2118-8-5**] 05:43PM BLOOD freeCa-1.09*
[**2118-8-4**] 05:58PM BLOOD freeCa-1.04*

#STUDIES:
[]ECG Study Date of [**2118-7-31**]  9:22:44 PM
Sinus rhythm. Left atrial abnormality. Low limb lead voltage.
Variation in the precordial lead placement as compared to the
previous tracing of [**2118-7-30**]. Non-specific inferolateral ST-T
wave changes persist. No apparent No diagnostic interim change.
TRACING #1
 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 176 110 392/423 43 0 69


#RADIOLOGY:
[]CT cervical spine [**2118-7-30**]:
IMPRESSION:
1.  Minimally displaced transverse fracture through the C6
vertebral body with associated prevertebral soft tissue
prominence.  Dedicated cervical spine MRI is recommended to
evaluate for spinal cord edema given the nature of the injury.
2.  Multilevel degenerative changes with disc space narrowing as
well as large anterior and posterior osteophytes, greatest at
C3-C4 with moderate central canal narrowing.  This region can
also be further assessed.

[]MR CERVICAL SPINE W/O CONTRAST Study Date of [**2118-7-30**] 2:48 PM

IMPRESSION:
1.  Large posterior osteophyte and spondylosis identified at
C3/C4 level,
impinging the thecal sac up on the left, with the questionable
area of spinal cord edema demonstrated on the diffusion-weighted
sequence.
2.  C6 vertebral body transverse fracture, with associated bone
and soft
tissue edema, causing significant spinal canal stenosis up on
the left with no frank evidence of diffusion abnormalities at
this level.
3.  Multilevel degenerative changes throughout the cervical
spine as described above.

[]CHEST (PORTABLE AP) Study Date of [**2118-7-31**] 10:03 PM
FINDINGS:  In comparison with the study of [**5-7**], there are lower
lung volumes which may account for the apparent increase in the
transverse diameter of the heart.  Ill-defined engorged vessels
are consistent with elevated pulmonary venous pressure.  Mild
elevation of the left hemidiaphragm with opacification just
above it.  Although this could merely reflect atelectasis and
effusion, in view of the clinical history the possibility of a
supervening pneumonia in the region must be considered.

[] CT HEAD W/O CONTRAST Study Date of [**2118-7-31**] 10:13 PM
IMPRESSION:  Old left cerebellar infarctions. No evidence of
hemorrhage,
fracture, or recent infarction.

[]TTE [**2118-8-1**]
IMPRESSION: Mild symmetric LVH with mild focal left ventricular
systolic dysfunction. The right ventricle is not well seen. Mild
mitral regurgitation

[]CHEST (PORTABLE AP) Study Date of [**2118-8-3**] 5:43 AM
FINDINGS:  In comparison with the study of [**7-31**], there is little
change.  The degree of opacification at the left base is less
prominent, though this could reflect slightly better
inspiration.

[]CERVICAL SINGLE VIEW IN OR  Study Date of [**2118-8-4**] 1:59 PM
IMPRESSION:
1.  Status post posterior C4 through T1 spinal fusion.
2.  Surgical hardware appears intact.
3.  Incidental note is made of an endotracheal tube terminating
superior to the thoracic inlet.  Radiographs performed on [**8-4**], [**2117**] at 14:00 hours, follow chest radiograph demonstrated ET
tube terminating inferior to the thoracic inlet.

[]CHEST (PORTABLE AP) Study Date of [**2118-8-4**] 5:41 PM
CONCLUSION:
1.  ET tube is too high ending 9.6 cm above carina.
2.  Stable pulmonary edema is mild to moderate.

[]TTE [**2118-8-5**]
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Mild mitral regurgitation. Moderate pulmonary hypertension.

[]TTE [**2118-8-9**]
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild mitral regurgitation with normal valve
morphology. Pulmonary artery hypertension.

#MICROBIOLOGY:
[][**2118-7-31**] 11:03 pm URINE      Source: Catheter.
                            **FINAL REPORT [**2118-8-2**]**
   URINE CULTURE (Final [**2118-8-2**]):    NO GROWTH.

[][**2118-7-31**] 11:36 pm BLOOD CULTURE      # 1.
                            **FINAL REPORT [**2118-8-7**]**
   Blood Culture, Routine (Final [**2118-8-7**]):    NO GROWTH.

[][**2118-8-1**] 6:45 am BLOOD CULTURE      #2.
                            **FINAL REPORT [**2118-8-7**]**
   Blood Culture, Routine (Final [**2118-8-7**]):    NO GROWTH

[][**2118-8-3**] 6:30 am BLOOD CULTURE
                            **FINAL REPORT [**2118-8-9**]**
   Blood Culture, Routine (Final [**2118-8-9**]):    NO GROWTH.

[][**2118-8-3**] 6:01 am URINE     Site: NOT SPECIFIED      CHEM#
[**Serial Number 77842**]S [**8-3**].
                            **FINAL REPORT [**2118-8-4**]**
   URINE CULTURE (Final [**2118-8-4**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.

[][**2118-8-4**] 5:30 pm MRSA SCREEN      Source: Nasal swab.
                            **FINAL REPORT [**2118-8-7**]**
   MRSA SCREEN (Final [**2118-8-7**]):    No MRSA isolated

[][**2118-8-5**] 10:35 am BLOOD CULTURE      Source: Line-aline.
                            **FINAL REPORT [**2118-8-11**]**
   Blood Culture, Routine (Final [**2118-8-11**]):    NO GROWTH.

[][**2118-8-5**] 10:46 am BRONCHOALVEOLAR LAVAGE
                            **FINAL REPORT [**2118-8-9**]**
   GRAM STAIN (Final [**2118-8-5**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2118-8-9**]):
      10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
      YEAST.    ~7000/ML.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.
      YEAST.    ~5000/ML.  SECOND MORPHOLOGY.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.
      HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
~3000/ML.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.
         Beta-lactamse negative: presumptively sensitive to
ampicillin.
         Confirmation should be requested in cases of treatment
failure in
         life-threatening infections..
         BETA LACTAMASE REQUESTED BY DR [**Last Name (STitle) **]. BARDIA (#[**2-/5016**])
[**2118-8-9**].

[][**2118-8-5**] 10:35 am URINE     Site: CATHETER      Source:
Catheter.
                            **FINAL REPORT [**2118-8-6**]**
   URINE CULTURE (Final [**2118-8-6**]):    NO GROWTH.

[][**2118-8-5**] 11:43 am BLOOD CULTURE      AC.
                            **FINAL REPORT [**2118-8-11**]**
   Blood Culture, Routine (Final [**2118-8-11**]):    NO GROWTH.

[] [**2118-8-5**] 4:57 pm URINE
                           **FINAL REPORT [**2118-8-6**]**
   Legionella Urinary Antigen  (Final [**2118-8-6**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
           (Reference Range-Negative).
      Performed by Immunochromogenic assay.
      A negative result does not rule out infection due to other
L.
      pneumophila serogroups or other Legionella species.
Furthermore, in
      infected patients the excretion of antigen in urine may
vary

[][**2118-8-8**] 12:37 am SPUTUM      Source: Endotracheal.
                            **FINAL REPORT [**2118-8-8**]**
   GRAM STAIN (Final [**2118-8-8**]):
      >25 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.
   RESPIRATORY CULTURE (Final [**2118-8-8**]):
      TEST CANCELLED, PATIENT CREDITED.

[][**2118-8-8**] 1:00 am URINE      Source: Catheter.
                            **FINAL REPORT [**2118-8-9**]**
   URINE CULTURE (Final [**2118-8-9**]):    NO GROWTH.

[][**2118-8-8**] 1:00 am BLOOD CULTURE      Source: Line-Rt
Subclavian.
                            **FINAL REPORT [**2118-8-14**]**
   Blood Culture, Routine (Final [**2118-8-14**]):    NO GROWTH.

[] [**2118-8-8**] 1:00 am BLOOD CULTURE      Source: Venipuncture.
                            **FINAL REPORT [**2118-8-14**]**
   Blood Culture, Routine (Final [**2118-8-14**]):    NO GROWTH.

[][**2118-8-12**] 4:00 pm SWAB      Source: neck wound.
   GRAM STAIN (Final [**2118-8-12**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   WOUND CULTURE (Final [**2118-8-14**]):    NO GROWTH.
   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

Brief Hospital Course:
[]BRIEF HOSPITAL COURSE:  70M with history of CAD, diastolic
CHF, COPD, and diabetes who was transferred to [**Hospital1 18**] from
outside hospital with a C6 fracture after falling in a near
syncopal episode, possibly from a hypoglycemic event.  Patient
was evaluated by ortho/spine and was taken to the OR on [**2118-8-4**],
transferred to TSICU post op intubated.  Patient was evaluated
for NSTEMI by cardiology, treated for a presumed ventilator
associated pneumonia, extubated, and aggressively diuresed prior
to transfer to the floor.  Once on the floor, patient continued
to improve and diuresis was completeted with patient near dry
weight at discharge.  Patient will follow up with orthopedic
surgery, cardiology, and his PCP.
.
[]BRIEF ICU COURSE:
[**8-4**] Went to OR for C3-T1 posterior fusion with laminectomy.
Admitted to TSICU post-op intubated and on Neo. OGT placed. ETT
advanced. 500cc bolus given.
[**8-5**]: continued ST depressions on telemetry -> labetalol 10 mg
IV once, febrile to 103 -> Cx drawn, bronchoscopy performed
showed inflammation with purulent sputum, BAL sent for culture
and gram stain. Albumin 12.5g bolus. CVL, +Vanc/Cefepime/Cipro,
right subclavian placed. Trop still uptrending, cards advises
just follow no hep for now.
[**8-6**]: trended Troponin, esmolol drip,heparin gtt
8/19:1U PRBC (HCT24.1) followed by lasix 20 IV x1, trops
trending down. Started on PO metoprolol w/ IV Metoprolol for
breakthrough. [**Last Name (un) **] consulted for BS of 200's, insulin drip
started. Tube feeds started and advancing to goal of 75cc/hr.
Thick sputum requiring frequent suctioning. Temp 101.2->
pan-cultures sent
[**8-8**]: 1 u PRBC, (+) lasix 40 iv qonce x2, d/c insulin gtt -->
lantus 30 [**Hospital1 **] + RISS, increased vanc to 1 g q8h, d/c heparin
gtt, (+) plavix 75 mg (fine by spine), (+) heparin tid, (+)
lasix gtt
[**8-9**]: d/c vanco, patient extubated on face tent. maintaing
saturations. OG tube removed. Start on clear liquids. (+) bumex
1 g for diuresis,self d/ced a line
[**8-10**]: d/c'ed cefepime/cipro and started unasyn for H. flu,
started lasix 40 mg po and d/c'd lasix gtt, cards recs
restarting Lisinopril, plan to transfer to floor.
.
[]ACTIVE ISSUES:
# NSTEMI: elevated troponins since [**2118-8-5**], c/f NSTEMI. Patient
had concerning ST depressions on EKG tracings.  Cardiology was
consulted and continued to follow during the rest of the
patient's hospitalization. Left ventricular function interval
improved on echo [**8-9**].  The patient was continued on his home
regimen of ASA 325mg, clopidogrel 75mg, and atorvastatin 80mg.

.
# Ventilator Associated Pneumonia:  Patient had extended
intubation s/p surgery, with bibasilar opacities L>R, c/f
evolving PNA in the setting of endotracheal intubation. BAL
results revealed beta-lactamase negative haemophilus influenza
and patient was started on empiric treatment for VAP given
recent prolonged extubation.  F/u sputum culture on [**2118-8-8**]
contaminated and thus not pursued. finished 7 day course of
empiric therapy for VAP with cefepime/levofloxacin.
.
# [**Last Name (un) **]: Likely pre-renal etiology secondary to diuresis s/p
surgery and subsequent ICU admission where patient was
aggressively hydrated in the setting of hypotension.
Differential includes ATN, AIN and obstruction. AIN less likely
since no fevers or rashes. No recent contrast studies. Urine
output speaks against obstruction. Between [**2118-8-8**] and [**2118-8-12**],
patient had an average net negative diuresis of ~2L daily.
During this time, his creatinine bumped up by roughly 0.1 per
day to a plateau of 1.9 while getting 40mg PO lasix then 40mg
torsemide. Diuresis was stopped on [**2118-8-13**], and by the day of
discharge, the patient's creatinine was 1.4.  The patient's
baseline creatinine is ~1.0.  The patient's home diuresis
regimen is 40mg PO lasix [**Hospital1 **].
.
# C6 Fracture: Minimally displaced per OSH CT and confirmed in
house. Orthopedics was consulted and felt that his fracture
might be amenable to nonoperative management. CT and MRI were
done, which confirmed the C6 fracture and identified
prevertebral edema.  No neurological deficits were noted on
exam, although the patient did complain of central lower neck
pain radiating down both arms. Spine Surgery followed the
patient. A hard collar was maintained at all times with bedrest.
 [**8-4**] Went to OR for C3-T1 posterior fusion with laminectomy.
Admitted to TSICU post-op intubated and on Neo. OGT placed. ETT
advanced. 500cc bolus given.  Post op, patient's wound was c/d/i

.
# Hypoglycemic Episode / Diabetes: He reports that his Insulin
regimen was recently changed to Lantus and fixed dose Humalog
instead of 70/30 [**Hospital1 **]. He was started on approximately 70% of his
home Lantus every day with a sliding scale. His home regimen
will likely need to be adjusted given his apparent hypoglycemic
event. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Clinic consult was called to tailor his insulin
regimen given his recent event and its ostensible relation to
hypoglycemia.
.
# Post operative pain:  The patient was given oxycodone PO for
post op pain, with dilaudid IV for severe breakthrough pain.  On
[**2118-8-12**], patient began to experience s/s of delirium thought to
be likely secondary to narcotics.  His dosing schedule was
spaced out to Q8H PRN from Q6H PRN and over the next 24 hours,
the patient's mental status returned to baseline.  He required
no pain medications in the 24 hours prior to discharge.
.
[]CHRONIC ISSUES:
# Angina:  The patient was continued on his home dose of
ranolazine.
.
# Hx of Paroxysmal Atrial fibrillation:  The patient was
monitored on telemetry during this hospitalization.  He was
continued on metoprolol for rate control.  He had one burst of
afib in the ICU that was controlled with IV metoprolol X 1 and
an increased maintenence dose of metoprolol.  He was
transitioned from 100mg [**Hospital1 **] to 150mg [**Hospital1 **].
.
# IDDM II: followed by [**Last Name (un) **], with monitoring of BS lantus [**Hospital1 **]
+ humalog SSI [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs.
.
# Neurogenic pain:  We continued home dose of amitiyptyline.
.
# Essential hypertension: Blood pressures remained stable
throughout this admission.  Continued home metoprolol 150 [**Hospital1 **]
with hold parameters while hospitalized.  Was discharged with
300mg Toprol XL daily formulation.
.
# OSA
- CPAP at night
.
[]TRANSITIONAL ISSUES:
1.) patient will follow up with his outpatient cardiologist.
2.) At rehab, patient will require daily weights and add a PM
dose of 40mg PO lasix if fluid weight increases > 5 pounds while
on 40mg PO lasix daily.
3.) The rehab facility will Check serum creatinine level every
other day and report results to staff physician in charge of
patient to monitor kidney function while on diuretics.
4.) The patient is very sensitive to the effects of narcotics
and can quickly develop delirium.
5.) please do not give patient albuterol because the increased
HR side effect makes him anxious.
6.) please set up an appointment with the patient's primary care
provider within the next 1-2 weeks for medication reconciliation
and f/u s/p hospitalization.
7.) patient is to wear C-collar at all times when not lying down
in bed; further recs to be obtained at outpatient orthopedic
surgery appointment.


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 80 mg PO DAILY
2. ranolazine *NF* 1,000 mg Oral [**Hospital1 **]
3. Pantoprazole 40 mg PO Q12H
4. Venlafaxine XR 75 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Aspirin 325 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 150 mg PO BID
10. Lisinopril 5 mg PO DAILY
11. Furosemide 40 mg PO BID
hold for sbp < 100
12. Polyethylene Glycol 17 g PO DAILY
13. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
hold for sbp < 100
14. Amitriptyline 25 mg PO DAILY
15. Glargine 70 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner


Discharge Medications:
1. Amitriptyline 25 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
hold for sbp < 100
6. Nitroglycerin SL 0.4 mg SL PRN chest pain
7. Polyethylene Glycol 17 g PO DAILY
8. ranolazine *NF* 1000 mg ORAL [**Hospital1 **]
9. Senna 1 TAB PO BID:PRN constipation
10. Venlafaxine XR 75 mg PO DAILY
11. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
Do not exceed 4000 mg in 24 hours.
12. Lactulose 15 mL PO DAILY:PRN constipation
13. Lisinopril 5 mg PO DAILY
14. Bisacodyl 10 mg PR DAILY:PRN constipation
15. Cephalexin 500 mg PO Q6H Duration: 10 Days
16. Furosemide 40 mg PO DAILY
hold for sbp < 100 or Cr > 1.5.
17. Clopidogrel 75 mg PO DAILY
18. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
19. Metoprolol Succinate XL 300 mg PO DAILY
hold for SBP < 100 or HR < 60
20.  Glargine 30 Units Q12H
Insulin SC Sliding Scale using HUM Insulin


Discharge Disposition:
Extended Care

Facility:
[**Hospital 38**] Rehab

Discharge Diagnosis:
Primary:
- C6 fracture dislocation
- Partial surgical wound dehiscence
- Ventilator associated pneumonia
- Acute renal failure
- Non-ST elevation myocardial infarction
- Acute on chronic diastolic heart failure
- Delirium
- Constipation

Secondary:
- 3-vessel CAD s/p CABG; multiple NSTEMIs and PCIs
- Upper GI bleeding
- Prior stroke
- Diabetes mellitus
- Hypertension
- COPD
- Obstructive sleep apnea
- Morbid obesity
- Normocytic anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 **]. As you may recall, you were
transferred to us after being diagnosed with a broken bone in
your neck (a C6 fracture). We took pictures of your neck to help
us assess your anatomy and determine whether any intervention
would be necessary.  You were taken to the operating room to
stabilize your neck.  There was difficulty taking out the tube
used to help you breathe after the operation.  During your stay
in the intensive care unit, you were treated for a lung
infection.  There was also concern for a small heart attack.
You were seen by the cardiologists and treated with medicines.


Please remember to weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs.

Followup Instructions:
As soon as you are discharged from the hospital, please call
your primary care physician and arrange [**Name Initial (PRE) **] follow-up visit within
4-8 days.

In addition, the following visits have already been made for
you:

Department: CARDIAC SERVICES
When: WEDNESDAY [**2118-8-3**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage





Admission Date:  [**2118-8-19**]              Discharge Date:   [**2118-8-24**]

Date of Birth:  [**2047-9-30**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
syncope

Major Surgical or Invasive Procedure:
NONE


History of Present Illness:
70 year old male with CAD s/p CABG (SVG-OM, LIMA-LAD) in [**2093**]
and multiple subsequent NSTEMIs and PCIs (most recently a BMS to
SVG-OM [**2118-3-31**]), CHF (EF 40-45%), HTN, HLD, paroxysmal Afib
(not on coumadin), DM, COPD, OSA, prior CVA, and recent
significant GIB ([**4-/2118**]) who presents with a C6 vertebral body
fracture after falling on [**2118-7-29**].

Pt known to use with recent office visits and inpatient consult
in OMR. S/P cervical spine surgery after fall, complicated by
severe PNA (likely [**1-20**] aspiration)/sepsis and hypotension with
demand ischemia and positive TnT. Treated medically, had to be
diuresed with Lasix gtt (received lots of fluids by SICU team).
Transferred to [**Hospital 38**] rehab and after finishing a BM (while
pulling his trousers), had a 5 sec pause and fell (was caught by
nurse). Has been on Motoprolol 300/d and Ranexa. Severe CAD s/p
PCI/stent to SVG [**2-/2118**] and relook few days later with patent
stent. Native coronaries  vessels are not amenable to PCI.

Needs work up and EP consult. If this is a true (not iatrogenic
or artifact) pause, then a device may need to be considered.
Most recent echo [**2118-8-9**] showed recovery of his LVEF to >55%
(from baseline of 40%.
.
ROS:
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.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. Otherwise negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema.

Past Medical History:
CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

Social History:
Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA.


Family History:
Adopted, unknown


Physical Exam:
#ADMISSION PHYSICAL EXAM:
VS: T 98.5, BP 114/71, HR 71, RR 20 , O2 98% on 3L NC.
GENERAL: NAD, AxOx3.
HEENT:  JVP unable to assess [**1-20**] habitus and C-collar. Sclera
anicteric. PERRL, EOMI. MMM
CARDIAC: RRR, normal S1, S2. 2/6 SEM herad best at LUSB, No/r/g.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: pretibial edema 1+ No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
.
#DISCHARGE PHYSICAL EXAM:
VS: T 98.1, BP (104-129)/(62-67), HR 86, RR 20, O2 97% 3L.
GENERAL: NAD, AxOx3.
HEENT:  JVP unable to assess [**1-20**] habitus and C-collar. Sclera
anicteric. PERRL, EOMI. MMM
CARDIAC: RRR, normal S1, S2. 2/6 SEM herad best at LUSB, No/r/g.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: pretibial edema 1+ No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+


Pertinent Results:
#ADMISSION LABS:
[**2118-8-19**] 09:30PM   GLUCOSE-235* UREA N-24* CREAT-1.1 SODIUM-144
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-32 ANION GAP-12
[**2118-8-19**] 09:30PM   CK(CPK)-29*
[**2118-8-19**] 09:30PM   CK-MB-3 cTropnT-0.49*
[**2118-8-19**] 09:30PM   CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2118-8-19**] 09:30PM   WBC-8.6 RBC-3.16* HGB-9.1* HCT-29.0* MCV-92
MCH-28.9 MCHC-31.5 RDW-17.7*
[**2118-8-19**] 09:30PM   PLT COUNT-338#
[**2118-8-19**] 09:30PM   PT-13.9* PTT-32.7 INR(PT)-1.3*
.
#PERTINENT LABS:
[**2118-8-23**] 04:05AM BLOOD WBC-7.6 RBC-3.15* Hgb-9.2* Hct-28.2*
MCV-90 MCH-29.1 MCHC-32.5 RDW-18.1* Plt Ct-273
[**2118-8-21**] 10:30AM BLOOD WBC-8.7 RBC-3.43* Hgb-10.0* Hct-31.3*
MCV-91 MCH-29.3 MCHC-32.1 RDW-18.1* Plt Ct-342
[**2118-8-20**] 07:45AM BLOOD WBC-8.4 RBC-3.29* Hgb-9.5* Hct-30.3*
MCV-92 MCH-29.0 MCHC-31.5 RDW-17.9* Plt Ct-348
[**2118-8-22**] 10:30AM BLOOD PT-13.1* PTT-33.9 INR(PT)-1.2*
[**2118-8-21**] 10:30AM BLOOD PT-13.4* PTT-31.5 INR(PT)-1.2*
[**2118-8-23**] 04:05AM BLOOD Glucose-131* UreaN-20 Creat-1.3* Na-141
K-3.8 Cl-98 HCO3-35* AnGap-12
[**2118-8-21**] 10:30AM BLOOD Glucose-201* UreaN-19 Creat-1.1 Na-144
K-4.1 Cl-99 HCO3-36* AnGap-13
[**2118-8-20**] 03:18PM BLOOD Glucose-144* UreaN-22* Creat-1.2 Na-144
K-5.1 Cl-102 HCO3-36* AnGap-11
[**2118-8-20**] 07:45AM BLOOD Glucose-157* UreaN-22* Creat-1.0 Na-145
K-4.3 Cl-103 HCO3-34* AnGap-12
.
#MICROBIOLOGY:
[][**2118-8-20**] 12:47 pm SWAB      Source: posterior neck.
   GRAM STAIN (Final [**2118-8-20**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   WOUND CULTURE (Final [**2118-8-23**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    SPARSE GROWTH.
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    SPARSE GROWTH.
   ANAEROBIC CULTURE (Preliminary):    NO ANAEROBES ISOLATED.
.
#RADIOLOGY:
[]CHEST (PA & LAT) Study Date of [**2118-8-20**] 11:50 AM
IMPRESSION:  When compared to prior study, [**8-10**], there has
been interval increase in pleural effusions, mainly on the left.




Brief Hospital Course:
[]BRIEF CLINICAL COURSE:
70 year old male with CAD s/p CABG (SVG-OM, LIMA-LAD) in [**2093**]
and multiple subsequent NSTEMIs and PCIs (most recently a BMS to
SVG-OM [**2118-3-31**]), CHF (EF 40-45%), HTN, HLD, paroxysmal Afib
(not on coumadin), DM, COPD, OSA, prior CVA, and
recent significant GIB ([**4-/2118**]), recently admitted in early
[**Month (only) **] s/p fall with c6 fracture and surgical repair, c/f
NSTEMI, now with 5 second pause on tele at rehab post d/c,
admitted for possible pacemaker placement.
.
[]ACTIVE ISSUES:
.
# Sinus Arrythmia: Patient was recently discharged from [**Hospital1 18**] to
[**Hospital **] rehab.  At rehab on [**2118-8-17**], the patient had a 5
second pause on telemetry that coincided with a syncopal event.
He was sent to [**Hospital6 33**] for further workup.  No
pauses were seen on tele there.  The patient was transferred to
[**Hospital1 18**] for further workup and eval for placement of pacemaker.
EP was consulted upon arrival of the patient; they reviewed OSH
tracings and EKGs. According to EP, there was no indication for
pacemaker placement if the patient's symptoms were related to
taking too high a dose of metoprolol.  We decreased his home
dose of 200mg toprol XL to 50mg PO BID and the patient was
asymptomatic throughout the remainder of this hospitalization.
.
# Acute on chronic CHF (EF 40-45%): Patient is clinically volume
overloaded. Was aggressively diuresed during recent admission.
Patient also has pleural effusions. The patient was switched
from 40mg PO lasix daily to PO torsemide 80mg Qday.  His net
diuresis was between 500cc-1500cc per day.  We trended his
creatinine daily and at the time of discharge his creatinine
1.2, near his baseline.
.
# NSTEMI: Multiple document NSTEMI's in past, most recently on
[**2118-8-5**] s/p C6-T1 laminectomy on [**2118-8-4**].  At OSH, trops
elevated [**2118-8-15**] 0.66 then 0.56. Baseline Cardiac enzymes on
admission trop 0.46 and CKMB 3.  We decided not to continue
trending troponins given that the CKMB was continuing to
downtrend.  We monitored the patient on telemetry and obtained
serial EKGs that did not reveal any new pathology. We continued
the patient on a lower dose of his metoprolol.
.
# Cervical spine drainage: The patient presented with posterior
neck surgical site drainage, c/f ongoing dehiscence, seen by
ortho spine.  They cleaned the wound and put in their
recommendations for nursing staff to continue.  The patient has
follow up in the Spine Center.
.
# OSA: The patient was continued on CPAP at night, with oxygen
saturations >95%.
.
[]TRANSITIONAL ISSUES:
-patient will likely require home O2 for symptomatic control of
dyspnea
-patient will need to have his posterior cervical neck surgical
site monitored for continued wound dehiscence.  He has follow up
scheduled with the Spine Center.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius transfer records.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PR DAILY:PRN constipation
3. Lorazepam 0.5 mg PO Q8H:PRN anxiety
4. Nitroglycerin Ointment  2% 0.5 in TP Q6H
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Sorbitol 30 mL PO QHS: PRN constipation
7. Amitriptyline 25 mg PO HS
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 80 mg PO HS
10. Cephalexin 500 mg PO Q6H
11. Clopidogrel 75 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Furosemide 40 mg PO DAILY
14. Heparin 5000 UNIT SC TID
15. Glargine 30 Units Bedtime
16. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
17. Lisinopril 5 mg PO DAILY
18. Levofloxacin 500 mg IV Q24H
19. Metoprolol Succinate XL 200 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q24H
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. ranolazine *NF* 1,000 mg Oral [**Hospital1 **]
24. Senna 1 TAB PO HS:PRN constipation
25. Tamsulosin 0.4 mg PO HS
26. Venlafaxine XR 75 mg PO DAILY


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 80 mg PO HS
5. Bisacodyl 10 mg PR DAILY:PRN constipation
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Glargine 30 Units Bedtime
9. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
10. Lisinopril 5 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.4 mg SL PRN chest pain
13. Pantoprazole 40 mg PO Q24H
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. ranolazine *NF* 1,000 mg Oral [**Hospital1 **]
16. Senna 1 TAB PO HS:PRN constipation
17. Tamsulosin 0.4 mg PO HS
18. Venlafaxine XR 75 mg PO DAILY
19. Outpatient [**Hospital1 **] Work
Please check AST, ALT, Alk Phos, Total Bili on [**2118-8-29**] and fax
results to Attn: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital **] Clinic Fax: [**Telephone/Fax (1) 1419**]
20. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 100 or HR < 60 and page H.O. if holding
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice daily
[**Telephone/Fax (1) **] #*60 Tablet Refills:*0
21. Torsemide 80 mg PO DAILY
Hold for SBP < 100
RX *torsemide 20 mg 4 tablet(s) by mouth daily [**Telephone/Fax (1) **] #*120 Tablet
Refills:*0


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
sinus pause
acute on chronic systolic congestive heart failure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you.

You were admitted to the [**Hospital1 69**]
after you had some abnormal heart rhythms that caused you to
feel faint. Because of this, we decreased the medicine that
slows down your heart rate (metoprolol) and gave you some
medication to take off some fluid to improve your breathing. You
will go back to rehab to continue your progress.  You will
follow up with your outpatient cardiologist
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2118-8-31**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: WEDNESDAY [**2118-8-31**] at 12:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: SPINE CENTER
When: WEDNESDAY [**2118-8-31**] at 1 PM
With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 8603**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
{'Closed fracture of sixth cervical vertebra,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Disruption of external operation (surgical) wound,Acute posthemorrhagic anemia,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Morbid obesity,Other specified forms of chronic ischemic heart disease,Sinoatrial node dysfunction,Old myocardial infarction,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Esophageal reflux,Depressive disorder, not elsewhere classified,Aortocoronary bypass status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of insulin,Unspecified fall,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other antihypertensive agents causing adverse effects in therapeutic use'}


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: fall

PRESENT ILLNESS: This is a 70M h/o cdCHF, CAD, COPD, IDDM2 transferred to [**Hospital1 **]
from OSH with C6 fx s/p near syncopal fall.

MEDICAL HISTORY: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 80 mg PO DAILY
2. ranolazine *NF* 1,000 mg Oral [**Hospital1 **]
3. Pantoprazole 40 mg PO Q12H
4. Venlafaxine XR 75 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Aspirin 325 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 150 mg PO BID
10. Lisinopril 5 mg PO DAILY
11. Furosemide 40 mg PO BID
hold for sbp < 100
12. Polyethylene Glycol 17 g PO DAILY
13. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
hold for sbp < 100
14. Amitriptyline 25 mg PO DAILY
15. Glargine 70 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: #ADMISSION PHYSICAL EXAM:
VS: T 97.9, BP 117/54, HR 69, RR 18, SpO2 94% on RA
Gen: Elderly male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Cervical collar in place.  Unable to asses JVP or nodes.
CV: RRR with normal S1, S2.  No M/R/G appreciated.
Chest: CTAB on limited anterolateral exam without crackles,
wheezes, or rhonchi.
Abd: Hypoactive bowel sounds. Soft, NT, ND.
Ext: WWP.  Digital cap refill <2 sec.  No C/C/E.  Distal pulses
intact radial 2+, DP 2+, PT 2+.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.

FAMILY HISTORY: Adopted, unknown

SOCIAL HISTORY: Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA. 

### Response:
{'Closed fracture of sixth cervical vertebra,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Disruption of external operation (surgical) wound,Acute posthemorrhagic anemia,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Morbid obesity,Other specified forms of chronic ischemic heart disease,Sinoatrial node dysfunction,Old myocardial infarction,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Esophageal reflux,Depressive disorder, not elsewhere classified,Aortocoronary bypass status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Long-term (current) use of insulin,Unspecified fall,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other antihypertensive agents causing adverse effects in therapeutic use'}
